Complex PTSD Questionnaire for Trauma Survivors

If you would like results of this questionnaire please send SASE and your completed questionnaire to Dr. M. B. Williams, 17 S. 5th St., Room K, Warrenton, VA 20186.

Fill out the items below. Higher scores are more indicative of Complex PTSD. All seven dimensions are included.

  1. No impact
  2. Little impact
  3. Some impact
  4. A lot of impact
  5. Severe impact

For the following questions, unless you are given additional directions, please CIRCLE the answer that seems most appropriate. The choices for 1, 2, 3, 4, and 5 are as follows:

  1. Absent, no effect, an effect does not exist
  2. Subthreshold—only a little but not enough to bother me a great deal
  3. This happens to me sometimes
  4. This happens often
  5. This happens most of the time to me
  1. Do small problems get you more upset than they used to? Do you 1/2/3/4/5 get much more angry now at a minor frustration?
  2. Do you cry more easily than you used to, for example, at a sad movie? 1/2/3/4/5
  3. Do you get more nervous now about things you have to do? 1/2/3/4/5 Do you overreact to minor incidents? If you answered 2, 3, 4, or 5 to any of the first three questions, how much do you overeact?

    not at all

    a little

    I get extremely upset sometimes

    I often am extremely upset and may even have tantrums

  4. Do you find it hard to calm yourself down after you become upset? 1/2/3/4/5 If you answered 2 or 3 or 4 or 5, can you give an example?

    Please circle which applies to how long you stay upset?

    seconds

    minutes

    hours

    days

  5. Do you find that things that used to put you back on track 1/2/3/4/5 (like playing music, going out with friends) don’t seem to work anymore?
  6. Have you been in many accidents or near accidents, including 1/2/3/4/5 |little accidents at home, since the trauma ended?
  7. Do you find you are now more careless about making sure that 1/2/3/4/5 you are safe (e.g., avoiding unsafe places and people; locking doors and windows)?
  8. Have you deliberately tried to hurt yourself (e.g. burning or 1/2/3/4/5 cutting yourself)? If you answered anything but 1, please respond. This happened as:

    one minor episode or accident

    more than 1 minor accident or superficial episodes

    at least 1 serious accident or frequent superficial episodes

    more than 1 serious accident, several potential near-misses or frequent and serious episodes

  9. Have you ever thought of killing yourself? 1/2/3/4/5 If you answered other than 1, what have you thought of doing? How often is killing yourself on your mind?

    rarely

    occasionally

    frequently, regularly

    almost always

    always

  10. Have you actually tried to kill yourself? 1/2/3/4/5 If you answered other than 1, how?
  11. Do you feel angry much/most of the time? 1/2/3/4/5 If you answered other than 1,

    my anger doesn’t bother me or interfere with my life

    I feel quite angry but can shift my anger to other matters

    anger interferes with my paying attention to daily tasks

    anger dominates my daily life

  12. Do you have thoughts or images of hurting someone else? 1/2/3/4/5 If you answered other than 1, would you give an example of whom and how?
  13. Are you less able to control anger now than before? 1/2/3/4/5

    If so, then do you

    snap at people

    yell or throw things

    attack people physically

  14. Are you so worried about upsetting others or losing control that 1/2/3/4/5 you try not to show anger at all?
  15. Do you make an active effort to keep yourself from thinking about sex? 1/2/3/4/5
  16. Are you actually disgusted about the idea of sex? 1/2/3/4/5
  17. Does it bother you to be touched? 1/2/3/4/5
  18. Do you avoid sexual involvements with previous partners? 1/2/3/4/5
  19. Do you avoid new sexual involvements? 1/2/3/4/5
  20. Do you find yourself thinking about sex too much of the time? 1/2/3/4/5 If you answered other than 1, how does this affect your life?
  21. Are you sexually active in ways that may cause you problems or 1/2/3/4/5 put you in danger (sex with people you do not know very well, unprotected sex, for example)? If you answered other than 1, what behaviors do you do?
  22. Do you get into situations that might be dangerous to you, 1/2/3/4/5 e.g., going to places that are not safe, driving too fact, involving yourself in dangerous sports, selling drugs, gambling? If you answered other than 1, in which do you participate?
  23. Since the traumatic event happened, was there a period of time 1/2/3/4/5 when you could not remember it, were confused about what happened (e.g., couldn’t remember certain aspects of it, including when it began or how long it lasted) or weren’t sure it really happened?

    If you answered other than 1,

    some details are missing

    a few lapses of memory

    entire missing episodes

    no memory for months or years of my life

    Exactly which of these occurred and to what degree?

  24. Do you have difficulty now accounting for periods of time in your 1/2/3/4/5 daily life?
  25. Are you confused about names of familiar people or places? 1/2/3/4/5
  26. Do you find yourself in places without knowing how you got there? 1/2/3/4/5 If you answered anything but 1, to questions 24, 25, or 26, how much of a problem is this to you?

    no problem

    somewhat of a problem

    this is a major problem for me

  27. Do you find you lose track of time? 1/2/3/4/5 If you answered other than 1, what is that like for you?
  28. Not counting when you use (used) drugs or alcohol, do you 1/2/3/4/5 sometimes feel so unreal that it is as if you were living in a dream or not really there? If you answered other than 1, does this cause problems in your work or social life?
  29. Do you sometimes feel like there are two or more totally 1/2/3/4/5 different people living inside yourself who control how you behave at different times?
  30. Do you have trouble getting the event or the trigger off your mind? 1/2/3/4/5
  31. Are you able to stop thinking about the event when you are 1/2/3/4/5 working or doing something that requires your attention?
  32. Have you lost your confidence in being able to deal with 1/2/3/4/5 everyday situations (daily chores, work, paying bills, driving, paying attention to your children)? If you answered other than 1, could you please give examples?
  33. Do you believe there is something “wrong” with you because of 1/2/3/4/5 the event, something that can never be fixed? If you answered other than 1, can you describe what you feel is wrong with or “different” about you?
  34. Do you feel guilty about not having done more to prevent the 1/2/3/4/5 event from happening? If you answered other than 1, could you describe what you now think you could have done then?
  35. Do you try to hide your traumatic history from others or fear 1/2/3/4/5 what may be exposed about you if the trauma is revealed (e.g., if other learn of your past)?
  36. Do you avoid talking about the trauma with people? 1/2/3/4/5
  37. Do you keep your trauma history a secret? 1/2/3/4/5
  38. Do you feel embarrassed if you talk about the trauma? If so, why? 1/2/3/4/5
  39. Do you have the belief that nobody else could possible 1/2/3/4/5 understand what you went through during the trauma?
  40. Do you believe that your trauma history does not really 1/2/3/4/5 bother you? Do you think that others sometimes make too much of a “big deal” about it?
  41. Do you sometimes think that the event happened for very good reasons?/1/2/3/4/5 If you answered other than 1, what are those reasons?
  42. Do you sometimes think that the perpetrator of the event 1/2/3/4/5 (if the event was caused by a person) is special? Do you admire him or her?
  43. Do you think about getting revenge against the perpetrator 1/2/3/4/5 of the event? If you answered other than 1, what would you want to do and how often?
  44. If the event was caused by an act of God or nature, are you angry at God? 1/2/3/4/5 How do you explain the meaning of the event to yourself?
  45. Do you feel safe in your life at the present time? 1/2/3/4/5
  46. Do you have difficulties trusting others? 1/2/3/4/5 If you answered other than 1, would you list examples of mistrust.
  47. Has your ability to relate to other changed? 1/2/3/4/5 If you answered other than 1, specifically

    I have fewer relationships

    I am more distant in relationships with others

    I set more careful boundaries

    I have fewer boundaries

    I spend less time with others

    If you spend less time with others (free time) now than before, to what extent?

    a little bit less

    somewhat less

    much less

    a lot less time

  48. What other events have happened to you since the originally named traumatic event occurred?

    I have been ___________________________________________

    I have been raped ____ times

    I have been mugged/robbed ____ times

    I have been in ____ natural disasters (examples)

    I have witnessed ____ traumatic events (examples)

    I have been battered (hit) ____ times

  49. Have you hurt others in ways similar to how you were traumatized? 1/2/3/4/5 If you answered other than 1, what have you done?
  50. Have you felt helpless and/or pessimistic about the future? 1/2/3/4/5

    How, specifically, has your view of the future changed? 1/2/3/4/5

  51. Have your feelings changed about your ability to find happiness 1/2/3/4/5 in love relationships so that you no longer find happiness in these relationships?
  52. Do you now find more happiness in your relationships? 1/2/3/4/5
  53. Do you find more satisfaction in your work now? 1/2/3/4/5
  54. Do you find less satisfaction in your work now? 1/2/3/4/5
  55. Has it been hard to find a reason to go on with life? 1/2/3/4/5
  56. Have your ethical and/or religious beliefs changed because 1/2/3/4/5 of the trauma that happened to you? If you answered other than 1, could you give examples?