A PTSD diagnosis requires exposure to at least one trauma. Traumas include being exposed to threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Examples are direct exposure, witnessing a trauma, or learning that a relative or close friend was exposed.

At least one “intrusion” symptom is required for a PTSD diagnosis. These symptoms include unwanted and upsetting memories, nightmares, flashbacks, and emotional distress or physical reactions following reminders. At least one “avoidance” symptom is also required for a PTSD diagnosis. These symptoms include avoidance of trauma-related thoughts or feelings, and/or avoidance of trauma-related reminders. At least two “negative alterations in cognitions and mood” are required. These include negative thoughts or feelings that began or worsened after the trauma, an inability to recall key features of the trauma, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative mood, decreased interest in activities, feeling isolated, and difficulty experiencing positive mood. Finally, there needs to be at least two “hyperarousal” symptoms, such as irritability or aggression, risky or destructive behaviour, hypervigilance, heightened startle reaction, difficulty concentrating, and difficulty sleeping.

Symptoms must last for more than one month and cause significant distress or problems to the individual’s daily functioning. Symptoms must not be due to medication, substance use, or other illness. The latest World Health Organization’s International Classification of Diseases (ICD-11) also includes complex PTSD, which involves the core symptoms of PTSD plus disturbances in self organisation, mood dysregulation, negative self-concept, and disturbances in relationships.

A variety of tools have been developed to screen for or diagnose PTSD. The gold standards for diagnosis are the Clinician-Administered PTSD Scale (CAPS) and the Structured Clinical Interview for DSM-V (SCID-5), PTSD module. There are also a wide range of self-report PTSD measures, including the Primary Care PTSD Screen (PC-PTSD) and the PTSD Checklist (PCL), which are mostly used to monitor PTSD symptom severity, but can also be used for screening and diagnosing PTSD in people who have been exposed to trauma.

What is the evidence regarding diagnosis and detection of PTSD?

Moderate to high quality evidence finds a small increase in the severity of PTSD symptoms in people exposed to DSM-5 nominated traumas of actual or threatened death or serious injury or of threat to the physical integrity of self or others compared to people exposed to other traumas such as divorce, financial stress, or minor car accidents.

Around 24.5% of people diagnosed with PTSD have a delayed onset (>6 months post trauma), with most of these people experiencing earlier and milder subclinical symptoms. Delayed-onset PTSD is highest in professional groups and in those who experienced combat trauma (prevalence in both is around 40%).

There is reasonable sensitivity and good specificity of the PC-PTSD and the PCL for predicting a diagnosis of PTSD. There is good diagnostic validity and internal consistency, and reasonable test-retest and external (convergent) validity of the PCL. For children, the average T score on the Trauma Symptom Checklist for Children is around 50 in those exposed to traumatic events, which is 15 points less than the clinical cut-off for PTSD on this scale. Factors associated with increased scores on the Trauma Symptom Checklist for Children include international (vs. U.S.) samples, sexual abuse (vs. neglect, community violence, or complex trauma), female sex, and older age in sexual abuse samples.

Moderate to low quality evidence finds machine learning techniques (mostly support vector machine learning) using neuroimaging, neuropsychological, or audio data can reasonably predict PTSD in people previously diagnosed with PTSD using traditional means (mostly the CAPS or PCL).

August 2021

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Standardised assessment tools for PTSD are vital for assessing a range of variables including symptoms, functioning, and quality of life. They are often used within a controlled research environment, but high-quality assessment tools are also useful in practice for both clinical management and outcome prediction.

What is the evidence for outcome assessment tools for PTSD?

Moderate quality evidence finds a model comprising 4-factors of intrusions, avoidance, hyperarousal, and dysphoria/numbing yielded the best fit for clustering PTSD symptoms. Assessment measures for this model included the Clinician-Administered PTSD Scale, Harvard Trauma Questionnaire, Modified PTSD Symptom Scale, PTSD Checklist, PTSD Diagnostic Scale, PTSD Symptom Scale, SCID = Structured Clinical Interview for DSM-IV Diagnosis, Screen for Post-traumatic Stress Symptoms. Intrusions symptoms included intrusive thoughts of trauma, recurrent dreams of trauma, flashbacks, emotional reactivity to trauma cues, and physiological reactivity to trauma cues. Avoidance symptoms included avoiding thoughts of trauma and avoiding reminders of trauma. Hyperarousal symptoms included hypervigilance, exaggerated startle response, sleep disturbance, irritability, and difficulty concentrating. Dysphoria/numbing symptoms included inability to recall aspects of the trauma, loss of interest, detachment, restricted affect, and sense of foreshortened future. Sleep disturbance, irritability, and difficulty concentrating may also be classed as dysphoria symptoms.

Moderate to high quality evidence finds similar scores on clinician-administered and self-report PTSD rating scales in clinical trials. Subgroup analysis found a trend for more conservative scores on clinician-administered scales in trials of children and adolescents, but not in trials of adults.

There were weak to moderate correlations between increased Centrality of Event Scale scores (having a negative event central to one’s identity and life story) and increased PTSD symptoms (avoidance, arousal, re-experiencing), post-traumatic growth, grief, trauma cognitions, memory vividness, emotional intensity, shame, physical reaction, depression, anxiety, negative trauma emotions, dissociation, neuroticism, life danger and injury traumas, female sex, and openness. There were no or very weak correlations between increased Centrality of Event Scale scores and decreased satisfaction with life, social support, extraversion, conscientiousness, and agreeableness. There were small to medium-sized associations between increased PTSD symptom scores and decreased mindfulness scores on the Five Facet Mindfulness Questionnaire.

Moderate to low quality evidence is unable to recommend the use of any particular scale for assessing outcomes in youth exposed to traumatic events. Scales assessed were; the Child Behaviour Checklist-PTSD, University of Los Angeles–Post-Traumatic Stress Disorder Scale – reaction index, Child PTSD Symptom Scale, Child Dissociative Checklist, Adolescent Dissociative Experiences Scale, Solution Focused Recovery Scale, Child and Youth Resilience Measure-28, Child and Youth Resilience Measure-12, Minnesota Multiphasic Personality Inventory-Adolescent, Beck Self-Concept Inventory for Youth, Adult Attachment Interview, Global Assessment of Functioning Scale, Children’s Global Assessment of Functioning Scale, Adolescent Clinical Sexual Behaviour Inventory, Child Sexual Behaviour Inventory, Vineland Adaptive Behaviour Scale-II, Trauma Symptom Checklist for Young Children, Trauma Symptom Checklist for Young Children–Short Form, Assessment Checklist for Children, Brief Assessment Checklist for Children, Trauma Assessment for Young Children, Child Paediatric Emotional Distress Scale, Trauma Play Scale, Story Stem Assessment Profile, Dominic Interactive Assessment, Assessment Checklist for Adolescents, and the Brief Assessment Checklist for Adolescents.

August 2021

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