Staff Perspective: Focusing on the Diagnosis of PTSD
Since June is PTSD awareness month, it is appropriate to take some time and focus on the diagnosis and practice of diagnosing this particular disorder. This blog will review some points about the diagnosis of PTSD that have emerged from clinical experience, training and supervision, and recent findings from the literature on PTSD.
1) PTSD diagnosis does not validate all difficult life experiences
Clinicians working with military service members and veterans may encounter patients who view the diagnosis as a validation of their experiences. As a result, feedback from a clinical interview, or results from validated measures such as the Clinician’s Administered PTSD Scale for DSM-5 (CAPS-5) that do not support a diagnosis of PTSD can be experienced by patients as invalidating of difficult life experiences. While the DSM-5 allows for other trauma related diagnoses, the diagnosis of PTSD requires that an individual experiences a criterion A event. Clinicians need to be empathic and sensitive to patients concerns, exploring the meaning that this diagnosis may have for the individual. It can be helpful to take a descriptive approach, acknowledging the symptoms and presenting complaints while focusing on the goals that the patient has versus becoming overly focused on the particular terminology or labels for the patient’s experience.
2) Accuracy of EHR PTSD diagnoses in veteran populations
What would you need to see in a patient’s electronic health record (EHR) to give confidence that the information was accurate? The answers I have received from former interns and other mental health providers fall into two categories:
1) thorough documentation about how the patient meets the diagnostic criteria for PTSD or other psychiatric conditions by providing specific examples; and
2) documentation of results from a validated measure of PTSD such as the CAPS-5.
There has been a handful of studies examining the concordance between PTSD diagnoses in EHRs and results from structure clinical interviews assessing PTSD. Results from these studies have found a relatively low false positive rate (i.e., results from a structured interview confirming a diagnosis, but not documented in the EHR) between 3.4-8.6%. The false negative rate (i.e., diagnosis of PTSD in the EHR, but not confirmed from a structured clinical interview) was higher with one study finding it in 24.9% of the cases the authors reviewed (Harper et al., 2021). Overall, the results from these studies indicate independent assessments matched what was in the EHR between 70-73% of the time.
3) The PCL-5 is screening and outcome measure
The PTSD Checklist for DSM-5 (PCL-5) is a widely used 20 item self-report measure based on the symptoms for criterion B, C, D, and E. The patient endorses items on a scale of 0-4 based on the level of functioning for the past month. Scores above 33 are considered to be a positive screen for probable PTSD. It is important to note that the purpose of screening tools is to alert providers to potential content that warrants further assessment. If a patient screens positive on the PCL-5, it is important that providers clarify whether symptoms are in relation to a traumatic event (i.e., Criterion A) or a result of something else (e.g., pre-existing issues, medical conditions, other psychiatric conditions). Patients can also forget or not pay attention to the time frame, so it can also be good to clarify the extent to which patients have been experiencing these symptoms. The PCL-5 as a screener tool is meant to help aid diagnostic decision making and not be the sole determinant. It is also important to note that the PCL can be used for tracking progress in treatment. When using the PCL-5 for evaluating treatment responses, a minimum of a 10-point change needs to occur for it to be considered clinically meaningful.
4) Diagnosis of PTSD and utilization of emergent mental health services
A recent study by Harper et al. (2021) examined how the concordance between a patient’s diagnosis of PTSD in an EHR and a separate structured interview related to the utilization of emergent and non-emergent mental health services. The authors highlight literature concerning diagnostic errors occur that occur in patient’s medical records. The authors noted that some studies have found 50-66% of patients who meet diagnostic criteria for depression and anxiety disorder did not have it accurately reflected in their medical record. To further understand the effects that diagnostic errors may have, the authors examined 1,299 veterans enrolled in VA healthcare. The authors found that true positives (i.e., those who had a diagnosis of PTSD in the EHR and confirmed by a separate structured clinical interview) had both the highest rates of utilizing both emergent and non-emergent mental health services. The authors also found that false negatives (i.e., those who had a diagnosis of PTSD by a structured clinical interview but no PTSD diagnosis in the EHR) had a greater utilization of emergent mental health resources (i.e., emergency room, urgent care, psychiatric hospitalizations) and compared to true negatives (i.e., those who did not have a diagnosis of PTSD in the EHR or a diagnosis as a result of a structured clinical interview). Based on these findings, the authors argued that it is important to ensure the accurate diagnosis of PTSD so that patients are able to receive the necessary non-emergent mental health services. These efforts could help to reduce the utilization of emergent services for patients struggling with PTSD.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland, TX.
Reference:
Harper, K. L., Ellickson-Larew, S., Bovin, J. M., Keane, T. M., & Marx, B. P. (2021, June
3). Discrepancies between electronic records and clinical interview diagnosis
of PTSD: Differences in mental health care utilization. Psychological Services.
Advance online publication. http://dx.doi.org/10.1037/ser0000560
Since June is PTSD awareness month, it is appropriate to take some time and focus on the diagnosis and practice of diagnosing this particular disorder. This blog will review some points about the diagnosis of PTSD that have emerged from clinical experience, training and supervision, and recent findings from the literature on PTSD.
1) PTSD diagnosis does not validate all difficult life experiences
Clinicians working with military service members and veterans may encounter patients who view the diagnosis as a validation of their experiences. As a result, feedback from a clinical interview, or results from validated measures such as the Clinician’s Administered PTSD Scale for DSM-5 (CAPS-5) that do not support a diagnosis of PTSD can be experienced by patients as invalidating of difficult life experiences. While the DSM-5 allows for other trauma related diagnoses, the diagnosis of PTSD requires that an individual experiences a criterion A event. Clinicians need to be empathic and sensitive to patients concerns, exploring the meaning that this diagnosis may have for the individual. It can be helpful to take a descriptive approach, acknowledging the symptoms and presenting complaints while focusing on the goals that the patient has versus becoming overly focused on the particular terminology or labels for the patient’s experience.
2) Accuracy of EHR PTSD diagnoses in veteran populations
What would you need to see in a patient’s electronic health record (EHR) to give confidence that the information was accurate? The answers I have received from former interns and other mental health providers fall into two categories:
1) thorough documentation about how the patient meets the diagnostic criteria for PTSD or other psychiatric conditions by providing specific examples; and
2) documentation of results from a validated measure of PTSD such as the CAPS-5.
There has been a handful of studies examining the concordance between PTSD diagnoses in EHRs and results from structure clinical interviews assessing PTSD. Results from these studies have found a relatively low false positive rate (i.e., results from a structured interview confirming a diagnosis, but not documented in the EHR) between 3.4-8.6%. The false negative rate (i.e., diagnosis of PTSD in the EHR, but not confirmed from a structured clinical interview) was higher with one study finding it in 24.9% of the cases the authors reviewed (Harper et al., 2021). Overall, the results from these studies indicate independent assessments matched what was in the EHR between 70-73% of the time.
3) The PCL-5 is screening and outcome measure
The PTSD Checklist for DSM-5 (PCL-5) is a widely used 20 item self-report measure based on the symptoms for criterion B, C, D, and E. The patient endorses items on a scale of 0-4 based on the level of functioning for the past month. Scores above 33 are considered to be a positive screen for probable PTSD. It is important to note that the purpose of screening tools is to alert providers to potential content that warrants further assessment. If a patient screens positive on the PCL-5, it is important that providers clarify whether symptoms are in relation to a traumatic event (i.e., Criterion A) or a result of something else (e.g., pre-existing issues, medical conditions, other psychiatric conditions). Patients can also forget or not pay attention to the time frame, so it can also be good to clarify the extent to which patients have been experiencing these symptoms. The PCL-5 as a screener tool is meant to help aid diagnostic decision making and not be the sole determinant. It is also important to note that the PCL can be used for tracking progress in treatment. When using the PCL-5 for evaluating treatment responses, a minimum of a 10-point change needs to occur for it to be considered clinically meaningful.
4) Diagnosis of PTSD and utilization of emergent mental health services
A recent study by Harper et al. (2021) examined how the concordance between a patient’s diagnosis of PTSD in an EHR and a separate structured interview related to the utilization of emergent and non-emergent mental health services. The authors highlight literature concerning diagnostic errors occur that occur in patient’s medical records. The authors noted that some studies have found 50-66% of patients who meet diagnostic criteria for depression and anxiety disorder did not have it accurately reflected in their medical record. To further understand the effects that diagnostic errors may have, the authors examined 1,299 veterans enrolled in VA healthcare. The authors found that true positives (i.e., those who had a diagnosis of PTSD in the EHR and confirmed by a separate structured clinical interview) had both the highest rates of utilizing both emergent and non-emergent mental health services. The authors also found that false negatives (i.e., those who had a diagnosis of PTSD by a structured clinical interview but no PTSD diagnosis in the EHR) had a greater utilization of emergent mental health resources (i.e., emergency room, urgent care, psychiatric hospitalizations) and compared to true negatives (i.e., those who did not have a diagnosis of PTSD in the EHR or a diagnosis as a result of a structured clinical interview). Based on these findings, the authors argued that it is important to ensure the accurate diagnosis of PTSD so that patients are able to receive the necessary non-emergent mental health services. These efforts could help to reduce the utilization of emergent services for patients struggling with PTSD.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland, TX.
Reference:
Harper, K. L., Ellickson-Larew, S., Bovin, J. M., Keane, T. M., & Marx, B. P. (2021, June
3). Discrepancies between electronic records and clinical interview diagnosis
of PTSD: Differences in mental health care utilization. Psychological Services.
Advance online publication. http://dx.doi.org/10.1037/ser0000560