Criterion E1 captures irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression towards people or objects.

To code this symptom as present, the respondent will generally express their irritability or anger through verbal or physical aggression toward people or objects.  This can include both overtly angry behaviors such as yelling and throwing things, as well as passive-aggressive behaviors such as storming out of a room. It is important to ask questions about each of these types of expressions separately, exactly as they are written in the CAPS-5, so you can be sure that you have all the information you need. The CAPS-5 scoring key for this item suggests the following heuristics: 1) clearly present = anger/irritability is expressed mostly verbally; 2) pronounced = anger/irritability is expressed with at least some physical aggression. In general, an extreme intensity will only be given when both verbal and physical aggression are present, and the physical aggression is directed at another person.

Criterion E2 captures reckless or self-destructive behavior. For this item, only code behavior that involves objective harm such as the potential for life-threat, serious injury, or financial ruin.  For the behavior to be scored, the respondent must be engaging in this behavior with disregard for the outcome, usually with the intent to regulate a painful emotional state. The behavior must be dangerous, but not all dangerous behaviors meet E2. For example, we would not code situations in which the respondent is engaging in thrill-seeking activities but is following normative precautions (e.g., skydiving as part of a reputable program). Make sure to consider cultural norms when evaluating clinical significance. In addition, remember that not all behaviors that break the law will be scorable for this item. For example, speeding on the highway is often not reckless.

To code this item, it is particularly compelling if the person can acknowledge that the behavior is reckless and recognize that the aspect of danger meets an emotional need. However, although the respondent’s appraisal of the behavior as reckless or high-risk is important, it is not always necessary to code the item.

Criterion E3 captures hypervigilance. Many people with military experience will endorse clearly present intensity for this symptom, by virtue of their training. Useful heuristics for scoring this item include: 1) clearly present = behaviors consistent with being alert or watchful in crowds (e.g., scanning in public, sitting with one’s back against the wall, insisting upon facing the exit and/or being close to an exit); 2) pronounced = hypervigilant behaviors typically expressed in multiple settings (e.g., at home, in crowds) and which include more exaggerated behaviors than those seen in a clearly present presentation (e.g., walking the perimeter at home each night); and 3) extreme = behaviors that far outweigh any possible threat (e.g., sleeping with a gun under one’s pillow despite living in a safe neighborhood).  As with other CAPS-5 items, clinicians should not reify these descriptions; they should always use their best judgment when coding an individual’s response to questions. Be careful to separate external avoidance (C2) from hypervigilance. If the person avoids crowds because they are unsafe, this is C2. However, if when the person has to be in crowds, they engage in active behaviors to stay safe, this is hypervigilance.

Criterion E4 captures exaggerated startle response. There may be some overlap between startle and B5 (physical reactions to trauma reminders). For example, a loud noise may both startle the person and cause physical reactions because it is reminiscent of an IED explosion. However, whereas item B5 is related to reminders of traumatic experiences, in E4, you are looking for physical conditioning, such as startle reactions that come from the unexpected, like a loud noise or an unexpected approach. Further, whereas B5 must be caused by a trauma reminder, startle reactions do not have this requirement. To be counted towards the PTSD diagnosis, the startle reactions simply must have started or gotten worse after the traumatic event(s) occurred.

Criterion E5 captures problems with concentration. You can use what you observe in the interview, as well as what the respondent reports, to score this item. Be mindful not to confuse hypervigilance or anhedonia for problems with concentration. Helpful follow-up questions to assess for concentration difficulties include asking “Do you have trouble reading? …watching a half hour TV show? …an hour TV show? … following conversations?”

Criterion E6 captures sleep disturbances, such as difficulty falling or staying asleep, or restless sleep.  Getting too much sleep may be clinically important as a depressive symptom, but it is not counted here as a PTSD symptom because it is not driven by arousal. In general, coding for this item is done by determining how much sleep the respondent gets on an average night, how much they think they should be getting, and scoring the difference using the CAPS-5 key. For example, if a respondent says she gets 6 hours on average but would like to get 8, this is an average of 2 hours of sleep loss, which is coded as Pronounced intensity.