How to Not Miss a PTSD Diagnosis

The benefits of screening for PTSD outweigh the risks of upsetting clients.

Posted Nov 06, 2018

PeterPan23/Wikimedia Commons
Source: PeterPan23/Wikimedia Commons

In a study published in the February 2018 issue of the journal Depression & Anxiety, researchers in the United Kingdom reported on a survey of 1,946 adults. Participants with at least one psychiatric diagnosis were included in the sample. First, researchers wanted to know if a clinician had ever diagnosed them in the past with posttraumatic stress disorder (PTSD). Next, participants self-reported on their current PTSD symptoms by completing the Trauma Screening Questionnaire (TSQ). Four hundred thirty-eight individuals scored above a validated cutoff, suggesting that they currently had a probable diagnosis of PTSD.  Out of these 438 with current PTSD, only 169 had been diagnosed with PTSD by a clinician in the past (Lewis et al., 2018).  That means 62 percent of individuals with PTSD had never been diagnosed in the past.

The researchers examined demographic variables, but the rate of misdiagnosis did not differ by age, occupation, substance abuse, or admissions to psychiatric hospitals. Misdiagnosis was more common in women, those who were first involved with psychiatric services at a younger age, lower income, and lower education, but these variables should not be viewed as contributing to the misdiagnosis. It is likely that the explanation is much more complicated than concluding that having these variables causes clinicians to miss PTSD diagnoses.

Missing the diagnosis of PTSD in 62 percent of people is not good news, but this rate is actually better than the older studies on this topic. Van Zyl and colleagues (2008) studied adult psychiatric inpatients in South Africa and found that PTSD was missed by clinicians about 90 percent of the time. Miele & O’Brien (2010) studied two treatment programs for children and adolescents in Pennsylvania and also found that PTSD was missed by clinicians about 90 percent of the time.

It seems justified to conclude that there is no longer a question of whether diagnoses are missed.  The better question is how to address the problem. The answer is simple, but apparently hard to do.

In order to not miss the diagnosis of PTSD, do what the researchers did in these studies. Give standardized assessments of traumatic events and PTSD symptoms to everyone in your practice. There are many good, free, self-administered questionnaires. Cost and access are not problems, so there must be other roadblocks.

Clinicians are often concerned that asking about trauma so early in a relationship will be off-putting to clients. However, we have followed the practice of universal screening on the first visit for nearly 1,000 clients of all ages, and we almost never have any pushback. When clients realize that this is how we practice, they understand the value of it. 

Another concern of clinicians is that asking about trauma will be upsetting. Again, we have not seen that in real life. Our faith in the resilience of patients has been well-founded. Finkelhor and colleagues (2014) interviewed over 2,000 youths, aged 10 to 17 years about their exposure to traumatic events and about trauma-related symptoms. Next, they asked the youths if the questions in the survey upset them and, knowing now the nature of the survey, would they have still agreed to do it. Only 0.3 percent said that they would not participate again because of the questions.  These findings ought to give confidence that asking these types of questions do not make the vast majority of youths upset.

We do this in my clinics. New intakes do not pass from the waiting room to the clinicians’ offices on their first visit until they have completed a packet of measures. If the questions are not relevant because they have not experienced traumas, the PTSD questionnaire takes about only one minute.

Remember these two things. First, PTSD symptoms are highly internalized. You can’t tell who has PTSD by looking at them. You have to ask about the events and the symptoms. Second, patients with PTSD often manage to get by with workarounds, but just because they are getting by does not mean they do not need help. A woman who had PTSD from a motor vehicle accident managed with the workaround of never driving on highways for 13 years before she got help. A man with PTSD from a work accident was too fearful to leave his home, so he developed the workaround of getting a stay-at-home job. These patients may not have had to use those workarounds if their PTSD had been diagnosed and properly treated. The benefits of broader, systematic screening seem to outweigh any risks.

References

Finkelhor, D., Vanderminden, J., Turner, H., Hamby, S., & Shattuck, A. (2014). Upset among youth in response to questions about exposure to violence, sexual assault and family maltreatment. Child Abuse & Neglect, 38(2), 217-223.

Lewis C, Raisanen L, Bisson JI, Jones I, Zammit S (2018). Trauma exposure and undetected posttraumatic stress disorder among adults with a mental disorder. Depression & Anxiety 35:178-184

Miele, D., & O'Brien, E.J. (2010). Underdiagnosis of posttraumatic stress disorder in at risk youth. Journal of Traumatic Stress, 23(5), 591-598.

van Zyl, M., Oosthuizen, P.P., & Seedat, S. (2008). Post traumatic stress disorder: Undiagnosed cases in a tertiary inpatient setting. African Journal of Psychiatry, 11, 119-122.