PTSD Checklist for DSM-5 (PCL-5)

Background of the Instrument

The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) is a self-report

measures that assesses the presence and severity of PTSD symptoms based on the Diagnostic
and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association
[APA], 2013). The PCL-5 is the revised version of the Posttraumatic Stress Disorder Checklist
(PCL) developed by Weathers, Litz, Herman, Huska and Keane (1993) for National Center for
PTSD. The PCL is one of the most widely used self-report measure of PTSD. It consists of 17
items that correspond to 17 symptoms criteria of PTSD in the Diagnostic and Statistical Manual
of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994).
Respondents are required to indicate how much they have been disturbed by each symptom in
the past month on a 5-point scale. There are three versions of the PCL that differ slightly in the
instructions and wording correspond to the referring index event: the PCL-Military (PCL-M)
that assesses symptoms in relation to military experience, the PCL-Civilian (PCL-C) that
assesses symptoms in response to any traumatic event, and the PCL-Specific (PCL-S) that
assesses symptoms in relation to an identified stressful experience (VA National Center for
PTSD, 2014; Weathers et al, 1993).

As there is revision in the diagnostic criteria for PSTD in DSM-5 (American Psychiatric
Association [APA], 2013), the PCL was revised in accordance with DSM-5 by Blevins,
Weathers, Davis, Witte, and Domino (2015). The several major revisions made to the PCL-5
include rewording of the existing items to reflect changes to existing symptoms, the addition
of three new symptoms of PTSD (blame, negative emotions, and reckless or self-destructive
behavior), and the changing of rating scale from 1-5 to 0-4. After revision, the PCL-5 forms a
20-items questionnaire that corresponds to the DSM-5 symptom criteria for PTSD. A sample
item of PCL-5 is “In the past month, how much were you bother by repeated, disturbing, and
unwanted memories of the stressful experience?”. The respondents are required to indicate how
much they are bothered with the specific symptom on a 5-point scale, ranging from 0=”Not at
all” to 4= “Extremely”. The PCL-5 is closest to the PCL-S version, while there are no
corresponding PCL-M or PCL-C versions of PCL-5. Although there is only one version of the
PCL-5 symptom items, there are three versions of the PCL-5 that vary slightly in how Criterion
A is assessed. According to DSM-5, Criterion A requires exposure to a traumatic event that
involve actual or possible threat of death, violence or serious injury for PTSD diagnosis. The
first version of PCL-5 does not have Criterion A assessment. The second version provides
explanation of Criterion A and examples of qualifying events, asks respondents to identify their
worst event, and then assesses whether the worst event meets Criterion A. The third version
includes the Life Events Checklist for DSM-5 (LEC-5) besides a more detailed assessment of
Criterion A. The first version is intended to be used when Criterion A is measured by some
other method, while the second and third versions are designed to be used when a brief
Criterion A assessment is required (Blevins et al., 2015).

The psychometric properties of the PCL-5 has been validated. PCL-5 was reported with
strong internal consistency (α = .94), test-retest reliability (r = .82), as well as convergent (rs
= .74 to .85) and discriminant (rs = .31 to .60) validity (Blevins et al., 2015). Besides,
confirmatory factor analyses indicated adequate fit of PCL-5 with the DSM-5 4-factor model
(Blevins et al., 2015). Therefore, the PCL-5 is a valid and reliable questionnaire to assess
PTSD symptoms.

The Purpose of the Instrument

The PCL-5 can be used in a variety of clinical and research assessment contexts for
PTSD assessment. The purposes of using PCL-5 include making a provisional PTSD diagnosis,
monitoring symptom change during and after treatment, and screening individuals for PTSD.
It is especially useful to provide information about PTSD symptoms when administering a
structure interview is not feasible (Weathers et al., 1993). PCL-5 results can help to determine
appropriate next steps or treatment options for the patient in an intake or assessment session.
Individuals who meet diagnosis criteria of PTSD according to PCL-5 are recommended to have
further assessment and structured interview with certified clinicians in order to confirm on the
diagnosis. For patients who are receiving treatment for PTSD, PCL-5 is a short and self-
administered measure that is convenient for them to take routinely in order to check on their
progress of treatment.
The Administration Process

The PCL-5 is a self-report questionnaire that can be completed by respondents

themselves or administered in person or by telephone. Nevertheless, self-administration is the
preferred mode of administration. The patients can complete the measures at the waiting room
before a session starts or when a session ends, or at home prior to an appointment (VA National
Center for PTSD, 2017). It takes about 5-10 minutes to complete the questionnaire.

The PCL-5 can be administered in one of three versions:

(i) Without Criterion A assessment (brief instructions and items only), which is suitable to
be used when trauma exposure is assessed by some other method
(ii) With a brief Criterion A assessment
(iii)With the revised Life Events Checklist for DSM-5 (LEC-5) and extended Criterion A
assessment

The PCL-5 is designed to assess patient symptoms in the past month. In the case where
administration of PCL-5 is needed for more or less frequently than once a month for various
reasons, the timeframe in the measure may be modified to meet the purpose of the assessment.
However, the administrator should be aware that such changes may alter the psychometric
properties of the measure (VA National Center for PTSD, 2017).

Scoring and Interpretation

The interpretation of the PCL-5 should be done by a clinician or an appropriately

trained professional. There are several scoring methods for the PCL-5 as described in the
following (VA National Center for PTSD, 2017):
a) Summing the scores for each of the 20 items to get a total symptom severity score
(range = 0-80).
b) Summing the scores for the items within a given cluster to get DSM-5 symptom cluster
severity scores, i.e., cluster B (items 1-5), cluster C (items 6-7), cluster D (items 8-14),
and cluster E (items 15-20).
 c) Serve as a provisional PTSD diagnosis by treating each item rated as 2= “Moderately”
or above as symptom endorsed and then determine whether an individual meets the
DSM-5 diagnostic rule: at least one Criterion B item (questions 1-5), one Criterion C
item (questions 6-7), two Criterion D items (questions 8-14), two Criterion E items
(questions 15-20).

Based on preliminary validation work, the suggested cut-point for PCL-5 total symptom
severity score is 33 (VA National Center for PTSD, 2017). In other words, when an individual
get total PCL-5 score of 33 or higher, he/ she is recommended to do further assessment in order
to confirm a diagnosis of PTSD. Nevertheless, characteristics of the patient’s setting and the
purpose of assessment should be taken into consideration before using the PCL-5 total severity
score to make a provisional diagnosis for PTSD. For screening purpose or when maximal
detection of possible cases is desired, a lower cut-point score is suggested. On the other hand,
a higher cut-point score is suggested when a provisional diagnosis is required or to minimize
false positives (VA National Center for PTSD, 2017).

It should be noted that the PCL-5 can only serves as supplementary diagnosis for PTSD.
If an individual meets a provisional diagnosis of PTSD using Method (a) or (c) above, he or
she needs further assessments and structured interview conducted by certified clinician to
confirm on the diagnosis. The clinician will determine whether the symptoms meet criteria for
PTSD and lead to clinically significant distress or impairment as well as to examine the
possibility that the symptoms are caused by other conditions (i.e., substance use, medication
conditions, bereavement, etc.). Some examples of the more comprehensive measures of PTSD
include the Clinician-Administered PTSD Scale (CAPS) and PTSD Symptom Scale-Interview
(PSS-I).

The PCL-5 can also be used to monitor patient progress in a treatment. Literature shows
that a 5-10 point change in PCL-5 score indicates reliable change (i.e., change not due to chance)
while a 10-20 point change indicates clinically significant change (VA National Center for
PTSD, 2017). Therefore, it is suggested to use 5 points as a minimum threshold to determine
whether an individual has responded to treatment and 10 points as a minimum threshold to
determine whether the improvement is clinically meaningful.
Implication

Evidence-based treatments rely on the use of standardized assessment to help

personalize treatment planning, inform treatment decisions and provide optimal care. The
PCL-5 can be given at an intake or assessment session of PTSD to help determine the
appropriate next steps or treatment options. For example, if the patient get a total score of 33
or higher, he/ she is suggested to take further assessment or receive PTSD treatment. It should
be noted that the cut-point of total score may be adjusted according to the goal of assessment,
as mentioned in the above section.

In addition, the PCL-5 can be used conveniently for routine monitoring of improvement
or change in PTSD symptoms over time or tracking of treatment progress. Clinicians may
utilize the data from PCL-5 to guide treatment decisions, identify potential intervention targets
and assist in differential diagnosis. As PCL-5 can be self-administered, it helps to engage the
client as an active partner in their health care decisions. It helps to improve communication
between providers and facilitate collaboration among different services. On the hand, the
information can alert clinicians to change their interventions when there is lack of progress or
even worsening of symptoms. The clinicians will need to explore and identify possible therapy-
interfering behaviors while looking for alternative interventions.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: Author.
Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The
Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial
psychometric evaluation. Journal of Traumatic Stress, 28, 489-498. doi:
10.1002/jts.22059
VA National Center for PTSD (2017, May 11). PTSD Checklist for DSM-5 (PCL-5) [Fact
sheet]. Retrieved https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-
checklist.asp
VA National Center for PTSD. (2014). Using the PTSD Checklist for DSM-IV (PCL) [Leaflet].
Retrieved from https://www.ptsd.va.gov/professional/assessment/documents/
PCL_handoutDSM4.pdf
Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October).
The PTSD Checklist: Reliability, validity, and diagnostic utility. Paper presented at the
annual meeting of the International Society for Traumatic Stress Studies, San Antonio,
TX.
 Result of the Test

Total Symptom Severity Score = 17 / 80

Interpretation:
Since the score obtained is below the suggested cut-point score at 33, the recipient does not
meet the diagnostic criteria for PTSD.

DSM-5 Symptom Cluster Severity Scores

Score for cluster B (item 1-5) = 4 / 20 (20%)
Score for cluster C (item 6-7) = 4 / 8 (50%)
Score for cluster D (item 8-14) = 6 / 28 (21%)
Score for cluster E (item 15-20) = 3 / 24 (13%)