How to Assess PTSD Risk in Trauma-Exposed Veterans
How should clinicians assess PTSD risk in US military veterans based on direct versus indirect trauma exposure?
Veterans commonly report potentially traumatic events that extend well beyond combat, and not all exposures carry the same PTSD risk. This guide applies to trauma-exposed US military veterans and helps clinicians structure assessment around the exposure patterns most strongly linked to PTSD in this study.
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Screen for the full range of potentially traumatic events
Ask about potentially traumatic events broadly rather than limiting assessment to combat-related experiences. In this study, 93.4% of veterans reported at least 1 potentially traumatic event, and the most frequently endorsed events were transportation accidents and natural disasters.
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Differentiate direct from indirect exposure
Classify an event as direct exposure when it happened to the veteran and as indirect exposure when the veteran witnessed it, learned about it happening to a close family member or friend, or was exposed to aversive details as part of a job. This distinction matters because direct exposures were more strongly associated with PTSD than indirect exposures.
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Elicit whether the veteran has caused serious harm to others
Specifically ask whether the veteran experienced serious injury, harm, or death caused to someone else. Although this exposure was relatively uncommon, it carried the highest conditional probability of PTSD in the study at 22.2% for lifetime PTSD and 11.3% for past-month PTSD.
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Estimate cumulative direct trauma burden
Count the number of direct potentially traumatic event exposures across trauma types rather than focusing only on a single index trauma. Each additional direct exposure was associated with higher odds of lifetime PTSD (OR = 1.36; 95% CI, 1.30–1.42) and past-month PTSD (OR = 1.38; 95% CI, 1.31–1.46).
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Do not rely on indirect exposure burden alone for risk stratification
Document indirect exposures, but do not weight cumulative indirect exposure burden the same way as direct exposure burden when estimating PTSD risk. In adjusted models, the number of indirect exposures was not associated with lifetime PTSD (OR = 1.01; 95% CI, 1.00–1.03) or past-month PTSD (OR = 0.99; 95% CI, 0.97–1.00).
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Screen current and lifetime PTSD symptoms against the identified trauma
Assess PTSD symptoms in relation to the veteran's worst trauma and evaluate both current and lifetime symptom burden. In this study, the PCL-5 was used to rate symptoms over the past month and over the lifetime, and a cutpoint of 38 was used to classify PTSD for population-based screening estimates.
Clinical Considerations
- PTSD status in the study was based on a modified self-report PCL-5 rather than a diagnostic interview.
- The study used a conservative PCL-5 cutoff of 38, and prevalence estimates may differ with other cutpoints.
- Because most veterans reported both direct and indirect exposures, there was overlap between these exposure categories.
- The cross-sectional, retrospective design limits causal inference about trauma exposure and PTSD.
Bottom Line
In US military veterans, direct trauma exposure burden, especially experiences involving harm caused to others, is the exposure pattern most useful for PTSD risk assessment.
