How to Use the PCL-5

Many people—including providers—think only people who’ve been to war get diagnosed with Post-traumatic Stress Disorder or PTSD. But it’s not the only traumatic event that can cause it: Natural disasters, rape and sexual violence, violent crime, and near death experiences are examples of traumatic events that can also lead to PTSD.

The PCL-5 or PTSD Checklist-5 is an assessment tool that helps providers learn whether their clients meet the criteria for PTSD. Clinicians first determine if their clients have experienced a traumatic event then use the PCL-5 to check for symptoms of PTSD. 

Background information

The PCL-5 was created by the National Center for PTSD in the 1990s to screen clients for PTSD and diagnose it. Since then, it’s been revised to reflect DSM updates to PTSD diagnostic criteria. Clients can answer 20 questions on their own about the symptoms they’ve experienced the past month, related to their trauma. 

The screener questions are grouped into 4 clusters: intrusion, avoidance, negative alterations of cognitions and mood, and alterations in arousal and reactivity. Question clusters allow the screener to be scored in different ways.

Scoring

Though the PCL-5 is self-administered, my experience has taught me that it can be helpful to give some guidance to clients before they take it. These reminders can provide a more accurate score.

• Define what would fit the criteria of a traumatic event.
• Remind clients that the symptoms should be related to the identified traumatic event.
• Specify that symptoms should be from the last month. If the event happened years ago, clients should answer the assessment based on recent symptoms. 
• Reassure clients that even if symptoms change over time, they’ll use this tool frequently during treatment, not just once. 

Scoring the PCL-5 can be complex because it can be interpreted in different ways. That’s also part of what makes it a useful tool. You can use the aggregated score from all the questions to make a diagnosis, or use question clusters to make a provisional diagnosis. Clustered scoring also gives insight into the severity of specific symptoms, which can inform treatment.

Using the total score

The total score can help you diagnose PTSD for use in session or determine if you should refer your client to another clinician who specializes in PTSD. Simply add up the score of all 20 questions. The highest total severity score is 80. 

If the client scores above 33 in total, it is probable that they have PTSD. You can also check the DSM-5 for more criteria on forming a PTSD diagnosis. 

Using cluster scoring

PCL-5 questions can be used to measure the severity of specific symptoms by scoring question clusters—or groups of questions within the assessment that relate to a specific symptom. Cluster scoring can help identify which symptoms are most severe.

The cluster questions are:

• Intrusion, cluster B, questions 1 to 5
• Avoidance, cluster C, questions 6 to 7
• Negative alterations in cognitions and mood (NACM), cluster D, questions 8 to 14
• Alterations in arousal and reactivity (AR), cluster E, questions 15 to 20

You can also use clusters to make a provisional diagnosis for PTSD. If a client rates that they’ve been bothered by a symptom “Moderately” or higher (i.e. scores a 2 or higher) on the minimum in every cluster, then they might qualify for a provisional diagnosis, based on the DSM-5.  

You can determine a provisional diagnosis if a client rates 2 or higher on at least:

• One question in intrusion, cluster B;
• One question in avoidance, cluster C;
• Two questions in negative alterations in cognitions and mood, cluster D;
• And two questions in alterations in arousal and reactivity, cluster E.

Administering the assessment

The PCL-5 asks people to think how they’ve been feeling the past month. They then rate how much they’ve been bothered by these problems on a scale from 0 to 4: 

• 0 — Not at all
• 1 — A little bit
• 2 — Moderately
• 3 — Quite a bit
• 4 — Extremely

The questions are:

In the past month, how much were you bothered by: 

1. Repeated, disturbing, and unwanted memories of the stressful experience? 
2. Repeated, disturbing dreams of the stressful experience? 
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience? 
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience? 
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience? 
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10. Blaming yourself or someone else for the stressful experience or what happened after it? 
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? 
12. Loss of interest in activities that you used to enjoy? 
13. Feeling distant or cut off from other people? 
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting aggressively? 
16. Taking too many risks or doing things that could cause you harm? 
17. Being “superalert” or watchful or on guard? 
18. Feeling jumpy or easily startled? 
19. Having difficulty concentrating? 
20. Trouble falling or staying asleep? 

Treatment and/or other next steps

Clients with total scores that are 33 or higher could benefit from PTSD treatment. By consistently using the PCL-5 before, during, and after treatment, providers and clients can check for concrete evidence about whether symptoms are changing over the course of treatment. A change of 5 points is  the suggested minimum for a response to treatment, and a change of 10 points is the minimum for clinically meaningful improvement. 

Evidence-based treatments for PTSD include Cognitive Processing Therapy, Prolonged Exposure Therapy, and EMDR, which are clinically proven to reduce PTSD symptoms. 

Reminder: It’s important and helpful to talk to your clients about their scores for this assessment and any other assessments. Be direct and give them information you have. Ask if they have any questions about their score and treatment. 

As people process trauma, symptoms can—and often do—worsen but only temporarily. This is normal during PTSD treatment. 

However, clients may feel concern if they see that their scores seem to worsen. Talk to your clients about their scores and reassure them that treatments will teach them coping skills to handle their symptoms. This communication is also important to ensure clients don’t drop out of treatment. 

If you’re using UpLift, clients who identify their reason for visit as trauma or PTSD will automatically receive the PCL-5. You can review their scores in their chart before their session. 

You can also send the PCL-5 to any clients that you think would benefit from having it as part of their treatment. 

When you use the PCL-5 on UpLift, your clients will receive it every 28 days. 

Whether you’re treating clients on UpLift or somewhere else, be sure to talk with them about their assessment scores. Check in to make sure that this tool is still helpful for them to manage their symptoms, so you make sure you’re treating a client in a way that works for them.