Psychiatry Research 261 (2018) 504–507

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

27 ways to meet PTSD: Using the PTSD-checklist for DSM-5 to examine T

PTSD core criteria
⁎
C. Laurel Franklina,b,c, , Amanda M. Rainesa,c, Lisa-Ann J. Cuccurulloa,b,c, Jessica L. Chamblissa,
Kelly P. Maieritschd, A. Madison Tompkinsa, Jessica L. Waltona,b,c
a
Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, USA
b
Tulane University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1430 Tulane Avenue, New Orleans, LA 70112, USA
c
South Central VA Mental Illness Research Education and Clinical Center, 2400 Canal Street, New Orleans, LA 70119, USA
d
Edward Hines Jr. VA Hospital, 5000S. Fifth Street, Hines, IL 60141, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Posttraumatic stress disorder (PTSD) has been criticized for including symptoms that substantially overlap with
PTSD other depression and anxiety disorders. To address this concern, Brewin et al. (2009) reformulated the diagnosis
PTSD Checklist around a core symptom set. Although several studies have examined the utility of the core criteria in predicting
Diagnosis diagnostic status, none have done so using a self-report screening instrument. The sample included 617 veterans
Veterans
presenting for outpatient psychological services. As a part of the intake process, veterans completed the PTSD
Checklist for DSM-5 (PCL-5) and were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5).
Veterans meeting core criteria on the PCL-5 were over 22 times more likely to meet PCL-5 diagnosed PTSD than
veterans who met the core criteria on the PCL-5 but did not meet PCL-5 diagnosed PTSD (OR = 22.94; CI [12.76,
41.25]). Further, veterans who met core criteria on the PCL-5 were over 2 times more likely (OR = 2.34; 95.0%
CI [1.53, 3.59]) to meet CAPS-5 diagnosed PTSD than veterans who met the core criteria on the PCL-5 but did
not meet CAPS-5 diagnosed PTSD. Findings from the current study have implications for the assessment and
classification of PTSD.

1. Introduction
In preparation for the release of the Diagnostic and Statistical Manual
of Mental Disorders, Fifth edition (DSM-5; American Psychiatric
Association, 2013), Brewin et al. (2009) proposed to refocus the diag-
nosis of Posttraumatic Stress Disorder (PTSD) around a smaller set of
core criteria. Citing the high degree of overlap with other anxiety and
depressive disorders, the authors hypothesized that a simplified set of
symptoms would aid in the identification and classification of PTSD
while leading to reduced overlap with comorbid psychiatric conditions.
The Brewin et al. (2009) core criteria, based on Diagnostic and Statistical
Manual of Mental Disorders, Fourth edition (DSM-IV-TR; American
Psychiatric Association, 2000), consist of six symptoms, five of which
were found to be the most predictive of PTSD in a DSM-IV-TR field trial
(Kilpatrick et al., 1998). These symptoms were evenly divided into
three clusters and include distressing dreams or flashbacks (Criterion
B), internal or external avoidance (Criterion C), and hypervigilance or
exaggerated startle (Criterion E). According to the proposed criteria of
Brewin et al. (2009), a PTSD diagnosis requires that at least one
symptom in each cluster be met for a PTSD symptom count ranging
from three to six.
There are numerous clinical advantages to simplifying the diag-
nostic criteria of PTSD including enhanced diagnostic accuracy and
decreased assessment time (Maercker et al., 2013). However, only two
studies to date have examined the utility of such a reformulation. Using
a treatment-seeking sample of civilian trauma survivors (N = 170)
assessed using the Structured Clinical Interview for DSM-IV Axis I dis-
orders (SCID-I; First et al., 1996), van Emmerik and Kamphuis (2011)
examined PTSD prevalence rates using the Brewin et al. (2009) criteria.
The authors found virtually no difference in prevalence rates of PTSD
using the Brewin core criteria versus the DSM-IV criteria. Further, the
authors found that rates of comorbid depression and anxiety were lower
when the Brewin criteria were applied. Walton et al. (2017) recently
extended these findings by examining the Brewin et al. (2009) criteria
in a large sample of veterans (N = 383) assessed using the Clinician
Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013a,
2013b), the gold standard measure for diagnosing PTSD. The authors
found that the core criteria accurately identified 79% of veterans with a

⁎
Corresponding author at: Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, USA.
E-mail address: laurel.franklin@va.gov (C.L. Franklin).

https://doi.org/10.1016/j.psychres.2018.01.021
Received 10 October 2017; Received in revised form 5 January 2018; Accepted 9 January 2018
Available online 11 January 2018
0165-1781/ Published by Elsevier B.V.
C.L. Franklin et al.
DSM-5 diagnosis of PTSD. Moreover, using these core symptoms to
examine PTSD reduced the number of possible combinations from
636,120 (DSM-5) to 27 (core symptoms).
While these findings are compelling, clinicians often assign diag-
noses in absence of structured clinical interviews. In fact, the CAPS is
used less often than unstructured clinical interviews and self-report
measures that screen for PTSD, such as the PTSD Checklist (PCL; Elhai
et al., 2005). The PCL-5, a 20-item self-report questionnaire, uses a
Likert scale rating from zero (“not at all”) to five (“extremely) to in-
dicate symptom presence and severity. The PCL-5 is one of the most
widely used measures of PTSD. Indeed, the Veterans Health Adminis-
tration (VA) requires that a PCL be administered to all patients upon
entering treatment and strongly encourages the use of this self-report
measures throughout treatment to monitor patient progress. Psycho-
metrics for the PCL-5, validated against a CAPS-5 PTSD diagnosis,
suggest that a scores of 31–33 is optimal for determining probable PTSD
(Bovin et al., 2016), and a score of 33 is recommended for use at pre-
sent.
Examining whether the core symptoms can be used to evaluate
PTSD using a self-report measure is warranted. As such, the current
study examined whether the proposed core criteria could accurately
identify cases of PTSD within a large sample of veterans assessed using
a self-report screening measure (i.e., PCL) as well as a clinician-rated
diagnostic measure of PTSD (i.e., CAPS). Consistent with the findings of
Walton et al. (2017), it was hypothesized that the core PTSD criteria
would accurately identify a majority of individuals who screened po-
sitive for PTSD on the PCL or were diagnosed with PTSD via clinician
ratings on the CAPS. To our knowledge, this is the first study to examine
the predictive power of these core criteria within a population known to
have increased rates of traumatic exposure (American Psychiatric
Association, 2013; Kessler et al., 2005), while using a self-report
screening instrument of PTSD.
2. Methods
2.1. Sample and procedures
The sample consisted of 617 veterans presenting for psychological
services to one of two PTSD specialty clinics at VA facilities in the
Midwest and Southeast. As part of the intake process, veterans com-
pleted the PTSD Checklist for DSM-5 (Weathers et al., 2013b) and the
CAPS-5 (Weathers et al., 2013a) to determine the presence or absence
of PTSD for the purposes of admission to the PTSD program. The IRB at
both facilities approved this data for research purposes.
Veterans were primarily male (n = 540; 87.5%), with ages ranging
from 20 to 94 (M = 48.09, SD = 16.54). The racial/ethnic breakdown
was as follows: 56.7% (n = 350) Caucasian, 23.0% (n = 142) African-
American, 14.1% (n = 87) Native Hawaiian/Pacific Islander, 2.8% (n
= 21) Asian, 1.6% (n = 10) Hispanic, 0.8% (n = 5) American Indian/
Alaskan, and 0.2% (n = 1) other (e.g., biracial), with 0.2% (n = 1)
declining to identify. In terms of marital status, 48.5% (n = 299) of the
sample was married, 21.6% (n = 133) divorced, 19.4% (n = 120)
never married, 6.0% (n = 37) separated, and 3.4% (n = 21) widowed,
with 1.1% (n = 7) failing to identify. The majority of the sample
(45.2%; n = 279) had a high school diploma or the equivalent, fol-
lowed by 31.3% (n = 193) having some college, 13.0% (n = 80)
completing college, 5.2% (n = 32) having some graduate training,
2.3% (n = 14) completing graduate school, and 1.6% (n = 10) having
less than a high school education, with 0.5% (n = 3) failing to respond.
Lastly, index traumas recorded on the CAPS-5 included: 72.6% (n =
448) combat exposure, 11.8% (n = 73) military sexual trauma, 6.0% (n
= 37) other (e.g., natural disaster), 3.7% (n = 23) adult physical abuse,
3.2% (n = 20) childhood physical and/or sexual abuse, 1.9% (n = 12)
motor vehicle accident, 0.5% (n = 3) non-military related adult sexual
abuse, with 0.2% (n = 1) missing data.
505
Psychiatry Research 261 (2018) 504–507
2.2. Measures
2.2.1. Posttraumatic stress disorder checklist for DSM-5 (PCL-5)
The PCL-5 is a 20-item self-report measure designed to mirror each
DSM-5 PTSD symptom (Weathers et al., 2013b). A total-symptom score
of zero to 80 can be obtained by summing the items. Recent reports
suggest that a cut score of 33 can be used to determine probable PTSD
(Weathers et al., 2013b). Of note, reliability statistics for the PCL-5
indicated adequate-to-excellent internal consistency for the PCL-5 total
score (α = 0.90) and subscale scores (intrusion α = 0.83; avoidance α
= 0.80; negative alterations in cognitions/mood α = 0.80; arousal α =
0.77).
2.2.2. Clinician-administered PTSD Scale for DSM-5 (CAPS-5)
For the purposes of this study, the CAPS-5 was used to determine
presence of clinician-rated PTSD. The CAPS-5 is a 30-item clinician-
administered interview used to assess for DSM-5 PTSD diagnostic status
and symptom severity (Weathers et al., 2013a). The CAPS-5 was ad-
ministered as a part of routine clinical assessment by doctoral-level
psychologists, therefore no interrater reliability statistics are available.
Clinicians administering the CAPS-5 had either formal training via a
half-day workshop with the measure's primary author (Weathers et al.,
2013a) and/or were required to complete the CAPS-5 training video
and/or attend a half-day workshop by a clinician who was formally
trained on the CAPS-5.
2.3. Data analytic plan
To test the utility of the Brewin et al. (2009) core criteria, the six
proposed items from the PCL-5 were dichotomized to capture the pre-
sence or absence of symptom reporting. More specifically, a rating of
two (“moderately”) or more (“quite a bit or extremely”) on any core
item was coded as an endorsement of that item, whereas a zero (“not at
all”) or one (“a little bit”) on any item was coded as the absence of that
item. The score of two or higher was chosen because it is indicative of
moderate presence and distress related to each symptom. Individuals
were included as meeting core-PTSD criteria if they endorsed one or
more (i.e., minimum of three and maximum of six) of the proposed core
symptoms within each of the three (DSM-IV-TR) criterion-clusters. The
PCL-5 was also used to determine probable PTSD using the re-
commended cut score of 33 (yes/no). Lastly, the CAPS-5 was used to
determine presence of clinician-rated PTSD, based on DSM-5 scoring
rules (yes/no). A series of two logistic regression analyses were run with
PCL-5 core criteria as the independent variable and the presence of
PTSD, based on the PCL-5 or the CAPS-5 as the dependent variables.
3. Results
Table 1 displays the number of individuals that met the PTSD core
criteria by whether they also screened positive for PTSD on the PCL-5 or
were diagnosed with PTSD on the CAPS-5. To assess the likelihood of
meeting PTSD on the PCL-5 using the core criteria, a logistic regression
was computed. No data was missing from the current sample. The full
model was statistically significant, χ2 (1, N = 616) = 131.74, p < .001,
indicating that the model was able to distinguish between respondents
who did and did not meet PCL-5 PTSD. The model explained between
19.2% (Cox and Snell R square) and 37.9% (Nagelkerke R squared) of
the variance in PTSD status and correctly classified 88.7% of cases.1
Results revealed that veterans who meet the core criteria on the PCL-5
were over 22 times more likely (odds ratio [OR] = 22.57, 95.0% CI
[13.55, 48.24]) to meet PCL-5 diagnosed PTSD than veterans who met
1
The Cox and Snell R2 has an upper bound less than 1.0. As such, it is often reported
along with a corrected version: Nagelkerke R2. This pseudo R2 adjusts Cox & Snell's so
that the range of possible values extends to 1 thereby improving interpretability.
C.L. Franklin et al.
Table 1
Crosstabulation of core PTSD symptom presence to PTSD.
PTSD Criteria Met
Core Symptom Definition
PCL-5
Not Met
Not Met 56
Met 14
CAPS-5
Not Met 50
Met 96
Note. PCL-5 = PTSD Checklist, Fifth edition; CAPS-5 = Clinician Administered PTSD
Scale, Fifth edition.
the core criteria on the PCL-5 but did not meet PCL-5 diagnosed PTSD.
Next, to assess the likelihood of meeting PTSD on the CAPS-5 using
the core criteria, a logistic regression was utilized. No data was missing
from the current sample. The full model was statistically significant, χ2
(1, N = 616) = 18.48, p < .001, indicating that the model was able to
distinguish between respondents who did and did not meet CAPS-5
PTSD. The model as a whole explained between 3.0% (Cox and Snell R
square) and 4.4% (Nagelkerke R squared) of the variance in PTSD status
and correctly classified 76.3% of cases.1 Results revealed that veterans
who meet core symptoms on the PCL-5 were over 2 times more likely
(odds ratio [OR] = 2.5, 95.0% CI [1.68, 3.87]) to meet CAPS-5 diag-
nosed PTSD than veterans who met the core criteria on the PCL-5 but
did not meet CAPS-5 diagnosed PTSD.
4. Discussion
The current investigation sought to replicate and extend prior re-
search examining the utility of the Brewin et al. (2009) core criteria
within a large sample of veterans assessed using a self-report screening
instrument. Consistent with initial prediction, results revealed that the
veterans who endorsed this subset of symptoms on the PCL-5 were
significantly more likely to screen positive for PTSD on the PCL-5 or
meet diagnostic criteria for PTSD via clinician ratings on the CAPS-5.
These findings are consistent with the limited empirical work available
(van Emmerik and Kamphuis, 2011; Walton et al., 2017) and the notion
that an increased focus on the core disturbance could lead to improved
ease of identification without drastically altering diagnostic hit rates
(Brewin et al., 2009).
Although most cases were accurately identified using the Brewin
et al. (2009) proposed criteria, a small proportion of cases were not. For
example, 12.6% of individuals were not accurately identified using the
PCL-5 to diagnose PTSD and 23.2% were not accurately identified using
the CAPS-5 to diagnose PTSD. It is possible that these individuals en-
dorsed other symptoms unique to PTSD that are not captured within the
proposed core criteria. Indeed, there has been disagreement about what
constitutes the core of the disorder, with some researchers suggesting
that the avoidance and numbing symptoms are actually the defining
features (North et al., 2009). As such, alternative models and criterion
sets should continue to be explored.
The current findings have important implications regarding the
classification of PTSD. Indeed, PTSD was originally conceptualized as a
fear-based anxiety disorder (i.e., like panic or phobia; Watson, 2005).
However, PTSD is more commonly linked to distress-based disorders
(e.g., depression, generalized anxiety; Watson, 2005) within hier-
archical frameworks (Cox et al., 2002) and as such, was removed from
the anxiety disorders chapter in the recent revision of the DSM-5
(American Psychiatric Association, 2013). Recent changes to PTSD
symptom criteria might be one factor that further contributes to its
placement within such hierarchical models. For instance, expansion of
diagnostic criteria to include symptoms characteristic of dysphoria
(Simms et al., 2002) may strengthen the link between PTSD and other
Psychiatry Research 261 (2018) 504–507
distress-based disorders such as depression. On the other hand, mod-
ifications that substantially reduce overlap with comorbid conditions
like depression, such as those recommended by Brewin and colleagues
(2009), are likely to weaken the link between PTSD and distress-based
disorders.
The current study should be considered in light of its limitations and
Met
opportunities for subsequent research. First, the sample consisted pri-
74
473 marily of treatment-seeking male veterans. Given that women are twice
as likely to meet diagnostic criteria for PTSD and over four times as
80 likely to have chronic PTSD (Breslau et al., 1998; Kessler et al., 1995),
391 future research should examine the utility of these core criteria within
women and other diverse samples. Second, it is possible that another
combination of symptoms exist that would lead to similar or even im-
proved findings. As such, alternative models should be tested in an
effort to balance sensitivity and specificity. Third, we did not evaluate
the clinical utility of the new DSM-5 Criterion D symptoms. Thus, as
previously mentioned, future research should examine other possible
combinations, particularly those that take into account DSM-5 changes.
Despite these limitations, the current findings add to a growing
body of literature examining the diagnostic accuracy of the Brewin
et al. (2009) core criteria. Consistent with previous research, it appears
that the majority of cases were accurately identified when using this
simplified set of core criteria. As previously noted, an increased em-
phasis on the core symptomatology could lead to improved identifica-
tion and assessment of symptoms as well as reduced overlap with other
disorders. Further, it could lead to reduced heterogeneity. As such,
researchers should continue to explore the utility of these and other
PTSD symptoms to improve our understanding of this psychological
phenomenon.
Acknowledgements
The contents of this report do not represent the views of the
Department of Veterans Affairs or the U. S. Government.
Contributions
Author one formulated the research question and wrote the in-
troduction and results sections. Author two wrote the discussion sec-
tion. Author three wrote the methods section. Author four assisted with
formatting and prepared the table. Author five and seven assisted with
data collection. Author six assisted with formatting and editing as well
as data entry. All authors provided critical feedback and contributed
substantially to the overall manuscript and/or data collection.
Conflict of interest
The authors declare no conflict of interest.
Role of funding
The research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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