Confounding Factors

There are a number of ways that PTSD trauma assessment can be challenging. Some PTSD symptoms are difficult to assess because of confounding factors that make it difficult to determine whether the symptom is trauma related. These symptoms generally fall in Cluster D (negative alterations in cognitions and mood) and Cluster E, alterations in arousal and reactivity.

Confounding factors include:

• Non-trauma factors appearing to be PTSD symptoms
• Chronicity
• Multiple traumas

In general, if the symptom can be connected to the trauma exposure, then it would be counted towards the PTSD diagnosis.

Non-Trauma Factors Explaining What Appear to be PTSD Symptoms

Determining trauma-relatedness can also be challenging when a non-trauma-related symptom mimics a PTSD symptom. For instance, the following factors may complicate giving a trauma-relatedness rating:

• Difficulty remembering trauma events may be related to memory impairment associated with aging
• Loss of interest in previously enjoyed activities may occur because previously enjoyed activities are no longer feasible owing to physical limitations
• Sleep disturbance may be associated with having a newborn child in the home

Chronicity

It is necessary to establish a link between the PTSD symptoms reported by the respondent during a CAPS-5 administration and the reported trauma exposure. There are some occasions when this may prove to be more difficult than expected. For example, determining the trauma-relatedness of PTSD symptoms may be especially difficult for individuals who were exposed to childhood traumas. These individuals may not remember a time prior to the trauma, making it difficult to know whether the symptoms began in relation to the trauma.

If you are unsure whether a symptom is trauma related, the trauma-relatedness should be coded as "probable." A symptom should only be coded as "unlikely" to be trauma related when you are certain that the symptom is not trauma related. In other words, unless you have definitive information indicating that the symptom is not trauma related, you should give the benefit of the doubt to the respondent. Symptoms that existed prior to the index trauma that were worsened by exposure to the index trauma should also be considered trauma related and counted toward the diagnosis. For example, if an individual reported that he always had trouble sleeping, but these problems increased after the index event, we would count the sleep disturbance as trauma related.

Multiple Traumas

Assessing PTSD in an individual who has been multiply traumatized can be challenging. To understand why, we must first consider the three possibilities of trauma exposure that a CAPS-5 interviewer will encounter:

• If the individual endorses only one traumatic event, or identifies one unique event as the worst event, conduct one CAPS-5 based on the one event, or the one determined to be the worst.
• If the individual indicates that his/her worst trauma exposure was due to multiple incidents of the same type of event (e.g., multiple instances of childhood sexual abuse or multiple combat exposures), administer the CAPS-5 once, and the multiple events of the same type would be treated as a singular exposure.
• If the individual indicates that he/she has several events that were equally bad, and these events fall into different categories (e.g., one childhood sexual abuse incident and one combat incident), administer a separate CAPS-5 interview for each identified event.
• The CAPS-5 is not designed to simultaneously assess PTSD symptoms for multiple disparate traumatic events. Administer a separate CAPS-5 interview for each identified event.
• Such situations are relatively rare and usually one event will clearly emerge as the most salient and the one associated with most or all of the symptoms.

It is important to examine the weight of the evidence (i.e., symptoms worsen around anniversaries or reminders of the event, the clientinterviewee describes clear etiological links between the trauma(s) and the symptoms) for an association between current symptoms and the traumatic event. You should also not assume that a symptom is unrelated because symptom onset does not follow immediately or shortly after the traumatic exposure.