PCL-5 vs PC-PTSD-5: PTSD screening and assessment compared

A veteran returns from deployment and visits their primary care provider. A civilian is in therapy three months after a car accident. A refugee is being evaluated at a resettlement clinic. All three may be experiencing PTSD, but they need very different levels of assessment.

The PC-PTSD-5 and PCL-5 are both developed by the National Center for PTSD, both aligned with DSM-5 criteria, and both free to use. But they serve fundamentally different roles. One is a 5-item gatekeeper that takes two minutes. The other is a 20-item assessment that maps the full symptom picture.

Understanding when to use each, and when to use both, matters for anyone working with trauma-exposed populations.

At a glance

What each tool measures

The PC-PTSD-5: One question per symptom domain

The PC-PTSD-5 begins with a trauma exposure screening question: "Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire; a physical or sexual assault or abuse; an earthquake or flood; a war; seeing someone be killed or seriously injured; having a loved one die through homicide or suicide. Have you ever experienced this kind of event?"

If the answer is no, screening stops. If yes, five questions follow, each targeting a different PTSD symptom domain:

1. Intrusion: "Had nightmares about the event(s) or thought about the event(s) when you did not want to?"
2. Avoidance: "Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?"
3. Hyperarousal: "Been constantly on guard, watchful, or easily startled?"
4. Negative alterations: "Felt numb or detached from people, activities, or your surroundings?"
5. Negative cognitions: "Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?"

Each question gets a Yes (1) or No (0). Total score: 0-5.

What makes the PC-PTSD-5 work so well is its efficiency. One item per symptom domain, yes/no format, completed in under two minutes. The fifth item (guilt/blame) was added when the instrument was updated from the original 4-item PC-PTSD to align with DSM-5's new Criterion D cluster (negative alterations in cognitions and mood).

The PCL-5: The full DSM-5 symptom map

The PCL-5 assesses all 20 DSM-5 PTSD symptoms across four clusters:

Cluster B, Intrusion (items 1-5):
- Repeated, disturbing memories
- Repeated, disturbing dreams
- Flashbacks (reliving the experience)
- Emotional distress at reminders
- Physical reactions to reminders

Cluster C, Avoidance (items 6-7):
- Avoiding trauma-related thoughts or feelings
- Avoiding trauma-related external reminders

Cluster D, Negative cognitions and mood (items 8-14):
- Trouble remembering the event
- Strong negative beliefs about self/others/world
- Distorted blame
- Persistent negative emotions
- Loss of interest in activities
- Feeling distant or cut off
- Difficulty experiencing positive feelings

Cluster E, Arousal and reactivity (items 15-20):
- Irritable or aggressive behavior
- Self-destructive or reckless behavior
- Hypervigilance
- Exaggerated startle response
- Difficulty concentrating
- Sleep disturbance

Each item is rated on a 0-4 scale: "Not at all," "A little bit," "Moderately," "Quite a bit," "Extremely." Total score ranges from 0 to 80.

This structure allows the PCL-5 to do things the PC-PTSD-5 cannot: provide severity scores per cluster, support provisional diagnosis using the DSM-5 algorithm, and track specific symptom changes during treatment.

Scoring and interpretation

PC-PTSD-5 scoring

The PC-PTSD-5 uses two cutoff options depending on clinical goals:

The overall diagnostic accuracy (AUC) is 0.941 when validated against the CAPS-5 (Prins et al., 2016).

The interpretation is binary:

PCL-5 scoring

The PCL-5 supports multiple scoring approaches:

Total severity score (0-80):

The National Center for PTSD recommends a cutoff between 31 and 33. A lower cutoff (31) maximizes sensitivity for screening. A higher cutoff (33) minimizes false positives for provisional diagnosis.

Provisional DSM-5 diagnosis: Treat each item rated 2 ("Moderately") or higher as an endorsed symptom. Then apply the DSM-5 diagnostic rule: at least 1 Cluster B item, 1 Cluster C item, 2 Cluster D items, and 2 Cluster E items.

Cluster scores: Sum items within each cluster for a symptom profile:
- Cluster B (Intrusion): Items 1-5 (range 0-20)
- Cluster C (Avoidance): Items 6-7 (range 0-8)
- Cluster D (Negative cognitions/mood): Items 8-14 (range 0-28)
- Cluster E (Arousal/reactivity): Items 15-20 (range 0-24)

Change scores: A 5-10 point change is considered reliable (not attributable to measurement error). A 10-20 point change indicates clinically meaningful improvement.

When to use the PC-PTSD-5

Primary care universal screening

This is the tool's home territory. In primary care settings where every patient is screened for trauma exposure and PTSD, the PC-PTSD-5's brevity makes it feasible at scale. The VA uses it as its standard primary care PTSD screen.

The workflow is straightforward:
1. Ask the trauma exposure question
2. If yes, ask the five symptom questions
3. Score of 3+ triggers further evaluation
4. Score of 0-2 requires no further PTSD assessment

High-volume clinical settings

Emergency departments, urgent care, intake screenings for substance abuse programs, and community health centers all need to screen efficiently. The PC-PTSD-5 can be embedded in check-in forms or administered by non-specialist staff.

Populations with unknown trauma history

When you don't know whether a patient has experienced trauma, the PC-PTSD-5's built-in trauma exposure question is a real advantage. The PCL-5 assumes trauma exposure and jumps straight to symptoms. The PC-PTSD-5 asks about exposure first, making it a true population-level screening tool.

When you need a quick yes-or-no answer

A referring physician who wants to know "Should this patient see a trauma specialist?" doesn't need a 20-item severity profile. They need a positive or negative screen. The PC-PTSD-5 answers that question directly.

Research screening for study enrollment

Studies that need to identify trauma-exposed individuals with probable PTSD can use the PC-PTSD-5 as a rapid screen to determine eligibility for further assessment.

When to use the PCL-5

Full PTSD assessment

When the clinical question goes beyond "Is PTSD present?" to "How severe is it, and what does the symptom profile look like?", the PCL-5 is the right tool. Its 20 items provide a detailed map of PTSD symptoms.

Provisional diagnosis

The PCL-5's item-level data supports a provisional DSM-5 PTSD diagnosis using the symptom cluster algorithm. While a definitive diagnosis requires a structured clinical interview (such as the CAPS-5), the PCL-5 provides a reasonable approximation that can guide initial treatment decisions.

Treatment planning

Cluster-level scores tell clinicians where the symptom burden is heaviest. A patient with high intrusion scores but low avoidance scores will benefit from different therapeutic strategies than one with the opposite pattern. Prolonged Exposure therapy, for example, specifically targets avoidance, while Cognitive Processing Therapy addresses the negative cognitions captured in Cluster D.

Treatment monitoring

The PCL-5 is designed for repeated administration during treatment. Its established change thresholds (5-10 points for reliable change, 10-20 for clinically meaningful change) make it the standard for tracking PTSD treatment response.

Typical monitoring schedule:
- Baseline before treatment begins
- Every 2-4 weeks during active treatment
- At treatment completion
- At follow-up intervals (3, 6, 12 months)

Specialty mental health settings

Trauma-focused therapy programs, PTSD clinics, and psychiatric settings typically use the PCL-5 rather than the PC-PTSD-5. These settings have already identified the patient as trauma-exposed and potentially PTSD-positive. The question is no longer "Is PTSD present?" but "How bad is it, and is it getting better?"

Forensic and disability evaluations

When documentation of PTSD severity is needed for legal, disability, or compensation purposes, the PCL-5's severity score and cluster profile provide more substantive evidence than a binary PC-PTSD-5 result.

How they work together: The two-stage approach

Like the PHQ-2 and PHQ-9, the PC-PTSD-5 and PCL-5 function best as a two-stage system:

Stage 1: PC-PTSD-5 as the gate

Administer the PC-PTSD-5 to all patients (or all patients in a high-risk population). Those who screen negative (score 0-2) are cleared for PTSD purposes. Those who screen positive (score 3+) advance to Stage 2.

Stage 2: PCL-5 for detailed assessment

Positive screens complete the PCL-5 for full symptom evaluation. This provides severity scoring, cluster analysis, and a provisional diagnostic framework.

Stage 3 (if warranted): Clinical interview

Neither the PC-PTSD-5 nor the PCL-5 is a definitive diagnostic tool. For formal diagnosis, the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) remains the reference standard. The PCL-5 can support a provisional diagnosis and inform whether the CAPS-5 is warranted.

VA and DoD recommendations

The Veterans Administration and Department of Defense have established clear guidance for PTSD screening:

- The PC-PTSD-5 is the recommended primary care screening tool for all veterans
- It's administered annually and after any deployment
- Positive screens are followed by full evaluation, typically including the PCL-5
- The PCL-5 is the standard for treatment monitoring in VA PTSD programs

This two-tiered system has been in place since the PC-PTSD's original development and is one of the most well-implemented mental health screening programs in any healthcare system.

Psychometric comparison

Both tools have strong psychometric properties. The PCL-5's internal consistency (Cronbach's alpha of 0.94-0.96) reflects its 20-item structure and the intercorrelation of PTSD symptoms. The PC-PTSD-5's strong AUC (0.941) shows that even five dichotomous items can achieve excellent screening accuracy when well-chosen.

Important considerations for specific populations

Gender differences

Research has found that the PC-PTSD-5 cutoff of 4 works well for men but may produce more false negatives for women. Clinicians may consider using the lower cutoff of 3 for women, particularly when follow-up resources are available. The PCL-5 does not show the same gender-based cutoff concerns, though women tend to score slightly higher on some symptom clusters.

Veteran vs civilian populations

Both tools were initially validated in VA samples but have been subsequently validated in civilian populations. Optimal cutoffs may differ between veteran and civilian samples. The PC-PTSD-5 civilian validation found 100% sensitivity and 85.2% specificity at a cutoff of 4, even stronger performance than in the original veteran sample.

Cultural considerations

Both instruments have been translated and validated across multiple languages and cultures. However, symptom expression varies culturally. Some cultures emphasize somatic symptoms (headaches, body pain) over psychological ones (flashbacks, emotional numbing). Neither tool captures somatic presentations particularly well, so clinical interview remains important for culturally diverse populations.

Complex PTSD

Neither the PC-PTSD-5 nor the PCL-5 directly assesses the additional features of complex PTSD (emotion dysregulation, negative self-concept, interpersonal difficulties). If complex PTSD is suspected, supplementary assessment is needed.

For individuals: Which should you take?

If you've experienced a traumatic event and want to understand whether PTSD might be affecting you:

Start with the PC-PTSD-5 if you're looking for a quick initial check. Five yes/no questions will tell you whether your symptoms warrant closer attention. If your score is below 3, PTSD is unlikely to be a significant factor at this time.

Take the PCL-5 if you already know you've been affected by trauma and want to understand the severity and pattern of your symptoms. The 20 items take about 5-10 minutes and give you a detailed picture of how PTSD is showing up across different symptom areas.

Take both if you want the full picture. Start with the PC-PTSD-5 as a quick gate. If it's positive, complete the PCL-5 for the detailed assessment. Bring both results to your provider.

Important: If you score high on either tool, please talk to a mental health professional. PTSD is a treatable condition. Evidence-based treatments like Cognitive Processing Therapy and Prolonged Exposure have strong track records, and most people improve significantly with appropriate care.

Common questions

Can the PC-PTSD-5 replace the PCL-5?

For screening purposes, yes. For severity assessment, treatment monitoring, or provisional diagnosis, no. They serve different clinical functions, and the PC-PTSD-5 cannot provide the detailed information the PCL-5 offers.

Can the PCL-5 replace the PC-PTSD-5?

Technically, the PCL-5 provides all the information the PC-PTSD-5 does and more. However, the PCL-5 doesn't include a trauma exposure screening question -- it assumes exposure. And administering 20 items to every primary care patient is impractical. The PC-PTSD-5 exists precisely because the PCL-5 is too long for universal screening.

What if I score positive on the PC-PTSD-5 but below threshold on the PCL-5?

This happens and is clinically meaningful. It may indicate subthreshold PTSD symptoms, recent symptom improvement, or differences in how the tools capture symptoms (yes/no vs. severity rating). Continue monitoring and discuss the discrepancy with your provider.

How often should each tool be administered?

The PC-PTSD-5 is typically administered annually or at initial presentation. The PCL-5 is administered at baseline and every 2-4 weeks during treatment, then at follow-up intervals.

My PCL-5 score dropped by 8 points during treatment. Is that meaningful?

A 5-10 point change on the PCL-5 is considered reliable (beyond measurement error). Your 8-point drop represents genuine symptom improvement. A change of 10-20 points would be considered clinically meaningful. You're on the right trajectory.

Does the PC-PTSD-5's trauma exposure question bias results?

The question serves a practical purpose: if no trauma exposure has occurred, PTSD screening is unnecessary. However, some individuals may not recognize their experiences as traumatic (e.g., childhood neglect, medical procedures), potentially leading to false negatives on the exposure question. Clinical judgment should supplement the screening.

The bottom line

The PC-PTSD-5 is your rapid screening tool: 5 items, 2 minutes, a clear positive/negative result with a built-in trauma exposure check. Use it for universal screening in primary care and high-volume settings.

The PCL-5 is your full assessment tool: 20 items covering all DSM-5 PTSD symptoms, with severity scoring, cluster analysis, provisional diagnostic capability, and established change thresholds for treatment monitoring. Use it after positive screens, in specialty settings, and throughout treatment.

Together, they form a two-stage system that balances efficiency with thoroughness. Screen broadly with the PC-PTSD-5. Assess deeply with the PCL-5. Treat with confidence.