Trauma Therapist Toolkit

2nd Edition
 TRAUMA THERAPIST TOOLKIT
2nd Edition

IATP is committed to training therapists who provide treatment to clients who are trauma
survivors and who experience traumatic stress. Some of the materials included in this Toolkit
will be more suited for therapists new to the field while other materials will be more
appropriate for clinicians who have additional experience treating trauma-related stress.
Regardless of your skill level and/or area of specialty working in the field of trauma, you are
likely to find some useful materials contained in this Toolkit.

This is the second edition of the Trauma Therapist Toolkit, which is reviewed, augmented, and
updated regularly. Check back frequently for the most current interventions, techniques,
assessment instruments, journal articles, treatment protocols, and other helpful materials to
assist you in your practice.

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 Table of Contents

PROFESSIONAL RESOURCES
Posttraumatic Stress Disorder in the DSM-5: Controversy, Change, and
Conceptual Considerations 4
PTSD Diagnosis and Treatment for Mental Health Clinicians 12
Self of the Therapist 26
Ten Key Capacities of the Real Self 27
My Key Capacities 28
Non-Anxious Journal 29
Self-Soothing (Anxiety Reduction) Skills 30
The Clearness Committee: An Alternative Method for Group Clinical
Supervision 34
Intake and Assessment: Pre-Session Ritual 37
Intake 38
Client Information You Have a Right To 39
Intake and Assessment: Psycho-Traumatology Evaluation 41
The Psycho-Traumatology Evaluation Structured Clinical Interview 42
Clinician-Administered PTSD Scale for DSM-5 Online Training 45
ASSESSMENTS
Clinician-Administered PTSD Scale for DSM-5 Past Month Version 46
Clinician-Administered PTSD Scale for DSM-5 Child/Adolescent Version 64
Adolescent Dissociative Experiences Scale-II 90
Child Dissociative Checklist Version 3 94
Dissociative Experiences Scale II 97
Dissociative Regression Scale 101
Impact of Events Scale – Revised 103
PTSD Check List – 5 with Life Events Checklist – 5 and Criterion A 105
Satisfaction With Life Scale 110
CLINICAL EVALUATION
Symptom Checklist 112
Mental Health Examination 114
Psycho-Traumatology Evaluation (Sample) 115
TREATMENT RESOURCES 133

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 Tri-Phasic Model 114
Managing Dissociative Regression 118
Grounding and Containment 120
Flashback Journal 132
ADDENDUM TO PUBLICATION AGREEMENT 133

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 Posttraumatic Stress Disorder in the DSM-5:
Controversy, Change, and Conceptual Considerations
(Pai, Suris, & North, 2017)

Abstract: The criteria for posttraumatic stress disorder PTSD have changed considerably
with the newest edition of the American Psychiatric Association’s (APA) Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). Changes to the diagnostic criteria from the
DSM-IV to DSM-5 include: the relocation of PTSD from the anxiety disorders category to a
new diagnostic category named “Trauma and Stressor-related Disorders”, the elimination of
the subjective component to the definition of trauma, the explication and tightening of the
definitions of trauma and exposure to it, the increase and rearrangement of the symptoms
criteria, and changes in additional criteria and specifiers. This article will explore the
nosology of the current diagnosis of PTSD by reviewing the changes made to the diagnostic
criteria for PTSD in the DSM-5 and discuss how these changes influence the
conceptualization of PTSD.

1. Introduction

Posttraumatic stress disorder (PTSD) has attracted controversy since its introduction as
a psychiatric disorder in the third edition of the American Psychiatric Association’s (APA)
Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 [1]. With each
revision of the DSM, the criteria for PTSD have changed substantially [2]. Following
publication of the fourth edition of the DSM (DSM-IV) in 1994 [3], PTSD experts criticized
the criteria extensively, proposing myriad ways to address the problems they identified [4–7].
The literature accumulating during this time presented various polemical arguments
concerning the definition of trauma and even questioning the need for it in the definition of
PTSD [5,6,8], which and how many symptoms to include in the PTSD criteria and how they
should be grouped [8], and even whether PTSD is a valid diagnosis at all [9]. Although the
subsequent DSM-IV text revision edition of the manual (DSM-IV-TR) revised the text
accompanying the criteria, the diagnostic criteria for PTSD did not change in this version.
Therefore, this article will refer to these two versions together as DSM-IV/-TR.
The fifth edition (DSM-5) of the criteria required seven years of planning, six years of
actual work group activity, and a year to finalize the materials for publication and obtain the
approval of the APA Assembly and Board of Trustees. The revision efforts included an
extensive review of literature, secondary analyses, professional presentations and town halls,
vigorous debates among trauma experts and nosologists, and rounds of public and
professional reviews of the proposed criteria [10,11]. This was described as a “very
conservative approach” [12] (p. 548), with the appreciation that because important clinical
and scientific consequences could result from any modifications to the diagnostic criteria, the
work group needed to have very strong evidence before making any changes. Regardless,
the changes in the diagnostic criteria for PTSD from DSM-IV/-TR to DSM-5 were
substantial.
This article will explore the nosology of the current diagnosis of PTSD. Specifically,
it will critically examine the DSM-5 diagnostic criteria for PTSD, review changes in the

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criteria made in the DSM-5, and consider how the criteria shape current conceptualizations of
PTSD.

2. Diagnostic Classification of PTSD

Perhaps the most substantial conceptual change in the DSM-5 for PTSD was the removal
of the disorder from the anxiety disorders category. Considerable research has demonstrated
that PTSD entails multiple emotions (e.g., guilt, shame, anger) outside of the fear/anxiety
spectrum [13,14], thus providing evidence inconsistent with inclusion of PTSD with the
anxiety disorders. In the DSM-5, PTSD was placed in a new diagnostic category named
“Trauma and Stressor-related Disorders” indicating a common focus of the disorders in it as
relating to adverse events. This diagnostic category is distinctive among psychiatric disorders
in the requirement of exposure to a stressful event as a precondition. Other disorders included
in this diagnostic category are adjustment disorder, reactive attachment disorder, disinhibited
social engagement disorder, and acute stress disorder. This is the only diagnostic category in
the DSM-5 that is not grouped conceptually by the types of symptoms characteristic of the
disorders in it.

3. Criterion A: Exposure to Trauma

PTSD begins with criterion A, which requires exposure to a traumatic event. Criterion
A is not only the most fundamental part of the nosology of PTSD, but also it’s most
controversial aspect [12]. Some trauma experts criticized criterion A in the DSM-IV as too
inclusive [5,6,15] and warned that this change had the potential to promote “conceptual
bracket creep” [16] or “criterion creep” [17]. Some authors questioned the value of criterion
A altogether [8,18,19], even suggesting that it should be abolished [8]. Criterion A was
retained in the DSM-5, but it was modified to restrict its inclusiveness.
Not all stressful events involve trauma. The DSM-5 definition of trauma requires
“actual or threatened death, serious injury, or sexual violence” [10] (p. 271). Stressful events
not involving an immediate threat to life or physical injury such as psychosocial stressors [4]
(e.g., divorce or job loss) are not considered trauma in this definition.
The DSM-5 has clarified and narrowed the types of events that qualify as “traumatic”.
The ambiguous DSM-IV/-TR term “threat to physical integrity” [3] (p. 427) was removed
from the definition of trauma in the DSM-5. Medically based trauma is now limited to
sudden catastrophe such as waking during surgery or anaphylactic shock. Non-immediate,
non-catastrophic life-threatening illness, such as terminal cancer, no longer qualifies as
trauma, regardless of how stressful or severe it is. Medical incidents involving natural causes,
such as a heart attack, no longer qualify (with the stated exception of life-threatening
hemorrhage in one’s child, as described in the text accompanying the criteria). This
seemingly minor revision of the definition of medically based trauma appears to have had a
substantial influence on PTSD findings. A DSM-IV/DSM-5 comparison study conducted by
Kilpatrick and colleagues [20] using highly structured self-report inventories demonstrated
that 60% of PTSD cases that met DSM-IV but not proposed DSM-5 PTSD criteria were
excluded from the DSM-5 because the traumatic events involved only nonviolent deaths.
In addition to requiring the occurrence of a traumatic event, criterion A stipulates that
the individual must have had a qualifying exposure to the trauma [2]. In other words, trauma
is necessary, but it is not sufficient for consideration of PTSD without a qualifying exposure
to that trauma. The DSM-IV/-TR provided three qualifying exposure types: direct personal
exposure, witnessing of trauma to others, and indirect exposure through trauma experience of
a family member or other close associate. Although some critics had argued for removal of

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the third (indirect) type of exposure [5,6], the DSM-5 retained all three types of exposure
from the DSM-IV/-TR, now listed in the DSM-5 as A1–A3. A fourth exposure type (A4) has
been added: repeated or extreme exposure to aversive details of a traumatic event, which
applies to workers who encounter the consequences of traumatic events as part of their
professional responsibilities (e.g., military mortuary workers, forensic child abuse
investigators).
DSM-IV/-TR used the phrase “experienced, witnessed, or was confronted with” [3]
(p. 467) to refer to the three types of exposures that are now listed and explicitly defined
respectively as A1–A3 in the DSM-5. The ambiguous DSM-IV/-TR term “confronted with”,
in apparent reference to indirect exposure through close associates, has been completely
removed from the definition of exposure to trauma in the DSM-5. The DSM-IV/-TR did not
specify whether witnessed exposures had to be in person, or whether media reports could
constitute a witnessed exposure. The DSM-5 has now clearly required the witnessing of
trauma to others to be “in person” [10] (p. 271). Exposure through media is further narrowed
in the DSM-5 by specifying that “criterion A4 does not apply to exposure through electronic
media, television, movies or pictures unless it is work-related” [10] (p. 271). These specific
changes to the criteria defining trauma and qualifying exposures to it have important potential
ramifications for the assessment and estimation of PTSD prevalence in real-life settings. For
example, using the unspecified DSM-IV/-TR definition of witnessed trauma exposure,
research studies counted media reports as trauma exposures, permitting nearly anyone living
in the United States of America to trauma-exposed in the 11 September 2001 terrorist attacks
[5]. The nationwide incidence of “probable PTSD” related to the disaster was thus reported as
4% of the population [21], constituting an estimated total burden of 11 million cases [2]. The
consequences of imprecise definitions of trauma and exposure to it are particularly extensive
when large populations with non-qualifying trauma exposures are considered trauma-exposed
for the purposes of measuring symptoms. Careful application of DSM-5 criteria in the future
can avert substantial inaccuracies in the estimation of PTSD prevalence.
The DSM-5 removed the subjective personal response of “intense fear, horror, or
helplessness” that had been added to criterion A in the DSM-IV. The requirement of a
subjective response as part of the trauma criterion created a serious conceptual error by
conflating the subjective experience of trauma with objective exposure to the traumatic event
[4]. The personal response to trauma exposure, including posttraumatic symptoms, needs to
be separated from the definition of trauma exposure for conceptual clarity [2]. In agreement
with North and colleagues, McNally [5] (p. 598) recommended the elimination of criterion
A2, arguing: “In the language of behaviorism, it confounds the response with the stimulus. In
the language of medicine, it confounds the host with the pathogen”. The decision to remove
criterion A2 from the DSM-5, however, was instead based on two specific research findings:
(1) the requirement of a subjective response would exclude individuals who did not endorse
fear, helplessness, or horror during the traumatic event, yet met the rest of the diagnostic
criteria for PTSD [22,23], especially military personnel [2,24]; (2) the subjective response
does not add predictive ability to the objective definition [22,25].
Exposure to trauma is the foundation for the rest of the criteria that comprise the
diagnosis of PTSD [4,12,16,26]. Breslau et al. [27] emphasized that the link between PTSD
symptoms and exposure to a traumatic event is what makes the diagnosis of PTSD a distinct
disorder. They posed the question, “Without exposure to trauma, what is posttraumatic about
the ensuing syndrome?” [27] (p. 927). North et al. [4] whimsically added that without
exposure to trauma, a syndrome following a nontraumatic stressor might more appropriately
be named “poststressor stress disorder” and one associated with no identified stressor called
“nonstressor stress disorder”.

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 4. The Symptom Criteria

PTSD symptoms are conditionally linked to trauma exposure. Almost all other disorders
in the DSM criteria are defined based on their characteristic symptoms, and thus the
conditional nature of PTSD creates complexity not encountered in other disorders. According
to the current diagnostic criteria, assessment of PTSD symptoms is appropriate only if
criterion A is met, i.e., the individual has had a qualifying exposure to a requisite trauma.
Without this trauma exposure, psychiatric symptoms reported by an individual would not
qualify as PTSD symptoms. Each symptom must be anchored to the traumatic event through
a temporal and/or contextual relationship [4]. The DSM-5 stipulates that to qualify, the
symptoms must begin (symptom criteria B and C) or worsen (symptom criteria D and E) after
the traumatic event. Even though the symptoms must be linked to a traumatic event, this
linking does not imply causality or etiology. Hence, the diagnostic criteria for PTSD are
actually descriptive and agnostic toward etiology and therefore consistent with the generally
descriptive and agnostic approach to defining psychiatric disorders in the American
diagnostic system [4].
Revision of the PTSD symptom groups in the DSM-5 relied on guidance from factor
analytic research; however, findings from factor analytic studies examining the latent
structure of PTSD symptoms to determine the most parsimonious symptom groupings have
been inconsistent [28]. Additional factor analytic research has demonstrated substantial
overlap of PTSD symptoms with symptoms of other disorders (especially depressive and
anxiety disorders), inviting criticism of the validity of PTSD as a distinct disorder [15]. This
factor analytic research has been limited, however, by use of self-report scales not anchoring
symptoms to the traumatic event as defined by the diagnostic criteria for PTSD [4]. Factor
analytic studies using data collected from structured diagnostic interviews that correctly link
the symptoms contextually and temporally to the trauma exposure are needed to address these
unresolved problems in the conceptualization of PTSD symptom criteria.
The DSM-5 increased the number of symptom groups from three to four and the
number ofsymptoms from 17 to 20. The DSM-5 symptom groups are intrusion, avoidance,
negative alterations in cognition and mood, and alterations in arousal and reactivity. To form
the new group, DSM-5 separated the avoidance and numbing symptoms into different
groups. The two avoidance items from the DSM-IV/-TR avoidance/numbing group (criterion
C) now comprise the DSM-5 avoidance group (criterion C), and the numbing symptoms are
now included with cognitive symptoms and mood symptoms in the negative cognition and
mood group (criterion D).With this reorganization, at least one avoidance symptom is now
required for an individual to meet diagnostic criteria in the DSM-5, in contrast to DSM-IV/-
TR criteria which permitted a PTSD diagnosis even if no avoidance symptoms were
endorsed.
Three new symptoms were added to the PTSD criteria in the DSM-5: persistent
negative emotional state, persistent distorted cognitions about the cause or consequences of
the trauma leading to blame of self or others, and reckless or self-destructive behavior.
Reckless or self-destructive behavior was found to have low prevalence and poor factor
loading in the DSM-5 field trials, and this symptom was predominantly endorsed by the
subgroup reporting the most severe symptoms [12,29]. The finding that only a limited subset
of people endorsing severe symptoms acknowledged reckless or self-destructive behavior
suggests that this symptom represents more a characteristic of a high symptom-endorsing

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subgroup and less a feature of the disorder itself. Reckless or self-destructive behavior was
added as a symptom to the DSM-5 criteria despite these research findings, because clinicians
and researchers who observe it in the PTSD patient populations they work with believed it to
represent a clinically important feature of the disorder [29]. Elsewhere it has been argued that
inclusion of reckless/self-destructive behavior, persistent distorted cognitions, aggression
toward others, and emphasis on dissociation have inserted cluster B personality features into
PTSD, and that it may reflect selection biases based on observations of these features in
specific subpopulations of PTSD, such as patients receiving psychiatric treatment [2]. Hoge
and colleagues [30] criticized the added reckless/self-destructive behavior and negative
emotional state symptoms as nonspecific to the psychopathology of PTSD and the persistent
distorted cognitions symptom as over-pathologizing.
A number of DSM-IV-TR PTSD symptoms were revised in the DSM-5 [2,30]. Some
of the revisions involved minor wording changes (e.g., adding the word “involuntary” to
“intrusive distressing recollections of the event”), and others were more foundational (e.g.,
“sense of a foreshortened future” reformulated as “persistent and exaggerated negative beliefs
or expectations about oneself, others, or the world”; “restricted range of affect” changed to
“persistent inability to experience positive emotions”). A study comparing DSM-IV/-TR and
DSM-5 symptom checklists for PTSD indicated that the changes to PTSD symptoms
reflected in the checklists may have substantially altered the identification of PTSD cases
[31].

5. Additional Criteria and Specifiers

A new set of PTSD criteria was added for children six years of age or younger to
reflect their levels of development. The criteria for younger children do not have the
“repeated or extreme exposure to aversive details of the traumatic event” exposure type, have
only three symptom groups consisting of a total of 16 symptoms, have different symptoms
grouped together compared to the adult symptom criteria, and indirect trauma exposure
through a close associate is limited to a parent or care-giving figure. Additionally, intrusive
memories in younger children do not have to appear distressing (as in play re-enactment) and
nightmares do not have to be contextually based on the traumatic event.
The acute and chronic PTSD specifiers were eliminated in the DSM-5, and the
concept of delayed-onset PTSD was replaced with “delayed expression” defined as “the full
diagnostic criteria are not met until at least 6 months after the event (although the onset and
expression of some symptoms may be immediate)” [10] (p. 272). This is a diagnostic
threshold definition of onset, using the point at which full diagnostic criteria are first met or
last met as the point of onset or remission, respectively. Studies using repeated self-report
symptom measures have used this method of determining onset and remission. Prior versions
of DSM criteria have defined onset and remission of disorders as the point at which
symptoms begin or end (i.e., a symptom-based definition of onset/remission), and structured
diagnostic interviews have historically used this method of determining onset and remission
[32]. The replacement of the previous PTSD onset criteria with the new delayed expression
of onset definition in the DSM-5 has effectively substituted a diagnostic threshold-based
definition (which is found to yield a higher prevalence) for the historic symptom-based
definition of onset [32]. This shift is destined to make it impossible to compare the onset of
PTSD across studies using the new definition with historical estimates from previous
research.
The DSM-5 introduced a new dissociative features specifier to note the presence of
associated persistent or recurrent depersonalization or derealization symptoms. This new
feature of the disorder is a reflection of the focus of the DSM-5 Trauma, PTSD, and

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Dissociative Disorders Sub-Work Group of the Anxiety Disorders Work Group committee
that proposed the new PTSD criteria.

6. Conclusions

The diagnostic criteria for PTSD were substantially modified in the DSM-5, despite
the revision process being described as “very conservative” by the work group [12]. The new
changes in criterion A provide more conceptual clarity. Trauma exposure is objectively
defined, and the subjective responses to trauma exposure (criterion A2) have been removed
from criterion A, separating them from the trauma definition and confining them to the
symptom criteria. This separation of the subjective response to trauma from the objective
definition of trauma is an important advancement in the nosology of this conditionally-based
disorder. The new criteria for trauma and exposure to it further limit the types of events that
qualify as trauma for consideration of this disorder and more carefully define qualifying
exposures to trauma.
Development of diagnostic criteria is an iterative process [4,33]. Additional research
will be needed to validate this revision of the PTSD criteria, including study of descriptive
characteristics, differential diagnosis, biological markers, and genetic factors [34]. Because
the conditional definition of PTSD introduces complexity to its definition, it is paramount to
study the criteria for PTSD with careful adherence to established criteria to permit testing of
the criteria that are in use to inform future work.

Author Contributions: Anushka Pai, Alina M. Suris and Carol S. North conceptualized this
article and contributed to writing the manuscript together.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
3rd ed.; American Psychiatric Association: Washington, DC, USA, 1980.
2. North, C.S.; Surís, A.M.; Smith, R.P.; King, R.V. The evolution of PTSD criteria across
editions of DSM. Ann. Clin. Psychiatry 2016, 28, 197–208.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
4th ed; American Psychiatric Association: Washington, DC, USA, 1994.
4. North, C.S.; Suris, A.M.; Davis, M.; Smith, R.P. Toward Validation of the Diagnosis of
Posttraumatic Stress Disorder. Am. J. Psychiatry 2009, 166, 34–41.
5. McNally, R.J. Can we fix PTSD in DSM-V? Depress. Anxiety 2009, 26, 597–600.
6. Spitzer, R.L.; First, M.B.; Wakefield, J.C. Saving PTSD from itself in DSM-V. J. Anxiety
Disord. 2007, 21, 233–241.
7. McHugh, P.R.; Treisman, G. PTSD: A problematic diagnostic category. J. Anxiety Disord.
2007, 21, 211–222.
8. Brewin, C.R.; Lanius, R.A.; Novac, A.; Schnyder, U.; Galea, S. Reformulating PTSD for
DSM-V: Life after Criterion A. J. Trauma. Stress 2009, 22, 366–373.
9. Summerfield, D. The invention of post-traumatic stress disorder and the social usefulness
of a psychiatric category. BMJ 2001, 322, 95–98.
10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 5th ed.; American Psychiatric Association: Arlington, VA, USA, 2013.
11. Regier, D.A.; Kuhl, E.A.; Kupfer, D.J. The DSM-5: Classification and criteria changes.
World Psychiatry 2013,
12. Friedman, M.J. Finalizing PTSD in DSM-5: Getting Here From There and Where to Go
Next: Finalizing PTSD in DSM-5. J. Trauma. Stress 2013, 26, 548–556.

9
13. Friedman, M.J.; Resick, P.A.; Bryant, R.A.; Strain, J.; Horowitz, M.; Spiegel, D.
Classification of trauma and stressor-related disorders in DSM-5. Depress. Anxiety
2011, 28, 737–749.
14. Resick, P.A.; Miller, M.W. Posttraumatic stress disorder: Anxiety or traumatic stress
disorder? J. Trauma. Stress 2009, 22, 384–390.
15. Rosen, G.M.; Spitzer, R.L.; McHugh, P.R. Problems with the post-traumatic stress
disorder diagnosis and its future in DSM V. Br. J. Psychiatry 2008, 192, 3–4.
16. McNally, R.J. Progress and Controversy in the Study of Posttraumatic Stress Disorder.
Annu. Rev. Psychol.2003, 54, 229–252.
17. Rosen, G.M. Traumatic events, criterion creep, and the creation of pretraumatic stress
disorder. Sci. Rev Ment. Health Pract. 2004, 3, 39–42.
18. Maier, T. Post-traumatic stress disorder revisited: Deconstructing the A-criterion. Med.
Hypotheses 2006, 66, 103–106.
19. Kraemer, B.; Wittmann, L.; Jenewein, J.; Maier, T.; Schnyder, U. Is the Stressor Criterion
Dispensable? Psychopathology 2009, 42, 333–336.
20. Kilpatrick, D.G.; Resnick, H.S.; Milanak, M.E.; Miller, M.W.; Keyes, K.M.; Friedman,
M.J. National Estimates of Exposure to Traumatic Events and PTSD Prevalence
Using DSM-IV and DSM-5 Criteria: DSM-5 PTSD Prevalence. J. Trauma. Stress
2013, 26, 537–547.
21. Schlenger, W.E.; Caddell, J.M.; Ebert, L.; Jordan, B.K.; Rourke, K.M.; Wilson, D.;
Thalji, L.; Dennis, J.M.;Fairbank, J.A.; Kulka, R.A. Psychological reactions to
terrorist attacks: Findings from the National Study of Americans’ Reactions to
September 11. JAMA 2002, 288, 581–588.
22. Breslau, N.; Kessler, R.C. The stressor criterion in DSM-IV posttraumatic stress disorder:
An empirical investigation. Biol. Psychiatry 2001, 50, 699–704.
23. Karam, E.G.; Andrews, G.; Bromet, E.; Petukhova, M.; Ruscio, A.M.; Salamoun, M.;
Sampson, N.; Stein, D.J.; Alonso, J.; Andrade, L.H.; et al. The Role of Criterion A2 in
the D. Psychiatry 2010, 68, 465–473.
24. Adler, A.B.;Wright, K.M.; Bliese, P.D.; Eckford, R.; Hoge, C.W. A2 diagnostic criterion
for combat-related posttraumatic stress disorder. J. Trauma. Stress 2008, 21, 301–308.
25. Bedard-Gilligan, M.; Zoellner, L.A. The utility of the A1 and A2 criteria in the diagnosis
of PTSD. Behav. Res. Ther. 2008, 46, 1062–1069.
26. Weathers, F.W.; Keane, T.M. The criterion a problem revisited: Controversies and
challenges in defining and measuring psychological trauma. J. Trauma. Stress 2007,
20, 107–121.
27. Breslau, N.; Chase, G.A.; Anthony, J.C. The uniqueness of the DSM definition of post-
traumatic stress disorder: Implications for research. Psychol. Med. 2002, 32, 573–576.
28. Armour, C.; M˝ullerová, J.; Elhai, J.D. A systematic literature review of PTSD’s latent
structure in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV to
DSM-5. Clin. Psychol. Rev. 2016, 44, 60–74.
29. Miller, M.W.; Wolf, E.J.; Kilpatrick, D.; Resnick, H.; Marx, B.P.; Holowka, D.W.;
Keane, T.M.; Rosen, R.C.; Friedman, M.J. The prevalence and latent structure of
proposed DSM-5 posttraumatic stress disorder symptoms in U.S. national and veteran
samples. Psychol. Trauma Theory Res. Pract. Policy 2013, 5, 501–512.
30. Hoge, C.W.; Yehuda, R.; Castro, C.A.; McFarlane, A.C.; Vermetten, E.; Jetly, R.;
Koenen, K.C.; Greenberg, N.; Shalev, A.Y.; Rauch, S.A.M.; et al. Unintended
Consequences of Changing the Definition of Posttraumatic Stress Disorder in DSM-5:
Critique and Call for Action. JAMA Psychiatry 2016, 73, 750.
31. Hoge, C.W.; Riviere, L.A.;Wilk, J.E.; Herrell, R.K.;Weathers, F.W. The prevalence of
post-traumatic stress disorder (PTSD) in US combat soldiers: A head-to-head

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 comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist.
Lancet Psychiatry 2014, 1, 269–277.
32. North, C.S.; Oliver, J. Analysis of the longitudinal course of PTSD in 716 survivors of 10
disasters. Soc. Psychiatry Psychiatr. Epidemiol. 2013, 48, 1189–1197.
33. Guze, S.B. Nature of psychiatric illness: Why psychiatry is a branch of medicine. Compr.
Psychiatry 1978, 19, 295–307.
34. North, C.S.; Yutzy, S.H. PTSD. In Psychiatric Diagnosis; University Press: New York,
NY, USA, 2010; pp. 129–166.

© 2017 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

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PTSD Diagnosis and Treatment for Mental
Health Clinicians
by Matthew J. Friedman, M.D., Ph.D. Executive Director, National Center for PTSD
Professor of Psychiatry and Pharmacology,
Dartmouth Medical School

While this article is a bit dated, it provides an excellent primer

for diagnosing and treating PTSD.

Abstract

This article focuses on four issues: PTSD assessment, treatment approaches, therapist
issues, and current controversies. Important assessment issues include the trauma history,
co morbid disorders, and chronicity of PTSD. Effective intervention for acute trauma
usually requires a variant of critical incident stress debriefing. Available treatments for
chronic PTSD include group, cognitive-behavioral, psychodynamic, and pharmacological
therapy. Therapist self-care is essential when working with PTSD patients since this work
may be functionally disruptive and psychologically destabilizing. Current controversies
include advocacy vs. therapeutic neutrality, eye movement desensitization and
reprocessing (EMDR), the so-called false memory syndrome, and the legitimacy of
complex PTSD as a unique diagnostic entity.

Originally published in Community Mental Health Journal 32(2): 173-189, (April 1996).

PTSD is an easy diagnosis to make when the patient tells you that s/he has been badly
traumatized and believes that such exposure has precipitated current psychological
problems. Thanks to a massive psychoeducational program provided by the print and
electronic media, the public has become familiar with the concept of PTSD and
recognizes that it can be caused by war trauma, domestic violence, sexual assault,
industrial accidents, and natural disasters. Media coverage of major recent events such as
the Persian Gulf War, Hurricane Andrew, cases of child abuse, and the genocide in
Bosnia have often underscored the psychological impact of such events thereby
contributing to the growing sophistication of a public that knew little about PTSD until
the late 1980s. Furthermore, PTSD is an attractive explanatory model for many people
because it places responsibility for their suffering on factors outside themselves, factors
over which they often had neither responsibility nor control.

Clinicians have also found the PTSD construct attractive and useful. It provides an
explanatory model that is easy to address therapeutically and that promotes empathic
patience, even with the most difficult and demanding clientele. Although the growing
acceptance of trauma-focused assessment and treatment strategies has created clinical
options that were not exercised as recently as ten year ago, such options have also

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generated a number of potential problems. In this article, I will address four issues: PTSD
detection and diagnosis; treatment approaches; therapist issues; and current controversies.

Making the Diagnosis

The switch from DSM-III-R (American Psychiatric Association, 1987) to DSM-IV

(American Psychiatric Association, 1994) will bring few changes in the diagnostic
criteria for PTSD. As shown in Table 1, the stressor criterion (A1) will no longer
characterize trauma as outside the range of normal human experience since we have been
forced to recognize that exposure to catastrophic stress is an unwelcome but not unusual
aspect of the human condition. Furthermore, the stressor criterion (A2) now requires that
in addition to exposure, the patient need also have an intense emotional reaction to the
traumatic event such as panic, terror, grief, or disgust. (In DSM-III (American Psychiatric
Association, 1980) and DSM-III-R, Criterion A was restricted to exposure per se [A1]
and did not address the subjective response [A2].) Otherwise, the B, C, and D, symptoms
have remained the same with the exception of a slight rearrangement such that D6 in
DSM-III-R has become B5 in DSM-IV.

PTSD patients are stuck in time and are continually re-exposed to the traumatic event
through daytime recollections that persistently interrupt ongoing thoughts, actions, or
feelings. They are assaulted by terrifying nightmares that awaken them and make them
afraid to go back to sleep. They cannot tolerate any reminders of the trauma since these
often trigger intense fear, anxiety, guilt, rage, or disgust. In some cases, they suffer
PTSD flashbacks, psychotic episodes in which reality dissolves and they are plunged
back into the apparent reality of a traumatic event that has haunted them for years or
decades. During such episodes they find themselves fighting off rapists, being attacked
by enemies, or fleeing from explosions with the same intense feelings they experienced
during the initial trauma. Such intrusive recollections (Criterion B) can persist for over
50 years (Schnurr, 1992) and may get worse, rather than better, with time (Archibald and
Tuddenham, 1965).

PTSD patients develop avoidant/numbing symptoms (Criterion C) to ward off the

intolerable emotions and memories recurrently stirred up by these intrusive recollections.
Sometimes they develop dissociative or amnestic symptoms that buffer them from painful
feelings and recollections. They also adopt obsessional defenses and other behavioral
strategies such as drug and alcohol abuse, eating disorders, sexual acting out and
workaholism, to ward off intrusive recollections.

Finally, PTSD patients suffer from autonomic hyperarousal (Criterion D). Such
symptoms include insomnia, irritability that may progress to rage, agitation and
jumpiness manifested by an exaggerated startle response, and hypervigilence that may
become indistinguishable from frank paranoia. PTSD patients are always on guard,
dedicated to avoiding ever being re-exposed to the terrifying circumstances that changed
their lives forever. It is difficult for them to trust other people or the environment. The
need for safety and protection may outweigh all other considerations including intimacy,
socialization and other pleasurable pursuits.

In other words, the clinician attempting to engage the PTSD patient in treatment is asking
the patient to take a tremendous risk. S/he is asking the patient to give up all the
protective behaviors and psychological strategies that have emerged to ward off intrusive

13
recollections and hyperarousal symptoms. Therefore, the therapist must recognize that
assessment and treatment are potentially destabilizing. Therapy can only succeed in an
environment of sensitivity, trust, and safety (Herman 1992). Therapists must recognize
that it may take a long time for patients to shed the many layers of protective symptoms
that have evolved over countless years since the trauma. It is important for the therapist to
let the patient know as soon as possible that s/he recognizes that the prospect of therapy is
frightening and painful. It is also important that therapists suppress their own need to get a
trauma history as soon as possible and set a pace that the patient can tolerate. In my own
work, I always tell patients to signal me when our trauma-focused therapy has become too
upsetting. I promise to back off whenever they signal me that therapy has become too
distressing. And I always keep my promise. In this way, I fortify the atmosphere of trust
and safety and preserve the forward momentum of therapy despite a momentary pause or
two.

Some patients may be so relieved that they finally have an opportunity to discuss long
suppressed, painful, and possibly shameful past events that they cannot wait to review
such material with a therapist. A second group may be equally motivated but may appear
resistant because of fears that therapy will stir up intolerable feelings. They require the
safety mentioned earlier. A third group may have sought treatment for depression,
anxiety, chemical dependency, eating disorders, somatic complaints, or adjustment
disorders rather than for PTSD. Indeed, among cohorts of treatment seeking PTSD
patients, up to 80% have at least one additional psychiatric diagnosis including affective
disorders (26-65%), anxiety disorders (30-60%), alcoholism or drug abuse (60-80%), or
personality disorders (40-60%) (Friedman, 1990; Jordan, et al., 1991; Kulka, et al.,1990).
For such patients, PTSD sometimes emerges as a diagnostic possibility only after the
clinician has obtained a careful trauma history as part of a comprehensive assessment.
Finally, there is a group of difficult patients who present, because of disruptive or self-
destructive behaviors and who initially appear to suffer primarily from a personality
disorder.

Patients in this latter category may be adult survivors of protracted childhood sexual
abuse whose trauma history may be obscured by DSM-III-R labels such as borderline
personality disorder (BPD), multiple personality disorder (MPD), and somatoform
disorder. In addition to PTSD symptoms, they often present with problems of affect
regulation, impulsive behavior, dissociative symptoms, problems of trust, inappropriate
sexual behavior, and a wide variety of somatic complaints (Herman, 1992). These latter
problems may demand the lion's share of therapy. Treatment of these patients may be
further complicated by fragmented thought processes, incomplete memories, and
dissociative symptoms.

The trauma history is essential. Given high rates of comorbidity mentioned earlier, and
given a significant amount of overlap between symptoms seen in PTSD, depression, and
other anxiety disorders, the trauma history is the major vehicle through which PTSD can
be diagnosed and distinguished from other major mental disorders. There are many
anecdotes about severely traumatized patients whose therapists never bothered to ask
about childhood or adult trauma. They followed their therapists' leads and spent
countless hours reviewing Oedipal conflicts, family dynamics, or here-and-now
interpersonal conflicts. Belated discovery of the centrality of sexual abuse, combat
stress, or domestic violence provided the key to understanding their current symptoms
and became a productive focus for therapy.

14
It is usually not difficult to obtain a trauma history. Patients are generally forthcoming
and frequently pleased to finally have an opportunity to tell their trauma story to someone
who appears sufficiently knowledgeable and sensitive to ask about it. For all the reasons
mentioned earlier, however, telling the trauma story can be difficult. The first trauma
story to emerge is often only the tip of the iceberg. More distressing material will come
later after the therapist has established trust and safety and has shown that he or she has
the courage, wisdom, and empathy to listen to such material and sufficient positive regard
for the patient to encourage further disclosure. Therapists can signal patients through their
questions and responses that they understand the behavioral and emotional impact of a
rape, natural disaster, or war. Such signals are readily perceived by patients who usually
respond positively now that they have been reassured that it will be safe and productive to
tell the full trauma story to this therapist at this time.

As with other medical and psychiatric disorders, PTSD patients may exhibit a wide
spectrum of impairment. At one extreme, affected individuals may exhibit a high level of
interpersonal, social, and vocational function. At the other extreme, some PTSD patients
may be totally incapacitated by this disorder and may appear to have a chronic mental
illness. Such patients may be misdiagnosed as having chronic schizophrenia and may be
indistinguishable from such patients unless the clinician has undertaken a careful trauma
history and diagnostic assessment. Two reports on psychotic female state hospital
inpatients (Beck & Van der Kolk, 1987; Craine et al., 1988) indicate that those with a
history of childhood or adolescent sexual abuse were more likely than non-abused patients
to have intrusive, avoidant/numbing and hyperarousal symptoms associated with the
abuse. In fact, 66% of these previously abused and currently psychotic patients met
criteria for PTSD although none had ever received that diagnosis. Furthermore, they could
be distinguished from non-abused state hospital patients by the prominence of sexual and
abusive themes in their thoughts and behavior.

To summarize, detection of PTSD can be difficult because of patient fears that

therapy will reactivate intolerable symptoms, because of the many co-morbid Axis I
and Axis II DSM-III-R disorders that frequently accompany PTSD, and because
some patients may be too fragmented, amnestic, dissociative, and otherwise impaired
to participate in therapy. Assessment can only succeed in a safe therapeutic
environment that promotes a comprehensive review of each patient's trauma history
at a pace and intensity that is tolerable.

Treatment

Many therapeutic approaches have been advocated for PTSD. The reader is referred to a
number of comprehensive reviews of the most prominent treatments for PTSD including
psychodynamic therapy (Marmar, et al., 1993), cognitive-behavioral therapy (Foa, et al.
1995), pharmacotherapy (Friedman & Southwick, 1995), group, family, couples, and
inpatient treatment (Williams & Sommer, 1995), and treatment for patients dually
diagnosed with PTSD and alcoholism/ substance abuse (Kofoed, et al., 1993). Therapists
working with patients who have survived a variety of traumatic events (war, natural
disasters, etc.) generally agree that therapy can be divided into three phases:

1. Establishing trust, safety, and "earning the right to gain access" to carefully
guarded traumatic material (Lindy, 1993; p. 806)

15
 2. Trauma-focused therapy: exploring traumatic material in depth, titrating
intrusive recollections with avoidant/numbing symptoms (Horowitz, 1986)

3. Helping the patient disconnect from the trauma and reconnect with family, friends,
and society.

It should be noted that patients who reach the third phase have integrated post-
traumatic events and are ready to concentrate, almost exclusively, on here-and-now
issues concerning marriage, family, and other current issues (Herman, 1992; Lindy,
1993; Scurfield, 1993).Marmar, et al. (1995; 1993) have suggested that there are five
identifiable post-traumatic syndromes, each requiring a different treatment approach:
normal stress response; acute catastrophic stress reaction; uncomplicated PTSD; PTSD
co-morbid with other disorders; and post-traumatic personality.

The normal stress response occurs when healthy adults who have been exposed to a
single discrete traumatic event in adulthood experience intense intrusive recollections,
numbing, denial, feelings of unreality, and arousal. Such individuals usually achieve
complete recovery following individual or group debriefing (Armstrong, et al., 1991)
derived from critical incident stress debriefing (CISD), models initially developed by
Mitchell (1983) and Raphael (1986). Often a single two-hour group debriefing experience
is all that is needed. Such sessions begin by describing the traumatic event. They then
progress to exploration of survivors' emotional responses to the event. Next, there is an
open discussion of symptoms that have been precipitated by the trauma. Finally, there is
a resolution in which survivors' responses are normalized and adaptive coping strategies
are identified.

Acute catastrophic stress reactions are characterized by panic reactions, cognitive

disorganization, disorientation, dissociation, severe insomnia, tics and other movement
disorders, paranoid reactions, and incapacity to manage even basic self-care, work, and
interpersonal functions (Marmar, 1991). Treatment includes immediate support, removal
from the scene of the trauma, use of anxiolytic medication for immediate relief of
anxiety and insomnia, and brief supportive aggressive dynamic psychotherapy provided
in the context of crisis intervention.

Uncomplicated PTSD may respond to group, psychodynamic, cognitive behavioral,

pharmacological, or combination approaches. During the past ten years, we have come to
appreciate the powerful therapeutic potential of positive peer group treatment as practiced
in Vet Centers for military veterans and in rape crisis centers for sexual assault and
domestic violence victims. It can be argued that the peer-group setting provides an ideal
therapeutic setting for trauma survivors because their post-traumatic emotions, memories,
and behaviors are validated, normalized, understood, and de-stigmatized. They are able to
risk sharing traumatic material in the safety, cohesion and empathy of fellow trauma
survivors. It is often much easier to accept confrontation from a fellow sufferer who has
impeccable credentials as a trauma survivor than from a professional therapist who never
went through those experiences first-hand. As group members achieve greater
understanding and resolution over traumatic themes, they are re-moralized. As they climb
out of the pit of trauma-related shame, guilt, rage, fear, doubt, and self-condemnation, they
prepare themselves to focus on the present rather than the past (Herman, 1992; Scurfield,
1993).

16
Brief psychodynamic psychotherapy focuses on the traumatic event itself. Through the
retelling of the traumatic event to a calm, empathetic, compassionate and non-judgmental
therapist, the patient achieves a greater sense of self-cohesion, develops more adaptive
defenses and coping strategies, and more successfully modulates intense emotions that
emerge during therapy (Marmar, et al., 1995). The therapist needs to constantly address
the linkage between post-traumatic and current life stress. S/he needs to help the patient
identify current life situations that set off traumatic memories and exacerbate PTSD
symptoms.

There are two cognitive-behavioral approaches, exposure therapy and cognitive-

behavioral therapy. Exposure therapy includes systematic desensitization on the one hand
and imaginal and in-vivo techniques such as flooding, on the other. In general, flooding
has been much more effective than systematic desensitization. The second approach,
cognitive-behavioral therapy, includes a variety of anxiety management training
strategies for reducing anxiety such as relaxation training, stress inoculation training,
cognitive restructuring, breathing retraining, biofeedback, social skills training, and
distraction techniques (see Hyer, 1994; and Foa, et al., 1995 for references). Foa and
associates (Foa, et al., 1991; Rothbaum, et al., 1992) have shown flooding and anxiety
management training (stress inoculation therapy) are both effective for rape victims with
PTSD. They have also speculated that a combination of both treatments might be more
effective than either treatment alone.

Given our expanding understanding of the many neurobiological abnormalities

associated with PTSD (see Friedman, 1991; Southwick, et al., 1992; Murburg, 1994;
Friedman, Charney, & Deutch,1995), pharmacotherapy appears to have a place in PTSD
treatment. From a practical perspective, there is no question that drugs can provide some
symptomatic relief of anxiety, depression, and insomnia, whether or not they ameliorate
core PTSD intrusive and avoidant/ numbing symptoms. In most but not all trials,
improvement has been achieved with imipramine, amitriptyline, phenelzine, fluoxetine,
and propranolol. A quantitative analysis by Southwick, et al. (1992), suggested that
tricyclic antidepressants and monoamine oxidase inhibitors are generally efficacious in
PTSD patients, especially with regard to intrusion and avoidant symptoms, although
fluoxetine, amitriptyline, and possibly valproate have shown efficacy against avoidant
symptoms (Fesler, 1991; Davidson, et al., 1990; Van der Kolk, et al., 1994). At this time
no particular drug has emerged as a definitive treatment for PTSD although medication is
clearly useful for symptom relief thereby making it possible for patients to participate in
group, psychodynamic, cognitive-behavioral, or other forms of psychotherapy.

PTSD comorbid with other DSM-III-R Axis I disorders is actually much more common
than uncomplicated PTSD. As noted earlier, PTSD is usually associated with at least one
other major psychiatric disorder such as depression, alcohol/substance abuse, panic
disorder, and other anxiety disorders (Friedman, 1990; Jordan et al., 1991; Breslau et al.,
1991; Kofoed, et al., 1993). Sometimes the co-morbid disorder is the presenting complaint
that requires immediate attention. At other times, the PTSD appears to be the major
problem. In general, the best results are achieved when both PTSD and the co-morbid
disorder(s) are treated concurrently rather than one after the other. This is especially true
for PTSD and alcohol/substance abuse (Abueg & Fairbank, 1991; Kofoed, et al., 1993).
Treatment previously described for uncomplicated PTSD should also be used for these
patients.

17
Post-traumatic personality disorder is found among individuals who have been exposed
to prolonged traumatic circumstances, especially during childhood, such as childhood
sexual abuse. These individuals often meet DSM-III-R criteria for diagnoses such as
borderline personality disorder, somatoform disorder, and multiple personality disorder.
Such patients exhibit behavioral difficulties (such as impulsivity, aggression, sexual
acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), emotional
difficulties (such as affect liability, rage, depression, panic) and cognitive difficulties,
(such as fragmented thoughts, dissociation, and amnesia). Treatment generally focuses
on behavioral and affect management in a here-and-now context with emphasis on
family function, vocational rehabilitation, social skills training, and alcohol/drug
rehabilitation.

Long-term individual and group treatments have been described for such patients by
Herman (1992), Koller, et al. (1992), and Scurfield (1993). Trauma-focused treatment
should only be initiated after long therapeutic preparation. Inpatient treatment may be
needed to provide adequate safety and safeguards before undertaking therapeutic
exploration of traumatic themes. The three phases of treatment, described earlier, apply
to these patients as well as those with uncomplicated PTSD, but treatment may take
much longer, may progress at a much slower rate, and may be fraught with much more
complexity than with other traumatized patients.

Therapist Issues

Trauma work is difficult. Traumatized patients have suffered greatly and the therapeutic
process often opens old wounds with alarming intensity. It is difficult, if not impossible,
to maintain a stance of therapeutic neutrality when a patient tells you how s/he was
brutally abused as a child, tortured by political enemies, or was forced to watch loved
ones be murdered. Such narratives generate powerful emotions in therapist as well as
patient.

Therapists sometimes find themselves having intrusive thoughts or nightmares about the
events recounted by their patients. Therapists may experience guilt that they were
personally spared from such horrors. They may feel profoundly powerless because they
could not protect patients from previous trauma and present distress. Such feelings can
produce a number of inappropriate responses that interfere with therapy and disturb the
therapist on a personal level. Herman (1992) notes that powerful emotions generated
during therapy may prompt the therapist to engage in rescue attempts, boundary
violations, or attempts to control the patient.

Therapists may also activate a number of avoidant/numbing coping strategies such as

doubting, denial, avoidance, disavowal, isolation, intellectualization, constricted affect,
dissociation, minimization, or avoidance of traumatic material (Danieli, 1988; Herman,
1992; Lindy, 1988). McCann and Pearlman (1990) have called this phenomenon
"vicarious traumatization," while Figley (1995) has called such secondary traumatization
"compassion fatigue."

In my opinion, it is useful to separate out three different, but not mutually exclusive,
circumstances in which therapists working with traumatized clientele may become
distressed, immobilized, and symptomatic. First, therapists who have never been

18
traumatized themselves may become overwhelmed by the material generated during the
course of treatment with PTSD patients. They may experience (secondary) traumatic
nightmares, guilt, feelings of powerlessness, rescue fantasies, or avoidant/numbing
behavior as described above. This can set up a vicious cycle in which the more
symptomatic, maladaptive, and ineffective therapists become, the more they plunge
themselves into their work. When this occurs, they are less likely to recognize that they
have a serious problem and, unfortunately, are less likely to seek supervision or
assistance from colleagues.

Second, therapists experience a bona fide countertransference reaction in which the

patient's material triggers intrusive recollections of traumatic experiences that happened
to them in the past. Since exposure to trauma is not a rare event and since mental health
professionals have no more immunity from such exposure than anyone else, such
countertransference reactions should be expected to arise often enough to warrant careful
monitoring by therapists and supervisors alike. Third, therapists are themselves exposed
to the same kind of traumatic experiences for which they attempt to assist others. An
example would be offering treatment to survivors of a natural disaster to which the
therapist him or herself has also been exposed. Under such circumstances, the therapist
must seek debriefing or treatment for his or her own post-traumatic symptoms before s/he
can expect to assist others.

It is not enough for therapists to recognize these occupational hazards. They must make a
conscious sustained and systematic effort to prevent such secondary traumatization
through self-care activities. Such measures include developing a supportive environment,
monitoring caseloads in terms of size and number of trauma cases, making boundaries
between personal and professional activities, having regular supervision, and establishing
an institutional structure that will address this problem (Courtois, 1988; Gusman, et al.,
1991). For example, Yassen (1993) has recommended time-limited group treatment for
therapists and human service professionals who work with victims of sexual abuse and
who themselves have previously been exposed to sexual trauma.

Controversial Issues

Although the PTSD diagnosis, itself, was controversial when it first appeared in 1980,
that is no longer the case. However, there are currently four controversies in the trauma
field that are worth noting: advocacy, eye- movement desensitization and reprocessing
(EMDR), the
false memory syndrome, and complex PTSD.

Many trauma patients have been victimized by an overpowering aggressor such as a rapist
or terrorist. Most therapists are privately outraged by the violence that has been
perpetrated on their clientele. Under such circumstances it can be exceedingly difficult to
balance one's stance as a neutral professional with one's humanistic values concerning
justice and abusive power. Some argue that advocacy is an essential component of the
therapist role when your clientele are victims, while others insist that one must always
maintain therapeutic neutrality despite one's personal beliefs. It is crucial for each
clinician to acknowledge this issue and to strive to achieve the proper balance for him or
herself.

19
EMDR is a controversial therapy developed by Shapiro (1989) in which the patient is
instructed to imagine a painful traumatic memory while visually focusing on the rapid
movement of the therapist's finger. Shapiro believes that such saccadic eye movements
reprogram brain function so that the emotional impact of the trauma can finally be
integrated. She and her followers are convinced that patients can achieve resolution of
previously disruptive trauma-related emotions through this procedure. Others have
suggested that EMDR is really an exposure therapy in disguise and that eye movements
may be irrelevant (Foa et al., 1995, Pitman, et al., 1993). Well- controlled empirical
support for EMDR is lacking, the few completed controlled studies have been equivocal,
and methodological questions have been raised (Boudewyns et al., 1993; Foa et al.,
1995; Pitman et al., 1993). What¹s remarkable, however is that a number of seasoned
PTSD clinicians are convinced that EMDR is the most effective available treatment for
PTSD despite the fact that many others are highly skeptical of this approach.

Therapists working with adults who had been sexually assaulted as children have reported
that such patients have sometimes had no memories of these childhood assaults at the start
of treatment. During the course of therapy, however, such repressed traumatic memories
reportedly emerge so that patients regain access to discrete recollections of childhood
events such as father-daughter incest (Herman & Schatzow, 1987). Patients who claim to
have regained traumatic memories of this nature have confronted parents whom they now
regard as perpetrators of childhood sexual trauma. In some cases, they have taken parents
to court for these alleged abuses.

Sometimes the accused parents vehemently deny that such events ever occurred and
maintain that these "traumatic memories" are really emblematic of a "false memory
syndrome" that has of therapy. Loftus (1993) has written extensively about the problem of
authenticating such rediscovered previously repressed memories. Williams (1994), on the
other hand, has shown that women who were sexually assaulted during childhood,
(documented by recorded visits to hospital emergency rooms), are sometimes unable to
recall that traumatic event. This hotly debated issue has theoretical, clinical, and forensic
implications which will need to be sorted out in the future.

Finally, clinicians who work with victims of prolonged trauma such as incest and torture
argue that such patients suffer from a clinical syndrome that is not adequately
characterized by the PTSD construct (Herman, 1992). Although most patients in this
category meet PTSD diagnostic criteria, it is argued that their primary problem is not
PTSD. Instead, Herman (1992) has proposed that their major problems concern
impulsivity, affect regulation, dissociative symptoms, self-destructive behavior,
abnormalities in sexual expression, and somatic symptoms and has called this syndrome,
complex PTSD. Identification and treatment of these patients has been described
previously (post-traumatic personality). The controversy is whether complex PTSD is
distinct from PTSD and whether it should have its own diagnostic identity. After much
discussion, it was decided not to include complex PTSD in the DSM-IV. The controversy
has stimulated a number of research initiatives. It is expected that this issue will be
revisited during development of the next revision of the DSM-IV, the DSM-V.

20
 Summary

PTSD is not difficult to detect if the clinician includes a careful trauma history as part of
his or her comprehensive assessment. The major current diagnostic questions concern the
possibility that there are a number of acute and chronic post-traumatic syndromes of
which PTSD is the most distinct and identifiable example. Complex PTSD has been
suggested as another post-traumatic syndrome which affects individuals who have
protracted exposure to trauma, especially childhood sexual trauma. Another diagnostic
issue concerns the relative importance of PTSD when it is associated with other co-
morbid diagnosis such as depression, alcohol/substance abuse, anxiety disorders, and
Axis II diagnoses. A third but related diagnostic issue concerns the fact that PTSD can
progress to a chronic mental illness. Such patients are so impaired that they are
superficially indistinguishable from other chronic patients and can often be found on the
fringes of society, in homeless shelters, and enrolled in programs designed for patients
with chronic mental illness such as schizophrenia.

The most widely used treatment for acute traumatic exposure is some CISD-type
approach administered in an individual or group format. Among the treatments for
chronic PTSD, group, psychodynamic, cognitive- behavioral, and pharmacologic
approaches are used widely although few randomized clinical trials have been conducted
on any of these treatment approaches. When PTSD is associated with Axis I disorders,
both PTSD and the co-morbid problems should be treated concurrently. When PTSD is
associated with a personality disorder, treatment usually needs to be long-term and
complicated.

There are a number of issues that must be acknowledged and addressed by therapists who
work with traumatized clientele, which stem from the powerful emotions generated in the
therapists during treatment. Inappropriate coping strategies by therapist may interfere
with treatment and produce a disturbing syndrome which has been called vicarious
victimization or compassion fatigue. Therapist self-care is an essential priority for these
reasons.

Four controversies in the trauma field have attracted considerable attention. They are the
proper balance between advocacy and therapeutic neutrality, the efficacy of EMDR as a
treatment, the so-called false memory syndrome, and the possibility that complex PTSD
is a unique diagnosis in its own right that is distinct from PTSD.

Table 1
DSM-IV Criteria for PTSD

A. The person has been exposed to a traumatic event in which both of the following have been
present:

(1) the person has experienced, witnessed, or been confronted with an event or events that involve
actual or threatened death or serious injury, or a threat to the physical integrity of self or
others
(2) the person¹s response involved intense fear, helplessness, or horror. Note: in children, it may
be expressed instead by disorganized or agitated behavior.

21
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or
perceptions.
Note: in young children, repetitive play may occur in which themes or aspects of the trauma
are expressed
(2) recurrent distressing dreams of the event. Note: in children, there may be frightening dreams
without recognizable content
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience, illusions, hallucinations, and dissociative flashback episodes, including those that
occur upon awakening or when intoxicated). Note: in young children, trauma-specific
reenactment may occur
(4) intense psychological distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event
(5) physiological reactivity upon exposure to internal or external cues that symbolize or resemble
an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness
(not present before the trauma), as indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a
normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or
more) of the following:

(1) difficulty falling or staying asleep

(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month

F. The disturbance causes clinically significant distress or impairment in social, occupational, or

other important areas of functioning

References:

Abueg, F. & Fairbank, J. (1991). Behavioral treatment of the PTSD substance abuser, inPost-
traumatic stress disorder: A behavioral approach to assessment and treatment. Edited
by Saigh, P.A. New York: Pergamon Press.
American Psychiatric Committee on Nomenclature and Statistics (1980). Diagnosis and
statistical manual of mental disorders, third edition. Washington, DC: American
Psychiatric Association.

22
American Psychiatric Committee on Nomenclature and Statistics (1987). Diagnosis and
statistical manual of mental disorders, third edition-revised. Washington, DC:
American Psychiatric Association.
American Psychiatric Committee on Nomenclature and Statistics (1994). Diagnosis and
statistical manual of mental disorders, fourth edition. Washington, DC: American
Psychiatric Association.
Archibald, H.C. & Tuddenham, R.D. (1965). Persistent stress reaction after combat: A 20
year follow-up.Archives of General Psychiatry, 12, 475–481.
Armstrong, K., O'Callahan, W. & Marmar, C.R. (1991). Debriefing Red Cross disaster
personnel: The multiple stressor debriefing model.Journal of Traumatic Stress, 4,
481–491.
Beck, J.C. & van der Kolk, B. (1987). Reports of childhood incest and current behavior of
chronically hospitalized psychotic women.American Journal of Psychiatry, 144,
1474–1476.
Boudewyns, P.A., Swertka, S.A., Hyer, L.A., et al. (1993). Eye movement desensitization for
PTSD of combat: A treatment outcome pilot study.The Behavior Therapist, 16, 29–
33.
Breslau, N., Davis, C.G., Andreski, P., et al. (1991). Traumatic events and post-traumatic
stress disorder in an urban population of young adults.Archives of General Psychiatry,
48, 216–222.
Courtois, C.A. (1988). Healing the incest wound: Adult survivors in therapy. New York:
W.W. Norton.
Craine, L.S., Henson, C.B., Colliver, J.A., et al. (1988). Prevalence of a history of sexual
abuse among female psychiatric patients in a state hospital system.Hospital and
Community Psychiatry, 39, 300–304.
Danielli, Y. (1988). Confronting the unimaginable: Psychotherapist's reactions to victims of
the Nazi Holocaust inHuman adaptation to extreme stress from the Holocaust to
Vietnam. Edited by Wilson, J.P., Harel, Z. & Kahana, B. New York: Plenum Press.
Davidson, J., Kudler, H., Smith, R., et al. (1990). Treatment of post-traumatic stress disorder
with amitriptyline and placebo.Archives of General Psychiatry, 47, 259–266.
Fesler, F.A. (1991). Valproate in combat-related post-traumatic stress disorder.Journal of
Clinical Psychiatry, 52(9), 361–364.
Figley, C.R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in
those who treat the traumatized. New York: Brunner/Mazel.
Foa, E.B. & Riggs, D.S. (1993). Post-traumatic stress disorder in rape victims, inAmerican
psychiatric press review of psychiatry, volume 12. Edited by Oldham, J., Riba, M.B.,
& Tasman, A. Washington, DC: American Psychiatric Press.
Foa, E.B., Rothbaum, B.O., Murdock, T, et al. (1991). The treatment of PTSD in rape
victims.Journal of Consulting and Clinical Psychology, 59, 715–723.
Foa, E.B., Rothbaum, B.O., Molnar, C. (1995). Cognitive-behavioral therapy of PTSD,
inNeurobiological and clinical consequences of stress: from normal adaptation to
PTSD. Edited by Friedman, M.J., Charney, D.S., & Deutch, A.Y. Philadelphia:
Lippincott-Raven, 483–494.
Friedman, M.J. (1990). Interrelationships between biological mechanisms and
pharmacotherapy of posttraumatic stress disorder, inPosttraumatic stress disorder:
Etiology, phenomenology, and treatment. Edited by Wolf, M.E. & Mosnaim, D.A.
Washington, DC: American Psychiatric Press.
Friedman, M.J. (1991). Biological approaches to the diagnosis and treatment of post-
traumatic stress disorder.Journal of Traumatic Stress, 4(1), 67–91.

23
Friedman, M.J., Charney, D.S. & Deutch, A.Y. (1995). Neurobiology and clinical
consequences of stress: From normal adaptation to PTSD. Philadelphia: Lippincott-
Raven.
Friedman, M.J. & Southwick, S.M. (1995). Towards pharmacotherapy for PTSD,
inNeurobiological and clinical consequences of stress: From normal adaptation to
PTSD. Edited by Friedman, M.J., Charney, D.S., & Deutch, A.Y. Philadelphia:
Lippincott-Raven, 465–482.
Gusman, F.D., Abueg, F.R. & Friedman, M.J. (1991). Operation Desert Storm clinician
packet. Palo Alto: National Center for PTSD.
Herman, J.L. (1992). Trauma and recovery. New York: Basic Books.
Herman, J.L. & Schatzow, E. (1987). Recovery and verification of memories of childhood
sexual trauma.Psychoanalytic Psychology, 4, 1–14.
Horowitz, M.J. (1986). Stress response syndromes (2nd edition). New York: Jason Aronson.
Hyer, L. (1994). Trauma victim: Theoretical issues and practical suggestions. Muncie, IN:
Accelerated Development, Inc.
Jordan, K., Schlenger, W., Hough, R., et al. (1991). Lifetime and current prevalence of
specific psychiatric disorders among Vietnam veterans and controls.Archives of
General Psychiatry, 48, 207–215.
Kofoed, L., Friedman, M.J. & Peck, R. (1993). Alcoholism and drug abuse in patients with
PTSD.Psychiatric Quarterly, 64, 151–171.
Koller, P., Marmar, C.R. & Kanas, N. (1992). Psychodynamic group treatment of post-
traumatic stress disorder in Vietnam veterans.International Journal of Group
Psychotherapy, 42, 225–246.
Kulka, R.A., Schlenger, W.E., Fairbank, J.A., et al. (1990). Trauma and the Vietnam War
generation. New York: Brunner/Mazel.
Lindy, J.D. (1988). Vietnam: A casebook. New York: Brunner/Mazel.
Lindy, J.D. (1993). Focal psychoanalytic psychotherapy, inThe international handbook of
traumatic stress syndromes. Edited by Wilson, J.P. & Raphael, B. New York: Plenum
Press.
Loftus, E.F. (1993). The reality of repressed memories.American Psychologist, 48, 418–537.
Marmar, C.R. (1991). Brief dynamic psychotherapy of post-traumatic stress
disorder.Psychiatric Annals, 21, 405–414.
Marmar, C.R., Foy, D., Kagan, B., et al. (1993). An integrated approach for treating post-
traumatic stress, inAmerican psychiatric press review of psychiatry, volume 23. Edited
by Oldham, J.M., Riba, M.B. & Tasman, A. Washington, DC: American Psychiatry
Press.
Marmar, C.R., Weiss, D.S. & Pynoos, R.B. (1995). Dynamic psychotherapy of post-
traumatic stress disorder, inNeurobiological and clinical consequences of stress:
From normal adaptation to PTSD. Edited by Friedman, M.J., Charney, D.S., &
Deutch, A.Y. Philadelphia: Lippincott-Raven, 495–506.
McCann, L. & Pearlman, A. (1990). Vicarious traumatization: A framework for
understanding the psychological effects of working with victims.Journal of Traumatic
Stress, 3, 131–149.
Mitchell, J. (1983). When disaster strikes ... The critical incident stress debriefing
process.Journal of Emergency Medical Services, 8, 36–39.
Murburg, M.M. (1994). Catecholamine function in post-traumatic stress disorder: Emerging
concepts. Washington, DC: American Psychiatric Press.
Pitman, R.K., Orr, S., Altman, B., et al. (1993, October). A controlled study of eye movement
desensitization/reprocessing (EMDR) treatment for post-traumatic stress disorder.

24
 Paper presented at the Annual Meeting of the International Society for Traumatic
Stress Studies, San Antonio, TX.
Raphael, B. (1985). When disaster strikes. New York: Basic Books.
Rothbaum, B.O., Fog, E.B., Riggs, D.S., et al. (1992). A prospective examination of post-
traumatic stress disorder in rape victims.Journal of Traumatic Stress, 5, 455–475.
Schnurr, P.P. (1991). PTSD and combat-related psychiatric symptoms in older
veterans.PTSD Research Quarterly, 2(1), 1–6.
Scurfield, R. (1993). Treatment of PTSD in Vietnam veterans, inThe international handbook
of traumatic stress syndromes. Edited by Wilson, J.P. & Raphael, B. New York:
Plenum Press.
Shapiro, F. (1989). Efficacy of eye movement desensitization procedure in the treatment of
traumatic memories.Journal of Traumatic Stress, 2, 199–233.
Southwick, S.M., Krystal, J.H., Johnson, D.R., et al. (1992). Neurobiology of post-traumatic
stress disorder, inAnnual review of psychiatry, volume II. Edited by Tasman, A.
Washington, DC: American Psychiatric Press.
van der Kolk, B.A., Dryfus, D., Michaels, M., et al. (1994). Fluoxetine in post-traumatic
stress disorder.Journal of Clinical Psychiatry, 55, 517–522.
Williams, M.B. & Sommer, J.F. (1994). Handbook of post-traumatic therapy. Westport, CT:
Greenwood Press.
Williams, L.M. (1994). Recall of childhood trauma: A prospective study of women's
memories of child sexual abuse.Journal of Consulting and Clinical Psychology, 62,
1167–1176.
Yassan, J. (1993). Group work with clinicians who have a history of trauma.NCP Clinical
Newsletter, 3, 10–11.

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 Self-Of-The-Therapist

After reading Dr. Friedman’s article in the Diagnosis and Treatment of PTSD, you are
aware that you as the therapist must attend to your own responses as you work with
traumatic stress or PTSD. The client’s traumatic material evokes powerful emotions in
the therapist as well as the client. Friedman pointed out that therapist may become
overwhelmed, experience counter-transference, or be experiencing their own traumatic
response at the time. These responses may jeopardize the efficacy of the therapist. To
ensure that the client is receiving the best trauma treatment, therapist must focus on
developing and maintaining the “Self-of-the-therapist” as one of the most important
aspects of treatment with traumatized individuals.

When working with clients who exhibit traumatic stress, it is of the utmost importance to
practice Anecdotally, I have found that when I spend a few moments breathing, relaxing, and
grounding myself before going into the session, client outcomes are better. I am then more
able to establish a safe, supportive environment in which my client can freely process their
trauma narrative. This process also allows for the rapid development of the therapeutic
relationship, which has been shown to be one of the most important aspects of treatment.

We will begin developing your skills in this area before moving on to providing training in
assessment and treatment skills. By developing self-awareness of your own
responses to your clients’ trauma, you are able to maintain a calm, peaceful
presence that builds a foundation for the c linical work. All the remaining skills
can be learned and applied, but the development of the “self -of the-therapist”
must be an ongoing process.

To begin the process of developing your own personal and professional self, we have
included an excerpt from James F. Masterson’s Book, (1988) The search for the real self:
Unmasking the personality disorders of our age. New York: Free Press.

26
 Ten Key Capacities of the Real Self
James F. Masterson, MD

Review these “ten key capacities” and write an evaluation of your own strengths and the
areas in which you feel you need further development. This can become a professional
goal statement for you in your development of a trauma therapist.

1. Capacity to experience a wide range of feelings deeply with liveliness, joy, vigor,
excitement and spontaneity.

2. Capacity to expect appropriate entitlements From early experiences of mastery, coupled

with parental acknowledgment and support of the real self, healthy individuals build a
sense of entitlement to appropriate experiences of mastery and pleasure, as well as the
environmental input needed to achieve these objectives.

3. Capacity for self-activation and assertion This capacity includes the ability to identify
one’s own unique individuality, wishes, dreams, and goals and to be assertive in
expressing them autonomously.

4. Acknowledgment of self-esteem This capacity allows a person to identify and

acknowledge that he has effectively coped with a problem or crisis in a positive and
creative way.

5. The ability to soothe painful feelings The real self will not allow us to wallow in misery.
When things go wrong and we are hurt, the real self devises ways to minimize and soothe
painful feelings.

6. The ability to make and stick to commitments The real self allows us to make
commitments to relationships and career goals. Despite obstacles and setbacks, a person
with a strong sense of real self will not abandon her goal or decision when it is clear that
it is a good one and in her best interest.

7. Creativity Based on helping people allow their real selves to emerge, is the ability to
replace old familiar patterns of living and problem-solving with new and equally or more
successful ones.

8. Intimacy The capacity to express the real self fully in a close relationship with another
person with minimal anxiety about abandonment or engulfment [ability to self-soothe this
anxiety].

9. The ability to be alone The real self allows us to be alone without feeling abandoned. It
enables us to manage ourselves and our feelings on our own through periods when there
is no special person in our lives and not confuse this type of aloneness with the psychic
aloneness, springing from an impaired real self, that drives us to despair or the
pathological need to fill up our lives with meaningless sexual activity or dead-end
relationships just to avoid coming face to face with the impaired real self.

10. Continuity of self This is the capacity to recognize and acknowledge that we each have a
core that persists through space and time.

27
 My Key Capacities

Capacities Identified Capacities Needed How I Will Address This Need

28
 Non-Anxious Journal

Symptom of Anxiety Trigger SUDs Self-soothing Skill(s) SUDs

used

29
 Self-Soothing (Anxiety Reduction) Skills

Recent research on brain activity has indicated that high levels of anxiety impede
cognitive and motor skills. The higher an individual’s anxiety rises beyond optimal
levels, the more reactive (and less skilled) this individual becomes. Performance,
language skills, information accessing, motor coordination and judgment all suffer from
high levels of anxiety.
Performance

optimal

Anx Iet y

What does this mean for the helper working with trauma survivors? It means
that unless you become an expert at lowering your own anxiety, you are likely to
become accessing victimized by your clients – that you will find yourself
overwhelmed, de-skilled and even traumatized by your client’s stories and affect.
Maintaining a peaceful, non-anxious presence means that you will be more able to
access and utilize all of your training, that you will be able to continue to “bear
witness” to your clients’ heinous stories and that you will be able to create and
maintain a safe environment for healing. There is little that you can do when working
as a helper that is more important than the maintenance of a non-anxious presence.
As you begin to develop mastery with self-soothing skills and are able to remain
non- reactive to other’s reactivity and your own emotions, chances are you will find
yourself being much less reactive in other areas of your life. This is known as the
principle of isomorphism – when you affect change in one area of life and it has a
generative effect across the board to all other areas.
One last note on developing and maintaining a non-anxious presence. This is
different than appearing calm while anxiety rages on the inside. Even while appearing
calm, the helper whose anxiety has crossed over the optimal level will suffer a decrease
in cognitive and motor performance. So, self-soothing involves the ability to use
cognitive, affective and behavioral skills to create relaxation and lowered reactivity. If
you gain nothing else from this course, enhancing your ability to self-soothe will improve
both you and your client’s experience in therapy

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Self-Soothing Skills

Cognitive - It has been demonstrated that feelings are generated by what we think.
Often feelings seems to erupt spontaneously, however, upon closer inspection we find
that there is usually a belief system, or schema, associated with the advent of a particular
emotion. Cognitive theorists and therapist have long known that by attending to and
replacing the negative, fear-based ways in which we talk to ourselves with more positive,
life-affirming language we can improve the way we feel.
Take a minute to recall the times in which you have become anxious in working
with another person. What types of things was your mind saying to you and about the
situation. You will probably find some pretty dark images, coercive language and self-
defeating thoughts associated with that anxiety. You are the owner of your thoughts and
you are invited to begin to become intentional, instead of reactive, with your thinking
during times of anxiety.

Reactive Intentional
Example: “I am going to screw this “I am doing the best that I can. I can
up…this is too much for me to handle!” remain calm and help.”

Affective/Body - Probably the most effective way to establish relaxation and to

remain non-anxious is by releasing the tension in our bodies. Many of the most seasoned
therapists will report that they find themselves having to release tension from their bodies
dozens of time each session. Our bodies seem to tense up, preparing to fight or flee, even
before we perceive that we have been threatened in some way. Sometimes a simple deep
31
breath can be very effective in lowering our anxiety.
The pelvic floor muscle group (sphincter, gluteus, abdominal, hamstring and
lower back) seems to be the “seat of anxiety.” Acknowledging and then releasing the
tension in these areas can be very effective in lowering anxiety. Laughter always results
in lessening of tension in this muscle group.
Where do you hold your tension? What ways can you begin to release tension in
these and other muscles? Take a minute to jot down where you most frequently hold
tension and some strategies for releasing this tension.

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Behavioral - Joseph Wolpe was the developer of systematic desensitization and one
of the first clinician/researchers to focus upon the lowering of stress. He realized that there
is a host of behaviors that one can do which mitigate the effects of stress. Some of these
include: taking a drink of water, Thought Field Therapy (tapping down), stretching,
changing postures, prayer, talking, etc.
Think of some of the things that you can do to begin to lower your anxiety, in
vivo, or in the moment. This is the most important skill to learn. We will talk later about
self-care and the ability to replenish and refuel yourself during down times, however for
now, it is important that you begin to develop ways to lower your anxiety while you are
face-to-face with a client.
It can be easily argued that your first intervention in treating traumatized
individuals is with yourself, assuring your own non-anxious presence, before moving on
to interventions with your client.

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Developmental/Traumatic Issues - It is only a matter of time, if it hasn’t happened

already, before a client sits down across from you and begins to describe issues with which
you yourself are dealing. Chances are, you will find it more difficult during these times to
develop and maintain a non-anxious presence. This is not something from which you need
32
to feel shame. It is, however, a wake-up call. For many it means that you will have to
work doubly hard to develop and maintain your non-anxious presence. For others, it means
that you may need to seek further help from your supervisor and/or therapist. These
instances are precisely for what the individual and group meetings of the T-105 practicum
are designed. Please address these difficulties with your supervisor and s/he will help you
design a plan to resolve these issues.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

33
 The Clearness Committee:
An Alternative Method for Group Clinical Supervision

“Each of us has an inner teacher, a voice of truth, that offers the guidance and power we
need to deal with problems”
Parker Palmer
The Courage To Teach

The Clearness Committee is drawn from Palmer’s (1997) book who discovered it from the
Quakers. The Quakers used this technique to help members of their congregation solve
their own problems because they had no clerical leaders. This material has been adapted for
use in clinical supervision with a strong argument towards believing that it is the
development of the “self-of-the-therapist” that is more important than the mastery of
technique.
Below are the directions, rules and anecdotes for the implementation of the Clearness
Committee in a group clinical supervisory setting.

1. The focus clinician seeking supervision or presenting the case writes up his/her case
and send this document to the member prior to the meeting. The write up should
contain three foci:
a. Statement of the problem - In this first area the clinician will want to focus upon the
problems that s/he is having with the case – NOT CLIENT PROBLEMS. This can
range from transference/ countertransference issues to questioning appropriate
interventions to secondary traumatization issues to issues of truth vs. illusion in
treatment.
b. Relevant background – In this area, the clinician will want to discuss previous
experiences, both professional and personal, where this issue has become figural
and caused distress for him.
c. Sought after outcomes – The clinician should identify as clearly as possible the
goals for which she is striving. She should be able to “paint a picture” of how she
would like for the situation to resolve.

2. The meeting begins with the facilitator calling for a time of centering silence and
inviting the focus clinician to break the silence, when ready, with a brief summary of
the issue at hand. Then the committee members may speak—but everything they say
is governed one rule, a simple rule and yet one most people find difficult and
demanding: members are forbidden to speak to the focus clinician in any way except to
ask honest, open questions. This mean absolutely no advice, reflections, suggestions, or
interpretations. It means no “Why don’t you…?” It means no “There’s a
book/therapist/exercise/training that would help you a lot.” Nothing is allowed except
real questions, honest and open questions, questions that will help the focus person
remove the blocks to his or her inner truth without becoming burdened by the personal
agendas of the committee members. I may think that I know the answers to your
problems, and on rare occasions I may be right. But my answer is of absolutely no
value to you. The only answer that counts is the one that arises from your own inner
34
 truth. The discipline of the Clearness Committee is to give you greater access to that
truth—and to keep the rest of us from defiling or trying to define it.

3. What is an honest, open question? It is important to reflect on this, since we are so

skilled at asking questions that are advice or analysis in disguise: “Have you ever
thought that it might be your mother’s fault?” The best single mark of an honest, open
question is that the questioner could not possibly anticipate the answer to it: “did you
ever feel like this before?” There are other guidelines for good questioning. Ask
questions aimed at helping the focus person rather than satisfying your own curiosity.
Ask questions that are brief and to the point rather than larding them background
considerations and rationale—which make the question into a speech. Ask questions
that go to the person as well as the problem—for example, questions about feelings as
well as about facts. Trust your intuition in asking questions, even if your instinct seems
off the wall: “What color is your problem, and what color will it be when it is
resolved.”

4. Normally, the focus person responds to the questions as they are asked, in the presence
of the group, and those responses generate more, and deeper, questions. Though the
responses should be full, they should not be terribly long—resist the temptation to tell
your life story in response to every question! It is important that there be time for more
and more questions and responses, thus deepening the process for everyone. The more a
focus person is willing to answer aloud, the more material the person—and the
committee—will have to work with. But this should never happen at the expense of the
focus person’s need to protect vulnerable feelings or maintain privacy. It is vital that the
focal person assume total power to set the limits of the process. SO everyone must
understand that the focus person at all times has the right not to answer a question. The
unanswered question is not necessarily lost—indeed, it may be the question that is so
important that it keeps working on the focus person long after the committee has
ended.

5. The Clearness Committee must not become a grilling or cross-examination. The pace of
the questioning is crucial—it should be relaxed, gentle and humane. A machine-volley
of questions makes reflection impossible and leaves the focus person attacked rather
than evoked. Do not be afraid of silence in the group—trust and treasure it. If silence
falls, it does not mean that nothing is happening or that the process has broken down. It
may well mean that the most important thing of all is happening: new insights are
emerging from within people, from their deepest source of guidance.

6. From the beginning to the end of the Clearness Committee, it is important that everyone
work hard to remain totally attentive to the focal person and his or her needs. This
means suspending the normal rules of social gathering—no chitchat, no responding to
other people’s questions or the focal person’s answers, no joking to break the tension,
no noisy and nervous laughter. We are simply to surround the focus person with quiet,
loving space, resisting even the temptation to comfort or reassure or encourage this
person, but simply being present with our attention, our questions and our care. If a
committee member damages this ambiance with advice, leading questions, or rapid-fire
inquisition, other members (including the focus person) should remind the offender of
35
 the rules—and the offender is not at liberty to mount a defense or argue the point. The
Clearness Committee is for the sake of the focus person, and the rest of us need to tell
our egos to recede.

7. The Clearness Committee should run for the full time allotted for each focal person.
Don’t end early fearing that the group has “run out of questions”—patient waiting will
be rewarded with deeper questions than have yet been asked. About ten minutes before
the end of the meeting, the facilitator should ask the focus person if s/he wants to
suspend the “questions only” rule and invite members to mirror back what they have
heard the focus person saying. If the focus person says no, the questions continue, but if
s/he says yes, mirroring can begin with more questions. Mirroring does not provide an
excuse to give advice or “fix” the person—that sort of invasiveness is still prohibited.
Mirroring simply means reflecting the focus person’s own language—and body
language—to see if s/he recognized the image. With each mirroring the focus person
should have the opportunity to say, “Yes, that’s me” or “No, that’s not.” In the final
five minutes, the facilitator should invite the participants to celebrate and affirm the
focus person and his/her strengths. This is an important time, since the focus person
has just spent a long time being vulnerable. And there is much to celebrate, for in the
course of the Clearness Committee, people reveal gifts and graces that characterize
human beings at their deepest and best.

8. Remember, the Clearness Committee is not intended to “fix” the focus person, so there
should be no sense of letdown if the focus person does not have his or her problem
“solved” when the process ends. A good clearness process does not end—it keeps
working in the focus person long after the meeting is over. The rest of us need simply
to keep holding that person in the light, trusting the wisdom of his or her inner teacher.

9. The processing of the Clearness Committee is indigenous to the meeting and members
should not confront the focus person once the meeting is over. What is said in the
Clearness Committee stays in the Clearness Committee.

10. In the rare instance where there are ethical and/or legal issues, the Clearness Committee
will continue working with the focus person and it will become the responsibility of the
facilitator to discuss this issue with the focus person immediately following the
meeting.

36
 Intake & Assessment: Pre-Session Ritual

The initial session with the trauma survivor is, in many ways, the most crucial. In the
previous sections we have discussed the importance of non-anxious presence and self-of-
the- helper phenomena. In this first session is where these concepts are made concrete and
put into practice.

Many therapists who have been doing therapy for some time and who could be
considered “successful” by both their clients and their own level of satisfaction with
their work have identified the need to have a pre-session ritual in which they prepare
themselves for the meeting with their client(s). During this ritual some therapists work
on lowering their anxiety to insure a non-anxious presence, others take a moment to
review their goals for the session, while others choose to pray and/or meditate. The
results are similar…a therapist who is prepared and empowered to assist their clients.

So, take a moment to think about how you would like to develop or enhance your pre-
session ritual(s). How can you lower your anxiety to assure a non-anxious presence?
What can you do to empower yourself as a sanctuary and change agent for your client?
What behaviors can you implement that will assist you with these tasks?

My Ritual

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

37
 Intake

It has been said that we will never again see our client as clearly as we do the first time
that we meet them. After we have met out client, the projection process, replete with
transference and countertransference, begins to distort our perceptions of which our
clients really are. If we are our “best selves” while we are doing therapy, then we can
minimize these distortions, however we are never as free from them as we are in the
initial meeting.

It is important that we create an atmosphere of safety, integrity and the capacity for
change for our incoming clients. How can we be intentional in this process? What are
some your ideas about how this can be accomplish?

_________________________________________________________________
_________________________________________________________________

The Greeting - The first opportunity that you have to speak with or meet your client will
be an opportunity to establish this environment. Some things that we have found to be
helpful in this process is to make eye contact, establish a relaxed and attending posture,
shake hands and to welcome the client to the session. Taking care of any physical needs,
such as temperature, location of bathrooms, comfortability of seating and other physical
comforts (i.e., water, tea, etc.) can demonstrate an immediate attendance to your client.

What is your particular style for greeting your clients? Is there anything that you do to
personalize this greeting?

________________________________________________________________
________________________________________________________________

Informed Consent, Therapy Contracts & Limits of Confidentiality - Early in the first
session it is important to inform the client about the expectations and requirements from
him/her while in therapy. It is important to teach them how to be clients. Many people,
especially trauma survivors, come to therapy without having ever been to therapy or,
even more challenging, have had previous unsuccessful experiences in therapy. It is
important to take some time, in an unhurried and non-anxious countenance, to explain
these important aspects to your client. There are several sources that can assist you in
developing your own handouts for clients that further explain these important aspects of
therapy. It is not enough to simply have your client sign an informed consent document,
it must also be discussed. The Paper Office (Zuckerman, 1997) Guilford Press. ISBN 1-
57230-104-X, provides several templates which will allow you to create an informed
consent document, an informational brochure about you and your practice, as well as
other important forms for release of information, billing, etc..
38
 Client Information You Have a Right to Know
When you come for therapy, you are buying a service to meet your individual needs. You
need good information about therapy to make the best choice for yourself and your
family. I have compiled a list of some questions you might want to ask me about how I
do therapy. You may have some questions that are not on this list. I welcome any questions
you may have and I will do my best to answer them for you. If my answers are not clear
or if I have left something out just ask me again. You have the right to full information
about therapy.

A. About Therapy

1. What will we do in therapy?

2. What will I have to do in therapy?
3. Could anything bad happen because of therapy?
4. What will I notice when I am getting better?
5. About how long will it take for me to see that I am getting better?
6. Will I have to take any tests? What for? What kind?
7. How many (that is, what fraction) of your clients with my kind of problem get
better?
8. How many (that is, what fraction) of your clients get worse?
9. How many (that is, what fraction) of people with the same kinds of problems I
have get better without therapy? How many get worse?
10. About how long will therapy take?
11. What should I do if I feel therapy isn't working?

B. About Other Therapy and Help

1. What other types of therapy or help are there for my problems?

2. How often do these other methods help people with problems like mine?
3. What are the risks or limits of these other methods?

C. About Our Appointments

1. How will we set up our appointments?

2. How long will our sessions last? Do I have to pay more for longer ones?
3. How can I reach you in an emergency?
4. If I can't reach you, to whom can I talk?
5. What happens if the weather is bad or I'm sick and can't come to an appointment?

D. About Confidentiality

1. What kinds of records do you keep about my therapy?

2. Who is allowed to read these records?
3. Are there times you have to tell others about the personal things we might talk
about? (LIMITS OF CONFIDENTIALITY)
39
E. About Money

1. What will you charge me for each appointment?

2. When do you want to be paid?
3. Do I need to pay for an appointment if I don't come to it, or if I call you and cancel
it?
4. Do I need to pay for telephone calls to you?
5. Will you ever raise the fee that you charge me? When?
6. If I lose some of my income, can my fee be lowered?
7. If I do not pay my bill, what will you do?

F. Other Matters

1. How much training and experience do you have? Do you have a license? What
are your other qualifications?
2. What kind of morals and values do you have?
3. To whom can I talk if I have a complaint about therapy that you and I can't
work out?

The list above deals with the most commonly asked questions, but many people want to
know more. Feel free to ask me any questions you have at any time. The more you
know, the better our work will go. You can keep the "Information for Clients" brochure
(if given) and this list. Please read them carefully at home, and if any questions come
up, write them on this page so we can talk about them when we meet next time.

These questions can be a helpful guide in establishing an environment of mutual respect

with your clients. You may choose to create a document similar to this to present to
your clients upon intake and ask them which questions they would like answered. Of
course, this will require that you be prepared to answer them. You should always
document discussion on these topics.

What have we missed? What other important ingredients go into the making of a
successful initial meeting? Please take a moment to jot down your thoughts on this.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

40
 Intake & Assessment: Psycho-Traumatology Evaluation

With the completion of the greeting, information for clients, informed consent and the
decision to continue with therapy, it is now time to initiate the evaluation. This is a
multi-step process which utilizes a structured clinical interview format and can include
a combination of self-reports and clinician administered instruments, a mental status
exam, an inventory of symptoms, the criteria for stabilization and recovery, a treatment
plan, goals of treatment and outcome criteria. All of this information becomes
synthesized into one report that we have called The Psycho-traumatology Evaluation
(Tinnin, 1996).

The Psycho-traumatology Evaluation was developed at West Virginia University’s

School of Behavioral Medicine for use in the Psycho-traumatology Intensive Outpatient
Program. This evaluation/assessment process has been established to conform with the
scientist/practitioner model of psychotherapy and, provides a structured clinical interview
with solid diagnostic information and baseline data for outcome measurement. While
some of the measurement instruments have not yet demonstrated empirical statistical
validity, they have great clinical utility.

Step One: Becoming Familiar with the Tools:

➢ Psycho-Traumatology Evaluation - Structured Clinical Interview

➢ Data Summary
➢ Psycho-Traumatology Evaluation Sample
➢ Trauma Profile
➢ Clinician Administered PTSD Scale (CAPS-5)
➢ Clinician-Administered PTSD Scale for Child/Adolescent Version (CAPS-CA-5)
➢ Adolescent Dissociative Experiences Scale-II (A-DES)
➢ Child Dissociative Checklist (CDC), Version 3
➢ Dissociative Experiences Scale (DES-II)
➢ Dissociative Regression Scale (DRS)
➢ Impact of Events Scale – Revised (IES-R)
➢ PTSD Check List – 5 (PCL-5)
➢ Satisfaction With Life Scale (SWLS)

NOTE: Prior to administering any assessment instruments take the time to familiarize
yourself with each one.

41
 The Psycho-Traumatology Evaluation
Structured Clinical Interview

This template is designed to provide the clinician with a “road map” through the
evaluation, session. It is recommended that you allow yourself ample time to collect
pertinent data and address any questions or concerns the client may have. As you progress
in skill and knowledge, you will find this time may fluctuate among clients.

It is helpful to describe to the client this process of assessment and evaluation. Let them
know that you will be asking several questions about their history and the way that they
have adapted and coped with these experiences. It is important to let them know that they
may refuse to answer any question and that, if they should become overwhelmed at any
time, they may stop the evaluation.

This template begins with demographic data. Some of you will have your own or your
agency’s forms to collect this data and will therefore be able to skip this section. It is
included so that you can have all this information on one document.

Helpful Hint
We have found it helpful, whenever possible, to give the self-report instruments to the
client before this session so that they are completed when you meet with the client. This
will allow you to refer to them for helpful information.

The evaluator should begin with questions targeting the level of distress and discomfort the
client is experiencing in the present. Asking them the simple question, “What is going on
with you that brings you to therapy now?” While it may seem insignificant, it is important
to determine what occurred that caused the client to seek therapy.

This question should be followed by a thorough and exhaustive discussion of the current
symptoms that the client is experiencing. The evaluator will begin to get a sense of the
intensity, frequency, and duration of the client’s posttraumatic and other symptoms from
these early questions. Exploring these parameters of the client’s symptoms will also help
the clinician to begin to explore appropriate treatment(s) (i.e., are the symptoms this client
is experiencing from one single traumatic experience or are they from multiple exposure to
traumatic events. How volatile is this client? Will s/he need extensive work toward
stabilization?).

After a reasonably thorough history, including discussion of all traumatic experiences, the
clinician should make an effort to “normalize” the client’s symptoms as normal adaptive
responses of a typical person to an unexpected negative and overwhelming experiences. It
is helpful here to provide a brief psychoeducational overview of how trauma and traumatic
stress affects the brain and personality of the survivor.
42
This is followed by a review of the client’s medical history. The client should be asked to
discuss all previous psychiatric treatment (including previous psychotherapy). This will
allow the clinician to discuss with the client the positive and negative experiences of
previous therapy to glean some understanding of what types and styles of treatment have
worked best with this client. It will also potentially help the clinician to avoid the mistakes
made by previous therapists. Current medical issues relevant to the traumatic experience
should be recorded. Also, the clinician should inquire into the current medication that has
been prescribed for the client and how regularly that they take this medication. If the client
is currently being treated by a physician and is prescribed psychotropic medication, then
the clinician should record these medications and dosage.

The client should be asked if s/he is using other substances, such as street drugs and
alcohol, to cope with the response to the traumatic event. The clinician should also secure a
release of information from the client so that s/he can contact the physician to inform
him/her that the client is seeing you for psychotherapy. It is important to cultivate strong
professional relationships with the client’s attending physician and move towards a multi-
disciplinary team approach to treatment in which you keep the physician apprised of
progress in the client’s care.

A section on Family History has been included in the Psycho-traumatology Evaluation.

The completion of this section is optional but provides important information for the
clinician about the client’s family-of-origin. Much of the work towards the end of therapy
will probably focus around these developmental issues and, for many clients, will become
relevant even before then. It is important for clients to begin to understand how their
resiliency to trauma was enhanced or diminished as a result of their family dynamics.
Interventions that interpret these dynamics can serve as a powerful tool towards the
resolution of shame and other cognitive distortions.

Trauma Profile

Symptom Check List allows you to inventory the posttraumatic symptoms that your client
is experiencing. This section provides you with the source of this data. This will allow you
to make your diagnoses with confidence as well as identify what problems you and the
client will want to address in treatment. The following clusters of symptoms should be
explored and addressed in our report:
 Intrusive Symptoms
 Avoidance Symptoms
 Arousal Symptoms
 Dissociative Symptoms
 Depressive Symptoms
 Other Symptoms.

Mental Status Exam provides a checklist style template for completing a mini-mental
status examination.This is a good way to document having explored suicide/homicide
ideation as well as substance abuse with your client.

43
Client Strengths/Resources is as much an intervention as it is evaluation. For this
portion of the evaluation the clinician should ask the client to inventory his/her
strengths and resources. Do not allow the client to discuss weakness or shortcomings,
keep them focused upon their strengths. When they have exhausted their supply, the
clinician may ask, “Do you mind if I add a few others to that list?” From here the
clinician can fill in other strengths for which the client is blind that the clinician
discovered during the evaluation thus far.

Expectations/Goals of Treatment Some therapists asks their clients “How will you
know when you are ready to fire me?” This is a playful, tongue-in-cheek way to elicit
from clients their desired outcomes from therapy. It is important that these goals be
communicated in positive terms (i.e., don’t accept “get rid of trauma” or “make it stop”
instead ask the client “What would you have if you ‘got rid of the trauma?’”) Make sure
that you reasonable, specific, and measurable goals (i.e., “How will you know that you
‘have a life?”). The goal of establishing goals with the client is for you and the client to
align your intentions toward a mutually agreed upon destination. By doing this you will
have moved closer the development of a strong therapeutic alliance.

Diagnosis is not the purpose of this training. This is a skill that requires much practice.
However, you have all you need to be able to propose the diagnosis of PTSD, provided
that the client meets the criteria (described in the Diagnostic Worksheet section of the
CAPS-5). You will need to use the DSM-V to provide differential and/or secondary
diagnoses on Axis I. Some of the more common ones include: Major Depressive
Disorder, Bipolar Disorder, Unspecified Dissociative Disorder, Substance-related
Disorders, Persistent Depressive Disorder (Dysthymia). Common differential diagnoses
with children include: Attention Deficit Hyperactivity Disorder, Conduct Disorder,
Oppositional Defiant Disorder, Reactive Attachment Disorder, and Separation Anxiety
Disorder

Preliminary Treatment Plan. This section should contain the Criteria for Stabilization,
the Criteria for Resolution as well as a comprehensive and circumspective treatment plan
complete with projected number of sessions and prognosis.

44
 Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)
Clinician Online Training

Date Created: 01/23/2017

Time to Complete: 4.5 hours

Credits: APA, ASWB, Other Orgs

Skill Level: Advanced

Author(s): Brian P. Marx, PhD, Michelle Bovin, PhD, & Patricia Watson, PhD

To register for training follow this link: https://www.train.org/vha/course/1068095/

This course provides instruction on administration and scoring of the CAPS-5, which has
been updated to correlate with DSM-5 diagnostic criteria for PTSD. The course is
interactive, and includes video of experts conducting assessments, providing tips and
sharing advanced interview skills for using the CAPS-5 in complex and challenging
clinical situations.
This training is a collaborative project developed by the National Center for PTSD and the
Center for Deployment Psychology.

Special Access Information for Non-VA Users

Access to this course is restricted to individuals with at least a master's degree in a clinical
discipline, or with research credentials. Non-VA users must
email ncptsd.assessment@va.gov to request a code to access the course in TRAIN. We will
respond within three business days.

Goals and Objectives

 Describe current and full diagnostic criteria for PTSD according to DSM-5.
 Describe purpose, benefits and key features of CAPS-5.
 Describe how to orient a client to the CAPS interview and assess for trauma
exposure.
 Identify interview principles required for administering the CAPS-5.
 Describe symptom ratings used in the CAPS-5.
 Identify techniques for addressing discrepancies and response bias in respondent
answers during CAPS-5 interview.
 Recognize potential co-occurring conditions that may accompany or share PTSD
symptoms.
45
 CLINICIAN-ADMINISTERED PTSD SCALE FOR DSM-5
Past Month Version
(Weathers, Blake, Schnurr, Kaloupek, Marx, & Keane, 2015)

Administration:

1. Identify an index traumatic event to serve as the basis for symptom inquiry. Administer the
Life Events Checklist and Criterion A inquiry provided on p. 5, or use some other structured,
evidence-based method. The index event may involve either a single incident (e.g., “the
accident”) or multiple, closely related incidents (e.g., “the worst parts of your combat
experiences”).
2. Read prompts verbatim, one at a time, and in the order presented, EXCEPT:
a. Use the respondent’s own words for labeling the index event or describing specific
symptoms.
b. Rephrase standard prompts to acknowledge previously reported information, but return
to verbatim phrasing as soon as possible. For example, inquiry for item 20 might begin:
“You already mentioned having problem sleeping. What kinds of problems?”
c. If you don’t have sufficient information after exhausting all standard prompts, follow up
ad lib. In this situation, repeating the initial prompt often helps refocus the respondent.
d. As needed, ask for specific examples or direct the respondent to elaborate even when such
prompts are not provided explicitly.
3. In general, DO NOT suggest responses. If a respondent has pronounced difficulty
understanding a prompt it may be necessary to offer a brief example to clarify and illustrate.
However, this should be done rarely and only after the respondent has been given ample
opportunity to answer spontaneously.
4. DO NOT read rating scale anchors to the respondent. They are intended only for you, the
interviewer, because appropriate use requires clinical judgment and a thorough
understanding of CAPS-5 scoring conventions.
5. Move through the interview as efficiently as possible to minimize respondent burden. Some
useful strategies:
a. Be thoroughly familiar with the CAPS-5 so that prompts flow smoothly.

b. Ask the fewest number of prompts needed to obtain sufficient information to support a
valid rating.

c. Minimize note-taking and write while the respondent is talking to avoid long pauses.

d. Take charge of the interview. Be respectful, but firm in keeping the respondent on task,
transitioning between questions, pressing for examples, or pointing out contradictions.
46
Scoring:

1. As with previous versions of the CAPS, CAPS-5 symptom severity ratings are based on
symptom frequency and intensity, except for items 8 (amnesia) and 12 (diminished interest),
which are based on amount and intensity. However, CAPS-5 items are rated with a single
severity score, in contrast to previous versions of the CAPS which required separate frequency
and intensity scores for each item that were either summed to create a symptom severity
score or combined in various scoring rules to create a dichotomous (present/absent) symptom
score. Thus, on the CAPS-5 the clinician combines information about frequency and intensity
before making a single severity rating. Depending on the item, frequency is rated as either
the number of occurrences (how often in the past month) or percent of time (how much of
the time in the past month). Intensity is rated on a four-point ordinal scale with ratings of
Minimal, Clearly Present, Pronounced, and Extreme. Intensity and severity are related but
distinct. Intensity refers to the strength of a typical occurrence of a symptom. Severity refers
to the total symptom load over a given time period, and is a combination of intensity and
frequency. This is similar to the quantity/frequency assessment approach to alcohol
consumption. In general, intensity rating anchors correspond to severity scale anchors
described below and should be interpreted and used in the same way, except that severity
ratings require joint consideration of intensity and frequency. Thus, before taking frequency
into account, an intensity rating of Minimal corresponds to a severity rating of Mild /
subthreshold, Clearly Present corresponds with Moderate/ threshold, Pronounced corresponds
with Severe / markedly elevated, and Extreme corresponds with Extreme /incapacitating.
2. The five-point CAPS-5 symptom severity rating scale is used for all symptoms. Rating scale
anchors should be interpreted and used as follows:
0 Absent The respondent denied the problem or the respondent’s report doesn’t fit the
DSM-5 symptom criterion.
1 Mild / subthreshold The respondent described a problem that is consistent with the
symptom criterion but isn’t severe enough to be considered clinically significant. The
problem doesn’t satisfy the DSM-5 symptom criterion and thus doesn’t count toward a
PTSD diagnosis.
2 Moderate / threshold The respondent described a clinically significant problem. The
problem satisfies the DSM-
5 symptom criterion and thus counts toward a PTSD diagnosis. The problem would be a
target for intervention. This rating requires a minimum frequency of 2 X month or some of
the time (20-30%) PLUS a minimum intensity of Clearly Present.
3 Severe / markedly elevated The respondent described a problem that is well above
threshold. The problem is difficult to manage and at times overwhelming, and would be a
prominent target for intervention. This rating requires a minimum frequency of 2 X week
or much of the time (50-60%) PLUS a minimum intensity of Pronounced.
4 Extreme / incapacitating The respondent described a dramatic symptom, far above
threshold. The problem is pervasive, unmanageable, and overwhelming, and would be a
high-priority target for intervention.

47
3. In general, make a given severity rating only if the minimum frequency and intensity for that
rating are both met. However, you may exercise clinical judgment in making a given severity
rating if the reported frequency is somewhat lower than required, but the intensity is higher.
For example, you may make a severity rating of Moderate / threshold if a symptom occurs 1 X
month (instead of the required 2 X month) as long as intensity is rated Pronounced or Extreme
(instead of the required Clearly Present). Similarly, you may make a severity rating of Severe /
markedly elevated if a symptom occurs 1 X week (instead of the required 2 X week) as long as
the intensity is rated Extreme (instead of the required Pronounced). If you are unable to decide
between two severity ratings, make the lower rating.
4. You need to establish that a symptom not only meets the DSM-5 criterion
phenomenologically, but is also functionally related to the index traumatic event, i.e., started
or got worse as a result of the event. CAPS-5 items 1-8 and 10 (reexperiencing, effortful
avoidance, amnesia, and blame) are inherently linked to the event. Evaluate the remaining
items for trauma-relatedness (TR) using the TR inquiry and rating scale. The three TR ratings
are:
a. Definite = the symptom can clearly be attributed to the index trauma, because (1) there is
an obvious change from the pre-trauma level of functioning and/or (2) the respondent
makes the attribution to the index trauma with confidence.
b. Probable = the symptom is likely related to the index trauma, but an unequivocal
connection can’t be made. Situations in which this rating would be given include the
following: (1) there seems to be a change from the pre-trauma level of functioning, but it
isn’t as clear and explicit as it would be for a Definite; (2) the respondent attributes a
causal link between the symptom and the index trauma, but with less confidence than for
a rating of Definite; (3) there appears to be a functional relationship between the
symptom and inherently trauma-linked symptoms such as reexperiencing symptoms
(e.g., numbing or withdrawal increases when reexperiencing increases).
c. Unlikely = the symptom can be attributed to a cause other than the index trauma because
(1) there is an obvious functional link with this other cause and/or (2) the respondent
makes a confident attribution to this other cause and denies a link to the index trauma.
Because it can be difficult to rule out a functional link between a symptom and the index
trauma, a rating of Unlikely should be used only when the available evidence strongly
points to a cause other than the index trauma. NOTE: Symptoms with a TR rating of
Unlikely should not be counted toward a PTSD diagnosis or included in the total CAPS-5
symptom severity score.
5. CAPS-5 total symptom severity score is calculated by summing severity scores for items 1-
20. NOTE: Severity scores for the two dissociation items (29 and 30) should NOT be included
in the calculation of the total CAPS-5 severity score.
6. CAPS-5 symptom cluster severity scores are calculated by summing the individual item
severity scores for symptoms contained in a given DSM-5 cluster. Thus, the Criterion B
(reexperiencing) severity score is the sum of the individual severity scores for items 1-5; the
Criterion C (avoidance) severity score is the sum of items 6 and 7; the Criterion D (negative
alterations in cognitions and mood) severity score is the sum of items 8-14; and the Criterion
E (hyperarousal) severity score is the sum of items 15-20. A symptom cluster score may also be
calculated for dissociation by summing items 29 and 30.
48
7. PTSD diagnostic status is determined by first dichotomizing individual symptoms as Present
or Absent, then following the DSM-5 diagnostic rule. A symptom is considered present only if
the corresponding item severity score is rated 2=Moderate / threshold or higher. Items 9 and
11-20 have the additional requirement of a trauma- relatedness rating of Definite or Probable.
Otherwise a symptom is considered absent. The DSM-5 diagnostic rule requires the presence of
least one Criterion B symptom, one Criterion C symptom, two Criterion D symptoms, and
two Criterion E symptoms. In addition, Criteria F and G must be met. Criterion F requires that
the disturbance has lasted at least one month. Criterion G requires that the disturbance cause
either clinically significant distress or functional impairment, as indicated by a rating of
2=Moderate or higher on items 23-25.

49
 CLINICIAN-ADMINISTERED PTSD SCALE FOR DSM-5
Past Month Version
Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2015)

Name: ____________________________________
Interviewer: ________________________________
Study: __________________________________:
ID#: ______________________________________
Date: ______________________________________________

Instructions:

Standard administration and scoring of the CAPS-5 are essential for producing reliable and valid
scores and diagnostic decisions. The CAPS-5 should be administered only by qualified
interviewers who have formal training in structured clinical interviewing and differential
diagnosis, a thorough understanding of the conceptual basis of PTSD and its various symptoms,
and detailed knowledge of the features and conventions of the CAPS-5 itself.

50
 Criterion A:
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened
death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting
human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to
exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

[Administer Life Events Checklist or other structured trauma screen]

I’m going to ask you about the stressful experiences questionnaire you filled out. First I’ll ask you to tell me a little bit
about the event you said was the worst for you. Then I’ll ask how that event may have affected you over the past
month. In general I don’t need a lot of information – just enough so I can understand any problems you may have had.
Please let me know if you find yourself becoming upset as we go through
the questions so we can slow down and talk about it. Also, let me know if you have any questions or don’t
understand something. Do you have any questions before we start?

The event you said was the worst was (EVENT). What I’d like for you to do is briefly describe what happened.

Index event (specify):

What happened? (How old were you? How were you involved? Who else was Exposure type:
involved? Was anyone seriously injured or killed? Was anyone’s life in danger?
How many times did this happen?) Experienced
Witnessed
Learned about
Exposed to aversive details

Life threat?
NO YES (self other )

Serious injury?
NO YES (self other )

Sexual violence?
NO YES (self other )

Criterion A met?
NO PROBABLE YES

For the rest of the interview, I want you to keep (EVENT) in mind as I ask you about different problems
it may have caused you. You may have had some of these problems before, but for this interview
we’re going to focus just on the past month. For each problem I’ll ask if you’ve had it in the past
month, and if so, how often and how much it bothered you.

51
 Criterion B:
Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:

Item 1 (B1): Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6
years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

In the past month, have you had any unwanted memories of (EVENT) while 0 Absent
you were awake, so not counting dreams? (Rate 0=Absent if only during dreams)
1 Mild / subthreshold
How does it happen that you start remembering (EVENT)?
2 Moderate / threshold
[If not clear:] (Are these unwanted memories, or are you thinking about
(EVENT) on purpose?) (Rate 0=Absent unless perceived as involuntary and 3 Severe / markedly elevated
intrusive)
4 Extreme / incapacitating
How much do these memories bother you?
Key rating dimensions =
Are you able to put them out of your mind and think about something else? frequency / intensity of distress
[If not clear:] (Overall, how much of a problem is this for you? How so?) Moderate = at least 2 X month
/ distress clearly present,
some difficulty dismissing
memories
Circle: Distress = Minimal Clearly Present Pronounced Extreme Severe = at least 2 X week /
pronounced distress,
How often have you had these memories in the past month? considerable difficulty
# of times dismissing memories

Item 2 (B2): Recurrent distressing dreams in which the content and/or affect of the dream are related to the
event(s). Note: In children, there may be frightening dreams without recognizable content.

In the past month, have you had any unpleasant dreams about (EVENT)? 0 Absent

Describe a typical dream. (What happens?) 1 Mild / subthreshold

[If not clear:] (Do they wake you up?) 2 Moderate / threshold
[If yes:] (What do you experience when you wake up? How long does it take you 3 Severe / markedly elevated
to get back to sleep?)
4 Extreme / incapacitating
[If reports not returning to sleep:] (How much sleep do you lose?)

How much do these dreams bother you? Key rating dimensions =

frequency / intensity of distress
Moderate = at least 2 X month /
Circle: Distress = Minimal Clearly Present Pronounced Extreme distress clearly present, less than
1 hour sleep loss
How often have you had these dreams in the past month? # of times Severe = at least 2 X week /
pronounced distress, more
than 1 hour sleep loss

52
Item 3 (B3): Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic
event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being
a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may
occur in play.

In the past month, have there been times when you suddenly acted or felt as if 0 Absent
(EVENT) were actually happening again?
1 Mild / subthreshold
[If not clear:] (This is different than thinking about it or dreaming about it – now
I’m asking about flashbacks, when you feel like you’re actually back at the time 2 Moderate / threshold
of (EVENT), actually reliving it.)
3 Severe / markedly elevated
How much does it seem as if (EVENT) were happening again? (Are you
4 Extreme / incapacitating
confused about where you actually are?)

What do you do while this is happening? (Do other people notice your Key rating dimensions
behavior? What do they say?) = frequency /
intensity of
How long does it last? dissociation
Moderate = at least 2 X month
Circle: Dissociation = Minimal Clearly Present Pronounced Extreme / dissociative quality clearly
present, may retain some
How often has this happened in the past month? # of times awareness of surroundings
but relives event in a manner
clearly distinct from
thoughts and memories
Severe = at least 2 X week /
pronounced dissociative
quality, reports vivid reliving,
e.g., with images, sounds,
smells

Item 4 (B4): Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).

0 Absent
In the past month, have you gotten emotionally upset when something
reminded you of (EVENT)? 1 Mild / subthreshold

What kinds of reminders make you upset? How 2 Moderate / threshold

much do these reminders bother you? 3 Severe / markedly elevated

Are you able to calm yourself down when this happens? (How long does it take?) 4 Extreme / incapacitating

[If not clear:] (Overall, how much of a problem is this for you? How so?)
Key rating dimensions =
frequency / intensity of distress
Moderate = at least 2 X month
Circle: Distress = Minimal Clearly Present Pronounced Extreme
/ distress clearly present,
some difficulty recovering
How often has this happened in the past month? # of times
Severe = at least 2 X week /
pronounced distress,
considerable difficulty
recovering

53
Item 5 (B5): Marked physiological reactions to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).

In the past month, have you had any physical reactions when something 0 Absent
reminded you of (EVENT)?
1 Mild / subthreshold
Can you give me some examples? (Does your heart race or your breathing
change? What about sweating or feeling really tense or shaky?) 2 Moderate / threshold

What kinds of reminders trigger these reactions? How 3 Severe / markedly elevated

long does it take you to recover? 4 Extreme / incapacitating

Key rating dimensions

Circle: Physiological reactivity =
How often has this happened in the past month? # of times
Minimal Clearly Present Pronounced Extreme = frequency /
intensity of
physiological arousal
Moderate = at least 2 X month
/ reactivity clearly present,
some difficulty recovering
Severe = at least 2 X week /
pronounced reactivity,
sustained arousal,
considerable difficulty
recovering

Criterion C:
Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic
event(s) occurred, as evidenced by one or both of the following:

Item 6 (C1): Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

In the past month, have you tried to avoid thoughts or feelings about 0 Absent
(EVENT)?
1 Mild / subthreshold
What kinds of thoughts or feelings do you avoid?
2 Moderate / threshold
How hard do you try to avoid these thoughts or feelings? (What kinds of things
do you do?) 3 Severe / markedly elevated

[If not clear:] (Overall, how much of a problem is this for you? How would things 4 Extreme / incapacitating
be different if you didn’t have to avoid these thoughts or feelings?)
Key rating dimensions
= frequency /
intensity of
Circle: Avoidance = Minimal Clearly Present Pronounced Extreme avoidance
How often in the past month? # of times Moderate = at least 2 X month /
avoidance clearly present
Severe = at least 2 X week /
pronounced avoidance

54
Item 7 (C2): Avoidance of or efforts to avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

In the past month, have you tried to avoid things that remind you of 0 Absent
(EVENT), like certain people, places, or situations? What
1 Mild / subthreshold
kinds of things do you avoid?
2 Moderate / threshold
How much effort do you make to avoid these reminders? (Do you have to make a
plan or change your activities to avoid them?) 3 Severe / markedly elevated

[If not clear:] (Overall, how much of a problem is this for you? How would 4 Extreme / incapacitating
things be different if you didn’t have to avoid these reminders?)
Key rating dimensions
= frequency /
intensity of
Circle: Avoidance = Minimal Clearly Present Pronounced Extreme avoidance

How often in the past month? # of times Moderate = at least 2 X month /

avoidance clearly present
Severe = at least 2 X week /
pronounced avoidance

Criterion D:
Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

Item 8 (D1): Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

In the past month, have you had difficulty remembering some important 0 Absent
parts of (EVENT)? (Do you feel there are gaps in your memory of (EVENT)?)
1 Mild / subthreshold
What parts have you had difficulty remembering?

Do you feel you should be able to remember these things?

2 Moderate / threshold

[If not clear:] (Why do you think you can’t? Did you have a head injury during 3 Severe / markedly elevated
(EVENT)? Were you knocked unconscious? Were you intoxicated from alcohol or
drugs?) (Rate 0=Absent if due to head injury or loss of consciousness or intoxication 4 Extreme / incapacitating
during event)
Key rating dimensions = amount
[If still not clear:] (Is this just normal forgetting? Or do you think you may have of event not recalled / intensity
blocked it out because it would be too painful to remember?) (Rate of inability to recall
0=Absent if due only to normal forgetting) Moderate = at least one
important aspect / difficulty
Circle: Difficulty remembering = Minimal Clearly Present Pronounced Extreme remembering clearly present,
some recall possible with effort
In the past month, how many of the important parts of (EVENT) have you had
difficulty remembering? (What parts do you still remember?) Severe = several important
aspects / pronounced difficulty
# of important aspects remembering, little recall even
with effort.
Would you be able to recall these things if you tried?

55
Item 9 (D2): Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
(e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,”“My whole nervous system is
permanently ruined”).

In the past month, have you had strong negative beliefs about yourself, other 0 Absent
people, or the world?
1 Mild / subthreshold
Can you give me some examples? (What about believing things like “I am bad,” “there is
something seriously wrong with me,” “no one can be trusted,” “the world is completely 2 Moderate / threshold
dangerous”?)
3 Severe / markedly elevated
How strong are these beliefs? (How convinced are you that these beliefs are actually
4 Extreme / incapacitating
true? Can you see other ways of thinking about it?)
Key rating dimensions =
frequency / intensity of beliefs
Circle: Conviction = Minimal Clearly Present Pronounced
Extreme Moderate = some of the time
(20-30%) / exaggerated
How much of the time in the past month have you felt that way, as a negative expectations clearly
present, some difficulty
percentage? % of time considering more realistic
beliefs
Did these beliefs start or get worse after (EVENT)? (Do you think they’re related to
(EVENT)? How so?) Severe = much of the time (50-
60%) / pronounced
Circle: Trauma-relatedness = Definite Probable Unlikely exaggerated negative
expectations, considerable
difficulty considering more
realistic beliefs

Item 10 (D3): Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that
lead the individual to blame himself/herself or others.

In the past month, have you blamed yourself for (EVENT) or what happened as a
result of it? Tell me more about that. (In what sense do you see yourself as having 0 Absent
caused (EVENT)? Is it because of something you did? Or something you think you should
have done but didn’t? Is it because of something about you in general?) 1 Mild / subthreshold

What about blaming someone else for (EVENT) or what happened as a result 2 Moderate / threshold
of it? Tell me more about that. (In what sense do you see (OTHERS) as having caused
(EVENT)? Is it because of something they did? Or something you think they should have 3 Severe / markedly elevated
done but didn’t?)
4 Extreme / incapacitating
How much do you blame (YOURSELF OR OTHERS)?
Key rating dimensions =
How convinced are you that (YOU OR OTHERS) are truly to blame for what frequency / intensity of blame
happened? (Do other people agree with you? Can you see other ways of thinking about
it?) Moderate = some of the time
(20-30%) / distorted blame
(Rate 0=Absent if only blames perpetrator, i.e., someone who deliberately caused the clearly present, some
difficulty considering more
event and intended harm) realistic beliefs
Severe = much of the time (50-
60%) / pronounced distorted
Circle: Conviction = Minimal Clearly Present Pronounced Extreme blame, considerable difficulty
considering more realistic
How much of the time in the past month have you felt that way, as a beliefs
percentage? % of time

56
Item 11 (D4): Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

In the past month, have you had any strong negative feelings such as fear, horror, 0 Absent
anger, guilt, or shame?
1 Mild / subthreshold
Can you give me some examples? (What negative feelings do you experience?)
2 Moderate / threshold
How strong are these negative feelings?
3 Severe / markedly elevated
How well are you able to manage them?
4 Extreme / incapacitating
[If not clear:] (Overall, how much of a problem is this for you? How so?)
Key rating dimensions =
Circle: Negative emotions = Minimal Clearly Present Pronounced Extreme frequency / intensity of
negative emotions
How much of the time in the past month have you felt that way, as a
Moderate = some of the time
percentage? % of time
(20-30%) / negative emotions
Did these negative feelings start or get worse after (EVENT)? (Do you think they’re clearly present, some difficulty
related to (EVENT)? How so?) managing
Circle: Trauma-relatedness = Definite Probable Unlikely Severe = much of the time
(50-60%) / pronounced
negative emotions,
considerable difficulty
managing

Item 12 (D5): Markedly diminished interest or participation in significant activities.

In the past month, have you been less interested in activities that you used 0 Absent
to enjoy?
1 Mild / subthreshold
What kinds of things have you lost interest in or don’t do as much as you used
to? (Anything else?) 2 Moderate / threshold

Why is that? (Rate 0=Absent if diminished participation is due to lack of 3 Severe / markedly elevated
opportunity, physical inability, or developmentally appropriate change in 4 Extreme / incapacitating
preferred activities)

How strong is your loss of interest? (Would you still enjoy (ACTIVITIES) once you got Key rating dimensions =
percent of activities affected
started?) / intensity of loss of interest
Moderate = some activities
Circle: Loss of interest = Minimal Clearly Present Pronounced Extreme (20-30%) / loss of interest
clearly present but still has
Overall, in the past month, how many of your usual activities have you been some enjoyment of
less interested in, as a percentage? % of activities activities
What kinds of things do you still enjoy doing? Severe = many activities
(50-60%)
Did this loss of interest start or get worse after (EVENT)? (Do you think it’s related / pronounced loss of
to (EVENT)? How so?) interest, little interest or
Circle: Trauma-relatedness = Definite Probable Unlikely participation in activities

57
Item 13 (D6): Feelings of detachment or estrangement from others.

In the past month, have you felt distant or cut off from other people? Tell 0 Absent

me more about that. 1 Mild / subthreshold

How strong are your feelings of being distant or cut off from others? (Who do you 2 Moderate / threshold
feel closest to? How many people do you feel comfortable talking with about personal
things?) 3 Severe / markedly elevated

4 Extreme / incapacitating

Circle: Detachment or estrangement = Key rating dimensions =

Minimal Clearly Present Pronounced Extreme frequency / intensity of
detachment or
How much of the time in the past month have you felt that way, as a estrangement
percentage? % of time
Moderate = some of the time
Did this feeling of being distant or cut off start or get worse after (20-30%) / feelings of
(EVENT)? (Do you think it’s related to (EVENT)? How so?) detachment clearly present
but still feels some
Circle: Trauma-relatedness = Definite Probable Unlikely interpersonal connection
Severe = much of the time (50-
60%) / pronounced feelings of
detachment or estrangement
from most people, may feel
close to only one or two
people

Item 14 (D7): Persistent inability to experience positive emotions (e.g., inability to experience happiness,
satisfaction, or loving feelings).

In the past month, have there been times when you had difficulty 0 Absent
experiencing positive feelings like love or happiness?
1 Mild / subthreshold
Tell me more about that. (What feelings are difficult to experience?)
2 Moderate / threshold
How much difficulty do you have experiencing positive feelings? (Are you still
able to experience any positive feelings?) 3 Severe / markedly elevated

4 Extreme / incapacitating

Circle: Reduction of positive emotions = Key rating dimensions =

Minimal Clearly Present Pronounced Extreme frequency / intensity of
reduction in positive
How much of the time in the past month have you felt that way, as a emotions
percentage? % of time
Moderate = some of the
time (20-30%) / reduction
Did this trouble experiencing positive feelings start or get worse after of positive emotional
(EVENT)? (Do you think it’s related to (EVENT)? How so?) experience clearly present
but still able
Circle: Trauma-relatedness = Definite Probable Unlikely to experience some
positive emotions
Severe = much of the time (50-
60%) / pronounced
reduction of experience
across range of positive
emotions

58
 Criterion E:
Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

Item 15 (E1): Irritable behavior and angry outbursts (with little or no provocation) typically expressed as
verbal or physical aggression toward people or objects.

In the past month, have there been times when you felt especially 0 Absent
irritable or angry and showed it in your behavior?
1 Mild / subthreshold
Can you give me some examples? (How do you show it? Do you raise your voice or yell?
Throw or hit things? Push or hit other people?) 2 Moderate / threshold

3 Severe / markedly elevated

Circle: Aggression = Minimal Clearly Present Pronounced Extreme
4 Extreme / incapacitating
How often in the past month? # of times
Key rating dimensions
Did this behavior start or get worse after (EVENT)? (Do you think it’s related to = frequency /
(EVENT)? How so?) Circle: Trauma-relatedness = Definite Probable Unlikely intensity of
aggressive behavior
Moderate = at least 2 X month
/ aggression clearly
present, primarily verbal
Severe = at least 2 X week /
pronounced aggression, at
least some physical
aggression

Item 16 (E2): Reckless or self-destructive behavior.

In the past month, have there been times when you were taking more risks or 0 Absent
doing things that might have caused you harm?
1 Mild / subthreshold
Can you give me some examples?
2 Moderate / threshold
How much of a risk do you take? (How dangerous are these behaviors? Were you
injured or harmed in some way?) 3 Severe / markedly elevated

4 Extreme / incapacitating

Circle: Risk = Minimal Clearly Present Pronounced Extreme

Key rating dimensions =
How often have you taken these kinds of risks in the past month? frequency / degree of risk
# of times Moderate = at least 2 X month
/ risk clearly present, may
Did this behavior start or get worse after (EVENT)? (Do you think it’s related to have been harmed
(EVENT)? How so?)
Severe = at least 2 X week /
pronounced risk, actual harm
Circle: Trauma-relatedness = Definite Probable Unlikely or high probability of harm

59
Item 17 (E3): Hypervigilance.

In the past month, have you been especially alert or watchful, even when there 0 Absent
was no specific threat or danger? (Have you felt as if you had to be on guard?)
1 Mild / subthreshold
Can you give me some examples? (What kinds of things do you do when you’re alert or
watchful?) 2 Moderate / threshold

[If not clear:] (What causes you to react this way? Do you feel like you’re in danger 3 Severe / markedly elevated
or threatened in some way? Do you feel that way more than most people would
4 Extreme / incapacitating
in the same situation?)

Key rating dimensions

= frequency /
intensity of
Circle: Hypervigilance = Minimal Clearly Present Pronounced Extreme hypervigilance

How much of the time in the past month have you felt that way, as a Moderate = some of the time
percentage? % of time (20-30%) / hypervigilance
clearly present, e.g., watchful
Did being especially alert or watchful start or get worse after (EVENT)? in public, heightened
awareness of threat
(Do you think it’s related to (EVENT)? How so?)
Severe = much of the time
Circle: Trauma-relatedness = Definite Probable Unlikely (50-60%) / pronounced
hypervigilance, e.g., scans
environment for danger, may
have safety rituals,
exaggerated concern for
safety of self/family/ home

Item 18 (E4): Exaggerated startle response.

In the past month, have you had any strong startle reactions? What 0 Absent

kinds of things made you startle? 1 Mild / subthreshold

How strong are these startle reactions? (How strong are they compared to how most 2 Moderate / threshold
people would respond? Do you do anything other people would notice?)
3 Severe / markedly elevated
How long does it take you to recover?
4 Extreme / incapacitating

Circle: Startle = Minimal Clearly Present Pronounced Extreme Key rating dimensions =
frequency / intensity of startle
How often has this happened in the past month? # of times
Moderate = at least 2 X month
Did these startle reactions start or get worse after (EVENT)? (Do you think it’s / startle clearly present,
related to (EVENT)? How so?) some difficulty
recovering
Circle: Trauma-relatedness = Definite Probable Unlikely
Severe = at least 2 X week /
pronounced startle,
sustained arousal,
considerable difficulty
recovering

60
Item 19 (E5): Problems with concentration.

In the past month, have you had any problems with concentration? Can 0 Absent

you give me some examples? 1 Mild / subthreshold

Are you able to concentrate if you really try? 2 Moderate / threshold
[If not clear:] (Overall, how much of a problem is this for you? How would 3 Severe / markedly elevated
things be different if you didn’t have problems with concentration?)
4 Extreme / incapacitating

Circle: Problem concentrating = Minimal Clearly Present Pronounced Extreme Key rating dimensions
= frequency /
How much of the time in the past month have you had problems with intensity of
concentration
concentration, as a percentage? % of time problems
Did these problems with concentration start or get worse after (EVENT)? Moderate = some of the time
(Do you think they’re related to (EVENT)? How so?) (20-30%) / problem
Circle: Trauma-relatedness = Definite Probable Unlikely concentrating clearly present,
some difficulty
but can concentrate with effort
Severe = much of the time
(50-60%) / pronounced
problem concentrating,
considerable difficulty even
with effort

Item 20 (E6): Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

In the past month, have you had any problems falling or staying asleep? 0 Absent

What kinds of problems? (How long does it take you to fall asleep? How often do you 1 Mild / subthreshold
wake up in the night? Do you wake up earlier than you want to?)
2 Moderate / threshold
How many total hours do you sleep each night?
3 Severe / markedly elevated
How many hours do you think you should be sleeping?
4 Extreme / incapacitating

Key rating dimensions =

Circle: Problem sleeping = Minimal Clearly Present Pronounced Extreme frequency / intensity of
sleep problems
How often in the past month have you had these sleep problems?
# of times Moderate = at least 2 X
month / sleep disturbance
Did these sleep problems start or get worse after (EVENT)? (Do you think they’re clearly present, clearly longer
related to (EVENT)? How so?) latency or clear difficulty
staying asleep, 30-90 minutes
Circle: Trauma-relatedness = Definite Probable Unlikely loss of sleep
Severe = at least 2 X week /
pronounced sleep
disturbance, considerably
longer latency or marked
difficulty staying asleep,
90 min to 3 hrs loss of sleep

61
 Criterion F:
Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

Item 21: Onset of symptoms.

[If not clear:] When did you first start having (PTSD Total # months delay in onset
SYMPTOMS) you’ve told me about? (How long after the
trauma did they start? More than six months?) With delayed onset (> 6 onths)?
NO YES

Item 22: Duration of symptoms.

[If not clear:] How long have these (PTSD SYMPTOMS) lasted Total # months duration
altogether?
Duration more than 1 month?
NO YES

Criterion G:
The disturbance causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

Item 23: Subjective distress.

Overall, in the past month, how much have you been 0 None
bothered by these (PTSD SYMPTOMS) you’ve told me
1 Mild, minimal distress
about? [Consider distress reported on earlier items]
2 Moderate, distress clearly present but still
manageable

3 Severe, considerable distress

4 Extreme, incapacitating distress

Item 24: Impairment in social functioning.

In the past month, have these (PTSD SYMPTOMS) 0 No adverse impact

affected your relationships with other people? How so?
[Consider impairment in social functioning reported on 1 Mild impact, minimal impairment in social
earlier items] functioning

2 Moderate impact, definite impairment but many

aspects of social functioning still intact

3 Severe impact, marked impairment, few aspects of

social functioning still intact

4 Extreme impact, little or no social functioning

62
Item 25: Impairment in occupational or other important area of functioning.
[If not clear:] Are you working now?
[If yes:] In the past month, have these (PTSD
SYMPTOMS) affected your work or your ability to
work? How so?
[If no:] Why is that? (Do you feel that your (PTSD SYMPTOMS)
are related to you not working now? How so?)
[If unable to work because of PTSD symptoms, rate at least
3=Severe. If unemployment is not due to PTSD symptoms, or if
the link is not clear, base rating only on impairment in other
important areas of functioning]
Have these (PTSD SYMPTOMS) affected any other
important part of your life? [As appropriate, suggest
examples such as parenting, housework, schoolwork,
volunteer work, etc.] How so?
Global Ratings
Item 26: Global validity.
Estimate the overall validity of responses. Consider factors such
as compliance with the interview, mental status (e.g., problems
with concentration, comprehension of items, dissociation), and
evidence of efforts to exaggerate or minimize symptoms.
Item 27: Global severity.
Estimate the overall severity of PTSD symptoms. Consider
degree of subjective distress, degree of functional impairment,
observations of behaviors in interview, and judgment regarding
reporting style.
0 No adverse impact
1 Mild impact, minimal impairment in occupational/
other important functioning
2 Moderate impact, definite impairment but many
aspects of occupational/other important
functioning still intact
3 Severe impact, marked impairment, few aspects of
occupational/other important functioning still intact
4 Extreme impact, little or no occupational/other
important functioning
0 Excellent, no reason to suspect invalid responses
1 Good, factors present that may adversely affect
validity
2 Fair, factors present that definitely reduce validity
3 Poor, substantially reduced validity
4 Invalid responses, severely impaired mental status or
possible deliberate “faking bad” or “faking good”
0 No clinically significant symptoms, no distress and no
functional impairment
1 Mild, minimal distress or functional impairment
2 Moderate, definite distress or functional impairment
but functions satisfactorily with effort
3 Severe, considerable distress or functional
impairment, limited functioning even with effort
4 Extreme, marked distress or marked impairment in two
or more major areas of functioning
63
Item 28: Global improvement.

Rate total overall improvement since the previous rating. Rate the degree of change, 0 Asymptomatic
whether or not, in your judgment, it is due to treatment.
1 Considerable improvement

2 Moderate improvement

3 Slight improvement

4 No improvement

5 Insufficient information

Specify whether with dissociative symptoms: The individual’s symptoms meet the criteria
for posttraumatic stress disorder, and in addition, in response to the stressor, the individual
experiences persistent or recurrent symptoms of either of the following:

Item 29 (1): Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one
were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream;
feeling a sense of unreality of self or body or of time moving slowly).

In the past month, have there been times when you felt as if you were separated 0 Absent
from yourself, like you were watching yourself from the outside or observing your
thoughts and feelings as if you were another person? 1 Mild / subthreshold

[If no:] (What about feeling as if you were in a dream, even though you were 2 Moderate / threshold
awake? Feeling as if something about you wasn’t real? Feeling as if time was
3 Severe / markedly elevated
moving more slowly?)
4 Extreme / incapacitating
Tell me more about that.

How strong is this feeling? (Do you lose track of where you actually are or what’s Key rating dimensions
actually going on?) = frequency /
intensity of
What do you do while this is happening? (Do other people notice your dissociation
behavior? What do they say?) Moderate = at least 2 X month
/ dissociative quality clearly
How long does it last? present but transient,
retains some realistic sense
of self and awareness of
environment
Circle: Dissociation = Minimal Clearly Present Pronounced Extreme
Severe = at least 2 X week /
[If not clear:] (Was this due to the effects of alcohol or drugs? What about a pronounced dissociative
medical condition like seizures?) [Rate 0=Absent if due to the effects of a quality, marked sense of
detachment and unreality
substance or another medical condition]

How often has this happened in the past month? # of times

Did this feeling start or get worse after (EVENT)? (Do you think it’s related to
(EVENT)? How so?)
Circle: Trauma-relatedness = Definite Probable Unlikely

64
Item 30 (2): Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world
around the individual is experienced as unreal, dreamlike, distant, or distorted).

In the past month, have there been times when things going on around you
seemed unreal or very strange and unfamiliar?
0 Absent
[If no:] (Do things going on around you seem like a dream or like a scene from
a movie? Do they seem distant or distorted?) 1 Mild / subthreshold
Tell me more about that. 2 Moderate / threshold
How strong is this feeling? (Do you lose track of where you actually are or what’s 3 Severe / markedly elevated
actually going on?)
4 Extreme / incapacitating
What do you do while this is happening? (Do other people notice your
behavior? What do they say?)
Key rating dimensions
How long does it last? = frequency /
intensity of
dissociation
Circle: Dissociation = Minimal Clearly Present Pronounced Extreme Moderate = at least 2 X month
/ dissociative quality clearly
[If not clear:] (Was this due to the effects of alcohol or drugs? What about a present but transient, retains
medical condition like seizures?) [Rate 0=Absent if due to the effects of a some
substance or another medical condition] realistic sense of environment
Severe = at least 2 X week /
How often has this happened in the past month? # of times pronounced dissociative
quality, marked sense of
Did this feeling start or get worse after (EVENT)? (Do you think it’s related to unreality
(EVENT)? How so?)
Circle: Trauma-relatedness = Definite Probable Unlikely

65
 CAPS-5 SUMMARY SHEET

Name: ID#: Interviewer: _ Study: Date:

A. Exposure to actual or threatened death, serious injury, or sexual violence

Criterion A met? 0 = NO 1= YES

B. Intrusion symptoms (need 1 for diagnosis) Past

Symptom Sev MonthSx (Sev > 2 )?
(1) B1 – Intrusive memories 0 = NO 1= YES
(2) B2 – Distressing dreams 0 = NO 1= YES
(3) B3 – Dissociative reactions 0 = NO 1= YES
(4) B4 – Cued psychological distress 0 = NO 1= YES
(5) B5 – Cued physiological reactions 0 = NO 1= YES
B subtotals B Sev = #B Sx =

C. Avoidance symptoms (need 1 for diagnosis) Past

Symptom Sev MonthSx (Sev > 2 )?
(6) C1 – Avoidance of memories, thoughts, feelings 0 = NO 1= YES
(7) C2 – Avoidance of external reminders 0 = NO 1= YES
C subtotals C Sev = #C Sx =

D. Cognitions and mood symptoms (need 2 for Past

diagnosis)
Symptom Sev MonthSx (Sev > 2 )?
(8) D1 – Inability to recall important aspect of event 0 = NO 1= YES
(9) D2 – Exaggerated negative beliefs or expectations 0 = NO 1= YES
(10) D3 – Distorted cognitions leading to blame 0 = NO 1= YES
(11) D4 – Persistent negative emotional state 0 = NO 1= YES
(12) D5 – Diminished interest or participation in activities 0 = NO 1= YES
(13) D6 – Detachment or estrangement from others 0 = NO 1= YES
(14) D7 – Persistent inability to experience positive emotions 0 = NO 1= YES
D subtotals D Sev = #D Sx =

E. Arousal and reactivity symptoms (need 2 for Past

diagnosis)
Symptom Sev MonthSx (Sev > 2 )?
(15) E1 – Irritable behavior and angry outbursts 0 = NO 1= YES
(16) E2 – Reckless or self-destructive behavior 0 = NO 1= YES
(17) E3 – Hypervigilance 0 = NO 1= YES
(18) E4 – Exaggerated startle response 0 = NO 1= YES
(19) E5 – Problems with concentration 0 = NO 1= YES
(20) E6 – Sleep disturbance 0 = NO 1= YES
E subtotals E Sev = #E Sx =

66
PTSD totals Past Month
Totals Total Sev Total # Sx
Sum of subtotals
(B+C+D+E)
F. Duration of disturbance Current
(22) Duration of disturbance > 1 month? 0 = NO 1= YES

G. Distress or impairment (need 1 for diagnosis) Past Month

Criterion Sev Cx (Sev > 2 )?
(23) Subjective distress 0 = NO 1= YES
(24) Impairment in social functioning 0 = NO 1= YES
(25) Impairment in occupational functioning 0 = NO 1= YES
G subtotals G Sev = #G Cx =

Global ratings Past Month

(26) Global validity
(27) Global severity
(28) Global improvement

Dissociative symptoms (need 1 for subtype) Past Month

Symptom Sev Sx (Sev > 2 )?
(29) 1 – Depersonalization 0 = NO 1= YES
(30) 2 – Derealization 0 = NO 1= YES
Dissociative Diss Sev = #Diss Sx =
subtotals
PTSD diagnosis Past Month
PTSD PRESENT – ALL CRITERIA (A-G) MET? 0 = NO 1= YES
With dissociative symptoms 0 = NO 1= YES
(21) With delayed onset (> 6 months) 0 = NO 1= YES

63
 CLINICIAN-ADMINISTERED PTSD SCALE FOR DSM-5
CHILD/ADOLESCENT VERSION

Instructions

Standard administration and scoring of the Clinician-Administered PTSD Scale for DSM-5 –
Child/Adolescent Version (CAPS-CA-5) are essential for producing reliable and valid scores and
diagnostic decisions. The CAPS-CA-5 should be administered only by qualified interviewers who have
formal training in structured clinical interviewing and differential diagnosis, a thorough understanding of
the DSM-5 symptom criteria for PTSD, and detailed knowledge of the features and conventions of the
CAPS-CA-5 itself.

The CAPS-CA-5 is based upon DSM-5 criteria for PTSD for children and adolescents ages 7 and above.
Because the criteria and diagnostic thresholds are different for the Pre-school Subtype, the CAPS-CA-5 is
not intended for the evaluation of PTSD based on DSM-5 criteria for children ages 6 and younger.

Administration

1. Identify an index traumatic event to serve as the basis for symptom inquiry: administer a structured,
evidence-based method for taking a comprehensive trauma history, such as the Life Events Checklist –
Child Version for DSM-IV and Criterion A inquiry provided on p. 6. Alternatively, use the Trauma
History Profile portion of the UCLA Child/Adolescent PTSD Reaction Index for DSM-5©. The index
event may involve either a single incident (e.g., the accident) or multiple related incidents (e.g.,
experiencing physical or sexual abuse, witnessing domestic violence affecting an adult in the home).

2. Read prompts verbatim, one at a time, and in the order presented, EXCEPT:

a. Use the respondent’s own words for labeling the index event or describing specific symptoms.

b. Rephrase standard prompts to acknowledge previously reported information, but return to verbatim
phrasing as soon as possible. For example, inquiry for item 20 might begin: “You already
mentioned having problems sleeping. What kinds of problems?”

c. If you don’t have sufficient information after exhausting all standard prompts, follow up ad lib. In
this situation, repeating the initial prompt often helps refocus the respondent.

d. As needed, ask for specific examples or direct the respondent to elaborate even when such prompts
are not provided explicitly.

3. In general, DO NOT suggest responses. If a respondent has pronounced difficulty understanding a

prompt it may be necessary to offer a brief example to clarify and illustrate. However, this should be
done rarely and only after the respondent has been given ample opportunity to answer spontaneously.

4. DO NOT read rating scale anchors to the respondent. They are intended only for you, the interviewer,
because appropriate use requires clinical judgment and a thorough understanding of CAPS-CA-5
scoring conventions.
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5. Move through the interview as efficiently as possible to minimize respondent burden. Some useful
strategies:
a. Be thoroughly familiar with the CAPS-CA-5 so that prompts flow smoothly.
b. Ask the fewest number of prompts needed to obtain sufficient information to support a valid rating.
c. Minimize note-taking and write while the respondent is talking to avoid long pauses.
d. Take charge of the interview. Be respectful but firm in keeping the respondent on task,
transitioning between questions, pressing for examples, or pointing out contradictions.

Scoring

1. As with previous versions of the CAPS-CA, CAPS-CA-5 symptom severity ratings are based on
symptom frequency and intensity, except for items 8 (amnesia) and 12 (diminished interest), which are
based on amount and intensity. However, CAPS-CA-5 items are rated with a single severity score, in
contrast to previous versions of the CAPS-CA which required separate frequency and intensity scores
for each item that were either summed to create a symptom severity score or combined in various
scoring rules to create a dichotomous (present/absent) symptom score. Thus, on the CAPS-CA-5 the
clinician combines information about frequency and intensity before making a single severity rating.
Depending on the item, frequency is rated as either the number of occurrences (how often in the past
month) or percent of time (how much of the time in the past month). Intensity is rated on a four-point
ordinal scale with ratings of Minimal, Clearly Present, Pronounced, and Extreme. Intensity and
severity are related but distinct. Intensity refers to the strength of a typical occurrence of a symptom.
Severity refers to the total symptom load over a given time period, and is a combination of intensity
and frequency. This is similar to the quantity/frequency assessment approach to alcohol consumption.
In general, intensity rating anchors correspond to severity scale anchors described below and should be
interpreted and used in the same way, except that severity ratings require joint consideration of
intensity and frequency. Thus, before taking frequency into account, an intensity rating of Minimal
corresponds to a severity rating of Mild / subthreshold, Clearly Present corresponds with Moderate /
threshold, Pronounced corresponds with Severe / markedly elevated, and Extreme corresponds with
Extreme / incapacitating.

2. The five-point CAPS-CA-5 symptom severity rating scale is used for all symptoms. Rating scale
anchors should be interpreted and used as follows:

0 Absent The respondent denied the problem or the respondent’s report doesn’t fit the DSM-5
symptom criterion.

1 Mild / subthreshold The respondent described a problem that is consistent with the symptom
criterion but isn’t severe enough to be considered clinically significant. The problem doesn’t satisfy
the DSM-5 symptom criterion and thus doesn’t count toward a PTSD diagnosis.

2 Moderate / threshold The respondent described a clinically significant problem. The problem
satisfies the DSM- 5 symptom criterion and thus counts toward a PTSD diagnosis. The problem
would be a target for intervention. This rating requires a minimum frequency of 2 X month or some
of the time (20-30%) PLUS a minimum intensity of Clearly Present.

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 3 Severe / markedly elevated The respondent described a problem that is well above threshold. The
problem is difficult to manage and at times overwhelming, and would be a prominent target for
intervention. This rating requires a minimum frequency of 2 X week or much of the time (50-60%)
PLUS a minimum intensity of Pronounced.

4 Extreme / incapacitating The respondent described a dramatic symptom, far above threshold. The
problem is pervasive, unmanageable, and overwhelming, and would be a high-priority target for
intervention.

3. In general, make a given severity rating only if the minimum frequency and intensity for that rating are
both met. However, you may exercise clinical judgment in making a given severity rating if the
reported frequency is somewhat lower than required, but the intensity is higher. For example, you may
make a severity rating of Moderate / threshold if a symptom occurs 1 X month (instead of the required
2 X month) as long as intensity is rated Pronounced or Extreme (instead of the required Clearly
Present). Similarly, you may make a severity rating of Severe / markedly elevated if a symptom occurs
1 X week (instead of the required 2 X week) as long as the intensity is rated Extreme (instead of the
required Pronounced). If you are unable to decide between two severity ratings, make the lower rating.

4. You need to establish that a symptom not only meets the DSM-5 criterion phenomenologically, but is
also functionally related to the index traumatic event, i.e., started or got worse as a result of the event.
CAPS-CA-5 items 1-8 and 10 (reexperiencing, effortful avoidance, amnesia, and blame) are inherently
linked to the event. Evaluate the remaining items for trauma-relatedness (TR) using the TR inquiry and
rating scale. The three TR ratings are:

a. Definite = the symptom can clearly be attributed to the index trauma, because (1) there is an
obvious change from the pre-trauma level of functioning and/or (2) the respondent makes the
attribution to the index trauma with confidence.

b. Probable = the symptom is likely related to the index trauma, but an unequivocal connection can’t
be made. Situations in which this rating would be given include the following: (1) there seems to be
a change from the pre- trauma level of functioning, but it isn’t as clear and explicit as it would be
for a “definite;” (2) the respondent attributes a causal link between the symptom and the index
trauma, but with less confidence than for a rating of Definite; (3) there appears to be a functional
relationship between the symptom and inherently trauma-linked symptoms such as reexperiencing
symptoms (e.g., numbing or withdrawal increases when reexperiencing increases).

c. Unlikely = the symptom can be attributed to a cause other than the index trauma because (1) there
is an obvious functional link with this other cause and/or (2) the respondent makes a confident
attribution to this other cause and denies a link to the index trauma. Because it can be difficult to
rule out a functional link between a symptom and the index trauma, a rating of Unlikely should be
used only when the available evidence strongly points to a cause other than the index trauma.
NOTE: Symptoms with a TR rating of Unlikely should not be counted toward a PTSD diagnosis or
included in the total CAPS-CA-5 symptom severity score.

5. CAPS-CA-5 total symptom severity score is calculated by summing severity scores for items 1-20.
NOTE: Severity scores for the two dissociation items (29 and 30) should NOT be included in the
calculation of the total CAPS-CA-5 severity score.

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6. CAPS-CA-5 symptom cluster severity scores are calculated by summing the individual item severity
scores for symptoms contained in a given DSM-5 cluster. Thus, the Criterion B (reexperiencing)
severity score is the sum of the individual severity scores for items 1-5; the Criterion C (avoidance)
severity score is the sum of items 6 and 7; the Criterion D (negative alterations in cognitions and
mood) severity score is the sum of items 8-14; and the Criterion E (hyperarousal) severity score is the
sum of items 15-20. A symptom cluster score may also be calculated for dissociation by summing
items 29 and 30.

7. PTSD diagnostic status is determined by first dichotomizing individual symptoms as “present” or

“absent,” then following the DSM-5 diagnostic rule. A symptom is considered present only if the
corresponding item severity score is rated 2=Moderate/threshold or higher. Items 9 and 11-20 have
the additional requirement of a trauma-relatedness rating of Definite or Probable. Otherwise a
symptom is considered absent. The DSM-5 diagnostic rule requires the presence of least one Criterion
B symptom, one Criterion C symptom, two Criterion D symptoms, and two Criterion E symptoms. In
addition, Criteria F and G must be met. Criterion F requires that the disturbance has lasted at least one
month. Criterion G requires that the disturbance cause either clinically significant distress or
functional impairment, as indicated by a rating of 2=moderate or higher on items 23-25.

8. Use the Frequency Rating Sheet (Appendix A) to help the child answer HOW MANY DAYS the
reaction has
happened in the past MONTH. Hand the Frequency Rating Sheet to child and point to the calendar as
you explain the rating choices as follows: ‘0’ means that in the past month, you have not had the
reaction at all, not even on one day. ‘1’ means that you have had the reaction around 1 to 3 days in the
past month. ‘2’ means that you have had the reaction around 2 to 3 days a week in the past month. ‘3’
means that you have had the reaction around 3 to 4 days a week over the past month. And ‘4’ means
that you have had the reaction almost every day over the past month.

Interviewer: Note that a score of ‘0’ corresponds to a score of “Absent”; a score of ‘1’ corresponds to
5-10% of the time; a score of ‘2’ corresponds to 20-30% of the time; a score of ‘3’
corresponds to approximately 50% of the time; and a score of ‘4’ corresponds to a rating
of “Pervasive.”

Practice trial questions using the calendar as follows: “Let’s do some practice questions to make sure that
you understand how to use the calendar. If I asked, ‘How many days in the past month have you had a
headache,’ which calendar tells how many days in the past month you have had a headache? What about,
‘How many days in the past month have you watched television?’ Point to the calendar that tells how
many days in the past month you have watched television. How about if I asked, ‘How many days in the
past month have you done homework? Point to the calendar that tells how many days in the past month
you have done homework.” Continue with these types of questions until you are confident that the child
can use the calendar to rate how many days the reaction has happened in the past month. With school
aged children, it is helpful to work with the child to identify a day 30 days prior to the interview to serve
as a temporal reference, (e.g., since your brother’s birthday, since school began, etc.).

Use the Intensity Rating Sheet (Appendix B) to help the child answer HOW MUCH the problem has
bothered him/her over the past MONTH. The choices are: ‘Absent,’ ‘Mild,’ ‘Moderate,’ ‘Severe,’ and
‘Extreme.’ A rating of ‘Absent’ means that the child denied the problem or that the report doesn’t fit the
DSM-5 symptom criterion. A rating of “Mild’ means that the child described the problem, but the problem
67
is not severe enough to be clinically significant. A rating of ‘Moderate’ means that the child described a
clinically significant problem. A rating of ‘Severe’ means that the child described a problem that is well
above threshold. A rating of ‘Extreme’ means that the child described a dramatic symptom far above
threshold. See Section 2 above for instructions on the interpretation of symptom severity score using both
frequency and intensity ratings.

Hand the Intensity Rating Sheet to child and point to the glasses as you explain the rating choices for how
much the child is bothered by the problem as follows: The first glass (marked ‘Not at all’) that is empty,
means that the problem doesn’t bother you at all. The second glass (marked ‘Mild’), that has just a little
bit in it, means that the problem bothers you only a little bit. The third glass (marked ‘Moderate’), that is
almost half full, means that the problem bothers you quite a bit. The fourth glass (marked ‘Severe’), that is
much more than half full, means that the problem bothers you a lot and it is hard to know how to handle it
. And the fifth glass (marked ‘Extreme’) that is totally full means that the problem is so bad that it
couldn’t be worse.

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 National Center for PTSD

CLINICIAN-ADMINISTERED PTSD SCALE FOR DSM-5

CHILD/ADOLESCENT VERSION
(Revised September 2015)

69
Child’s Name: ID # Age: Sex: □ Girl □ Boy

Grade in School: School:

Teacher: City/State:

Interviewer Name/ID #

Date (month, day, year): /_ /_ (Session # _)

Robert S. Pynoos, Frank W. Weathers, Alan M. Steinberg, Brian P. Marx, Christopher M. Layne,
Danny G. Kaloupek, Paula P. Schnurr, Terence M. Keane, Dudley D. Blake, Elana Newman, Kathleen
O. Nader & Julie A. Kriegler

National Center for Posttraumatic Stress Disorder and National Center for Child Traumatic Stress

Do not use, duplicate or distribute without permission from: National Center for PTSD

Inquiries, comments, or requests for copies may be directed to the National Center for PTSD: ncptsd@va.gov

Please note that several authors have switched affiliations; K. Nader is now at Nader and Associates, Aliso
Viejo, CA; J. A. Kriegler is at Permanente Medical Group, Santa Clara, CA; D. D. Blake is now at Boise
Department of Veterans Affairs Medical Center; and, E. Newman is at University of Tulsa.

The authors acknowledge the assistance of Julie Kaplow for pilot testing item wording for DSM-5

70
 Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened
death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting
human remains; police officers repeatedly exposed to details of child abuse). Note:

Criterion A4: does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is
work related.

[Administer Life Events Checklist – Child Version for DSM-IV or other structured trauma screen.]

I’m going to ask you about the stressful experiences questionnaire you filled out. First I’ll ask you to tell me a little bit about the
event you said was the worst for you. Then I’ll ask how that event may have affected you over the past month. In general I don’t
need a lot of information – just enough so I can understand any problems you may have had. Please let me know if you find
yourself becoming upset as we go through the questions so we can slow down and talk about it. Also, let me know if you have any
questions or don’t understand something. Do you have any questions before we start?

The event you said was the worst was (EVENT). What I’d like for you to do is briefly describe what happened.

Index event (specify):

What happened? (How old were you? How were you involved? Who Exposure type:
else was involved? Was anyone seriously injured or killed?
Was anyone’s life in danger? How many times did this happen?) Experienced ____
Witnessed _____
Learned about ____
Exposed to aversive details ____

Life threat? NO YES [self __ other __)

Serious injury? NO YES [self ___ other _]

Sexual Violence NO YES (self ___ other __)

Criterion A met? NO PROBABLE YES

5. For the rest of the interview, I want you to keep (EVENT) in mind as I ask you about different problems it
may have caused you. You may have had some of these problems before, but for this interview we’re
going to focus just on the past month. For each problem I’ll ask if you’ve had it in the past month, and if
so, how often and how much it bothered you.

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Criterion B: Presence of one or more of the following intrusion symptoms associated with the traumatic event(s),
beginning after the traumatic event(s) occurred:

1. (B1) Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6
years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

In the past month, have you had upsetting thoughts, pictures or sounds of what happened come 0 Absent
into your mind when you didn’t want them to? Did this happen while you were awake, so not
counting dreams? [Rate 0=Absent if only during dreams] 1 Mild / subthreshold

How did these upsetting thoughts, pictures or sounds of what happened come into your mind? 2 Moderate / threshold

[If not clear:] Do these unwanted thoughts, pictures or sounds just pop into your head, 3 Severe / markedly
or do you think about what happened on purpose? elevated

[Rate 0=Absent unless perceived as involuntary and intrusive] 4 Extreme / incapacitating

How much do these thoughts, pictures or sounds bother you?

Are you able to put these thoughts, pictures or sounds out of your mind and think about
something else?
Circle: Distress = Minimal Clearly Present Pronounced Extreme

How often have you had these thoughts, pictures or sounds come into your mind in the past
month? # of times

Key rating dimensions = frequency / intensity of distress

Moderate = at least 2 X month / distress clearly present, some difficulty dismissing memories
Severe = at least 2 X week / pronounced distress, considerable difficulty dismissing memories

2. (B2) Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In
children, there may be frightening dreams without recognizable content.

In the past month, have you had any bad dreams about the bad thing that happened or 0 Absent
other bad dreams?
1 Mild / subthreshold
Describe one of these dreams for me. (What happens?)
2 Moderate / threshold
[If not clear:] (Do these bad dreams wake you up?)
3 Severe / markedly
[If yes:] (How do you feel when you wake up? How long does it take you to get back elevated
to sleep?)
4 Extreme /
How much do these bad dreams bother you? incapacitating

Circle: Distress = Minimal Clearly Present Pronounced Extreme

How often have you had these bad dreams in the past month? # of times

Key rating dimensions = frequency / intensity of distress

Moderate = at least 2 X month / distress clearly present, less than 1 hour sleep loss
Severe = at least 2 X week / pronounced distress, more than 1 hour sleep loss

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3. (B3) Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were
recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of
awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.

In the past month, have there been times when you suddenly feel like you are back at 0 Absent
the time when the bad thing happened, like it’s happening all over again?
1 Mild / subthreshold

[If not clear:] (This is different than thinking about it or dreaming about it – now I’m 2 Moderate / threshold
asking about feeling like you’re actually back at the time of the bad thing happening,
actually going through it again.) 3 Severe / markedly elevated

4 Extreme / incapacitating
How much does it seem as if the bad thing was happening again? (Are you confused
about where you actually are?)

What do you do when it feels like the bad thing is happening again? (Do other people
notice how you are acting? What do they say?)

How long does the feeling that the bad thing is happening all over again last?

Circle: Dissociation = Minimal Clearly Present Pronounced Extreme

How often has this feeling happened in the past month? # of times

Key rating dimensions = frequency / intensity of dissociation

Moderate = at least 2 X month / dissociative quality clearly present, may retain some awareness of surroundings but
relives event in a manner clearly distinct from thoughts and memories
Severe = at least 2 X week / pronounced dissociative quality, reports vivid reliving, e.g., with images, sounds, smells

4. (B4) Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).

In the past month, did you get very upset, afraid, or sad when something reminded 0 Absent
you of the bad thing that happened?
1 Mild / subthreshold

What kinds of things reminded you of the bad thing that happened? 2 Moderate / threshold

How much do these reminders bother you? 3 Severe / markedly elevated

Are you able to calm yourself down when this happens? (How long does it take?)
4 Extreme / incapacitating
Circle: Distress = Minimal Clearly Present Pronounced Extreme

How often in the past month have you been reminded of the bad thing that happened?
# of times

Key rating dimensions = frequency / intensity of distress

Moderate = at least 2 X month / distress clearly present, some difficulty recovering
Severe = at least 2 X week / pronounced distress, considerable difficulty recovering

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5. (B5) Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic
event(s).

In the past month, have you had strong feelings in your body when something 0 Absent
reminded you of the bad thing that happened, like your heart beats fast, your head
1 Mild / subthreshold
aches or your stomach aches?
2 Moderate / threshold
Can you give me some examples of these strong feelings in your body? (Does your
heart race or your breathing change? What about sweating or feeling really nervous or 3 Severe / markedly elevated
shaky?)
4 Extreme / incapacitating

What kinds of reminders (things that remind you of the bad thing that happened) make
you have strong feelings in your body?

How long does it take you to feel better?

Circle: Physiological reactivity = Minimal Clearly Present Pronounced Extreme

How often has this happened in the past month? # of times

Key rating dimensions = frequency / intensity of physiological arousal

Moderate = at least 2 X month / reactivity clearly present, some difficulty recovering
Severe = at least 2 X week / pronounced reactivity, sustained arousal, considerable difficulty recovering

Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic
event(s) occurred, as evidenced by one or both of the following:

6. (C1) Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the
traumatic event(s).

In the past month, have you tried not to think about or have feelings about the bad 0 Absent
thing that happened?
1 Mild / subthreshold

What kinds of thoughts or feelings do you try to stay away from or avoid? 2 Moderate / threshold

How hard do you try to avoid these thoughts or feelings? (What kinds of things do you 3 Severe / markedly elevated
do?)
4 Extreme / incapacitating
Circle: Avoidance = Minimal Clearly Present Pronounced Extreme

How often has this happened in the past month? # of times

Key rating dimensions = frequency / intensity of avoidance

Moderate = at least 2 X month / avoidance clearly present Severe
= at least 2 X week / pronounced avoidance

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7. (C2) Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations)
that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

In the past month, have you tried to stay away from people, places, or things that 0 Absent
remind you of the bad thing that happened?
1 Mild / subthreshold
What kinds of things do you try to stay away from or avoid?
2 Moderate / threshold
How hard do you try to stay away from or avoid these people, places or things? (Do
3 Severe / markedly elevated
you have to make a plan or change your activities to avoid them?)
4 Extreme / incapacitating
(Overall, how much of a problem is this for you? How would things be
[If not clear:]
different if you didn’t have to avoid these reminders?)

Circle: Avoidance = Minimal Clearly Present Pronounced Extreme

How often have you tried to stay away from or avoid people, places or things in the
past month?
# of times

Key rating dimensions = frequency / intensity of avoidance

Moderate = at least 2 X month / avoidance clearly present Severe
= at least 2 X week / pronounced avoidance

Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

8. (D1) Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not
to other factors such as head injury, alcohol, or drugs).

In the past month, have you had trouble remembering important parts of the bad thing 0 Absent
that happened? (Do you feel there are gaps in your memory of [EVENT]?)
1 Mild / subthreshold
What parts have you had trouble remembering?
2 Moderate / threshold
Do you feel like you should be able to remember these things and just can’t?
3 Severe / markedly elevated
Prompts for younger children: Did you hurt your head when the bad thing
[If not clear:]
happened? Did things seem really blurry or fuzzy at the time? Prompts for older 4 Extreme / incapacitating
children/adolescents: Why do you think you can’t remember? Did you hurt your head
when the bad thing happened? Did things seem blurry or fuzzy at the time? Were you
knocked out? Were you intoxicated from alcohol or drugs?
[Rate 0=Absent if due to head injury or loss of consciousness or intoxication during event]

(Is this just normal forgetting? Or do you think you may have blocked it out
[If still not clear:]
because it would be too painful to remember?) [Rate 0=Absent if due only to normal forgetting]
Circle: Difficulty remembering = Minimal Clearly Present Pronounced Extreme

In the past month, how many of the important parts of what happened have you had
trouble remembering? (What parts do you still remember?)
# of important aspects

Would you be able to remember these things if you tried?

Key rating dimensions = amount of event not recalled / intensity of inability to recall
Moderate = at least one important aspect / difficulty remembering clearly present, some recall possible with effort
Severe = several important aspects / pronounced difficulty remembering, little recall even with effort

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9. (D2) Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,”
“No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

In the past month, have you had bad thoughts about yourself, like “I am bad”? 0 Absent

In the past month, have you had bad thoughts about the world, like “The world is 1 Mild / subthreshold
really dangerous”?
2 Moderate / threshold
In the past month, have you had bad thoughts about other people, like “I will never be
able to trust other people”? 3 Severe / markedly elevated

Can you give me some examples? 4 Extreme / incapacitating

How strong are these beliefs? (How sure are you that these beliefs are actually true? Can
you see other ways of thinking about it?)

Circle: Conviction = Minimal Clearly Present Pronounced Extreme

How much of the time in the past month have you had these kinds of beliefs?

% of time

Did these beliefs start or get worse after the bad thing happened? (Do you think they are
related to what happened? How so?) Circle: Trauma-relatedness = Definite Probable Unlikely

Key rating dimensions = frequency / intensity of beliefs

Moderate = some of the time (20-30%) / exaggerated negative expectations clearly present, some difficulty
considering more realistic beliefs
Severe = much of the time (50-60%) / pronounced exaggerated negative expectations, considerable difficulty
considering more realistic beliefs

10. (D3) Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.

In the past month, have you felt that part or even all of what happened was your fault? 0 Absent
Tell me more about that. (In what sense do you see yourself as having caused the bad thing
to happen? Is it because of something you did? Or something you think you should have done 1 Mild / subthreshold
but didn’t?
2 Moderate / threshold
What about being angry with someone or something for making the bad thing happen,
not doing more to stop it, or to help after? Tell me more about that. (In what sense do you 3 Severe / markedly elevated
see other people as having caused the bad thing to happen? Is it because of something they
did? Or something you think they should have done but didn’t?) 4 Extreme / incapacitating

How much do you blame yourself?

How much do you blame others?

How much do you believe that you or other people are really responsible for what
happened? (Do other people agree with you? Can you see other ways of thinking about it?)
[Rate 0=Absent if only blames perpetrator, i.e., someone who deliberately caused the event and intended harm]

Circle: Conviction = Minimal Clearly Present Pronounced Extreme

How much of the time in the past month have you felt that way? % of time

Key rating dimensions = frequency / intensity of blame

Moderate = some of the time (20-30%) / distorted blame clearly present, some difficulty considering more realistic
beliefs
Severe = much of the time (50-60%) / pronounced distorted blame, considerable difficulty considering more realistic
beliefs

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11. (D4) Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) associated with the traumatic event.
In the past month, have you felt that what happened was sickening or gross? 0 Absent
In the past month, have you felt ashamed or embarrassed over what happened?
1 Mild / subthreshold
In the past month, have you felt guilty about what happened?
2 Moderate / threshold
In the past month, have you felt very afraid or scared?
In the past month, have you wanted to get back at someone for what happened or get 3 Severe / markedly elevated
revenge?
4 Extreme / incapacitating
Can you give me some examples of having these feelings? (What negative feelings do
you experience?)

How strong are these upsetting feelings?

How well are you able to handle or cope with these feelings?

Circle: Negative emotions = Minimal Clearly Present Pronounced Extreme

How much of the time in the past month have you had these upsetting feelings?
% of time

Did these upsetting feelings start or get worse after the bad thing that happened? (Do
you think they’re related to [EVENT]? How so?) Circle: Trauma-relatedness = Definite Probable
Unlikely

Key rating dimensions = frequency / intensity of negative emotions

Moderate = some of the time (20-30%) / negative emotions clearly present, some difficulty managing
Severe = much of the time (50-60%) / pronounced negative emotions, considerable difficulty managing

12. (D5) Markedly diminished interest or participation in significant activities.

In the past month, have you not felt like doing things with your family, friends or other 0 Absent
things that you liked to do?
1 Mild / subthreshold
What kinds of things have you lost interest in or don’t want to do as much as you used
2 Moderate / threshold
to? (Anything else?)
3 Severe / markedly elevated
Why is that? [Rate 0=Absent if diminished participation is due to lack of opportunity, physical inability, or
developmentally appropriate change in preferred activities]
4 Extreme / incapacitating
How strongly do you not want to do those things anymore? (How much interest have
you lost? Would you still enjoy [ACTIVITIES] once you got started?)
Circle: Loss of interest= Minimal Clearly Present Pronounced Extreme

Overall, in the past month, how many of your usual activities have you been less
interested in?
% of activities

What kinds of things do you still enjoy doing?

Did this loss of interest start or get worse after the bad thing happened? (Do you think
it’s related to [EVENT]? How so?) Circle: Trauma-relatedness = Definite Probable Unlikely

Key rating dimensions = percent of activities affected / intensity of loss of interest

Moderate = some activities (20-30%) / loss of interest clearly present but still has some enjoyment of activities
Severe = many activities (50-60%) / pronounced loss of interest, little interest or participation in activities

77
13. (D6) Feelings of detachment or estrangement from others.

In the past month, have you felt alone even when you are around other people? 0 Absent

1 Mild / subthreshold
Tell me more about that.
2 Moderate / threshold
How strong are your feelings of being alone or distant from others? (Who do you feel
closest to? How many people do you feel comfortable talking with about personal things?) 3 Severe / markedly elevated

Circle: Detachment or estrangement = Minimal Clearly Present Pronounced Extreme 4 Extreme / incapacitating

How much of the time in the past month have you felt that way? % of time

Did this feeling of being alone or distant from others start or get worse after what
happened? (Do you think it’s related to what happened? How so?) Circle: Trauma-relatedness =
Definite Probable Unlikely

Key rating dimensions = frequency / intensity of detachment or estrangement

Moderate = some of the time (20-30%) / feelings of detachment clearly present but still feels some interpersonal
connection
Severe = much of the time (50-60%) / pronounced feelings of detachment or estrangement from most people, may
feel close to only one or two people

14. (D7) Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving
feelings).

In the past month, have there been times when you had trouble feeling happiness, love 0 Absent
or other good feelings?
1 Mild / subthreshold

Tell me more about that. (What feelings are hard (difficult) to experience?)
2 Moderate / threshold

How hard is it for you to have happy, positive feelings? (Are you still able to experience 3 Severe / markedly elevated
any positive feelings?)
4 Extreme / incapacitating
Circle: Reduction of positive emotions = Minimal Clearly Present Pronounced Extreme

How much of the time in the past month has it been hard to have positive feelings?
% of time

Did this trouble having positive feelings start or get worse after the bad thing
happened? (Do you think it’s related to the bad thing that happened? How so?) Circle:
Trauma-relatedness = Definite Probable Unlikely

Key rating dimensions = frequency / intensity of reduction in positive emotions

Moderate = some of the time (20-30%) / reduction of positive emotional experience clearly present but still able to
experience some positive emotions
Severe = much of the time (50-60%) / pronounced reduction of experience across range of positive emotions

78
Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

15. (E1) Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical
aggression toward people or objects.

In the past month, have there been times when you were quick to show your anger or 0 Absent
got into arguments or physical fights?
1 Mild / subthreshold

Can you give me some examples? (How do you show it? Do you raise your voice or yell? 2 Moderate / threshold
Throw or hit things? Push or hit other people?)
3 Severe / markedly elevated
Circle: Aggression = Minimal Clearly Present Pronounced Extreme
4 Extreme / incapacitating
How often in the past month? # of times

Did this behavior start or get worse after (EVENT)? (Do you think it’s related to what
happened? How so?) Circle: Trauma-relatedness = Definite Probable Unlikely

Key rating dimensions = frequency / intensity of aggressive behavior

Moderate = at least 2 X month / aggression clearly present, primarily verbal
Severe = at least 2 X week / pronounced aggression, at least some physical aggression

16. (E2) Reckless or self-destructive behavior.

In the past month, have you hurt yourself on purpose? 0 Absent

In the past month, have you done risky or unsafe things that could really hurt you or 1 Mild / subthreshold
someone else?
2 Moderate / threshold
Can you give me some examples?
3 Severe / markedly elevated

How dangerous are doing these things? (Did you or someone else get hurt badly?) 4 Extreme / incapacitating

Circle: Risk = Minimal Clearly Present Pronounced Extreme

How often have you done these kinds of things in the past month? # of times

Did this behavior start or get worse after (EVENT)? (Do you think it’s related to [EVENT]?
How so?) Circle: Trauma-relatedness = Definite Probable Unlikely

Key rating dimensions = frequency / degree of risk

Moderate = at least 2 X month / risk clearly present, may have been harmed
Severe = at least 2 X week / pronounced risk, actual harm or high probability of harm

79
17. (E3) Hypervigilance.

In the past month, have you been on the lookout for danger or things that you are 0 Absent
afraid of (like looking over your shoulder even when nothing is there)? (Have you felt
1 Mild / subthreshold
as if you had to be on guard?)
2 Moderate / threshold
Can you give me some examples? (What kinds of things do you do when you’re looking
out for danger?) 3 Severe / markedly elevated

(What makes you feel this way? Do you feel like you’re in danger or that
[If not clear:] 4 Extreme / incapacitating
someone might hurt you in some way? Do you feel that way more than most people
would in the same situation?)

Circle: Hypervigilance = Minimal Clearly Present Pronounced Extreme

How much of the time in the past month have you felt that way? % of time

Did being on the lookout for danger start or get worse after what happened? (Do you
think it’s related to the bad thing that happened? How so?) Circle: Trauma-relatedness = Definite
Probable Unlikely

Key rating dimensions = frequency / intensity of hypervigilance

Moderate = some of the time (20-30%) / hypervigilance clearly present, e.g., watchful in public, heightened
awareness of threat
Severe = much of the time (50-60%) / pronounced hypervigilance, e.g., scans environment for danger, may have
safety rituals, exaggerated concern for safety of self/family/home

18. (E4) Exaggerated startle response.

In the past month, have you felt jumpy or startled easily, like when you hear a loud 0 Absent
noise or when something surprises you?
1 Mild / subthreshold

What kinds of things made you jumpy or startle? 2 Moderate / threshold

How strong are these jumpy feelings or startle reactions? (How strong are they 3 Severe / markedly elevated
compared to how most people would respond? Do you do anything other people would
4 Extreme / incapacitating
notice?)

How long does it take you to calm down?

Circle: Startle = Minimal Clearly Present Pronounced Extreme

How often has this happened in the past month? # of times

Did these startle reactions start or get worse after what happened? (Do you think
they’re related to [EVENT]? How so?) Circle: Trauma-relatedness = Definite Probable Unlikely

Key rating dimensions = frequency / intensity of startle

Moderate = at least 2 X month / startle clearly present, some difficulty recovering
Severe = at least 2 X week / pronounced startle, sustained arousal, considerable difficulty recovering

80
19. (E5) Problems with concentration.

In the past month, have you had any trouble concentrating or paying attention? 0 Absent

1 Mild / subthreshold
Can you give me some examples?
2 Moderate / threshold
Are you able to concentrate if you really try?
How strong are your problems with concentrating or paying attention? 3 Severe / markedly elevated

Circle: Problem concentrating = Minimal Clearly Present Pronounced Extreme 4 Extreme / incapacitating

How much of the time in the past month have you had problems with concentration?

% of time

Did these problems with concentration start or get worse after what happened? (Do
you think they’re related to what happened? How so?) Circle: Trauma-relatedness = Definite
Probable Unlikely

Key rating dimensions = frequency / intensity of concentration problems

Moderate = some of the time (20-30%) / problem concentrating clearly present, some difficulty but can concentrate
with effort
Severe = much of the time (50-60%) / pronounced problem concentrating, considerable difficulty even with effort

20. (E6) Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

In the past month, have you had any trouble with going to sleep, waking up often or 0 Absent
getting back to sleep?
1 Mild / subthreshold

What kinds of problems? (How long does it take you to fall asleep? How often do you 2 Moderate / threshold
wake up in the night? Do you wake up earlier than you want to?)
3 Severe / markedly elevated
How many hours do you sleep each night?
4 Extreme / incapacitating

How many hours do you think you should be sleeping?

Circle: Problem sleeping = Minimal Clearly Present Pronounced Extreme

How often in the past month have you had these problems with sleeping?
# of times

Did these problems with sleeping start or get worse after what happened? (Do you
think they’re related to [EVENT]? How so?) Circle: Trauma-relatedness = Definite Probable Unlikely

Key rating dimensions = frequency / intensity of sleep problems

Moderate = at least 2 X month / sleep disturbance clearly present, clearly longer latency or clear difficulty staying
asleep, 30-90 minutes loss of sleep
Severe = at least 2 X week / pronounced sleep disturbance, considerably longer latency or marked difficulty staying
asleep, 90 min to 3 hrs loss of sleep

81
Criterion F: Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

21. Onset of symptoms

When did you first start having some of the problems that you
[If not clear:] Total # months delay in onset
have told me about? (How long after what happened did they start? More With delayed onset (> 6 months)? NO YES
than six months?)

22. Duration of symptoms

[If not clear:] How long have these problems lasted altogether? Total # months duration

Duration more than 1 month? NO YES

Criterion G: The disturbance causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

23. Subjective distress

Overall, in the past month, how much have you been 0 None
bothered by these problems that you have told me about? 1 Mild, minimal distress
[Consider distress reported on earlier items]
2 Moderate, distress clearly present but still manageable

3 Severe, considerable distress

4 Extreme, incapacitating distress

24. Impairment in social functioning in school, with peers, with family, with work, or other important areas of functioning

In the past month, have these problems affected your
relationships (or made it hard for you to get along) with other
people like family or friends? How so? [Consider impairment in
social functioning reported on earlier items]
[If not clear:] Are you in school now?
In the past month, have these problems affected your
[If yes:]
schoolwork? How so? [Assess pre-trauma school performance and
possible presence of behavior problems]
0 No adverse impact
1 Mild impact, minimal impairment in social functioning
2 Moderate impact, definite impairment but many
aspects of social functioning still intact
3 Severe impact, marked impairment, few aspects of
social functioning still intact
4 Extreme impact, little or no social functioning

Have these problems affected any other important parts

[If no:]
of your life? [As appropriate, suggest examples such as parenting,
housework, schoolwork, volunteer work, etc.] How so?

25. Impairment in development

Do these reactions make it harder for you to do activities that other 0 No adverse impact
kids your age are doing? 1 Mild impact, minimal impairment in occupational/other
important functioning

2 Moderate impact, definite impairment but many

aspects of occupational/other important functioning
still intact

3 Severe impact, marked impairment, few aspects of

occupational/other important functioning still intact

4 Extreme impact, little or no occupational/other

important functioning

82
Global Ratings
26. Global validity
Estimate the overall validity of responses. Consider factors such
as compliance with the interview, mental status (e.g., problems
with concentration, comprehension of items, dissociation), and
evidence of efforts to exaggerate or minimize symptoms.
27. Global severity
Estimate the overall severity of PTSD symptoms. Consider
degree of subjective distress, degree of functional impairment,
observations of behaviors in interview, and judgment regarding
reporting style.
28. Global improvement
Rate total overall improvement since the previous rating. Rate
the degree of change, whether or not, in your judgment, it is due
to treatment.
0 Excellent, no reason to suspect invalid responses
1 Good, factors present that may adversely affect
validity
2 Fair, factors present that definitely reduce validity
3 Poor, substantially reduced validity
4 Invalid responses, severely impaired mental status or
possible deliberate “faking bad” or “faking good”
0 No clinically significant symptoms, no distress and no
functional impairment
1 Mild, minimal distress or functional impairment
2 Moderate, definite distress or functional impairment
but functions satisfactorily with effort
3 Severe, considerable distress or functional
impairment, limited functioning even with effort
4 Extreme, marked distress or marked impairment in two
or more major areas of functioning
0 Asymptomatic
1 Considerable improvement
2 Moderate improvement
3 Slight improvement
4 No improvement
5 Insufficient information
83
Specify whether with dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress
disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms
of either of the following:

29. (1) Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside
observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of
self or body or of time moving slowly).

In the past month, have you felt like you were seeing yourself or what you were doing 0 Absent
from outside of your body (like watching yourself in a movie)?
1 Mild / subthreshold
In the past month, have you felt that you were not connected to your body, like not
really being there inside? 2 Moderate / threshold

3 Severe / markedly
(What about feeling as if something about you wasn’t real? Feeling as if time
[If no:]
elevated
was moving more slowly?)
4 Extreme / incapacitating
Tell me more about that.

How strong is this feeling when it is happening? (Do you lose track of where you actually
are or what’s actually going on?)

What do you do while this is happening? (Do other people notice your behavior? What
do they say?)

How long does it last?

Circle: Dissociation = Minimal Clearly Present Pronounced Extreme

(Was this due to the effects of alcohol or drugs? What about a medical
[If not clear:]
condition like seizures?) [Rate 0=Absent if due to the effects of a substance or another medical condition]

How often has this happened in the past month? # of times

Key rating dimensions = frequency / intensity of dissociation

Moderate = at least 2 X month / dissociative quality clearly present but transient, retains some realistic sense of self
and awareness of environment
Severe = at least 2 X week / pronounced dissociative quality, marked sense of detachment and unreality

84
30. (2) Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is
experienced as unreal, dreamlike, distant, or distorted).

In the past month, have you felt like things around you look strange, like you are in a 0 Absent
fog?
1 Mild / subthreshold
In the past month, have you felt like things around you were not real, like you were in a
dream? 2 Moderate / threshold

[If no:] (Do things going on around seem distant or distorted?) 3 Severe / markedly elevated
Tell me more about that.
4 Extreme / incapacitating

How strong is this feeling when it is happening? (Do you lose track of where you actually
are or what’s actually going on?)

What do you do while this is happening? (Do other people notice your behavior? What
do they say?)

How long does it last?

Circle: Dissociation = Minimal Clearly Present Pronounced Extreme

(Was this due to the effects of alcohol or drugs? What about a medical
[If not clear:]
condition like seizures?) [Rate 0=Absent if due to the effects of a substance or another medical condition]

How often has this happened in the past month? # of times

Key rating dimensions = frequency / intensity of dissociation

Moderate = at least 2 X month / dissociative quality clearly present but transient, retains some realistic sense of
environment
Severe = at least 2 X week / pronounced dissociative quality, marked sense of unreality

85
 CAPS-CA-5 SUMMARY SHEET
Name: ID#: Interviewer: Study: Date:

A. Exposure to actual or threatened death, serious injury, or sexual violence

Criterion A met? 0 = NO 1 = YES

B. Intrusion symptoms (need 1 for diagnosis) Past Month

Sev Sx (Sev > 2 )?
(1) B1 – Intrusive memories 0 = NO 1 = YES
(2) B2 – Distressing dreams 0 = NO 1 = YES
(3) B3 – Dissociative reactions 0 = NO 1 = YES
(4) B4 – Cued psychological distress 0 = NO 1 = YES
(5) B5 – Cued physiological reactions 0 = NO 1 = YES
B subtotals B Sev = # B Sx =

C. Avoidance symptoms (need 1 for diagnosis) Past Month

Sev Sx (Sev > 2 )?
(6) C1 – Avoidance of memories, thoughts, feelings 0 = NO 1 = YES
(7) C2 – Avoidance of external reminders 0 = NO 1 = YES
C subtotals C Sev = # C Sx =

D. Cognitions and mood symptoms (need 2 for diagnosis) Past Month

Sev Sx (Sev > 2 )?
(8) D1 – Inability to recall important aspect of event 0 = NO 1 = YES
(9) D2 – Exaggerated negative beliefs or expectations 0 = NO 1 = YES
(10) D3 – Distorted cognitions leading to blame 0 = NO 1 = YES
(11) D4 – Persistent negative emotional state 0 = NO 1 = YES
(12) D5 – Diminished interest or participation in activities 0 = NO 1 = YES
(13) D6 – Detachment or estrangement from others 0 = NO 1 = YES
(14) D7 – Persistent inability to experience positive emotions 0 = NO 1 = YES
D subtotals D Sev = # D Sx =

E. Arousal and reactivity symptoms (need 2 for diagnosis) Past Month

Sev Sx (Sev > 2 )?
(15) E1 – Irritable behavior and angry outbursts 0 = NO 1 = YES
(16) E2 – Reckless or self-destructive behavior 0 = NO 1 = YES
(17) E3 – Hypervigilance 0 = NO 1 = YES
(18) E4 – Exaggerated startle response 0 = NO 1 = YES
(19) E5 – Problems with concentration 0 = NO 1 = YES
(20) E6 – Sleep disturbance 0 = NO 1 = YES
E subtotals E Sev = # E Sx =

86
PTSD totals Past Month
Total Sev Total # Sx
Sum of subtotals (B+C+D+E)

F. Duration of disturbance Current

(22) Duration of disturbance > 1 month? 0 = NO 1 = YES

G. Distress or impairment (need 1 for diagnosis) Past Month

Sev Cx (Sev > 2 )?
(23) Subjective distress 0 = NO 1 = YES
(24) Impairment in social functioning 0 = NO 1 = YES
(25) Impairment in occupational functioning 0 = NO 1 = YES
G subtotals G Sev = # G Cx =

Global ratings Past Month

(26) Global validity
(27) Global severity
(28) Global improvement

Dissociative symptoms (need 1 for subtype) Past Month

Sev Sx (Sev > 2 )?
(29) 1 -- Depersonalization 0 = NO 1 = YES
(30) 2 – Derealization 0 = NO 1 = YES

Dissociative subtotals Diss Sev = # Diss Sx =

PTSD diagnosis Past Month

PTSD PRESENT – ALL CRITERIA (A-G) MET? 0 = NO 1 = YES
With dissociative symptoms 0 = NO 1 = YES
(21) With delayed onset (> 6 months) 0 = NO 1 = YES

87
CAPS-CA-5 FREQUENCY RATING SHEET

HOW MANY DAYS DURING THE PAST MONTH

DID THE REACTION HAPPEN?

S M T W T F S
0
ABSENT

S M T W T F S 1
X MILD
X Between 1 and 3 days a month
(5 – 10%)
X

S M T W T F S 2
X X MODERATE
X X Between 2 and 3 days each week
X X X (20 – 30%)
X X

S M T W T F S 3
X X X X SEVERE
X X X Between 3 and 4 days each week
X X X (50%)
X X X X

S M T W T F S
4
X X X X X X
EXTREME
X X X X X
Almost every day
X X X X X
(Pervasive)
X X X X X X

88
 CAPS-CA-5 FREQUENCY RATING SHEET

HOW MUCH HAS THE PROBLEM BOTHERED YOU

DURING THE PAST MONTH?

Directions: Below are five pictures that show your different answer choices. Point to the one
that shows how much the problem bothered you in the past month.

NOT AT MILD MODERATE SEVERE EXTREME

ALL

OOOOOOOOO
OOOOOOOOO
OOOOOOOOO
OOOOOOOOO
OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO OOOOOOOOO OOOOOOOOO
OOOOOOOOO OOOOOOOOO OOOOOOOOO OOOOOOOOO
Markedly
Subthreshold Threshold Incapacitated
Elevated

89
 Adolescent Dissociative Experiences Scale-II (A-DES)

The A-DES is a 30 - item self-report instrument appropriate for those aged ten to twenty-one.
It is a screening tool that fits an adolescent's phase-appropriate development. The A-DES is
not a diagnostic tool. Its items survey dissociative amnesia, absorption and imaginative
involvement (including confusion between reality and fantasy), depersonalization,
derealization, passive influence/interference experiences, and identity alteration.

While the A-DES might be used to screen for dissociative experience in large populations in
a short period of time or as the basis for a differential diagnosis by a clinician learning about
dissociation, its primary use is in the evaluation of dissociative symptoms for individual
patients. Clinician's may learn nearly as much from exploring the reasons patients chose to
endorse certain items as they would from looking at test scores. Sidran Foundation offers the
A-DES along with a short manual about it for a nominal fee. The Sidran Foundation can be
reached at (410) 825-8888, or email: sidran@access.digex.net. Or on the Internet at
http://www.sidran.org.

The A-DES is scored by summing item scores and dividing by 30 (the number of items).
Overall scores can range from 0-10.

These questions ask about difference kinds of experiences that happen to people. For
each question, circle the number that tells how much that experience happens to you.
Circle a "0" if it never happens to you, circle a "10" of it is always happening to you.
If it happens sometimes but not all of the time, circle a number between 1 and 9 that
best describes how often it happens to you. When you answer, only tell how much these
things happen when you have not had any alcohol or drugs.

EXAMPLE:

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

90
 Adolescent Dissociative Experiences Scale-II (A-DES)
(Armstrong, Carlson, & Putnam)

1. I get so wrapped up in watching TV, reading, or playing a video game that I don't have any idea
what's going on around me.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

2. I get back tests or homework that I don't remember doing.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

3. I have strong feelings that don't seem like they are mine.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

4. I can do something really well one time and then I can't do it at all another time.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

5. People tell me I do or say things that I don't remember doing or saying.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

6. I feel like I am in a fog or spaced out and things around me seem unreal.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

7. I get confused about whether I have done something or only thought about doing it.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

8. I look at the clock and realize that time has gone by and I can't remember what has happened.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

9. I hear voices in my head that are not mine.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

10. When I am somewhere that I don't want to be, I can go away in my mind.

91
 0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

11. I am so good at lying and acting that I believe it myself.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

12. I catch myself "waking up" in the middle of doing something.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

13. I don't recognize myself in the mirror.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

14. I find myself going somewhere or doing something and I don't know why.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

15. I find myself someplace and I don't remember how I got there.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

16. I have thoughts that don't really seem to belong to me.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

17. I find that I can make physical pain go away.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

18. I can't figure out if things really happened or if I only dreamed or thought about them.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

19. I find myself doing something that I know is wrong, even when I really don't want to do it.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

20. People tell me that I sometimes act so differently that I seem like a different person.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always

92
21. It feels like there are walls inside of my mind.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

22. I find writings, drawings or letters that I must have done but I can't remember doing.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

23. Something inside of me seems to make me do things that I don't want to do.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

24. I find that I can't tell whether I am just remembering something or if it is actually
happening to me.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

25. I find myself standing outside of my body, watching myself as if I were another person.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

26. My relationships with my family and friends change suddenly and I don't know why.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

27. I feel like my past is a puzzle and some of the pieces are missing.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

28. I get so wrapped up in my toys or stuffed animals that they seem alive.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

29. I feel like there are different people inside of me.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

30. My body feels as if it doesn't belong to me.

0 1 2 3 4 5 6 7 8 9 10
(Never) (Always)

93
 The Child Dissociative Checklist (CDC)

The CDC is a tool which compiles observations by an adult observer regarding a

child's behaviors on a 20 item list. Behaviors which occur in the present and for the
last 12 months are included.

Research shows that healthy non-maltreated normal children usually score low on the
CDC, with younger children scoring slightly higher. As a group, maltreated children
score higher than those with no trauma history; however as a group they still score
substantially lower than children diagnosed with a dissociative disorder. As with any
screening tools, a trained clinician should assess the child in a face to face interview
before a diagnosis is confirmed.

NOTE: If the observer has no nighttime observation of the child, items 17 and 18
should be ignored.

For finer screening, the CDC also could be administered sequentially in an interval
based series.

NOTE: Non-dissociative children often increase their scores by a small amount

(1-3 points) over the first few completions because the questions draw
attention to minor dissociative behaviors that had not previously been
noticed.

The CDC can be used as a rough index of treatment progress. While evidence for this
use is limited, it seems that the CDC provides a reasonable indication of whether a
child is improving over time or with treatment.

Users of the CDC are cautioned that CDC scores reported in the literature for the
various groups are means that reflect the ‘average' child in a given group. Individual
children in any of the groups can, and often do, exhibit varying scores on the CDC.
Thus, a high score doesn't prove a child has a dissociative disorder, nor does a low
score rule it out. Since the CDC reports observers' ratings of a child, variations in the
observers' interpretations of behavior as well as actual variations in child behavior
may affect the variance. This is a potential complication in any observer-based
assessment, but it may be especially important when observers are drawn from those
whose perceptions may be clouded by their attachment to the child.

Scoring:

Any score above 12 should be considered suspicious, and a score above 19 is cause
for concern of a serious dissociative disorder.

94
 Child Dissociative Checklist (CDC), Version 3
(Frank W. Putnam)

Below is a list of behaviors that describe children. For each item that describes your child
now or within the past 12 months. Please circle 2 if the item is very true of your child. Circle
1 if the item is somewhat or sometimes true of your child. If the item is not true of your child,
circle 0.

0 1 2 (1) Child does not remember or denies traumatic or painful experiences

that are known to have occurred

0 1 2 (2) Child goes into a daze or trance-like state at times or often appears
“spaced-out.” Teachers may report that he or she “daydreams” frequently
in school

0 1 2 (3) Child shows rapid changes in personality. He or she may go from

being shy to being outgoing, from feminine to masculine, from timid
to aggressive

0 1 2 (4) Child is unusually forgetful or confused about things that he or she

should know, e.g. may forget the names of friends, teachers or other
important people, loses possessions or gets easily lost

0 1 2 (5) Child has a very poor sense of time. He or she loses track of time,
may think that it is morning when it is actually afternoon, gets
confused about what day it is, or becomes confused about when
something has happened

0 1 2 (6) Child shows marked day-to-day or even hour-to-hour variations in

his or her skills, knowledge, food preferences, athletic abilities such as
changes in handwriting, memory for previously learned information (i.e.
multiplication tables, spelling, use of tools or artistic ability)

0 1 2 (7) Child shows rapid regressions in age-level behavior, such as a twelve-

year-old starts to use baby-talk sucks thumb or draws like a four-year old

0 1 2 (8) Child has a difficult time learning from experience, such as

explanations, normal discipline or punishment do not change his or her
behavior

0 1 2 (9) Child continues to lie or deny misbehavior even when the evidence
is obvious

0 1 2 (10) Child refers to himself or herself in the third person (e.g. as she
or her) when talking about self, or at times insists on being called
by a different name. He or she may also claim that things that he or
she did actually happened to another person

95
0 1 2 (11) Child has rapidly changing physical complaints such as headache
or upset stomach. For example, he or she may complain of a headache
one minute and seem to forget about it the next

0 1 2 (12) Child is unusually sexually precocious and may attempt age-

inappropriate sexual behavior with other children or adults

0 1 2 (13) Child suffers from unexplained injuries or may even deliberately

injure self at times

0 1 2 (14) Child reports hearing voices that talk to him or her. The voices may
be friendly or angry and may come from “imaginary companions” or
sound like the voices of parents, friends or teachers

0 1 2 (15) Child has a vivid imaginary companion or companions. Child may

insist that the imaginary companion(s) is responsible for things that
he or she has done

0 1 2 (16) Child has intense outbursts of anger, often without app aren’t cause
and may display unusual physical strength during these episodes

0 1 2 (17) Child sleepwalks frequently

0 1 2 (18) Child has unusual nighttime experiences, e.g. may report seeing
“ghosts” or that things happen at night that he or she can’t account
for (e.g. broken toys, unexplained injuries)

0 1 2 (19) Child frequently talks to him or herself, may use a different voice
or argue with self at times

0 1 2 (20) Child has two or more distinct and separate personalities that take
control over the child’s behavior

96
 Dissociative Experiences Scale II (DES II)

The Dissociative Experiences Scale-II (DES-II) is a 28-item self-report scale used

to measure of the frequency of dissociative experiences. The scale was developed
to provide a reliable, valid, and convenient way to quantify dissociative
experiences. A response scale that allows subjects to quantify their experiences
for each item was used so that scores could reflect a wider range of dissociative
symptomatology than possible using a dichotomous (yes/no) format.

When scoring the DES-II, drop the zero on the percentage e.g. 30%=3; 80%=8
then add up single digits for the client’s score. Loosely interpreted, the score will
reflect the percentage of time that the clients experiences dissociative phenomena. Scores
of > 20 indicate significant level of dissociation and score > 30 indicate, generally, the
presence of PTSD, and when > 35 this individual should be evaluated for Dissociative
Identity Disorder using the SCID-D. This instrument measures the three main factures of
dissociation (amnesia, depersonalization/derealization, and absorption).

The Amnesia Factor measures memory loss (i.e. not knowing how you got
somewhere, being dressed in clothes you don’t remember putting on, finding new
things among belongings you don’t remember buying, not recognizing friends or
family members, finding evidence of having done things you don’t remember
doing, finding writings, drawings or notes you must have done but don’t
remember doing). Items - 3, 4, 5, 8, 25, 26

The Depersonalization/Derealization Factor: Depersonalization is characterized by

the recurrent experience of feeling detached from one’s self and mental processes
or a sense of unreality of the self (i.e. feeling that you are standing next to
yourself or watching yourself do something and seeing yourself as if you were
looking at another person, feeling your body does not belong to you, and looking
in a mirror and not recognizing yourself). Derealization is the sense of a loss of
reality of the immediate environment (i.e. feeling that other people, objects, and
the world around them is not real, hearing voices inside your head that tell you to
do things or comment on things you are doing, and feeling like you are looking at
the world through a fog, so that people and objects appear far away or unclear).
Items - 7, 11, 12, 13, 27, 28

The Absorption Factor includes being so preoccupied or absorbed by something

that you are distracted from what is going on around you. The absorption
primarily has to do with one’s traumatic experiences (i.e. realizing that you did
not hear part or all of what was said by another, remembering a past event so
vividly that you feel as if you are reliving the event, not being sure whether
things that they remember happening really did happen or whether they just
dreamed them, when you are watching television or a movie you become so
absorbed in the story you are unaware of other events happening around you,
becoming so involved in a fantasy or daydream that it feels as though it were
really happening to you, and sometimes sitting, staring off into space, thinking of
nothing, and being unaware of the passage of time). Items - 2, 14, 15, 17, 18, 20.
97
 Dissociative Experiences Scale-II (DES-II)
(Carlson, & Putnam).

Directions: This questionnaire consists of twenty-eight questions about experiences that

you may have in your daily life. We are interested in how often you have these
experiences. It is important, however, that your answers show how often these
experiences happen to you when you are not under the influence of alcohol or drugs. To
answer the questions, please determine to what degree the experience described in the
question applies to you, and circle the number to show what percentage of the time you
have the experience.

For example: 0% 10 20 30 40 50 60 70 80 90 100%

(Never) (Always)

1. Some people have the experience of driving or riding in a car or bus or subway and
suddenly realizing that they don’t remember what has happened during all or part of the
trip. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

2. Some people find that sometimes they are listening to someone talk and they suddenly
realize that they did not hear part or all of what was said. Circle the number to show what
percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

3. Some people have the experience of finding themselves in a place and have no idea how
they got there. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

4. Some people have the experience of finding themselves dressed in clothes that they
don’t remember putting on. Circle the number to show what percentage of the time this
happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

5. Some people have the experience of finding new things among their belongings
that they do not remember buying. Circle the number to show what percentage of
the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

6. Some people sometimes find that they are approached by people that they do not know,
who call them by another name or insist that they have met them before. Circle the number
to show what percentage of the time this happens to you
0% 10 20 30 40 50 60 70 80 90 100%

7. Some people sometimes have the experience of feeling as though they are standing next
to themselves or watching themselves do something and they actually see themselves as if
they were looking at another person. Circle the number to show what percentage of the
time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
98
8. Some people are told that they sometimes do not recognize friends of family members.
Circle the number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

9. Some people find that they have no memory for some important events in their lives
(for example, a wedding or graduation). Circle the number to show what percentage of
the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

10. Some people have the experience of being accused of lying when they do not think that
they have lied. Circle the number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

11. Some people have the experience of looking in a mirror and not recognizing
themselves. Circle the number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

12. Some people have the experience of feeling that other people, objects, and the world
around them are not real. Circle the number to show what percentage of the time this
happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

13. Some people have the experience of feeling that their body does not seem to belong to
them. Circle the number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

14. Some people have the experience of sometimes remembering a past event so vividly that
they feel as if they were reliving that event. Circle the number to show what percentage of
the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

15. Some people have the experience of not being sure whether things that they
remember happening really did happen or whether they just dreamed them. Circle the
number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

16. Some people have the experience of being in a familiar place but finding it strange and
unfamiliar. Circle the number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

17. Some people find that when they are watching television or a movie they become so
absorbed in the story that they are unaware of other events happening around them.
Circle the number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

18. Some people find that they become so involved in a fantasy or daydream that it feels as
though it were really happening to them. Circle the number to show what percentage of the
time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

99
19. Some people find that they sometimes are able to ignore pain. Circle the number
to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

20. Some people find that they sometimes sit staring off into space, thinking of nothing, and
are not aware of the passage of time. Circle the number to show what percentage of the time
this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

21. Some people sometimes find that when they are alone they talk out loud to
themselves. Circle the number to show what percentage of the time this happens to
you.
0% 10 20 30 40 50 60 70 80 90 100%

22. Some people find that in one situation they may act so differently compared with
another situation that they feel almost as if they were two different people. Circle the
number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

23. Some people sometimes find that in certain situations they are able to do things with
amazing ease and spontaneity that would usually be difficult for them (for example, sports,
work, social situations, etc.). Circle the number to show what percentage of the time this
happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

24. Some people sometimes find that they cannot remember whether they have done
something or have just thought about doing that thing (for example, not knowing whether
they have just mailed a letter or have just thought about mailing it). Circle the number to
show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

25. Some people find evidence that they have done things that they do not remember
doing. Circle the number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

26. Some people sometimes find writings, drawings, or notes among their belongings that
they must have done but cannot remember doing. Circle the number to show what
percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

27. Some people sometimes find that they hear voices inside their head that tell them to do
things or comment on things that they are doing. Circle the number to show what percentage
of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

28. Some people sometimes feel as if they are looking at the world through a fog, so that
people and objects appear far away or unclear. Circle the number to show what percentage
of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%

100
 Dissociative Regression Scale (DRS)
(Tinnin, Louis MD 1995)

The DRS was developed to measure the degree to which the client’s intrusive posttraumatic
and dissociative symptoms are causing a regression of ego functioning. If a client has a
higher DRS score than a DES score and they are both over 20, then this indicates that a
regression is present and stabilization must precede trauma resolution work. The further the
separation between the DRS and the DES (with the DRS being higher) the greater the degree
of regression.

Dissociative regression means that the clients has become so overwhelmed with their
intrusive and anxiety symptoms that their normal adult ego functioning (i.e., recording of
time, managing of tasks, volition, sense of identity) have been compromised. To begin
trauma work with these individuals in which they are confronting their trauma memories
will only exacerbate their symptoms.

DIRECTIONS
This questionnaire contains six items about experiences you may have had in your daily life. To answer these
items, please determine to what degree the experiences described in the questions applies to you and mark a
place on the line with a vertical slash at the appropriate place, as shown in the example below.

Example:

. . . . . . / . . . . .
0% / 100% of the time

101
 Dissociative Regression Scale (DRS)
(Tinnin, 1995)

Total: Mean:
DIRECTIONS

This questionnaire contains six items about experiences you may have had in your daily life. To answer these
items, please determine to what degree the experiences described in the questions applies to you and mark a
place on the line with a vertical slash at the appropriate place, as shown in the example below.

Example:
. . . . . . / . . . . .
0% / 100% of the time

1. Some people sometimes feel that they are not their usual self but are two or more different selves. Mark
the line to show what percentage of the time this happens to you.

. . . . . . . . . . .
0% 100% of the time

2. Some people have the feeling that their actions are being directed or controlled by others. Mark the line to
show what percentage of the time this happens to you.

. . . . . . . . . . .
0% 100% of the time

3. Some people sometimes lose their sense of time, duration and sequence of events during the day. Mark the
line to show what percentage of the time this happens to you.

. . . . . . . . . . .
0% 100% of the time

4. Some people experience changes in their body image as if their body were different or did not belong to
them. Mark the line to show the percentage of time this happens to you.

. . . . . . . . . . .
0% 100% of the time

5. Some people have the experience that other people, objects, and the world around them are not real. Mark
the line to show the percentage of time this happens to you.

. . . . . . . . . . .
0% 100% of the time

6. Some people find that they are sometimes literal-minded and have difficulty understanding jokes or figures
of speech. Mark the line to show the percentage of time this happens to you.

. . . . . . . . . . .
0% 100% of the time

102
 IMPACT OF EVENTS SCALE-Revised (IES-R)

The IES-R is a self-report measure designed to assess current subjective distress for any
specific life event. The IES-R has 22 items, 7 of which were added to the original 15-item
IES. Six of these 7 new items pertain to hyperarousal symptoms such as: anger and
irritability, heightened startle response, difficulty concentrating, and hypervigilance. One
new intrusion item pertains to the dissociative-like re-experiencing when experiencing true
flash-back.

Scoring Method:

Avoidance Subscale: Mean of items 5, 7, 8 11, 12, 13, 17, 22

Intrusions Subscale: Mean of items 1, 2, 3, 6, 9, 14, 16, 20
Hyperarousal subscale: Mean of items 4, 10, 15, 18, 19, 21
IES-R score: Sum of the above 3 clinical scales.

The revised version of the Impact of Event Scale has a scoring range of 0 to 88.
Scores that exceed 24 can be quite meaningful and have the following associations.

24 or more PTSD is a clinical concern. Those with scores this high who do not
have full PTSD will have partial PTSD or at least some of the
symptoms.

33 and above This represents the best cutoff for a probable diagnosis of PTSD.

37 or more This is high enough to suppress your immune system's functioning

(even 10 years after an impact even)

103
 IMPACT OF EVENTS SCALE-Revised (IES-R)
(Weiss, 2007)

INSTRUCTIONS: Below is a list of difficulties people sometimes have after stressful

life events. Please read each item, and then indicate how distressing each difficulty has
been for you DURING THE PAST SEVEN DAYS with respect to_________ (EVENT)
that occurred on

How much have you been distressed or bothered by these difficulties?

Not at all A little bit Moderately Quite a bit Extremely
1. Any reminder brought back feelings about it 0 1 2 3 4
2. I had trouble staying asleep 0 1 2 3 4
3. Other things kept making me think about it. 0 1 2 3 4
4. I felt irritable and angry 0 1 2 3 4
5. I avoided letting myself get upset when I
thought about it or was reminded of it 0 1 2 3 4
6. I thought about it when I didn't mean to 4
0 1 2 3
7. I felt as if it hadn't happened or wasn't real. 0 1 2 3 4
8. I stayed away from reminders of it. 0 1 2 3 4
9. Pictures about it popped into my mind. 0 1 2 3 4
10. I was jumpy and easily startled. 0 1 2 3 4
11. I tried not to think about it. 0 1 2 3 4
12. I was aware that I still had a lot of feelings
about it, but I didn't deal with them. 0 1 2 3 4
13. My feelings about it were kind of numb. 0 1 2 3 4
14. I found myself acting or feeling like I was back
at that time. 0 1 2 3 4
15. I had trouble falling asleep. 0 1 2 3 4
16. I had waves of strong feelings about it. 0 1 2 3 4
17. I tried to remove it from my memory. 0 1 2 3 4
18. I had trouble concentrating. 0 1 2 3 4
19. Reminders of it caused me to have physical
reactions, such as sweating, trouble breathing,
0 1 2 3 4
nausea, or a pounding heart.
20. I had dreams about it. 0 1 2 3 4
21. I felt watchful and on-guard. 0 1 2 3 4
22. I tried not to talk about it. 0 1 2 3 4

104
 PTSD Check List (PCL-5 with LEC-5 and Criterion A)

The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD, and
can be administered in one of three formats:

1. Without Criterion A (brief instructions and items only), which is appropriate when trauma
exposure is measured by some other method

2. With a brief Criterion A assessment

3. With the revised Life Events Checklist for DSM-5 (LEC-5) and extended Criterion A
assessment

The rating scale is 0-4 for each symptom descriptor: "Not at all," "A little bit," Moderately,"
"Quite a bit," and "Extremely.” The PCL-5 can be scored in different ways:

1. Total symptom severity score (range - 0-80) can be obtained by summing the scores for
each of the 20 items

2. DSM-5 symptom cluster severity scores can be obtained by summing the scores for the
items within a given cluster, i.e., cluster B (items 1-5), cluster C (items 6-7), cluster D (items
8-14), and cluster E (items 15-20)

A provisional PTSD diagnosis can be made by treating each item rated as 2 = "Moderately" or
higher as a symptom endorsed, then following the DSM-5 diagnostic rule which requires at least:
1 B item (questions 1-5), 1 C item (questions 6-7), 2 D items (questions 8-14), 2 E items
(questions 15-20). Preliminary validation work is sufficient to make initial cut-point suggestions,
but this information may be subject to change. A PCL-5 cut-point of 33 appears to be a
reasonable value to propose until further psychometric work is available.

Interpretation: Characteristics of a respondent's setting should be considered when using PCL

severity scores to make a provisional diagnosis. The goal of assessment also should be
considered. A lower cutoff should be considered when screening or when it is desirable to
maximize detection of possible cases. A higher cutoff should be considered when attempting to
make a provisional diagnosis or to minimize false positives.

Measuring Change: Good clinical care requires that clinicians monitor patient progress.
Evidence for the PCL for DSM-IV suggests that a 5-10 point change represents reliable change
(i.e., change not due to chance) and a 10-20 point change represents clinically significant
change. Therefore, it was recommended to use 5 points as a minimum threshold for determining
whether an individual has responded to treatment and 10 points as a minimum threshold for
determining whether the improvement is clinically meaningful using the PCL for DSM-IV.

Change scores for PCL-5 are currently being determined. It is expected that reliable and
clinically meaningful change will be in a similar range.

105
 PTSD Check List (PCL-5 with LEC-5 and Criterion A)
(Weathers, Litz, Keane, Palmieri, Marx, & Schnurr, 2013)

Part 1

Instructions: Listed below are a number of difficult or stressful things that sometimes happen to
people. For each event check one or more of the boxes to the right to indicate that: (a) it
happened to you personally; (b) you witnessed it happen to someone else; (c) you learned about
it happening to a close family member or close friend; (d) you were exposed to it as part of your
job (for example, paramedic, police, military, or other first responder); (e) you’re not sure if it
fits; or (f) it doesn’t apply to you. Be sure to consider your entire life (growing up as well as
adulthood) as you go through the list of events.

Happened Witnessed Learned Part of Not Doesn’t

Event
to me it about it my job sure apply
1. Natural disaster (for example,
flood, hurricane, tornado,
earthquake)
2. Fire or explosion

3. Transportation accident (for

example, car accident, boat
accident, train wreck, plane
crash)
4. Serious accident at work,
home, or during recreational
activity
5. Exposure to toxic substance
(for example, dangerous
chemicals, radiation)
6. Physical assault (for example,
being attacked, hit, slapped,
kicked, beaten up)
7. Assault with a weapon
(for example, being shot,
stabbed, threatened with
a knife, gun, bomb)
8. Sexual assault (rape,
attempted rape, made to
perform any type of sexual act
through force or threat of

106
 harm)

9. Other unwanted or
uncomfortable sexual
experience
10. Combat or exposure to a
war-zone (in the military or
as a civilian)
11. Captivity (for example,
being kidnapped, abducted,
held hostage, prisoner of
war)
12. Life-threatening illness or
injury
13. Severe human suffering

14. Sudden violent death (for

example, homicide, suicide)
15. Sudden accidental death

16. Serious injury, harm, or death

you caused to someone else
17. Any other very stressful
event or experience

Part 2

A. If you checked anything for #17 in PART 1, briefly identify the event you were thinking of:
____________________________________________________________________

B. If you have experienced more than one of the events in PART 1, think about the event you
consider the worst event, which for this questionnaire means the event that currently bothers
you the most. If you have experienced only one of the events in PART 1, use that one as the
worst event. Please answer the following questions about the worst event (check all options
that apply):

Briefly describe the worst event (for example, what happened, who was involved, etc.).

________________________________________________________________________

How long ago did it happen? _____________ (please estimate if you are not sure)

107
 How did you experience it?
_____ It happened to me directly
_____ I witnessed it
_____ I learned about it happening to a close family member or close friend
_____ I was repeatedly exposed to details about it as part of my job (for example, paramedic,
police, military, or other first responder)
_____ Other, please describe__________________________________________

Was someone’s life in danger?

_____ Yes, my life
_____ Yes, someone else’s life _____ No

Was someone seriously injured or killed?

_____ Yes, I was seriously injured
_____ Yes, someone else was seriously injured or killed _____ No

Did it involve sexual violence? _____ Yes _____ No

If the event involved the death of a close family member or close friend, was it due to some
kind of accident or violence, or was it due to natural causes?
_____ Accident or violence _____ Natural causes
_____ Not applicable (The event did not involve the death of a close family member or close
friend)

How many times altogether have you experienced a similar event as stressful or nearly as
stressful as the worst event?
_____ Just once
_____ More than once (please specify or estimate the total number of times you have had this
experience (______ )

Part 3

Below is a list of problems that people sometimes have in response to a very stressful
experience. Keeping your worst event in mind, please read each problem carefully and then
circle one of the numbers to the right to indicate how much you have been bothered by that
problem in the past month.
In the past month, how much were you bothered by: Not A Moderately Quite Extremely
at all little a bit
bit

1. Repeated, disturbing, and unwanted memories of the stressful

experience? 0 1 2 3 4

108
2. Repeated, disturbing dreams of the stressful experience? 0 1 2 3 4
3. Suddenly feeling or acting as if the stressful experience were
actually happening again (as if you were actually back there 0 1 2 3 4
reliving it)?
4. Feeling very upset when something reminded you of the
stressful experience? 0 1 2 3 4

5. Having strong physical reactions when something reminded you

of the stressful experience (for example, heart pounding, trouble 0 1 2 3 4
breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful
experience? 0 1 2 3 4

7. Avoiding external reminders of the stressful experience (for

example, people, places, conversations, activities, objects, or 0 1 2 3 4
situations)?
8. Trouble remembering important parts of the stressful
0 1 2 3 4
experience?
9. Having strong negative beliefs about yourself, other people, or
the world (for example, having thoughts such as: I am bad, there
0 1 2 3 4
is something seriously wrong with me, no one can be trusted,
the world is completely dangerous)?
10. Blaming yourself or someone else for the stressful experience
or what happened after it? 0 1 2 3 4

11. Having strong negative feelings such as fear, horror, anger,

guilt, or shame? 0 1 2 3 4

12. Loss of interest in activities that you used to enjoy? 0 1 2 3 4

13. Feeling distant or cut off from other people? 0 1 2 3 4
14. Trouble experiencing positive feelings (for example, being
unable to feel happiness or have loving feelings for people close 0 1 2 3 4
to you)?
15. Irritable behavior, angry outbursts, or acting aggressively? 0 1 2 3 4
16. Taking too many risks or doing things that could cause you
0 1 2 3 4
harm?
17. Being “superalert” or watchful or on guard? 0 1 2 3 4
18. Feeling jumpy or easily startled? 0 1 2 3 4
19. Having difficulty concentrating? 0 1 2 3 4
20. Trouble falling or staying asleep? 0 1 2 3 4

109
 Satisfaction With Life Scale (SWLS)
Diener, Emmons, Larsen, & Griffin, 1985)
(used with permission)

The Satisfaction With Life Scale (SWLS) is a 5-item instrument designed to measure global
cognitive judgments of satisfaction with one’s life. Life satisfaction is one factor in the more
general construct of subjective well-being. Theory and research from fields outside of
rehabilitation indicate that subjective well-being has at least three components: positive affective
appraisal, negative affective appraisal, and life satisfaction (Pavot & Diener, 2008). Life
satisfaction is distinguished from affective appraisal in that it is more cognitively than
emotionally driven. Life satisfaction can be assessed specific to a particular domain of life (e.g.,
work, family) or globally––the SWLS is a global measure of life satisfaction.

The SWLS has been used in the general population of many cultures, as well as a great variety of
clinical and social subpopulations. It has well-known qualities when used with people who have
experienced traumatic brain injury (TBI), though it has been primarily used with individuals who
have required acute rehabilitation for their injuries.
Scores on the SWLS have been shown to correlate with measures of mental health, and be
predictive of future behaviors such as suicide attempts. In the area of health psychology, the
SWLS has been used to measure the subjective quality of life of people experiencing serious
health concerns.

Relatively higher scores would indicate that a person perceives areas of their life they consider
important to be going well. Low scores would indicate the opposite. The presence of depression
normally results in lower scores, but the absence of depression does not guarantee higher scores.
The SWLS Total score is useful for group comparisons in research or program evaluation; for
clinical purposes, it would be essential to understand what life domains are important to the
individual and the basis of the evaluation made.

Scoring:
31-35 Extremely satisfied
26-30 Satisfied
21-25 Slightly satisfied
20 Neutral
15-19 Slightly dissatisfied
10-14 Dissatisfied
5-9 Extremely dissatisfied

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 Satisfaction With Life Scale (SWLS)
Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S., 1985)
(used with permission)

Below are five statements with which you may agree or disagree. Using the
scale below, indicate your agreement with each item by placing the
appropriate number on the line preceding that item. Please be open and
honest in your responding.

1 = Strongly disagree
2 = Disagree
3 = Slightly disagree
4 = Neither agree nor
5 = disagree agree
Slightly
6 = Agree
7 = Strongly agree

1. In most ways my life is close to ideal. ______

2. The conditions of my life are excellent. ______

3. I am satisfied with my life. ______

4. So far I have gotten the important things I want in life. ______

5. If I could live my life over, I would change almost nothing. ______

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 Symptom Check List
(from Trauma Profile)

Criterion A: Event + Reaction (CAPS-5; CAPS-CA-5)

 ________________________________________________________________________
 ________________________________________________________________________
 ________________________________________________________________________
 ________________________________________________________________________

Criterion B: Intrusion (CAPS-5; CAPS-CA-5; IES-R; PCL-5)

(B-1) Unwanted, intrusive, recurrent memories of the event
(B-2) Recurrent distressing dreams/nightmares
(B-3) Acted or felt as if [EVENT] was happening again/flashbacks
(B-4) Intense psychological distress with exposure to cues (internal/external)
(B-5) Physiological reactivity with exposure to cues

Criterion C: Avoidance (CAPS-5; CAPS-CA-5; IES-R; PCL-5)

(C-1) Efforts to avoid thoughts, feelings, or conversations associated with the
[EVENT]
(C-2) Efforts to avoid activities, places or people that remind of [EVENT]

Criterion D: Negative alterations in cognitions and mood (CAPS-5; CAPS-CA-5; IES-R; PCL-
5; SWLS)
(D-1) Inability to recall important aspects of the trauma
(D-2) Negative beliefs or expectations
(D-3) Distorted cognitions about [EVENT] leading to blame
(D-4) Negative emotional state
(D-5) Markedly diminished interest or participation in significant activities
(D-6) Feeling of detachment or estrangement from others
(D-7) Inability to experience positive emotions

Criterion E: Arousal (CAPS-5, CAPS-CA-5; IES-R, PCL-5)

(D-1) Irritability or outbursts of anger
(D-2) Reckless or self-destructive behavior
(D-3) Hypervigilance
(D-4) Exaggerated startle response
(D-5) Difficulty concentrating
(D-6) Difficulty falling or staying asleep

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Criterion F: Duration
More than one month (Criterion B, C, D, and E)
Delayed onset (> 6 months before symptoms)
Chronic (> 6 months)

Criterion G: Subjective Distress

Distress present
Area of life
 __________________________________________________________
 __________________________________________________________
 __________________________________________________________
 __________________________________________________________

Criterion H: Subjective Distress

______ Disturbance is not attributable to the physiological effects of a substance or another
medical condition

Dissociative Symptoms (ADES-2; CDC-3; DES-II; DRS; PCL-5)

___ Loss of time
___ Amnesia
___ Depersonalization
___ Derealization
___ Identity confusion (“parts”, alters)
___ Loss of consciousness

Depressive Symptoms (CAPS-5; CAPS-CA-5; PCL-5)

___ Depressed mood
___ Anhedonia
___ Weight loss/gain (> 5%)
___ Insominia/hypersomnia
___ Psychomotor agitation/retardation
___ Anergia
___ Feelings of worthlessness/inappropriate guilt
___ Diminished concentration
___ Suicide ideation/recurrent thoughts of death

Other Symptoms
___ Somatization (PCL-5)
___ Victim mythology/distorted belief system/Survivor Guilt
___ Weight loss/gain (> 5%)
___ Insominia/hypersomnia
___ Relational difficulties: (describe: _____________________________________)
___ Other
___ Other

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 MENTAL STATUS EXAMINATION

Check all that apply to client:

Oriented Affect Memory

Time Appropriate to Mood Immediate Normal Impaired
Place Inappropriate to Mood Recent Normal Impaired
Person Flat/Blunted Remote Normal Impaired
Not Oriented Labile

Mood Thought Process Thought Content Intelligence

Labile Spontaneous Logical/Coherent Above Average
Anxious Slow Paranoid/Persecutory Average
Manic Rapid Confused Below Average
Depressed/Sad Illogical Delusional/Bizarre
Self-Deprecating Impoverished Aggressive/Hostile
Flight of Ideas Phobias
Possible Thought Disorder Obsessive Ideas
Compulsive

Attitude Attire/Grooming Danger to Self/ Others

Cooperative Appropriate/Clean Suicide Ideations Yes No
Withdrawn Not Clean Suicide Plans Yes No
Evasive Inappropriate for Age/Sex Homicide Ideations Yes No
Manipulative Homicide Plans Yes No
Hostile/Resistant

Self-Concept Insight into Problem(s) Judgment

Good Excellent Good
Fair Moderate Fair
Poor Little or None Limited

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 Sample Psychotraumatology Evaluation
(Sample Report)

DATE: 15 December

CLIENT: XXX

IDENTIFYING INFORMATION: The client is a 38 year old married Hispanic female who
resides with her family in XXX and was referred to this therapist by XXX, a licensed clinical
psychologist in XXX, for assessment and treatment of her posttraumatic symptoms and
complications. XXX presents herself, accompanied by her husband (XXX), to this office for
assessment and treatment on December 13, 14 and 15.

PRESENTING PROBLEM(S):: The client was referred to this office for intensive outpatient
psychotrauma therapy by XXX. She has been receiving treatment from XX during the past
few months for her posttraumatic symptoms. Recently, her husband has learned that she has
been involved in an extramarital affair with a co-worker and this discovery precipitated a crisis
in their relationship that has led to this referral. The client is suffering from extreme
ambivalence regarding the decision she must make to either end the affair or separate from her
husband and family. The client reports that she is currently unable to make this decision. Both
the client and XXX believe that her involvement in the affair and her painful difficulty with
the impending decision may stem from earlier traumatic experiences. The client identifies the
development of insight and skills necessary to resolve this dilemma as the primary objective of
her treatment.

HISTORY: The client was born in XXX in 1961 where she lived for five years before her
family moved to XXX where she has lived since that time. She reports that her
grandmother was her primary caretaker and that both her parents had little involvement in
her development. Her father was an alcoholic and she reports that her mother was both
physically and emotionally abusive throughout her development. She states that she was
raped three (3) times by an uncle when she was six years old and told no one about these
incidents for several years.
As she developed into adolescence, the client states that she became very involved in the
church to escape the pain and difficulty of her home. At age 16, the client reports that her
Sunday school teacher (age 28) became enamored with her and made advances which had
strong sexual overtones. The client reports that she began to become progressively
involved with this Sunday school teacher until she was, in essence, living with her. She
states that she spent increasing amounts of time with this woman who made many
demands upon her and was kept almost as a “hostage.” The client reports that while they
never actually “had sex”, much of their time together was highly eroticized (petting,
caressing, nude massage) while at the same time this woman verbalized a legalistic
religious morality. The client reports that this relationship was maintained in this fashion

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for over five years and ended abruptly when the woman became afraid that she was being
investigated for her relationship with the client and feared losing her job at the university
where she was an instructor. During the period that the client was involved with this
woman she completed an undergraduate and graduate degree in accounting at this
university where she graduated cum laude.

Shortly after the dissolution of this relationship, the client met and married her husband,
XXX. The client reports that she has and does love her husband intensely. They have three
children, ages 14, 10 and 8. Her husband is the pastor of a church at which the client reports to
have become very much involved (playing the piano, playing in the church band, church
accounting, children’s ministry). She is also an executive-level manager in a long-distance
communications firm and has successfully maintained this job throughout the course of her
marriage. She reports that she managed each of these responsibilities flawlessly for several years,
even while she was becoming progressively depleted from her efforts.

In 1989, while pregnant with her second son, the client accidentally hit a pedestrian with her
automobile. The victim subsequently died from the wounds suffered in this accident. She was
vindicated from culpability for this accident in both civil and criminal courts.

The client reports that 10 months ago she met and eventually became obsessed with a co- worker
with whom she has had an ongoing sexual and romantic affair. She states that she is deeply in
love with this co-worker while maintaining strong feelings of love for her husband and family.
She has clear awareness of the difficulty this affair is causing her husband, her family and
herself. She has tried, on several occasions, to end this affair but has not been able to maintain
the separation. She describes this relationship as like an “addiction.” Her continued
involvement in this affair and her husband’s subsequent discovery has caused intense friction for
the client in her marriage, her job (where she may be facing disciplinary action for sexual
harassment), her family and the congregation of her church. Her continued involvement in this
affair, with its seeming self-destructive consequences, is perplexing to the client, her family and
her referring therapist.

Her desire to arrive at a decision to end her marriage, leave her family, and commit fully to the
relationship with her paramour or to terminate this relationship and return to her marriage and
family is the primary goal of her treatment. In addition to this goal, the client reports that she has
had several periods during which she “blacks out” with rage. Many of these experiences have
happened while disciplining her children, replicating her mother’s abuse episodes with her. She
states that she wants to develop insights and tools necessary to terminate this behavior so that she
is never again harmful towards her children. She also states that she has ongoing intrusive
symptoms, in the form of anxiety, nightmares and flashbacks, of the rapes that occurred when
she was six years old. She articulates a desire to resolve these symptoms during this week of
intensive outpatient therapy. The client’s husband reports, during the interview, that he is very
much committed to assisting his wife in resolving her issues and retains hope that she will return
to him, her children and their life together.

MEDICAL/PSYCHIATRIC: The client reports that she suffers from back pain, chronic

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fatigue syndrome and fibromyalgia. She has been treated for depression and anxiety for several
years by a psychiatrist with Serzone and benzodiazapines. She was recently hospitalized for
depression and is being followed by XXX, who has participated in this referral. She reports that
she is allergic to Sulfa.

Current Rx:
Prozac 20 mg/day
Klonopin 0.5mg BID

XXX symptoms are summarized in the following list:

PROBLEMS:

A. History of trauma: Criteria F, G and H. Subtype: Dissociation.

 Type I trauma of rape (3x) by uncle at age six, which she reports to have responded with
horror, terror and helplessness.

 Type I trauma of motor vehicle accident at age 28 while pregnant during which the
victim was killed.

 Type II trauma of severe physical abuse (contusions and lacerations) ongoing from
infancy to age 21 by mother. She also reports ongoing verbal and emotional abuse.

 Type II trauma of sexual captivity from ages 16 to 21 by Sunday school teacher.

B. Intrusive symptoms: Recurrent images and thoughts of each of the above traumatic
experiences (rape most prevalent), nightmares, severe psychological and physiological
distress with reminders of the trauma, dissociative flashbacks.

C. Avoidant symptoms: Efforts to avoid thinking about the trauma, avoidance of activities
which remind her of the rape, diminished interest in participating in significant activities,
Alexithymia, significant amnesia for events associated with trauma, feelings of detachment
and estrangement from others, restricted range of affect.

D. Negative mood or cognition symptoms: anhedonia, depressed mood most every day,
diminished libido, identity disturbance/ distortion, anhedonia, anergia, crying spells,
diminished concentration, inappropriate guilt/shame, victim mythology, extreme
performance standards, self-critical cognitive style.

E. Arousal symptoms: Severe insomnia/sleep disturbances, frequent irritability with

dissociative rage experiences, extreme exaggerated startle response, marked increase in
anxiety and sadness with reminders of the affair, hypervigiliance, physiological reactivity
upon exposure to events which symbolize or resemble her abuse experiences.

F. Persistence of Symptoms: for more than one month

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G. Level of Impairment: client is significantly impaired (ego-dystonic), affecting her
relationship which is self-destructive and somatization including shakiness and tremors,
marital difficulties.

Subtype: Dissociative Symptoms: Depersonalization, derealization, dissociative flashbacks,

retrograde and anteriograde amnesia, time loss,
.
FINDINGS:
Baseline values:

 Clinician Administered PTSD Scale (CAPS) = 29 (intrusive - severe) + 40 (avoidance -

severe) + 32 (arousal - extreme) = 101 total (severe clinical). Meets clinical significance
for every symptom of PTSD

 Dissociative Experiences Scale (DES) = 35.4 (significant dissociative phenomena)

 Dissociate Regression Scale (DRS) = 40 (significant dissociative regression)

 PTSD Check List 5 (PCL-5) = 80 (moderate general psychiatric

symptoms/somatization)

 Impact of Events Scale (IES-R) = 52 (Rape - extreme intrusion & avoidance)

 Satisfaction with Life Scale (SWLS) = 7 (Extremely Dissatisfied)

Mental Status: XXX is casually dressed, well groomed, of small stature and appears her stated
age with a presentation of attentive alertness. She exhibits good eye contact, amiable facial
expressions, with a friendly and cooperative demeanor. She is alert and oriented (x4), perceptive
and has extremely good verbal communication skills. Her outlook is guarded with significant
belief in future difficulties. Her affect is, much of the time, inappropriately bright to content (she
is tearful at times) and labile; her mood is anxious and depressed. She has a good attention span
and exhibits no episodes of intra-session amnesia for content during assessment. She reports
memory disturbances in the form of retrograde and anteriograde amnesia, as well as minimal
present loss of time. Her speech (English) is pressured but clear and articulate (Spanish is her
native language), coherent with a wealth of content and appropriate to content. She denies
suicidal ideation but indicates a mild preoccupation with thoughts of death. She denies homicidal
ideation or intent. She denies auditory and/or visual hallucinations and delusions. She does,
however, report episodes of depersonalization, depersonalization and dissociative flashbacks and
rages. She also reports ego-dystonic obsessions/compulsions in the form of continued
involvement with her extramarital affair. She reports very mild alcohol usage and denies any
further substance abuse. She has a remarkable fund of knowledge and is of extremely high
intelligence with good judgment. Her insight is excellent, as is her motivation for treatment.
Prognosis is hopeful.

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ASSESSMENT:
Diagnosis:
Primary: 309.81 Posttraumatic Stress Disorder
Secondary: 296.22 Major Depressive Disorder, Recurrent, Moderate
Tertiary: 300.15 Unspecified Dissociative Disorder

Criteria for stabilization:

 Self-reported ability to implement self-regulation strategies which allow client to

continue functioning and remain in control immediately following intrusive imagery,
thoughts and affect (grounding and containment).

 Self-reported mastery of affective regulation and negative arousal reduction

strategies.

 Establish self-reported environmental, interpersonal and intrapersonal safety

sufficient to begin trauma resolution phase of treatment.

 Development and practice of daily self-care activities which maintain stability in

adult functioning.

Criteria for recovery:

 Client resolves ambivalence regarding decision

 Problems B, C, D, E, F & G resolved

 IES-R< 25; CAPS-5 < 30; PCL-5 < 33; DES < 10

 Resolution of trauma memories AEB no intrusive imagery/thoughts

 Resolution of victim mythology and self-critical cognitive style.

CLIENT STRENGTHS/RESOURCES

“Loving”
”Strong will”
“Hard worker”
“Organized”
“Good humor”
Verbal abilities

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Support system (husband & family)
Financial management
Extreme intelligence
Integrity
Musical abilities
Strong spiritual/religious beliefs;
Compassionate
Financial stability

EXPECTATIONS FROM TREATMENT

1. “To make a decision [husband and family vs. paramour] that brings peace”

2. “To resolve the issues with my mother so that I never again hurt my children or
respond to them in a rage”

3. “Removal of some hurt [from past traumatic events]”

4. Resolve the psychological effects of the rapes by uncle at six years old.

5. Resolve “edginess”

6. “Being able to reconnect with and feel a part of my family”

TREATMENT PLAN:
Assessment/Evaluation (4- 6 hours)
 Introduction to treatment/Informed consent
 Structured Clinical Interview
 Psychotraumatology Evaluation
- Presenting Problem
- History and Progression of Symptoms
- Symptom Inventory/Assessment Battery/Baseline Data
- Clinician Administered Posttraumatic Stress Scale
- Dissociative Experiences Scale
- Dissociative Regression Scale
- Symptom Check List-45
- Trauma Recovery Scale
- Toronto Alexithymia Scale
- Beck Depression Inventory
- Impact of Events Scale

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  Medical History (including current Rx)
 Trauma History
 Family History
 Expectations from Treatment
 Resources Inventory
 Mental Status Exam
 Criteria for Stabilization
 Criteria for Recovery
 Treatment Plan (preliminary)
 Treatment Contract

Safety & Stabilization (2-4 hours)

 If Dissociative Regression present, then Anti-Regression Protocol (6-10 hours)
 If no Dissociative Regression, then continue with below (2-6 hours)
 Flashback Journal
 Grounding & Containment Strategies
 Arousal Reduction/Self-soothing skills
 Expression Strategies
 Continue with this phase until Criteria for Stabilization is achieved

Trauma Resolution – for Type I Trauma (non-abreactive) [4 – 8 hours]

 Time-Limited Trauma Therapy/Trauma Recovery Institute Method (Tinnin, 1994,

1998)
- Video-assisted Verbal Anamnesis (1.5 – 3 hours) – to create trauma narrative
- Recursive Review (1.5 – 3 hours) – integration and metabolization
- Non-verbal anamnesis/Trauma Art (2 – 3 hours) – resolution of intrusive imagery
- Video-dialogue (2 – 4 sessions; 1.5 – 2 hours each) – to resolve peri- and
posttraumatic
dissociation.

 Eye-Movement Desensitization & Reprocessing (with Resource Installment) (2 – 4

sessions; 1.5 – 2 hours each) – to resolve and restructure posttraumatic cognitive
distortions

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  Focal and Dynamic Psychotherapy – (1 – 4 sessions; 1.5 hours each) – to resolve
traumatic grief, victim mythology, and to facilitate re-engagement.

 Re-evaluation. Upon resolution of intrusive symptoms and significant amelioration of

avoidance (depressive) and arousal symptoms, move to Phase IV. If insufficient symptom
relief, treatment plan renegotiated with possible inclusion of other trauma resolution
strategy (i.e., Traumatic Incident Reduction, Neuro-linguistic

 Programming/Visual-Kinesthetic Dissociation, Direct Therapeutic

 Exposure/Cognitive-Behavioral Therapy)

Trauma Resolution – for Type II Trauma (mild to moderate abreactive) [3 – 15 hours]

 All above with on-going psychodynamic/hypnotherapeutic psychotherapy (2 – 10

sessions; 1.5 hours each)

 Re-evaluation. Upon resolution of intrusive symptoms and significant amelioration

of avoidance (depressive) and arousal symptoms, move to Phase IV. If insufficient
symptom relief, treatment plan renegotiated with possible inclusion of other trauma
resolution strategy (i.e., Traumatic Incident Reduction, Neuro-linguistic

 Programming/Visual-Kinesthetic Dissociation, Direct Therapeutic

 Exposure/Cognitive-Behavioral Therapy)

Reconnection [4-6 hours]

 Video-assisted Mission Statement Exercise (1.5 – 3 hours)

 Conjoint marital therapy (2 hours)

 Focal Psychotherapy (if needed) – Present/future oriented (1-4 sessions; 1.5 hours each)

 Follow-up Planning/Exit Interview/Outcome Data (1.5 – 3 hours)

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 Tri-Phasic Model
Judith Herman, M.D.

Judith Herman is a psychiatrist in the Boston area. She has worked extensively with Bessel
van der Kolk and is the author of two books, Father Daughter Incest (1981) and Trauma and
Recovery (1992), and numerous articles on the enduring effects of chronic trauma. Trauma
and Recovery is considered a seminal work on the history and treatment of chronic Type II
trauma. Herman conceives trauma recovery to proceed in three stages:
Safety

The central task of recovery is safety. Victims of chronic trauma are betrayed not only by their
loved ones but by their own bodies. Their symptoms become sources of triggers that cause re-
traumatization. The clinician’s primary goal is to help the client regain internal and external
control. This is accomplished through careful diagnosis and education. If flashbacks are the
chief symptom, the clinician helps the client to learn skills to reduce their frequency and
duration. Similarly, if the client is living in an abusive environment, the therapist discusses with
her alternatives, including the availability of shelters for battered women and other abuse
victims. The overriding goal is to enable the client to make a gradual shift from “unpredictable
danger to reliable safety” (p. 155) both in their environments and within themselves.
Accomplishing this goal may take as long as nine months.

Mourning and Remembrance

In the second phase of recovery the client reconstructs her story in minute detail. Because of the
nature of traumatic memories, this process is rarely linear. Bits and pieces of the story emerge
and can be told. The objective is to create a space in which the client can relive and begin to
make sense of the devastating experiences that have shaped her life. The clinician’s role is “bear
witness” to the client’s experiences, and help her find the fortitude to heal.

Several brief treatments can be used to enable the client to describe traumatic events. These
include EMDR, time-limited trauma therapy, and traumatic incident reduction. When the
client is not able to process the events verbally, art and music therapy are useful.

Reconnection

The final stage of recovery involves redefining oneself in the context of meaningful
relationships. Trauma survivors gain closure on their experiences when they are able to see the
things that happened to them with the knowledge that these events do not determine who they
are. Trauma survivors are liberated by the conviction that, regardless what else happens to them,
they always have themselves. Most survivors also are sustained by an abiding faith in a higher
power that they believe delivered them from oppressive terror. In many instances survivors find
a “mission” through which they can continue to heal and to grow. They often end up helping
others with similar histories of abuse and neglect. Successful resolution of the effects of trauma

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is a powerful testament to the indomitability of the human spirit.
In this course, the focus of attention will be on the first two of these three phases with a
concentration on helping participants develop adequate safety with and for their clients.

Safety

In 1996, while completing a fellowship in psychotraumatology at West Virginia University in

Morgantown, WV, I wrote an article on developing and maintaining safety with trauma
survivors which was later published as a chapter in Death and Trauma (Figley, 1997). In this
chapter, which provides a protocol for assessing and developing stabilization, I attempt to
define and operationalize the concept of “safety” into three levels, relative to the treatment of
trauma survivors. These three levels of safety are as follows:

I. Resolution of impending environmental (ambient, interpersonal and intrapersonal)

physical danger)
 Removal from “war zone” (e.g., domestic violence, combat, abuse)
 Behavioral interventions to provide maximum safety
 Address and resolve self-harm

II. Amelioration of self-destructive thoughts & behaviors (i.e., suicidal/homicidal

ideation/behavior, eating disorders, persecutory alters/ego- states, addictions, trauma-
bonding, risk-taking behaviors, isolation)

III. Restructuring victim mythology into a proactive survivor identity by development

and habituation of life-affirming self-care skills (i.e., daily routines, relaxation skills,
grounding/containment skills, assertiveness, secure provision of basic needs, self-
parenting)

One of the most difficult questions that a clinician must answer for him/ herself is:
What is the adequate level of safety/stability necessary to transition to Phase II (Trauma
Resolution) of treatment? We are taught from the first days of our clinical training to “Do no
harm (primum non nocere),” which makes it logical to assume that the more safety and
stability that we, as clinicians, can affect in the lives of our clients, the better for their
treatment – right? The answer to this question is a double-edged sword. For example, early
in my career as a trauma therapist I spent many therapy hours working with clients to establish
safety and stability that, when I now look back, I see clearly that it was my own anxiety about
approaching the traumatic material. And, upon further inspection, I can see how my anxiety
actually escalated the crises of my clients. It is a commonly held hypothesis among trauma
therapists that the most important ingredient to effective establishment of stabilization and
even treatment outcomes is the confidence and competence of the clinician. This has been the
reason for the sequencing of material for this course. It you will remember the first section of
T-105, it deals with self-of-the-therapist issues and the maintenance of a non-anxious presence.
This non- anxious presence along with an unwavering optimism for the client’s prognosis is
probably the most powerful intervention that you can provide toward the development of
stabilization for your clients. Secondly, you will find that destabilization and the lack of safety
is very often behaviors and thoughts of the client in response to the bombardment of intrusive

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symptoms (nightmares, flashbacks, psychological and physiological reactivity) in their lives.
A protracted period of attempting to over-develop safety for these clients is not helpful – what
is needed is an approach which develops the minimum (“good enough”) level of safety and
stabilization and then addresses and resolves the intrusive symptoms by narratizing the
traumatic experience. This is often counter-intuitive and almost always anxiety producing for
the clinician. However, the client will be much better equipped to change his/her self-
destructive patterns (e.g., addictions, eating disorders, abusive relationships) with the intrusive
symptoms resolved, having much more of their faculties available for intervention on their
own behalf.

So again, what is the minimal standard of safety necessary to begin Phase II of treatment?
While this question has not even been addressed in the literature, much less resolved, I will
propose the following criteria:

1. Level One [Resolution if impending environmental (ambient, interpersonal and

intrapersonal) physical danger] of safety, discussed above, must be achieved. Traumatic
memories will not resolve if the client is in active danger and the clinician must use
cognitive and especially behavioral treatments to assist the client is removing him/herself
from harm’s way. (Note: see “Am Safe vs. Feel Safe” discussion below)

2. Ability to distinguish between “Am Safe” and “Feel Safe.” Many trauma survivors
feel as if danger lurks around every corner, every next minute. In fact, the symptom
cluster of “Arousal” is mostly about this phenomenon. It is important for the clinician to
confront this distortion and help the client to distinguish, objectively, between “outside
danger” and “inside danger.” Outside danger, or a “real” environmental threat, must be
met with behavioral interventions designed to help the survivor remove or protect
her/himself from this danger. Inside danger, or the fear resultant from intrusive symptoms
of past traumatic experiences, must be met with interventions designed to lower arousal
and develop awareness and insight into the source (memory) of the fear.

3. Development of a battery of self-soothing, grounding, containment and

expression strategies AND the ability to utilize them for self-rescue from
intrusions. These techniques should be taught during the early sessions prior to
beginning Phase II of treatment. At a minimum, clients should be taught the
following skills:

a. 3-2-1 Sensory grounding technique

b. Visualization of a “safe-place”
c. Progressive relaxation (and/or other anxiety-reduction skills)
d. Development of self-soothing discipline (e.g., working out, music, art,
gardening, etc)
e. Containment strategy(ies)
f. Expression Strategy(ies)

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4. Ability to demonstrate self-rescue. It is useful to ask the client to begin to narrate his/her
traumatic experience(s) and when s/he begins to experience intensifying affect the
clinician should challenge him/her to implement the skills above to demonstrate the ability
to self-rescue from a full-blown flashback. This successful experience can then be utilized
later in treatment to empower the client to extricate him/herself from overwhelming
traumatic memories. It also is a testament to the client now being empowered with choice
to continue treatment and confront trauma memories. The metaphor of teaching a novice
sailor the procedures of sailing mechanics prior to casting off so that s/he can assist with
the management of the boat, instead of becoming a liability during rough seas, is a useful
tool for explaining this important skill.
5. Contract with client to address traumatic material. The final important ingredient of
the Safety Phase of treatment is negotiating the contract with the client to move forward to
Phase II (Trauma Resolution) with the client. Remember from previous work the
importance of mutual goals in the creation and maintenance of the therapeutic alliance—It
is important for the clinician to harness the power of the client’s willful intention to resolve
the trauma memories before moving forward. An acknowledgment of the client’s
successful completion of the Safety Phase of treatment coupled with an empowering
statement of positive prognosis will most likely be helpful here (i.e., “I have watched you
develop some very good skills to keep yourself safe and stable in the face of these horrible
memories. Judging from how well you have done this, I expect the same kind of success as
we begin to work toward resolving these traumatic memories. What do you need before
we begin to resolve these memories?”).

In your Psychotraumatology Evaluation with your client, you developed some objective criteria
for stabilization (see previous section). It is important to review these criteria before moving
forward. It is a good idea to administer another set of assessment instruments (e.g., CAPS-5,
DES-II, DRS, PCL-5, IES-R, and SWLS) and discuss the results with the client. It is not
necessary that the client meet all the objective criteria before moving to Phase II, however, the
clinician should be able to interpret these shortcomings to insure that there is no danger in
moving ahead with treatment. Some “red flags” which should alert the clinician that movement
forward may be premature are as follows:
 CAPS-5 = 101
 DES-II = 34.4
 DRS = 40 (with both scores > 20 and the difference between >
 IES-R = 52
 PCL-5 > 80
 SWLS = 7

If any of these scores are present then it could indicate that (a) the client needs more work
toward the development of stabilization skills and/or (b) the client is experiencing a dissociative
regression.

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 Managing Dissociative Regression
(adapted from Tinnin, 1995)

What is dissociative regression? This phenomenon has been described by Tinnin (1995) as
the condition that ensues when the ego (or left brain) is constantly being bombarded and
overwhelmed by intrusive symptoms (i.e., flashbacks, affect, abreactions, pain). Autonomous
executive ego functions, such as time, volition, identity and affect regulation begin to
deteriorate, or regress.

What are sign/symptoms of a dissociative regression? When the scores of the DRS are
significantly higher than the scores on the DES, or when the DRS score is over 50, you should
be alerted to the possibility of dissociative regression. Also, the following can indicate the
presence of regression:

1. Suicidal crises that dominate the focus of therapy and invoke rescue by the therapist.

2. Escalating abreactions that involve uncontrolled, recurrent dissociative states and

switching to alter personalities. This is a repeated reenactment, or reliving, of past
traumas. It generates high arousal in the body’s physiology and may be complicated
by addiction to endogenous opiates secreted by the brain. This may require an
intervention designed for addictive conditions.

3. Regressive dependency involves “ego regression”, or loss of self-regulation of basic

ego functions (Tinnin, 1990). It is manifested as a diffusion of identity with a weak
sense of self-constancy. The patient’s volition is also weakened with a turning to wish
fulfillment instead of willed action. The patient’s sense of time is diffused and may
affect the subjective time of day, sense of duration, and sequence of events. The
patient’s body image may be affected with the loss of a feeling of ownership and
constancy of the body. The person’s reality perception and capacity for verbal
symbolization (alexithymia) may be weakened. Finally, the patient’s capacity to
manage affect is diminished.

What should I do if my client exhibits dissociative regression? Stop all trauma work
immediately. The client cannot process traumatic materially effectively while
experiencing a dissociative regression and such work may cause further harm to the
already weakened ego. The following represents an effective treatment plan for dealing
with dissociative regression:

Prohibitions
• No alcohol or sedatives or stimulants
• No rumination
• No naps

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 Stimulus Barrier
• Medication (short-term neuroleptic or anticonvulsant)
• Interpersonal stimulation but avoiding over-stimulation
• Avoid rumination by motor activity (aerobic)

Reduce Ambiguity
• Adopt a benign, authoritative manner with formalized role boundaries and careful,
concrete communication, avoiding metaphor.

Auxiliary Ego Function

• “Therapeutic assistants” are enlisted from family, friends and significant others to
perform specific tasks, for example, in keeping the patient on schedule completing
therapeutic chores;
• Specific and prescribed – no “over helping”

Support Autonomous Ego Functions

• Daily schedule for sleep, meals and activities (q ½ hour) and hold patient to
schedule;
• patient keeps log of meals, sleep, activities, flashback journal;
• video-taping of sessions to foster identity;
• use of time-line narrative and graphic time-line to foster identity
• scrapbook or bulletin board
• autobiography

Grounding and Containment Skills

• For use with addictive reenactments and flashbacks.

How long will this take? If the client is cooperative with the treatment tasks described above,
most dissociative regressions abate within two - three weeks. If it continues longer, consult
psychiatrist/hospital.

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 Grounding & Containment

I. Overview of Safety
A. Inside or Outside
1. Safety Reconnaissance
a. Treatment Planning
2. “Am safe” vs. “feel safe”
B. A word about “Balanced Living/Systems Management”
II. Inside/Intrapersonal Management of Traumatic Stress
A. Triggers
1. What are “triggers”
2. Three Phases
1) Environmental Stimuli
2) Emergent Memory + Arousal
3) Emotional Aftermath
B. Grounding (in vivo ASAP)
1. 3-2-1 Sensory Grounding
2. Relaxation Strategies
a. Progressive
b. Autogenics
c. Biofeedback
d. Diaphragmatic (Belly) Breathing
e. Tubes-in-legs Breathing
f. Stress Inoculation (Michenbaum, 1989)
3. Postural Grounding
4. Transitional Object
5. Neuro-Linguistic Programming (NLP) Anchoring Techniques
6. Internal Safe Place
7. Mindfulness
8. Affirmations/Slogans (AA/NA)

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 9. Eye Movement
a. For acute dissociative flashbacks
10. Sensory Experiences (food, drink, smells, bath, ice)
11. Rubber Band
10. Grounding Tape
11. Post-It Notes
12. Spiral Technique
13. Light Steam
14. Journaling
15. Visualization
a. Stop Sign
b. “What appears to be a cave is, in truth, a tunnel”
18. Reading aloud
19. Serenity Prayer
C. Containment
1. Of What?
a. Triggers/Flashbacks
b. Suicide Ideations/Behaviors
c. Self Injurious Behavior
d. Switching
e. Intense Emotions
f. Alters (word of caution)
2. Internal Vault/Box
3. “What do you want that you are afraid that you won’t get?”
4. Internal Safe Place (with safe objects for sleep)
5. Dissociative Table Technique (Fraser, 1992)
6. Art Therapy with triggers
7. Cigar Box/Envelope w/ staples
8. Titration: metaphors (Slow Leak - Kluft)
9. Transference/Projective Identification (“Who am I right now…how do I want to
hurt you?”)

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 10. Rituals (Sleep)
11. Containment/Expression Tachometer

D. Expression
1. Timed/metered affect modulation
2. Sounds/primal scream (automobile)
3. Anxiety to Anger
4. Tearing Paper
5. Video-dialogue
6. Red Marker
7. Ice

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 Flashback Journal

Self-soothing
Symptom Trigger Memory SUDs Skill(s) used SUDs

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