Manual Supplement V OLUME 1, I SSUE 1 N OVEMBER 18, 2014 Posttraumatic Stress Disorder Checklist (PCL) The Posttraumatic Stress Disorder Checklist (PCL) is one of the most frequently used standardized self report measures for PTSD symptoms (Wilkins, Lang, & Norman, 2011). First introduced in 1993 by the the primary purpose for the instrument has been to: (1) assist in screening individuals for PTSD, (2) aid in the diagnostic assessment of PTSD, and (3) monitor change in PTSD symptoms. While the gold standard for a PTSD diagnosis is through a structured clinical interview, such as the Clinician-Administered PTSD Scale (CAPS-5) or the Posttraumatic Stress Scale- Interview (PSS-I), use of the PCL can assist in providing a provisional diagnosis (VA In its original form, the PCL was divided into three versions: (1) PCL-C, or the civilian version, referenced stressful experiences that can be used with any population; (2) PCL-M, the military version, referenced stressful military experiences often used with active service members and Changes in PTSD Criteria in DSM-5 Criterion A Revisions surrounded what constitutes a traumatic event. Indirect exposure, such as the death of a loved one, must be through violent or accidental means. DSM-5 also includes professionals who have never been in direct danger, but who are continually exposed to the consequences of traumatic events, such as military mortuary workers, rescue workers, emergency medical personnel, etc. Criterion A2 was eliminated due to research indicating that intense emotional reactions neither predict nor reduce the number of individuals developing PTSD (Friedman, 2013). Symptoms and Specifiers The DSM-5 focuses more attention on the behavioral symptoms associated with PTSD and provides four diagnostic clusters reexperiencing, avoidance, negative cognitions/mood, and arousal as opposed to the three clusters set forth in the DSM-IV (American Psychiatric Association, 2013; Friedman, 2013). All 17 symptoms in the DSM- IV have been retained and 3 more added, to bring the symptom criteria to 20 items*. Additionally, all 20 symptoms must be tied to the traumatic event, reducing ambiguity in diagnostic accuracy (Friedman, 2013). veterans; and (3) PCL-S, the specific version, was anchored to a specific identified traumatic event. These three versions followed the diagnostic criteria set forth in the Diagnostic and Statistical Manual, 4th edition (DSM- IV) (VA National Center for PTSD, It has been translated into Chinese, Spanish, and Bosnian (International Society for Traumatic Stress Studies, The most current version, the PCL-5, has been adapted for use with the DSM-5 (VA Diagnostic Thresholds a minimum of 6 symptoms are still necessary to fulfill full PTSD criteria, however the cluster breakdown has changed 1B, 1C, 2D, and 2E instead of 1B, 3C, and 2D due to the change in symptoms factor structure. *For a full list of DSM-5 diagnostic criteria compared to the DSM-IV, review Table 1 on page 2. INSIDE THIS ISSUE: PCL for DSM-IV 2 PCL-5 2 Administration/Scoring 3 Psychometrics 4 Strengths/Limitations 4 References 5 SPECIAL POINTS OF INTEREST: PTSD diagnostic criteria has been revised for the DSM-5. PCL-5 assessment includes optional measures for Criterion A and a Life Events Checklist. PCL-5 and PCL for DSM -IV scores are not interchangeable. PCL for DSM-IV were reliable and valid. Psychometrics for PCL-5 are expected to meet similar standards. Attached, find a copy of the PCL-5 with Criterion A and corresponding Life Events Checklist (LEC-5)
P AGE 2 Table 1 V OLUME 1, I SSUE 1 Friedman, 2013 PCL for DSM-IV The PCL for DSM-IV was separated into three formats: PCL-C (Civilian), PCL-M (Military), and PCL-S (Specific). While each version varied slightly in regards to instructions and the wording referring to the traumatic event, each version included 17 questions, corresponding with the diagnostic criteria for PTSD set forth by the DSM-IV. Assessment takers rated how bothersome a symptom had been over the past month on a 5 point Likert scale 1 (not at all), 2 (a little bit), 3 (moderately), 4 (quite a bit), and 5 (extremely). PCL-5 for DSM-5 The PCL-5 is composed of 20 questions assessing the 20 DSM-5 symptoms of PTSD. Assessment takers are asked to rate how bothered they have been by the symptom in the past month, using a Likert scale from 0-4 (0=not at all, 4=extremely). The PCL-5 is most similar to the PCL-S (specific) version for DSM-IV and there are no corresponding PCL-M or PCL-C versions of the PCL-5. Though there is only one version of the PCL-5, it may be administered in one of three formats: without Criterion A, with Criterion A, and with the Life Events Checklist for DSM-5 (LEC-5) and extended Criterion A component. The Criterion A measure assesses for traumatic events in the individual s history that would satisfy Criterion A from the DSM-5 and the LEC-5 provides more detailed information about the individual s trauma history. The wording of the PCL-5 reflects the changes to the existing symptoms and the addition of new symptoms necessary for a PTSD diagnosis in the DSM-5. Due to revisions in the rating scale (from 1-5 to 0-4) and increasing the question bank from 17 to 20, PCL-5 scores are not compatible with PCL for DSM-IV scores and cannot be used interchangeably. In the past month, how much were you bothered by: Repeated, disturbing, and unwanted memories of the stressful experience? 0 = not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely Sample question from PCL-5 (Weathers, Litz, Keane, Palmer, Marx, & Schnurr, 2013)
M ANUAL SUPP LEMENT P AGE 3 Administration/Scoring The PCL is a self report measure that requires about 5-10 minutes to complete. Clinicians have the option of having the client fill out the assessment themselves or utilizing the interview format (VA Additionally, the instrument can be completed either in session or in a waiting room prior to the session (US Department of Veteran Affairs, Scoring of the PCL can be handled in a variety of different ways (VA 2014; U.S. Department of Veteran Affairs, Total Symptom Severity Score May be obtained by summing the scores for the total questionnaire. Ranges include 17-85 for PCL for DSM-IV and 0-80 for PCL-5. Determine whether the score exceeds a normative threshold or cut off point. Cluster Symptom Severity Score Scores may be determined by summing the scores from a particular cluster. PCL for DSM-IV clusters: B (items 1-5), C (items 6-12), D (items 13-17). PCL-5 for DSM-5 clusters: B (items 1-5), C (items 6-7), D (items 8-14), E (items 15-20). Use as a provisional diagnosis tool While the gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician Administered PTSD Scale (CAPS) (VA National Center for PTSD, 2014), the PCL can be used to provide a provisional diagnosis. The clinician will determine whether an individual meets DSM symptom criteria by treating each item rated as Moderately or above as a symptom endorsed/present. PCL for DSM-IV: 1B item, 3C items, at least 2D items PCL for DSM-5: 1B item, 2C items, 2D items, 2E items Cut Points Currently, no definitive cut off threshold exists for either the PCL for DSM-IV or the PCL-5 for DSM-5. Studies show that recommended cut off values may vary depending on the prevalence of PTSD in the population being served, the setting, and the goal of assessment (Bliese, Wright, Adler, Cabrera, Castro, & Hoge, 2008; U.S. Department of Veteran Affairs, 2014; VA 2014; Norris & Hamblen, 2004). Generally, the lower the prevalence, the lower the clinician should set the cut off point, as the goal is to be as accurate as possible in identifying cases of PTSD (VA National Center for PTSD, Settings where PTSD is less common, such as primary care clinics, may require more sensitive cut off thresholds than settings where higher rates of PTSD are expected, such as a specialty mental health clinics (VA A higher cut off point is also considered when using the assessment to inform diagnosis or minimize false positives (VA According to Bliese et al (2008) s literature review of appropriate cut offs for the PCL for DSM-IV, when the sample was composed of a high risk group of Vietnam veterans, a cut off of 50 was recommended. When the sample was composed of severe accident and sexual assault victims, the recommended cut off point was 44. With female veterans in a primary care setting, the cut point was determined to be somewhere between 28 and 30. Lastly, the recommended cut value for screening older adults in primary care was found to be 37. Table 2 (VA 2014) depicts suggested cut points for PCL for DSM-IV. Consider using the low range if the goal is screening for PTSD and the high end if the goal is to aid in diagnosis. Preliminary validation work shows that suggested cut off points for the PCL-5 for DSM-5 are 11-14 points lower than those suggested for the PCL for DSM-IV. The US Department of Veteran Affairs (2014) suggests a general cut off point of 38 with the PCL-5 for DSM-5 until further psychometric data becomes available. Table 2 (VA 2014)
P AGE 4 V OLUME 1, I SSUE 1 Psychometrics Psychometrics for the PCL-5 for DSM- 5 are currently unavailable. As the PCL-5 is most similar to the PCL-S version of PCL for DSM-IV (U.S. Department of Veteran Affairs, 2014), psychometric data for the PCL-S is presented here. Psychometric data for PCL-5 is expected to meet similar standards (U.S. Department of Veteran Affairs, Strengths of the PCL Strengths of the PCL as an assessment for PTSD include: Test-Retest Reliability PCL-S demonstrates excellent reliability when retested immediately (r=0.92), good reliability at one week (r=0.87-0.88), and questionable reliability after two weeks (r=0.66-0.68). Testretest reliability decreases significantly over time (Wilkins, Lang, & Norman, 2011) Internal consistency General PCL- Utility as a guide for diagnostic assessment. Though it cannot be used to fully diagnose PTSD, it assists in screening and provisional diagnosis purposes. Use as an outcome instrument to help measure symptom change from one session or a series of sessions to another. In an era where good clinical care involves providing reports regarding client progress, studies suggest that 5-10 point change in scores is indicative of change not Limitations of the PCL S internal consistency measures 0.85-0.95, ranging from good to excellent (Wilkins, Lang, & Norman, 2011) Convergent validity PCL-S correlates significantly more highly with measures of PTSD than with measures assessing depression, other areas of psychopathology, or with physical pain as demonstrated by overall correlation between total PCL- S and Clinician Administered PTSD Scale (CAPS) scores (r=0.93) (Norris & Hamblen, 2004) Discriminant Validity PCL-S correlates significantly more highly with the CAPS than PTSD measures not anchored to DSM-IV PTSD symptom criteria (Wilkins, Lang, & Norman, 2011). due to chance and a 10-20 point change is clinically significant (VA 2014) for PCL for DSM-IV. PCL-5 scores are expected to be within a similar range. Ease of administration and scoring procedures. The PCL is a self-report measure that takes between 5 and 10 minutes to complete. Scoring requires an understanding of basic math principles. Ease of access. The PCL, created by the U.S. Department of Veteran Affairs, is in the public Structural Validity Studies show support for a four factor model of reexperiencing, avoidance, hyperarousal, and dysphoria/numbing instead of the current three factor model of re-experiencing, avoidance/numbing, and hyperarousal (Wilkins, Lang, & Norman, 2011). *Note: PCL-5 for DSM-5 moved from a 3 factor to a 4 factor model. Cut point A cut point of 44 showed a sensitivity of 0.94-9.7, a specificity of 0.86-0.87, and an overall diagnostic efficacy of 0.90-0.94 (Norris & Hamblen, 2011) with individuals in France who had experienced a variety of events. domain and therefore, easily accessible and free of cost to master s level clinicians and above. PCL-M and PCL-S correlate highly with clinicianadministered measures. It is likely that the PCL-5 will follow a similar pattern. PCL-5 includes an optional assessment of Criterion A. The PCL-5 includes a measure to accurately determine whether a traumatic event qualifies under the revised DSM-5 standards. Limitations of the PCL as an assessment for PTSD include: Limited to no research available on PCL-5 psychometrics. Due to it s relatively recent publication, psychometric research for the PCL-5 is still being conducted. Estimates are expected to be similar to data available for PCL for DSM-IV (U.S. Department of Veteran Affairs, No definitive cut offs available. Cut off criteria for scoring is variable and depends on the base-rate of prevalence of PTSD in the population and the needs of the given setting (Wilkins, Lang, & Norman, 2011) Suggested reading level equivalent to 10 to 13.2 years of academic schooling may be above the ability level of some clients.
M ANUAL SUPP LEMENT P AGE 5 References American Psychiatric Association. (2013). Posttraumatic stress disorder [Leaflet]. American Psychiatric Publishing. http:// www.dsm5.org/documents/ptsd%20fact%20sheet.pdf. Bliese, P. D., Wright, K. M., Adler, A. B., Cabrera, O., Castro, C. A., & Hoge, C. W. (2008). Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. Journal of Consulting and Clinical Psychology, 76(2), 272-281. Friedman, M. J. (2013). Finalizing PTSD in DSM-5: Getting here from there and where to go next. Journal of Traumatic Stress, 26, 548-556. Norris, F. H., & Hamblen, J. L. (2004). Standardized self-report measures of civilian trauma and PTSD. In J. P. Wilson & T. M. Keane (Eds.), Assessing Psychological Trauma and PTSD: A Practitioner's Handbook (2nd ed.). New York, NY: The Guilford Press. Posttraumatic Stress Disorder Checklist (PCL). (n.d.). Retrieved November 13, 2014, from International Society for Traumatic Stress Studies website: http://www.istss.org/ PosttraumaticStressDisorderChecklist.htm. U.S. Department of Veteran Affairs. (2014, May 2). PTSD Checklist for DSM-5 (PCL-5). Retrieved November 13, 2014, from U.S. Department of Veteran Affairs: National Center for PTSD website: http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd -checklist.asp. VA National Center for PTSD. ( Using the PTSD Checklist for DSM-IV (PCL) [Leaflet]. http://www.ptsd.va.gov/professional/ pages/assessments/assessment-pdf/pcl-handout.pdf. Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P. (2013).The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at www.ptsd.va.gov. Wilkins, K. C., Lang, A. J., & Norman, S. B. (2011). Synthesis of the psychometric properties of the PTSD Checklist (PCL) military, civilian, and specific versions. Depression and Anxiety, 28, 596-606.