Trauma Screening

Trauma Screening

Description

This skill helps administer and interpret validated PTSD and trauma screening instruments. The PC-PTSD-5 serves as a brief initial screener, while the PCL-5 provides comprehensive assessment of PTSD symptom severity aligned with DSM-5 criteria.

Clinical Context: These tools help identify probable PTSD, quantify symptom severity, track treatment response, and support clinical decision-making. They are support tools that supplement, not replace, comprehensive trauma-informed clinical evaluation.

⚠️ TRAUMA-INFORMED APPROACH REQUIRED: All trauma screening must follow trauma-informed principles. See references/trauma-informed-approach.md for essential guidance.

Quick Reference: Assessment Selection

Decision guide: Start with PC-PTSD-5 for quick screening. If score ≥3, administer full PCL-5. See references/screening-comparison.md for detailed guidance.

Assessment Selection Decision Tree

digraph assessment_selection {
    rankdir=LR;
    node [shape=box, style=rounded];

    start [label="Trauma\nExposure\nReported", shape=ellipse];
    time_check [label="Time/setting?", shape=diamond];
    pc_ptsd [label="PC-PTSD-5\n(1-2 min)\n5 questions", style="filled", fillcolor=lightblue];
    pc_result [label="PC-PTSD-5\nscore ≥3?", shape=diamond];
    pcl5 [label="PCL-5\n(5-10 min)\n20 items", style="filled", fillcolor=lightgreen];
    monitor [label="Negative Screen\nRoutine\nMonitoring", style="filled", fillcolor=gray90];
    direct_pcl [label="PCL-5 Directly\n(comprehensive)", style="filled", fillcolor=lightgreen];

    start -> time_check;
    time_check -> pc_ptsd [label="Brief\nscreening"];
    time_check -> direct_pcl [label="Full\nassessment\nneeded"];
    pc_ptsd -> pc_result;
    pc_result -> pcl5 [label="yes\n(≥3)"];
    pc_result -> monitor [label="no\n(0-2)"];
}

Usage

Example requests: "Screen for PTSD", "Administer PCL-5", "Score trauma screening", "Interpret PTSD results"

Quick Reference: Severity Levels

PC-PTSD-5 Interpretation

• 0-2: Negative screen - PTSD unlikely, routine monitoring
• ≥3: Positive screen - Administer full PCL-5 for comprehensive assessment

PCL-5 Severity Levels

• 0-30: Subclinical/mild - Watchful waiting, psychoeducation
• 31-44: Moderate PTSD - Evidence-based trauma therapy recommended
• 45-59: Severe PTSD - Active treatment strongly recommended, specialty referral
• ≥60: Extreme PTSD - Immediate intervention, consider higher level of care

Treatment response: 10-20 point decrease = clinically significant improvement

For detailed severity interpretations and treatment recommendations, see references/severity-levels.md

Interactive Administration (Optional)

Use this mode when the clinician says "start" or "administer" the PC-PTSD-5/PCL-5.

1. Confirm readiness, use a trauma-informed approach, and remind the patient they can pause or skip questions.
2. Explain the time frame and response scale for the selected instrument.
3. Ask one item at a time (verbatim from the asset file) and wait for a response before continuing.
4. Accept numeric or verbal responses; if unclear or out of range, ask for clarification.
5. If the patient becomes distressed or safety concerns arise, pause and follow trauma-informed safety guidance before continuing.
6. After the final item, calculate totals (and cluster scores for PCL-5), interpret severity, and provide next-step guidance.
7. Offer a brief documentation summary if requested.

Assessment Administration

PC-PTSD-5 (Primary Care PTSD Screen for DSM-5)

Complete assessment details: assets/pc-ptsd-5.md

Quick Facts:

• 5 binary (Yes/No) questions covering DSM-5 PTSD symptom clusters
• Score 1 point for each "Yes" response
• Cutoff ≥3: Optimal balance of sensitivity (93%) and specificity (85%)
• Positive screen indicates need for full PTSD assessment (PCL-5)
• Requires trauma exposure; not administered if no trauma history

Items (1 point each for "Yes"):

1. Nightmares/intrusive thoughts about trauma
2. Avoidance of trauma reminders
3. Hypervigilance/easily startled
4. Detachment/numbing
5. Guilt/self-blame

Next Steps:

• Score 0-2: Monitor, reassess if symptoms emerge
• Score ≥3: Administer full PCL-5 for comprehensive assessment

PCL-5 (PTSD Checklist for DSM-5)

Complete assessment details: assets/pcl-5.md

Quick Facts:

• 20 items mapping to DSM-5 PTSD criteria (0-4 Likert scale)
• Total score range: 0-80
• Cutoff ≥33: Probable PTSD diagnosis (requires clinical interview to confirm)
• Tracks symptom severity and treatment response
• Can assess DSM-5 diagnostic criteria via cluster analysis

Symptom Clusters:

• Cluster B (Items 1-5): Intrusion symptoms (range 0-20)
• Cluster C (Items 6-7): Avoidance (range 0-8)
• Cluster D (Items 8-14): Negative cognitions/mood (range 0-28)
• Cluster E (Items 15-20): Arousal/reactivity (range 0-24)

DSM-5 Provisional Diagnosis Criteria:

• ≥1 Cluster B item rated ≥2 (Moderately or higher)
• ≥1 Cluster C item rated ≥2
• ≥2 Cluster D items rated ≥2
• ≥2 Cluster E items rated ≥2

Clinical Cutoffs:

• Total score ≥33: Probable PTSD (clinical interview required for formal diagnosis)
• 10-20 point change: Clinically significant improvement
• 5-10 point change: Reliable improvement

Clinical Decision-Making

Trauma-Informed Response Pathway

digraph trauma_response {
    rankdir=TB;
    node [shape=box, style=rounded];

    positive [label="Positive Screen\nPC-PTSD-5 ≥3\nor\nPCL-5 ≥33", shape=ellipse, style="filled", fillcolor=yellow];

    assess_safety [label="Assess Safety:\n• Suicidal ideation?\n• Substance use?\n• Dissociation?", style="filled", fillcolor=orange];

    safety_concern [label="Immediate\nSafety Concern?", shape=diamond];

    crisis [label="CRISIS RESPONSE:\n• Safety protocol\n• Stabilization\n• Do not proceed\n  with trauma work", style="filled", fillcolor=red, fontcolor=white];

    assess_severity [label="Assess PTSD\nSeverity\n(PCL-5 score)", style="filled", fillcolor=lightblue];

    mild [label="PCL-5 0-30\nMild/Subclinical", shape=box];
    moderate [label="PCL-5 31-44\nModerate", shape=box];
    severe [label="PCL-5 45-59\nSevere", shape=box];
    extreme [label="PCL-5 ≥60\nExtreme", shape=box];

    tx_mild [label="• Psychoeducation\n• Coping strategies\n• Monitor", style="filled", fillcolor=lightgreen];
    tx_moderate [label="• Trauma therapy\n  (PE, CPT, EMDR)\n• Medication option\n• Regular f/u", style="filled", fillcolor=yellow];
    tx_severe [label="• Combination tx\n• Specialty referral\n• Close monitoring", style="filled", fillcolor=orange];
    tx_extreme [label="• Immediate specialty\n• Higher LOC\n• Intensive tx", style="filled", fillcolor=red, fontcolor=white];

    positive -> assess_safety;
    assess_safety -> safety_concern;
    safety_concern -> crisis [label="yes"];
    safety_concern -> assess_severity [label="no"];

    assess_severity -> mild;
    assess_severity -> moderate;
    assess_severity -> severe;
    assess_severity -> extreme;

    mild -> tx_mild;
    moderate -> tx_moderate;
    severe -> tx_severe;
    extreme -> tx_extreme;
}

For structured clinical decision trees covering screening, treatment selection, safety assessment, and treatment monitoring, see references/clinical-decision-trees.md

⚠️ Safety-First: Assess for suicidal ideation (use suicide-screening), substance use, dissociation. Do NOT begin trauma work if safety concerns present.

Evidence-Based Therapies: PE, CPT, EMDR, TF-CBT

Medications: SSRIs (sertraline, paroxetine, fluoxetine), SNRI (venlafaxine)

Safety Protocols

⚠️ TRAUMA-INFORMED CARE REQUIRED: Follow trauma-informed principles (safety/trust, voluntary participation, patient-controlled pacing, prepare for emotional reactions). See references/trauma-informed-approach.md.

Safety Assessment: Screen for suicidal ideation (use ../../suicide-screening/), assess current safety. Crisis intervention required per ../../docs/references/crisis-protocols.md.

Crisis Resources: 988 Lifeline, Text HOME to 741741, Veterans 988 Press 1, Emergency 911

Escalate when: Active SI, severe impairment, PCL-5 ≥60, psychotic symptoms, severe self-harm

Documentation

PC-PTSD-5 template: assets/pc-ptsd-5.md - Include trauma exposure, item responses, score (0-5), result, next steps.

PCL-5 template: assets/pcl-5.md - Include all 20 items (0-4), cluster subtotals, total score, severity, DSM-5 criteria met, provisional diagnosis, treatment recommendations, safety assessment.

Standards: ../../docs/references/documentation-standards.md

Limitations & Considerations

Support tool, not diagnostic: PCL-5 provides provisional diagnosis; clinical interview required. Scores require interpretation within trauma context. Cultural factors and dissociation affect reporting. Clinical judgment supersedes scores. Use collaborative, trauma-informed approach respecting autonomy and timing. See references/trauma-informed-approach.md.

Special Populations: Military/veterans (combat context), complex trauma (developmental/relational impact), childhood trauma (attachment issues), recent trauma <1 month (acute stress vs PTSD).

Comorbidity: PTSD commonly co-occurs with depression (50%), substance use (30-50%), anxiety. Screen with ../../depression-screening/, ../../substance-screening/, ../../anxiety-screening/. Address in treatment planning.

Workflow Integration

Related workflows: ../../intake-interview/ (comprehensive intake), ../../treatment-planning/ (trauma treatment plans), ../../documentation/ (progress notes). See ../../docs/references/crisis-protocols.md and ../../docs/references/referral-guidelines.md.

Additional Resources

For detailed guidance, see:

• references/severity-levels.md - Complete severity interpretations for PC-PTSD-5 and PCL-5
• references/screening-comparison.md - When to use PC-PTSD-5 vs PCL-5
• references/clinical-decision-trees.md - Treatment selection, monitoring, and escalation
• references/trauma-informed-approach.md - Essential trauma-informed screening techniques

References

PC-PTSD-5:

• Prins A, Bovin MJ, Smolenski DJ, et al. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and evaluation within a veteran primary care sample. J Gen Intern Med. 2016;31(10):1206-1211.

PCL-5:

• Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD, 2013.
• Bovin MJ, et al. Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychological Assessment. 2016;28(11):1379-1391.

Public domain - VA National Center for PTSD, freely available for clinical and research use