Posttraumatic Stress Disorder

History

• The experience of trauma includes exposure to threatened death, serious bodily injury, or sexual violence; such an event is required for the diagnosis, although witnessing (rather than personally experiencing) the traumatic event may also result in posttraumatic stress disorder ^{r1c1c2c3c4c5c6}
  • Because patients may not associate current symptoms with a traumatic event, especially if a lot of time has passed, it is important to ask any patients who repeatedly report to primary care with unexplained physical symptoms about traumatic event(s)
  • Patients may give negative responses to all-inclusive questions (eg, "Have you ever been abused?"); specific questions (eg, "Have you even been hit, beaten, or choked?") may be better ^r11
  • Men most often report combat experience, physical assault, witnessing death or assault, or being threatened with a weapon ^{r9c7c8c9c10c11}
  • Women more often report rape, sexual molestation, physical abuse, and childhood neglect ^{r9c12c13c14c15}
• Symptoms typically begin within 3 months of the traumatic event(s), although the full diagnostic criteria may not be met for years after the trauma ^r1
  • If duration of symptoms is less than 1 month, diagnosis cannot yet be made; however, if patient otherwise appears to have symptoms of posttraumatic stress disorder, consider diagnosis of acute stress disorder ^r1
  • Symptoms fall within 4 groups: intrusion, avoidance, negative changes in cognition and mood, and alterations in arousal ^r1
    • Intrusion symptoms
      • Recurrent, intrusive, and involuntary memories of the event(s) ^r1c16c17
        • Memories typically involve sensory, emotional, or physiologic components
        • Often manifests as distressing dreams that replay the event or that thematically represent the event ^c18
      • Reliving the experience through flashbacks that may last from seconds to hours or days ^r1c19
        • Flashbacks range from brief sensory intrusions to complete loss of reality and awareness of surroundings
        • Patient may act as if the event(s) were occurring at that moment
      • Intense distress or physiologic reactivity after exposure to triggering people, places, or events or physical sensations ^c20
    • Avoidance symptoms
      • Patient will attempt to avoid all triggers that are reminders of the event ^c21
      • Avoids talking about the event in detail
    • Changes in cognitions and mood ^c22c23
      • Emotional numbing ^c24
        • Loss of interest in participating in activities once enjoyed ^r1c25
        • A feeling of detachment from other individuals ^c26
        • A persistent inability to feel positive emotions ^r1c27
      • Persistent negative feelings ^c28
        • About self, including shame or guilt, which may manifest in statements such as "I am a bad person" or "My nervous system is permanently ruined"
        • About the outside world, which may manifest in statements such as "The world is a terrible and dangerous place" or "I cannot trust anyone"
      • Negative changes in cognition ^r1
        • Difficulty concentrating, remembering daily events, or attending to focused tasks ^c29c30c31
        • Loss of memory for significant parts of the event(s) ^c32
        • Distorted thoughts and reasoning about the cause or consequences of the event ^r1c33
      • Difficulty regulating emotions or maintaining interpersonal relationships (particularly for those with severe, repetitive, or prolonged trauma) ^r1c34c35
    • Altered arousal ^c36
      • Heightened sensitivity to perceived threats, both those related and not related to the traumatic event(s), and increased reactivity to unexpected stimuli ^r1c37c38
      • Aggression with little or no provocation or a quick temper ^r1c39c40
      • Participation in reckless or self-destructive behavior ^r1c41c42
      • Difficulty falling or staying asleep or having nightmares ^r1c43c44
• Symptoms manifest differently by age group
  • Children ^r1
    • Distressing dreams ^c45
      • Dream content may not be obviously related to the traumatic event(s)
    • Flashbacks can be experienced differently than in adults
      • May be manifested through play
      • Fear may not be expressed during the reexperiencing
    • Avoidance behaviors
      • In addition to avoiding people, places, and things that remind them of the trauma, school-aged children may avoid participation in new activities ^c46
    • Emotional and cognitive changes
      • Loss of positive expressions of emotion with increased expression of negative emotions (eg, sadness, shame, guilt) ^c47c48c49
      • Withdrawal from playing with friends ^c50
      • Developmental regression, including loss of language, may occur ^c51c52
    • Alterations in arousal
      • Angry outbursts or temper tantrums ^c53c54
  • Adolescents
    • May view themselves as cowardly ^c55
    • May view themselves as being changed in ways that make them undesirable to their peers ^c56
    • Reluctance to pursue developmental opportunities (eg, dating, driving) ^c57
    • May lose aspirations for the future ^c58
  • Older adults
    • May experience more avoidance, hyperarousal, sleep problems, and crying spells than younger people exposed to the same trauma ^{r1c59c60c61c62}
      • If posttraumatic stress disorder begins in younger adulthood but continues into older age, symptoms of hyperarousal, avoidance, and negative cognition and moods may be reduced ^r1
    • Negative health perceptions are common, accompanied by increased using of primary care services ^c63
    • May have suicidal ideation ^c64
• Patients with untreated posttraumatic stress disorder may use primary care services frequently, with a variety of unexplained somatic complaints

Physical examination

• Typically normal findings unless the trauma resulted in a persistent physical injury or scarring ^c65
• A mental status examination should be performed to assist with differential diagnosis ^r4

Causes

• Although the etiology of posttraumatic stress disorder is not fully known, it is thought to result from an absence of normal trajectory of recovery after exposure to a traumatic event ^r12c66
  • While many people experience a DSM-5-TR posttraumatic stress disorder–qualifying traumatic event, most do not develop posttraumatic stress disorder
  • A hypothesis is that the memory of the trauma is not fully processed and therefore the person maintains misperceptions or distorted thinking patterns that occurred at the time of the trauma ^r12c67
  • May be associated with neurobiologic alterations in the central and autonomic nervous systems ^r13c68
    • Certain alterations in the brain have been associated with posttraumatic stress disorder ^r13r14
      • Reduced brain volume in the hippocampus and anterior cingulate ^c69
      • Excessive amygdala activity ^c70
      • Reduced activation of the prefrontal cortex and hippocampus in response to trauma reminders

Risk factors and/or associations

Primary diagnostic tools

• Diagnosis is based on patient interview, which may be aided by a screening assessment tool at the initial diagnostic encounter and ideally is confirmed by a semistructured interview with a mental health professional ^{r16r17c148c149}
  • In the primary care setting, use a screening instrument to determine if patient appears likely to have posttraumatic stress disorder
    • Brief screening questionnaire can be helpful to determine whether a person has had an event that meets DSM-5 TR criterion A, or to determine the different types of criterion A events a person has experienced
      • Brief Trauma Questionnaire ^r18
        • 10-item questionnaire
        • A "yes" response to any question will meet criterion A
        • Available from the US Department of Veterans Affairs ^r18
    • PC-PTSD-5 (Primary Care PTSD Screen for DSM-5) ^r16
      • 5-item screening measure
      • If this screen reveals probable posttraumatic stress disorder, consider obtaining the PTSD Checklist for DSM-5 (PCL-5) as additional provisional evidence of posttraumatic stress disorder
      • Available from the US Department of Veterans Affairs ^r16
    • PCL-5 (PTSD Checklist for DSM-5) ^r17
      • 20-item self-report measure useful for both screening and for making a provisional diagnosis
      • Available in several versions, the PCL-5 version with criterion A is appropriate when trauma exposure has not been separately measured by some other method
      • Available from the US Department of Veterans Affairs ^r17

  • DSM-5 diagnostic criteria for posttraumatic stress disorder (children older than 6 years and adults).

    Data from American Psychiatric Association: Posttraumatic stress disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013:271-80.

    Category	Criteria
    Criterion A
    Exposure to actual or threatened death, serious injury, or sexual violence in at least 1 of the following ways:	1. Personally experiencing traumatic event(s)
    	2. Witnessing the event(s) in person as it occurred to others
    	3. Learning about the event(s) that occurred to a close friend or family member
    	4. Experiencing repeated or extreme exposures to details of event(s). (Does not include exposures through electronic media, television, movies, or pictures, unless work related.)
    Criterion B
    Presence of at least 1 intrusion symptom associated with and occurring after the traumatic event(s):	1. Recurrent, involuntary, and intrusive distressing memories of the event(s)
    	2. Recurrent distressing dreams related to the event(s)
    	3. Dissociative reactions (eg, flashbacks) in which the patient feels or acts as if the event(s) were recurring
    	4. Intense or prolonged psychological distress when exposed to internal or external cues related to an aspect of the event(s)
    	5. Marked physiologic reactions to these cues
    Criterion C
    Persistent avoidance of certain stimuli associated with the event(s):	1. Efforts to avoid distressing memories, thoughts, or feelings related to the event(s)
    	2. Efforts to avoid external reminders of those memories, thoughts, or feelings
    Criterion D
    Negative changes in cognitions and mood associated with the event(s), either starting or worsening after the event(s), as evidenced by at least 2 of the following:	1. Inability to recall key features of the traumatic event (due to dissociative amnesia; not due to head injury, alcohol, or drugs)
    	2. Persistent and exaggerated negative beliefs or expectations about self, others, or the world in general
    	3. Persistent distorted cognitions about the cause or consequence of the event(s), resulting in the patient blaming self or others
    	4. Persistent negative emotions, such as fear, horror, anger, guilt, or shame
    	5. Markedly diminished interest or participation in significant activities
    	6. Feeling of detachment or estrangement from others
    	7. Persistent inability to experience positive emotions, such as happiness, satisfaction, or love
    Criterion E
    Changes in arousal and reactivity beginning or worsening after the event(s), as indicated by 2 or more of the following:	1. Irritable behavior and angry outbursts (with little or no provocation)
    	2. Reckless or self-destructive behavior
    	3. Hypervigilance
    	4. Exaggerated startle response
    	5. Difficulty concentrating
    	6. Sleep disturbance(s)
    Criterion F
    Criteria B, C, D, and E must be met for more than 1 month after the traumatic event
    Criterion G
    The condition must cause clinically significant distress or impairment
    Criterion H
    The condition is not attributable to substance use or any other medical condition

• After initial screening, if posttraumatic stress disorder is likely, conduct an in-depth assessment to establish diagnosis; this assessment requires more time to complete and should be administered by someone knowledgeable about posttraumatic stress disorder and trained in administering the assessment (typically a psychologist or psychiatrist) ^r12
  • Several semistructured interviewing tools are available to guide assessment:
    • CAPS-5 (Clinician-Administered PTSD Scale for DSM-5) ^r3r19
      • 30-item interview ^r3
      • Considered gold standard for diagnosis by the Veterans Administration; can be obtained by request from the US Department of Veterans Affairs^r19
    • CAPS-CA-5 (Clinician-Administered PTSD Scale for DSM-5: Child/Adolescent Version) ^r19
      • For children and adolescents aged 7 years and older
      • Includes age-appropriate items and picture response options
      • Can be obtained by request from the US Department of Veterans Affairs ^r2
    • PSS-I-5 (PTSD Symptom Scale Interview) ^r3r20
      • Updated to include DSM-5 diagnostic criteria
      • Available by request from the University of Pennsylvania; details are available on the US Department of Veterans Affairs National Center for PTSD website^r20

Procedures

Most common

• Adjustment disorders ^r1c152
  • Similar to posttraumatic stress disorder, DSM-5 TR defines adjustment disorders as the presence of emotional or behavioral symptoms in response to identifiable stressor(s) occurring within 3 months of the onset of the stressor(s)
  • Unlike posttraumatic stress disorder, the stressor can be of any severity or type
  • Diagnose adjustment disorder over posttraumatic stress disorder in 1 of 2 situations:
    • When a patient is exposed to a stressor that meets criterion A for posttraumatic stress disorder but responds in a way that does not meet all other posttraumatic stress disorder criteria
    • When a patient responds in a way that meets all criteria for posttraumatic stress disorder to a stressor that does not meet criterion A
• Acute stress disorder ^r1c153
  • Similar to posttraumatic stress disorder, acute stress disorder is a reaction to actual or threatened death, serious injury, or sexual violation resulting in symptoms related to intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the stressful event(s)
  • Diagnostic criteria are slightly different from those of posttraumatic stress disorder, requiring at least 9 symptoms from any of the following categories: intrusion, negative mood, dissociation, avoidance, and arousal
  • Differentiate by symptom duration, which is limited to 3 days to 1 month after the traumatic event in acute stress disorder
• Major depressive disorder ^r1c154d1
  • Mood disorder characterized by persistent feelings of sadness or hopelessness or loss of interest in activities once enjoyed
  • When preceded by a traumatic event, this condition may be mistaken for posttraumatic stress disorder
  • Unlike posttraumatic stress disorder, does not include any criteria B or C symptoms
  • Differentiate from posttraumatic stress disorder by absence of several posttraumatic stress disorder criteria symptoms
• Personality disorder ^r1c155d2
  • Condition characterized by impairments in personality functioning and pathologic personality traits persisting over time
  • As with posttraumatic stress disorder, patient may have difficulty maintaining interpersonal relationships
  • Differentiate by absence of actual or threatened death, serious injury, or sexual violation
• Dissociative disorders ^r1c156
  • Disorders characterized by a loss of normal integration between memories, identity awareness and sensations, and body movements; include the following:
    • Dissociative amnesia ^r1c157
    • Dissociative identity disorder ^r1c158
    • Depersonalization-derealization disorder ^r1c159
  • Symptoms may be mistakenly classified as posttraumatic stress disorder with dissociative symptoms ^r1
    • However, if all criteria for posttraumatic stress disorder are met, then posttraumatic stress disorder with dissociative symptoms should be diagnosed
  • Unlike posttraumatic stress disorder, dissociative disorders do not always result from exposure to trauma ^r1
  • Differentiate from posttraumatic stress disorder by absence of several posttraumatic stress disorder criteria symptoms
• Obsessive-compulsive disorder ^r1c160
  • Psychological condition characterized by recurrent intrusive thoughts or repetitive stereotyped behaviors that last for at least 1 hour per day or interfere with normal functioning
  • Similar to posttraumatic stress disorder, obsessive-compulsive disorder is characterized by intrusive thoughts
  • However, in obsessive-compulsive disorder, thoughts do not typically relate to a past traumatic event
  • Differentiate from posttraumatic stress disorder by the presence of compulsions, urges to perform rituals in response to obsessions, and absence of criteria D and E symptoms

Admission criteria

• Suicidal or homicidal ideation ^r11
• Severe illness with lack of social support ^r11
• Significant functional impairment ^r11

Recommendations for specialist referral

• Refer to a mental health professional for definitive diagnosis and disease management ^r11
  • If managed in a primary care setting, the Veterans Administration/Department of Defense guideline recommends collaborative care to ensure that the veteran is receiving evidence-based care ^r4
• Collaborate with a specialist in substance use disorders for patients with severe drug or alcohol dependence
• Outpatient care is optimal for most patients; however, those with comorbid conditions may require inpatient care ^r11

Drug therapy

• Selective serotonin reuptake inhibitors
  • Sertraline ^r12c161
    • Sertraline Hydrochloride Oral tablet; Adults: 25 mg PO once daily initially. After 1 week, increase to 50 mg PO once daily. If necessary, increase by 25 to 50 mg/day at intervals of not less than 1 week. Therapeutic range: 50 to 200 mg/day. Max: 200 mg/day.
  • Paroxetine ^r12c162
    • Paroxetine Hydrochloride Oral tablet; Adults: 20 mg PO once daily is the initial and usual effective dose. May titrate by 10 mg/week if needed and tolerated. Effective dose range: 20 to 50 mg/day. Max: 50 mg/day PO. DEBILITATED or GERIATRIC ADULTS: 10 mg PO once daily initially, with titration by 10 mg/week if needed; Max: 40 mg/day PO.
  • Fluoxetine ^r5c163
    • Fluoxetine Hydrochloride Oral capsule [Depression/Mood Disorders]; Adults: Initially, 20 mg PO once daily. A range of 20 to 80 mg/day PO has been used; follow recommended titration schedules. A lower or less frequent dose may be considered in the geriatric adult. Mean effective dosage: 40 mg/day PO. Fluoxetine has been effective for a wide variety of traumatic stressors, including combat. Max: 80 mg/day PO. May divide daily dose into 2 doses, given morning and at noon, if the dosage is more than 20 mg/day.
  • Venlafaxine ^r4c164
    • Immediate release
      • Venlafaxine Hydrochloride Oral tablet; Adults: Initially, 75 mg/day PO, given in 2 or 3 divided doses. If needed, daily dose may be increased by 75 mg/day no less than every 4 days. Outpatient Max: 225 mg/day PO in divided doses. Institutional Max: 375 mg/day PO, given in 3 divided doses.
    • Extended release
      • Venlafaxine Hydrochloride Oral tablet, extended release; Adults: Initially, 37.5 mg PO once daily for 4 to 7 days to allow for tolerability before increasing to 75 mg PO once daily. If needed, may increase further by 75 mg/day at intervals of no less than every 4 days. Recommended Max: 225 mg/day PO.

Nondrug and supportive care

• Educative and supportive care (most useful for managing the acute aftermath of a traumatic event) ^r11c165c166
  • Education should focus on the following:
    • Expected physiologic and emotional response to trauma
    • Strategies for decreasing secondary or continual exposure to trauma
    • Ways to reduce stress (eg, breathing, physical exercises)
    • Importance of remaining mentally active
    • Importance of self-care
• Prolonged exposure therapy ^r12c167
  • Consists of 8 to 15 sessions for 60 to 90 minutes per session either weekly or biweekly
    • First few sessions focus on teaching the patient relaxation breathing exercises and providing psychoeducation about the symptoms of posttraumatic stress disorder and the role of avoidance in maintaining treatment
    • Next several sessions focus on imaginal exposure, during which time the patient describes the traumatic event out loud for a prolonged time (eg, 30-45 minutes)
    • Includes in vivo exposure, which involves teaching the patient how to manage trauma-related situations that were previously avoided
    • Between sessions, patients are expected to listen to recordings of sessions and practice in vivo exposures
  • Treatment application should be culturally informed ^r11
  • Dropout rate ranges from 10% to 38% ^r12
• Cognitive processing therapy ^r12c168
  • Typically 12 sessions in individual or group format
  • Similar to prolonged exposure therapy, includes psychoeducation and education about the role of avoidance in maintaining the disorder
  • Early in the process, the patient writes down and discusses the impact the traumatic event had on their life
  • Through discussion, the therapist probes the patient for potential maladaptive thinking patterns and helps to develop strategies for developing more effective thinking patterns
  • Dropout rates are approximately 20% ^r12
• Eye movement desensitization and reprocessing ^r12c169
  • Length of treatment depends on patient ability to manage emotions
  • Initially, patients are trained to manage negative emotions (reprocessing)
    • Patient is asked to list emotionally significant experiences and the distorted beliefs related to those experiences and desired beliefs
    • Patient is asked to think about a visual representation of the experience and to focus specifically on the physical sensations of the memory while engaging bilateral/saccadic eye movements
    • Patient then practices thinking the desired belief with the visual image of the trauma
  • Shown to be effective for both acute and chronic disease ^r11
• Cognitive behavioral therapy ^r32c170c171
  • Consists of 12 to 16 sessions and may be in an individual or group format
    • May also be provided through a computer or mobile device facilitated by a therapist (internet-based cognitive behavioral therapy)
      • Some data suggest computer delivery is as effective as in-person delivery and may be indicated for patients for whom in-person interventions are not possible or declined ^r4
      • Expert opinion is divided owing to concerns of substantial selection bias in trials
  • Focuses on the relationship among the patient's thoughts, feelings, and behaviors with the goal of helping the patient maintain a sense of control and reducing avoidance behaviors
  • May include exposure to trauma narrative or reminders of the trauma and psychoeducation about how trauma may affect a person; may also include stress management techniques
• Brief eclectic psychotherapy ^r33c172
  • Focuses on changing the patient's emotions to reduce shame and guilt and emphasizes the patient-therapist relationship
  • Consists of 16 weekly sessions for 45 minutes to 1 hour each
    • Therapy is initiated with psychoeducation and rationale for the therapy
    • First several sessions are focused on getting the patient to talk about the event in the present while being taught relaxation exercises
    • Final sessions are focused on exploring how the event has affected the patient and what can be learned from it
• Narrative exposure therapy ^r34c173
  • Based on the patient establishing a chronologic narrative of their life, focusing on the traumatic event, but including positive experiences to contextualize memories of the trauma
  • Therapist concludes therapy by presenting the patient with a written biography of his or her life
  • Often used in community settings or for patients who experience a trauma related to political, cultural, or social forces ^r34

Comorbidities

• Sleep disturbances ^c174
  • Present in nearly all veterans with posttraumatic stress disorder ^r4c175
  • For patients with posttraumatic stress disorder and insomnia, consider cognitive behavioral therapy for insomnia as first line treatment, with medication considered a second line intervention ^r4
  • Data are inconclusive for recommending a specific treatment for nightmares ^r4
• Substance use disorders ^c176
  • Patients with posttraumatic stress disorder and a substance use disorder (including nicotine/tobacco use disorder) can both tolerate and benefit from concurrent treatment for both conditions ^r4d3
  • Presence of a substance use disorder should not prevent concurrent treatment with evidence-based, trauma-focused therapy for posttraumatic stress disorder ^r4
  • Combining medications and psychotherapy may be an effective strategy for treating posttraumatic stress disorder and a co-occurring substance use disorder ^r4
• Other mental disorders, including depression and anxiety disorders ^c177c178c179
  • Patients are 80% more likely to have another mental disorder compared with those without posttraumatic stress disorder; screen patients for these disorders ^r1
• Traumatic brain injury ^c180
  • Among veterans deployed to the wars in Afghanistan and Iraq, co-occurrence of traumatic brain injury is 48% ^r1

Special populations

• Older adults
  • Symptoms of disease may be exacerbated in this population by declining health, decreasing cognitive function, and social isolation ^r1
  • These patients may be reluctant to report traumatic events or admit to emotional or psychological problems

At-risk populations

• Because of the availability of sound screening measures and the potential benefits of early identification of posttraumatic stress disorder, the US Department of Veterans Affairs and Department of Defense recommend screening after separation from military service and during deployment ^r4
  • Department of Veterans Affairs recommends annual screening for the first 5 years after separation from service and every 5 years after that
  • Department of Defense recommends routine screening throughout cycles of deployment
  • A single screening is not recommended, because the disorder can have a fluctuating course, with delayed onset and periods of remission and recurrence
  • No screening method should be the sole basis for diagnosis; a more structured assessment is required

Screening tests

• Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) ^r16r21c206
  • 5-item questionnaire with "yes"/"no" responses ^r21
    • Have you ever experienced an especially frightening, horrible, or traumatic event; for example, a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, or having a loved one die through homicide or suicide?
      • If the patient answers "yes," move on; if "no," then the test result is negative
    • In the past month, have you:
      • 1. Had nightmares about the event(s) or thought about the event(s) when you did not want to?
      • 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
      • 3. Been constantly on guard, watchful, or easily startled?
      • 4. Felt numb or detached from others, activities, or your surroundings?
      • 5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
    • Test result is positive if the patient answers "yes" to any 3 questions
      • Optimal sensitivity is reached if a 3-question cutoff is used
      • Optimal efficiency of the test is reached if a 4-question cutoff is used
• PTSD Checklist for DSM-5 (PCL-5) ^r35c207
  • 20-item questionnaire
    • Questions:
      • In the past month, how much were you bothered by:
        • 1. Repeated, disturbing, and unwanted memories of the stressful experience?
        • 2. Repeated, disturbing dreams of the stressful experience?
        • 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
        • 4. Feeling very upset when something reminded you of the stressful experience?
        • 5. Having strong physical reactions when something reminded you of the stressful experience (eg, heart pounding, trouble breathing, sweating)?
        • 6. Avoiding memories, thoughts, or feelings related to the stressful experience?
        • 7. Avoiding external reminders of the stressful experience (eg, people, places, conversations, activities, objects, situations)?
        • 8. Trouble remembering important parts of the stressful experience?
        • 9. Having strong negative beliefs about yourself, other people, or the world (eg, "I am bad," "there 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?
        • 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
        • 12. Loss of interest in activities that you used to enjoy?
        • 13. Feeling distant or cut off from other people?
        • 14. Trouble experiencing positive feelings (eg, being unable to feel happiness or have loving feelings for people close to you)?
        • 15. Irritable behavior, angry outbursts, or acting aggressively?
        • 16. Taking too many risks or doing things that could cause you harm?
        • 17. Being “superalert,” watchful, or on guard?
        • 18. Feeling jumpy or easily startled?
        • 19. Having difficulty concentrating?
        • 20. Trouble falling or staying asleep?
    • Scoring
      • 0: not at all
      • 1: a little bit
      • 2: moderately
      • 3: quite a bit
      • 4: extremely
      • An overall score of 33 correlates well with the DSM-IV and DSM-5 diagnostic criteria; a score of 38 is considered to be more specific ^r4