The German version of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): psychometric properties and diagnostic utility

Krüger-Gottschalk et al. BMC Psychiatry (2017) 17:379 DOI 10.1186/s12888-017-1541-6 RESEARCH ARTICLE Open Access The German version of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): psychometric properties and diagnostic utility Antje Krüger-Gottschalk1* , Christine Knaevelsrud2, Heinrich Rau3, Anne Dyer4, Ingo Schäfer5,6, Julia Schellong7 and Thomas Ehring8 Abstract Background: The Posttraumatic Stress Disorder (PTSD) Checklist (PCL, now PCL-5) has recently been revised to reflect the new diagnostic criteria of the disorder. Methods: A clinical sample of trauma-exposed individuals (N = 352) was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the PCL-5. Internal consistencies and test-retest reliability were computed. To investigate diagnostic accuracy, we calculated receiver operating curves. Confirmatory factor analyses (CFA) were performed to analyze the structural validity. Results: Results showed high internal consistency (α = .95), high test-retest reliability (r = .91) and a high correlation with the total severity score of the CAPS-5, r = .77. In addition, the recommended cutoff of 33 on the PCL-5 showed high diagnostic accuracy when compared to the diagnosis established by the CAPS-5. CFAs comparing the DSM-5 model with alternative models (the three-factor solution, the dysphoria, anhedonia, externalizing behavior and hybrid model) to account for the structural validity of the PCL-5 remained inconclusive. Conclusions: Overall, the findings show that the German PCL-5 is a reliable instrument with good diagnostic accuracy. However, more research evaluating the underlying factor structure is needed. Keywords: Posttraumatic stress disorder, DSM-5, PCL-5, Self-report questionnaire Background The diagnosis of posttraumatic stress disorder (PTSD) has undergone major changes with the transition from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) to DSM-5 [1]. These include an expansion from three to four symptom clusters, the introduction of three new symptoms, and the revision of some already existing symptoms (for an overview, see [2]). As the transition from DSM-IV to DSM-5 included substantial changes to the definition of PTSD, existing questionnaires used to assess PTSD needed to be revised by adding new items for * Correspondence: 1 Institute of Psychology, University of Münster, Fliednerstrasse 21, 48149 Münster, Germany Full list of author information is available at the end of the article symptoms added to the PTSD diagnosis, removing items that are no longer part of the DSM-5 definition, and rephrasing some items. The Posttraumatic Stress Disorder Checklist (PCL; [3]) is one of the most widely used self-report questionnaire to asses PTSD and has now been revised to correspond to the new DSM-5 criteria of PTSD (PCL-5; [4]). Changes between the PCL for DSM-IV and the PCL-5 include (a) adding three new items to assess the new PTSD symptoms blame, negative emotions, and reckless or self-destructive behavior, (b) changing the rating from a 1-5 scale to a 0-4 scale, (c) rewording of existing items to reflect the DSM-5 criteria, and (d) having only one PCL version instead of three versions for military members, civilians and specific events. © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Krüger-Gottschalk et al. BMC Psychiatry (2017) 17:379 Psychometric properties of the PCL-5 To our knowledge, four published studies to date have validated the new PCL-5; three were conducted in military or veteran samples ([5, 6, 7]; note that in reference 7 a preliminary version of the PCL-5 was used) and one in a college student sample [8]. In addition to the original English PCL-5, a Swedish version [9] and a Chinese version [10, 11] have also been examined. Results show high internal consistencies for the total scale (α = .90 - .96) as well as the four subscales (intrusions: α = .77 - .92; avoidance: α = .74 – .92; negative alterations in cognitions and mood: α = .78 - .89; hyperarousal: α = .75 - .84) [5, 6, 8, 9]. In addition, high re-test reliability has been found in three studies (r = .66-.84) [6, 8, 9]. There is consistent evidence for high concurrent validity of the PCL-5 in the sense of high correlations with other symptom measures of PTSD (r = .84 - .87) [5–8]. Furthermore, some evidence supporting discriminant validity of the questionnaire was found in that the PCL-5 score is more strongly correlated with measures of related constructs (e.g., other measures of PTSD, depression, anxiety symptoms) than those of unrelated constructs (e.g., personality features, alcohol abuse, psychopathy) [5, 6, 8]. In sum, there is emerging data showing good psychometric properties for the PCL-5. Diagnostic utility of the PCL-5 According to its developers, one of the purposes of the PCL-5 is to screen individuals for PTSD and make a provisional PTSD diagnosis.1 In order to test the diagnostic utility of the PCL-5 as a screening instrument, it appears necessary to compare it to a gold standard structured clinical interview, such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) [12]. To our knowledge, this has only been reported in two studies to date, namely Marmar et al. [7] with a preliminary version of the PCL-5 and in Bovin et al. [6] where the PCL-5 was evaluated against a CAPS-5 diagnosis of PTSD. Results showed that cutoff scores of 31-33 on the PCL-5 showed the best diagnostic utility in predicting CAPS diagnoses, with no difference between the three scores (sensitivity = .88, specificity = .69, overall efficiency = .80) [6]. This is in line with the cutoff of 33 suggested by the developers of the PCL-51. An alternative scoring method for the PCL-5 is treating each item rated as at least 2 (moderately) as a symptom endorsed and then following the DSM-5 diagnostic rule to establish a provisional PTSD diagnosis. When applying this rule to the PCL-5, Bovin and colleagues [6] also found good diagnostic agreement with the CAPS-5 (sensitivity = .81, specificity = .71, overall efficiency = .78). Although this recent study suggests that the PCL-5 possesses adequate diagnostic utility to be used Page 2 of 9 as screening instrument for PTSD, clearly more research is needed comparing the PCL-5 to the gold standard diagnosis established from a structured clinical interview in additional samples. Structural validity of the PCL-5 Based on c (...truncated)