Understanding The Checklist For PTSD

If you’ve been experiencing some of the symptoms of post-traumatic stress disorder (PTSD), you may wonder if you have the condition. The PTSD Checklist is a screening test used to determine the likelihood that you have PTSD. 

The PTSD Checklist is an important early step in PTSD diagnosis, but it does have some limitations. We’ve rounded up everything you need to know to understand the PTSD Checklist. 

What is PTSD?

PTSD, or post-traumatic stress disorder, is a mental health condition that develops after a traumatic event. Characterized mainly by feelings of extreme anxiety and intrusive memories, PTSD can be a terrifying and debilitating disorder. 

While a bit of anxiety and a change in mood can be normal after a scary or traumatizing event, these effects go past the normal adjustment period and severity for people with PTSD.

Over 90%¹ of adults in the United States have experienced at least one traumatic event, and up to 8% of those individuals will develop PTSD. This percentage rises even higher for people with trauma related to combat or sexual assault.

If your response to a traumatic event is impacting your ability to go about your daily life and is not dissipating, you may be suffering from PTSD. You may even find it worsens over time.

Symptoms of PTSD

PTSD symptoms differ from person to person, but there are some typical symptoms to look for, including the following:

• Repetitive, distressing memories of the traumatic event

• Flashbacks of the event as if it were happening again

• Distressing nightmares about the event

• Emotional and distressing reaction to things that remind you of the event

• Wanting to avoid thinking or talking about the event

• Avoiding situations, people, and places that remind you of the event

• Feelings of hopelessness

• Trouble remembering things

• Negative feelings toward yourself or others

• Struggling to maintain close relationships and feeling distant from those relationships

• Feeling emotionally numb

• Feeling disinterested in activities that once excited you

• Quick to anger

• Feeling on high alert or on guard

• Easy to startle

• Deep feelings of guilt and shame

• Sleep problems

• Inability to concentrate

• Engaging in reckless and self-destructive behavior (e.g., speeding, drinking)

As you can see, the symptoms of PTSD can be long and varied. There is also no hard and fast rule for when you might develop PTSD after the causal event.

Some people might start to experience their first symptoms within a month, while for others, it can take years for them to appear. 

Causes of PTSD 

We don’t exactly know why some people get PTSD, but it’s likely due to the severity and amount of exposure to trauma, your mental health history (including your family history), your general temperament, and your chemical and hormonal regulation. 

We know that when PTSD occurs, it is in response to a traumatic, threatening, or terrifying event. The kind of events we typically see that result in an individual developing PTSD include the following:

• An accident (car crash or natural disaster)

• Sexual assault

• Wartime or combat exposure

• Physical assault

• Threatened with physical violence

• Physical abuse in childhood

• Life-threatening medical diagnosis 

So why do some people get PTSD while others do not? While we don’t know the exact answer to this, some insight can be gleaned from certain risk factors and can increase your risk of developing PTSD after a traumatic event.

Risk factors that can leave you at higher risk of PTSD include the following:

• Previous exposure to trauma, especially in childhood

• High-risk stressful job (e.g., paramedic, police officer, wartime journalist, enlisted officer)

• Alcohol or drug abuse or dependency

• Previous mental health issues (e.g., depression or anxiety)

• Family history of mental health issues

• No support system to rely on after a traumatic event

How to get diagnosed: The importance of the PTSD Checklist 

Due to the serious negative impact that PTSD can have on your overall health and well-being, there has been a growing focus on the early identification of PTSD through screening tests. These tests are not definitive diagnoses but can be used to identify patients who are highly likely to be experiencing PTSD.

A positive screening test indicates that an individual could benefit from a full clinical evaluation for PTSD. 

There are many PTSD screening tests available, but the more commonly used test is the PTSD Checklist,² sometimes referred to as PCL.

The PTSD Checklist has been used for over 30 years and is commonly used:

• for clinical screening of PTSD

• to track the symptoms of PTSD

• as a diagnostic tool in research studies

• to establish rates of PTSD in large epidemiologic research studies (e.g., studies involving veterans) 

PCL has changed over the years, and the current one is called PCL-5, a self-reporting tool that uses 20 measures based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 is the fifth edition of a diagnostic manual published by the American Psychiatric Association. A manual is a key tool used in mental health diagnoses, and the fifth edition has the most up-to-date diagnostic criteria. 

Administration and scoring 

PCL-5 is a self-reported questionnaire that patients can complete without supervision. This 20-item questionnaire takes 5–10 minutes to complete. The length and self-reporting nature of PCL-5 makes it ideal to be completed in a waiting room before a psychological evaluation or session or as part of a research study. 

When completing the PCL-5, patients are given one of the following three formats:

• PCL-5 with Criterion A assessment

• PCL-5 without Criterion A assessment (typically used when trauma exposure is measured by another method)

• PCL-5 with an extended Criterion A assessment and a revised Life Events Checklist for DSM-5 (LEC-5). 

While PCL-5 can be completed by a patient, its results need to be scored by a professional and can be done so in the following four ways: 

1. Total symptom severity score: This score is created by adding the scores for all 20 items in the questionnaire. The total symptom severity score ranges from 0–80.

2. DSM-V symptom cluster severity score: Scores can also be created by adding the results with a specific cluster. In this case, you would get an individual score for each cluster. Items 1–5 = cluster B, items 6–7 = cluster C, items 8–14 = cluster D, and items 15–20 = cluster E.

3. Provisional PTSD diagnosis: A provisional PTSD diagnosis can be made by assigning an endorsed symptom to each item in PCL-5 that scores a 2 (“Moderately”) or higher. To reach a provisional diagnosis, the DSM-V diagnostic rules are then followed, which require at least one B item (questions 1–5), one C item (questions 6–7), two D items (questions 8–14), and two E items (questions 15–20) for diagnosis.

4. PCL-5 cutoff score: A PCL-5 cutoff score that falls between 31 and 33 indicates that PTSD is probable, although not definitive. However, various cutoff scores may be needed based on the populations being tested and the purpose of the screening test. 

Interpretation 

Interpretation of PCL-5 results needs to be completed by a clinician. There are many factors a clinician will consider when interpreting the results, including the characteristics of the setting where the PCL-5 was completed and the overall goal of the PCL-5 assessment. 

The clinician will also consider where the score sits in relation to the cutoff score to help reduce provisional false positives while also improving the detection of potential PTSD cases. 

Measuring change 

The PTSD Checklist is not used only as an initial evaluation before diagnosis but can also be used post-diagnosis to determine if treatment is improving the symptoms of PTSD. 

So how is change measured? When the PCL for DSM-IV was still in use, a 5–10 point change in scores demonstrated a reliable change in symptoms, while a 10–20 point change showed clinically significant change. Because of this, a 5-point change was previously recommended as the minimum threshold for treatment response, and a 10-point change was used as the minimum threshold for clinically meaningful treatment. 

Unfortunately, the measures of change have not yet been finalized for PCL-5, but it is expected that the range of change will be similar to PCL for DSM-IV. Until the updated measures are released, it’s recommended that the old change measures from PCL for DSM-IV be used in their place. 

Should we be using the checklist? 

The PTSD Checklist can be a useful screening tool, especially when used thoughtfully. Reviews¹ have praised the PTSD Checklist, which has several strengths as a PTSD screening test. While initially used for diagnosing PTSD in the military veteran population, several studies³ have now shown it to be an accurate diagnostic tool in the civilian populations in many different countries. 

While the PTSD Checklist can be extremely useful as a provisional diagnostic tool, it is not a perfect system and has been criticized for emphasizing convenience over precision. Bias, analysis, and variation can all impact the accuracy of any screening test.

However, when the PTSD Checklist is analyzed with a high sensitivity cutoff score and is used alongside second-tier PTSD diagnostic tools, it can be a useful and relatively accurate measure. 

When to reach out for help 

If you’ve been experiencing symptoms relevant to PTSD, you may want to consider reaching out to a medical professional. This is especially important if your symptoms have lasted longer than a month without improving, are worsening, or negatively impacting your life. In this case, you should reach out to a close friend, doctor, or psychologist as soon as possible. 

If your PTSD-like symptoms have developed into thoughts of self-harm or suicidal ideations, you should contact emergency services immediately. 

The lowdown

The PTSD Checklist is a useful pre-diagnostic tool to help indicate which patients may be experiencing PTSD. Recent changes to the checklist (PCL for DSM-IV to PCL-5 for DSM-5) have updated symptoms and scoring results to provide a more accurate provisional diagnostic tool. 

It’s important to remember that PCL-5 does not provide a definitive diagnosis, and further psychological evaluation is required to reach a confirmed diagnosis of PTSD. However, it is a useful, time-efficient way to identify patients most at risk of having the disorder.