Memory, Attention, and Concentration
Memory dysfunction is a common presenting problem from patients with PTSD and can be observed by third parties, such as family members, coworkers, or employers. Patients are told they are forgetting conversations they've had or tasks they were expected to perform. Memory problems can also be observed clinically in patients' inability to recall information from their pasts surrounding the traumatic event, missing appointment times, or forgetting to do between-session homework assignments, for example.
The assessment of memory in PTSD in some ways is no different from assessment of memory in general. The Wechsler Memory Scale-Third Edition (WMS-III) is a widely used instrument with a solid research base across clinical populations and sound psychometric properties. The WMS-III has not been identified as a specific instrument for use in PTSD assessment, but its clinical utility will help any clinician assess a PTSD patient's memory functioning, whether dysfunction is viewed as related to PTSD symptomotology.
Measurement of attention and concentration problems in PTSD patients follows along similar lines of memory assessment. Various non-PTSD specific measures of attention and concentration can be employed, such as the Trail Making Test Parts A and B or the Continuous Performance Test. To reiterate, these instruments are suggested as generic measures of attention and concentration deficits whether related to PTSD or not. Keep in mind, however, that the Trail Making Test Parts A and B is susceptible to anxiety effects, particularly performance anxiety, and that poor scores may reflect either the effects of anxiety or poor attention and concentration. Although this could be a confound in one's clinical formulation, it may, in fact, help a clinician see his or her examinee's attention and concentration functioning within the context of anxiety.
As has been discussed in Chapter 8, dissociative symptoms such as derealization, depersonalization, or psychogenetic amnesia are sometimes critical features of a PTSD patient's presentation. Research has shown considerable prevalence of dissociative symptoms in trauma victims. Sometimes these symptoms warrant a separate diagnosis of a Dissociative Disorder, but when assessing PTSD, they are a considered a necessary component to thorough assessment, and although formal assessment may ultimately be unnecessary, at the very least dissociative symptoms should be inquired about in the initial interview.
The DSM-IV-TR defines dissociation as the disruption in the usually integrated functions of consciousness, memory, identity, or perception . . . (p. 822). According to Steinberg (2004), there are five essentially measurable symptoms of dissociation that can be reliably and validly measured by the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). They are amnesia, depersonalization, derealization, identity confusion, and identity alteration. The SCID-D is a clinician-administered instrument for either adults or adolescents and allows for the eventual diagnosis of the five Dissociative Disorders in the DSM-IV-TR: Dissociative Amnesia, Dissociative Fugue, Depersonalization Disorder, Dissociative Identity Disorder, and Dissociative Disorder Not Otherwise Specified.
Personality, General Psychological Functioning, and Comorbid Diagnoses
As was discussed in Chapter 3, PTSD patients may exhibit altered personality functioning and significant dysfunction in other aspects of their functioning, including coping, ego-defense mechanisms, relationships, and motivation. Specific instruments for use with PTSD patients have not been identified in the literature. However, a clinician can use any number of more generic available instruments to assess these areas.
Personality functioning can be very adequately assessed using the Minnesota Multiphasic Personality Inventory-Second Edition (MMPI-2), the Millon Clinical Multiaxial Inventory-Third Edition (MCMI-III), the NEO-Personality Inventory (Neuroticism, Extroversion, Openness), or the 16 PF (Personality Factors). The MMPI-2 is considered the gold standard in personality and psychological functioning assessment and is particularly useful for PTSD because of some specialized scales developed to detect and assess PTSD symptomology. Keane, Malloy, and Fairbank (1984) developed the PK scale, consisting of specific items on the MMPI-2 to detect PTSD symptoms, and it is considered a good initial screening tool. Schlenger and Kulka (1989) also developed a PTSD subscale for the MMPI-2 that can be used to differentiate between veterans who are experiencing PTSD, those with other mental disorders, and those with no mental disorder.
Luxenberg and Levin (2004) propose that the Rorschach is a useful instrument in PTSD assessment. Although the Rorschach is a controversial instrument within the psychological assessment community, Luxenberg and Levin propose that it is useful in providing not only information about PTSD symptoms but also information about a patient's sense of self, worldview, perceptions of others, and affective functioning. The Rorschach is considered a good tool by some for use with patients who have trouble consciously accessing thoughts, feelings, and memories related to their traumas because it can get (purportedly) around defense mechanisms and limits to conscious recollection and reporting.
Certainly a patient's general health status and any problems should be part of a comprehensive assessment. Some professionals are not licensed or qualified to perform a standard medical history and physical, but general inquiry should always be performed. Of particular interest when discussing health issues in PTSD assessment are cardiac functioning, general immunity or immune functioning, and neurological status. As was discussed in Chapter 3, trauma victims may suffer from neurological problems as a direct result of the traumatic event they experienced. Patients should be assessed for a history of traumatic brain injury; closed-head injury, such as anoxic injuries (for example, from drowning accidents or exposures to gases); neurotoxic or toxic exposures; and chronic Alcohol Abuse and its complications.
A thorough Substance Abuse assessment should be included in the PTSD evaluation. Ruling in or ruling out Substance Disorders will help in all phases of patient interaction, diagnosis, treatment, and follow up. Instruments of particular use are the Addiction Severity Index, the Michigan Alcohol Screening Test, or the Drug Abuse Screening Test.
Finally, the presence of other mental disorders in PTSD patients should be determined. Depression is a common comorbid condition and can be assessed using formal methods, such as the SCID-I or the Beck Depression Inventory. The MMPI-2 can be useful for this purpose as well. Ultimately, if a thorough assessment is conducted from the outset, paths for assessment will be revealed and will require further inquiry and follow up.
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