The diagnostic accuracy of the PTSD checklist: a critical review.

The PTSD Checklist (PCL) is the most frequently used self-report measure of PTSD symptoms. Although the PCL has been in use for nearly 20 years and over a dozen validation studies have been conducted, this paper provides the first comprehensive review of its diagnostic utility. Eighteen diagnostic accuracy studies of the PCL are presented, followed by an examination of the potential roles of spectrum effects, bias, and prevalence in understanding the variation in sensitivity, specificity, and other operating characteristics across these studies. Two related issues as to the interchangeability of the PCL's three versions (civilian, military, and specific) and various scoring methods are also discussed. Findings indicate that the PCL has several strengths as a PTSD screening test and suggest that it can be a useful tool when followed by a second-tier diagnostic test such as a standardized interview. However, the PCL's operating characteristics demonstrate significant variation across populations, settings, and research methods and few studies have examined such factors that may moderate the PCL's utility. Recommendations and cautions regarding the use of the PCL as a clinical screening test, a diagnostic tool in research, and as an estimator of PTSD population prevalence are provided.

[1]  E. Peskind,et al.  Prazosin Effects on Objective Sleep Measures and Clinical Symptoms in Civilian Trauma Posttraumatic Stress Disorder: A Placebo-Controlled Study , 2008, Biological Psychiatry.

[2]  J. Elhai,et al.  Psychometric properties of the PTSD Checklist with older primary care patients. , 2005, Journal of traumatic stress.

[3]  F. Strack,et al.  The impact of administration mode on response effects in survey measurement , 1991 .

[4]  M. Stein,et al.  Sensitivity and Specificity of the PTSD Checklist in Detecting PTSD in Female Veterans in Primary Care , 2003, Journal of traumatic stress.

[5]  P. Schnurr,et al.  Understanding relationships among trauma, post-tramatic stress disorder, and health outcomes. , 2004, Advances in mind-body medicine.

[6]  John-Paul Wilson,et al.  Assessing psychological trauma and PTSD, 2nd ed. , 2004 .

[7]  R. Spitzer,et al.  Psychiatric diagnosis: are clinicians still necessary? , 1983, Comprehensive psychiatry.

[8]  Christopher R. Erbes,et al.  Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. , 2007, Military medicine.

[9]  S. Orsillo.  Measures for Acute Stress Disorder and Posttraumatic Stress Disorder , 2002 .

[10]  F. Norris,et al.  Standardized Self-Report Measures of Civilian Trauma and PTSD. , 2004 .

[11]  T. B. Üstün,et al.  The World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) , 2004, International journal of methods in psychiatric research.

[12]  A. Arntz,et al.  Low specificity of symptoms on the post-traumatic stress disorder (PTSD) symptom scale: a comparison of individuals with PTSD, individuals with other anxiety disorders and individuals without psychopathology. , 2007, The British journal of clinical psychology.

[13]  K. Taber,et al.  Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001. , 2009, Journal of psychiatric research.

[14]  P. Schnurr,et al.  Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD checklist. , 2008, Journal of traumatic stress.

[15]  B. Niles,et al.  Psychometric properties of PTSD Checklist in sample of male veterans. , 2008, Journal of rehabilitation research and development.

[16]  C. Engel,et al.  Association of Posttraumatic Stress Disorder with Somatic Symptoms, Health Care Visits, and Absenteeism among Iraq War Veterans , 2007 .

[17]  J. Elhai,et al.  Screening for PTSD in public‐sector mental health settings: the diagnostic utility of the PTSD checklist , 2007, Depression and anxiety.

[18]  J. Fairbank,et al.  Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. , 1998, The American journal of psychiatry.

[19]  Elisa R Braver,et al.  Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder. , 2008, American journal of epidemiology.

[20]  Brian H Willis,et al.  Spectrum bias--why clinicians need to be cautious when applying diagnostic test studies. , 2008, Family practice.

[21]  J. Okeson,et al.  Post-traumatic stress disorder among patients with orofacial pain. , 2006, Journal of orofacial pain.

[22]  B Christopher Frueh,et al.  Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics. , 2005, General hospital psychiatry.

[23]  Murray B Stein,et al.  An abbreviated PTSD checklist for use as a screening instrument in primary care. , 2005, Behaviour research and therapy.

[24]  A. Feinstein,et al.  Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. , 1978, The New England journal of medicine.

[25]  Chris R Brewin,et al.  Systematic review of screening instruments for adults at risk of PTSD. , 2005, Journal of traumatic stress.

[26]  J. Davidson,et al.  Structured interview for PTSD (SIP): Psychometric validation for DSM‐IV criteria , 1997, Depression and anxiety.

[27]  Tyler C Smith,et al.  New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study , 2008, BMJ : British Medical Journal.

[28]  John M. Kelley,et al.  Reassessing War Stress: Exposure and the Persian Gulf War , 1993 .

[29]  P. Lewinsohn,et al.  Comparability of telephone and face-to-face interviews in assessing axis I and II disorders. , 1997, The American journal of psychiatry.

[30]  David Moher,et al.  Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD Initiative. , 2003, Radiology.

[31]  S. Manne,et al.  Posttraumatic stress disorder among mothers of pediatric cancer survivors: diagnosis, comorbidity, and utility of the PTSD checklist as a screening instrument. , 1998, Journal of pediatric psychology.

[32]  David L Streiner,et al.  Diagnosing Tests: Using and Misusing Diagnostic and Screening Tests , 2003, Journal of personality assessment.

[33]  J. Spira,et al.  Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan. , 2007, Military medicine.

[34]  Charles Marmar,et al.  Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. , 2007, Archives of internal medicine.

[35]  Terri Tanielian,et al.  Invisible Wounds of War. Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery , 2008 .

[36]  J. Nicholas,et al.  Performance characteristics of the posttraumatic stress disorder checklist and SPAN in Veterans Affairs primary care settings. , 2007, General hospital psychiatry.

[37]  C. Zlotnick,et al.  The relative contribution of abuse severity and PTSD severity on the psychiatric and social morbidity of battered women in shelters. , 2008, Behavior therapy.

[38]  D. Charney,et al.  The development of a Clinician-Administered PTSD Scale , 1995, Journal of traumatic stress.

[39]  D. V. van Kammen,et al.  Open-label topiramate as primary or adjunctive therapy in chronic civilian posttraumatic stress disorder: a preliminary report. , 2002, The Journal of clinical psychiatry.

[40]  T. Hergueta,et al.  The mini international neuropsychiatric interview , 1998, European Psychiatry.

[41]  M. R. Widows,et al.  Relation of Psychological Vulnerability Factors to Posttraumatic Stress Disorder Symptomatology in Bone Marrow Transplant Recipients , 2000, Psychosomatic medicine.

[42]  R. Morey,et al.  The validity and diagnostic efficiency of the Davidson Trauma Scale in military veterans who have served since September 11th, 2001. , 2009, Journal of anxiety disorders.

[43]  T. W. Miller,et al.  Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist-Civilian Version (PCL-C) as a screening instrument. , 1998, Journal of consulting and clinical psychology.

[44]  D. Revicki,et al.  Telephone assessment of depression severity. , 1993, Journal of psychiatric research.

[45]  D. Sheehan,et al.  The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. , 1998, The Journal of clinical psychiatry.

[46]  S. Rosenberg,et al.  Trauma and posttraumatic stress disorder in severe mental illness. , 1998, Journal of consulting and clinical psychology.

[47]  Meghan E McDevitt-Murphy,et al.  Use of the Personality Assessment Inventory in Assessment of Posttraumatic Stress Disorder in Women , 2005 .

[48]  P. Bossuyt,et al.  Sources of Variation and Bias in Studies of Diagnostic Accuracy , 2004, Annals of Internal Medicine.

[49]  M. Zimmerman,et al.  Screening for posttraumatic stress disorder in a general psychiatric outpatient setting. , 2002, Journal of consulting and clinical psychology.

[50]  C. Hoge,et al.  Pentagon employees after September 11, 2001. , 2004, Psychiatric Services.

[51]  M. Kunik,et al.  Utility of telephone assessments in an older adult population. , 2007, Psychology and aging.

[52]  A. M. Ruscio,et al.  Psychometric Properties of Nine Scoring Rules for the Clinician- Administered Posttraumatic Stress Disorder Scale , 1999 .

[53]  D. Silove,et al.  The role of post‐traumatic stress disorder and depression in predicting disability after injury , 2009, The Medical journal of Australia.

[54]  J. Sheikh,et al.  The primary care PTSD screen (PC-PTSD): development and operating characteristics , 2004 .

[55]  J. Beckham,et al.  Clinical utility of the Primary Care - PTSD Screen among U.S. veterans who served since September 11, 2001 , 2010, Psychiatry Research.

[56]  Charles W Hoge,et al.  Mild traumatic brain injury in U.S. Soldiers returning from Iraq. , 2008, The New England journal of medicine.

[57]  Lynda A. King,et al.  Prewar factors in combat-related posttraumatic stress disorder: structural equation modeling with a national sample of female and male Vietnam veterans. , 1996, Journal of consulting and clinical psychology.

[58]  W. Katon,et al.  Validation of the PTSD checklist in an HMO sample of women. , 2002, General Hospital Psychiatry.

[59]  E. Carlson.  Psychometric Study of a Brief Screen for PTSD:Assessing the Impact of Multiple Traumatic Events , 2001, Assessment.

[60]  R. Kessler,et al.  Posttraumatic stress disorder in the National Comorbidity Survey. , 1995, Archives of general psychiatry.

[61]  Robert J. Ursano,et al.  Posttraumatic stress disorder and depression in battle-injured soldiers. , 2006, The American journal of psychiatry.

[62]  Paul D Bliese,et al.  Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. , 2008, Journal of consulting and clinical psychology.

[63]  R. Kessler,et al.  The stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation , 2001, Biological Psychiatry.

[64]  A. Jablensky.  Research Methods in Psychiatric Epidemiology: An Overview∗ , 2002, The Australian and New Zealand journal of psychiatry.

[65]  B. Rothbaum,et al.  Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. , 1991, Journal of consulting and clinical psychology.

[66]  Lisa Thalji,et al.  Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11. , 2002, JAMA.

[67]  R. Yehuda,et al.  Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy. , 2005, The Journal of clinical endocrinology and metabolism.

[68]  Lynda A. King,et al.  Modeling Physical Health and Functional Health Status: The Role of Combat Exposure, Posttraumatic Stress Disorder, and Personal Resource Attributes , 1999, Journal of traumatic stress.

[69]  J. Davidson,et al.  Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder , 1999, Psychiatry Research.

[70]  Martin M. Antony,et al.  Practitioner's guide to empirically based measures of anxiety , 2002 .

[71]  Michelle P. Salyers,et al.  Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness. , 2001, Psychological assessment.

[72]  E. Blanchard,et al.  Psychometric properties of the PTSD Checklist (PCL). , 1996, Behaviour research and therapy.

[73]  M. Detke,et al.  Is PTSD caused by traumatic stress? , 2007, Journal of anxiety disorders.

[74]  Iris Pigeot,et al.  Handbook of epidemiology , 2005 .

[75]  T. M. Davis,et al.  Posttraumatic stress disorder in female veterans: association with self-reported health problems and functional impairment. , 2004, Archives of internal medicine.

[76]  E. Newman,et al.  The psychometric utility of two self-report measures of PTSD among women substance users. , 2007, Addictive behaviors.

[77]  Kenneth J. Ruggiero,et al.  Psychometric Properties of the PTSD Checklist—Civilian Version , 2003, Journal of traumatic stress.

[78]  R W Sanson-Fisher,et al.  An examination of self- and telephone-administered modes of administration for the Australian SF-36. , 1998, Journal of clinical epidemiology.

[79]  P. Meehl,et al.  Antecedent probability and the efficiency of psychometric signs, patterns, or cutting scores. , 1955, Psychological bulletin.

[80]  Amee J. Epler,et al.  Screening for post-traumatic stress disorder in female Veteran's Affairs patients: validation of the PTSD checklist. , 2002, General hospital psychiatry.

[81]  B. Dohrenwend,et al.  The Psychological Risks of Vietnam for U.S. Veterans: A Revisit with New Data and Methods , 2006, Science.

[82]  R. Sumpter,et al.  Misdiagnosis of post-traumatic stress disorder following severe traumatic brain injury , 2005, British Journal of Psychiatry.

[83]  B. Rothbaum,et al.  Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. , 2001, Archives of general psychiatry.

[84]  M. Miller,et al.  Emotional Processing in PTSD: Heightened Negative Emotionality to Unpleasant Photographic Stimuli , 2009, The Journal of nervous and mental disease.

[85]  T. Keane,et al.  The Operating Characteristics of the PTSD Checklist in Detecting PTSD in HIV+ Substance Abusers , 2008 .

[86]  P. Resick,et al.  Cognitive processing therapy for sexual assault victims. , 1992, Journal of consulting and clinical psychology.

[87]  E. Foa,et al.  Comparison of the PTSD Symptom Scale–Interview Version and the Clinician-Administered PTSD Scale , 2000, Journal of traumatic stress.

[88]  Stephen H. D. Jackson,et al.  Validation of a screening instrument for post-traumatic stress disorder in a clinical sample of older adults , 2008, Aging & mental health.

[89]  N. Gene-Cos.  Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care , 2006 .

[90]  S. Wessely,et al.  Screening for psychological illness in military personnel. , 2005, JAMA.

[91]  A. Erkanli,et al.  Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: association with current symptomatology. , 2006, The Journal of clinical psychiatry.

[92]  C. Hoge,et al.  Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. , 2004, U.S. Army Medical Department journal.

[93]  Matt J. Gray,et al.  Which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects?: A survey of traumatic stress professionals. , 2005, Journal of traumatic stress.

[94]  S. Haynes,et al.  Development and preliminary validation of a brief broad-spectrum measure of trauma exposure : The Traumatic Life Events Questionnaire , 2000 .

[95]  John-Paul Wilson,et al.  Assessing psychological trauma and PTSD , 1997 .