Posttraumatic Stress Disorder Checklist for DSM-5 ( PCL5 ) : transcultural adaptation of the Brazilian version

Background: DSM-5 introduced some modifications on Posttraumatic Stress Disorder (PTSD) criteria. The instruments developed for the assessment of aspects related to PTSD needed a reformulation, as was the case of the Posttraumatic Stress Disorder Checklist (PCL). Objectives: To present the process of transcultural adaptation of the three forms of the PCL-5 to Brazilian Portuguese, as well as its face validity. Methods: The procedure involved independent translations, a synthesis version, back translation by an independent translator, evaluation by the original author, analysis by an expert committee, and a pretesting study (10 subjects with/without experience of a traumatic situation). The last two steps formed the face validity procedure. Results: The synthesis version was approved by the original author and the agreement percentage by the expert committee was excellent, with only two items showing < 90%. The pretesting study showed that the Brazilian version was well understood and linguistically and culturally accepted by the participants, which did not make significant suggestions for changes. Discussion: Transcultural adaptation of the PCL-5 for Brazilian Portuguese followed a rigid and standardized procedure. Therefore, after having its face validity assessed by an expert committee and by the target population, it is apt to be used. Osório FL et al. / Arch Clin Psychiatry. 2017;44(1):10-9


Introduction
The 5 th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), released on May 2013, introduced modifications in the different diagnostic categories, involving inclusion, reformulation, and exclusion of diagnosis.Regarding especially Posttraumatic Stress Disorder (PTSD), this disorder no longer belongs to the group of anxiety disorders and was included in a new chapter with five different disorders in which their origin can be specifically attributed to stressful and traumatic situations (Trauma-and Stress-Related Disorders) 1 .
Moreover, some modifications were made on PTSD criteria 1 .Considering these modifications, the instruments developed so far for the assessment of aspects related to PTSD needed a reformulation, as was the case of the Posttraumatic Stress Disorder Checklist (PCL), one of the most used instruments in the area 2 that aims to screen subjects with PTSD, make a provisional PTSD diagnosis, and to monitor symptomatic changes during/after treatment.
The PCL was initially proposed by Weathers 3 and Weathers et al. 4 in three versions (civilian, military and specific) composed by 17 items each, related to the diagnostic criteria of the DSM-III/ DSM-IV and scored in a Likert scale from 1 (not at all) to 5 (extremely).
The current version 2 , reformulated in several aspects, was denominated PCL-5 and is composed of 20 items.The main modifications of this new version include: a) availability of a single version in three different forms (without Criterion A, plus Criterion A, plus Life Events Checklist for DSM-5 (LEC-5) 5 and Criterion A); b) creation and adjustment of the items to current symptoms and diagnostic criteria (only nine items remained unchanged and three new items were included); c) new rating scale (0: not at all -4: extremely).
The PCL-5 can be interpreted in several distinct ways: a) total severity score; b) cluster severity scores; c) provisional PTSD diagnosis; d) cut-point suggestions (obtained through specific studies of psychometric validation already established in different contexts of the North American (military service members 6 , veterans 7,8 , trauma exposed college students 2 , community sample of adults 8 ) and Swedish (parents of children with burns 9 ) realities.
Thus, considering the importance of this instrument for PTSDrelated studies worldwide, it is essential that it should be translated, tested, and made available for use in the Brazilian context, as was the case of the PCL-4 10 .
The objective of the present study is to report the process of transcultural adaptation of the PCL-5 for the Brazilian Portuguese in its three forms and of its face validity.

Methods
Initially, authorization to perform the study was obtained after establishing contact by electronic mail with the group that holds the instrument's copyright (National Center for PTSD).
The procedure used to perform the transcultural adaptation of the PCL-5 was based in the stages proposed by Beaton et al. 11 , which involve translations by specialized and non-specialized bilingual translators, a synthesis version, back translation by an independent translator, evaluation by the original author, analysis by an expert committee (consensus version), and pretesting study.These last stages constitute the face validity procedure.
The expert committee had the role of judging, individually, the synthesis version previously approved by the original author according to different types of equivalence in relation to the original version.For conceptual equivalence, the terms used along the process of adaptation were analyzed for correspondence with the concepts of the original version.For semantic equivalence, the meaning (grammatical and vocabulary) of the terms of the two version was compared.For idiomatic equivalence, the correspondence between the referential (denotative) and literal meaning of the terms/expressions of both versions was analyzed.Finally, for the experimental or cultural equivalence the coherence and compatibility of the terms with the Brazilian context were analyzed 12 .
After this stage, the researcher responsible for the development of the synthesis version performed a concordance analysis of the evaluation done by the experts by calculating the agreement percentage (ratio between the number of evaluators that agreed with the equivalences and the total number of evaluators, multiplied by 100).After this analysis, the final version was developed including the new alterations.
To conclude the process of transcultural adaption a pretesting study was performed by applying the final consensus version to 10 subjects with and without experience with a traumatic situation.Individual interviews were performed to assess scale comprehension, and the subjects were asked to readand later to paraphrase the scale's instructions, items, and answer options.

Results and discussion
The independent translations from English to Portuguese were performed by an English teacher and two psychiatrists with different lines of work/investigation.The synthesis version was prepared by the first author (FLO), who has a long experience in the validation of this kind of instruments, and the back translation was conducted by a bilingual neuroscientist (RGS) and then was evaluated by one of members of National Center for PTSD (Matthew Yoder), being considered adequate.
The expert committee was composed by three psychiatrists with long clinical experience in anxiety (JASC/RFS) and trauma (TA) related disorders.
Table 1 shows the distribution of the agreement percentage from the expert committee regarding the synthesis version, for the different aspect of the validated instrument.
As can be observed in Table 1, the agreement percentage was excellent, with only two items with the percentage inferior to 90%.Despite this, since the expert suggestions were highly appropriate and according to the denominations used in the Brazilian version of the DSM-5, all of them were accepted and are described below.
For the LEC-5 instructions there were two disagreements.First, the expression "learned about it" was initially translated to "ouviu sobre", but for idiomatic reasons the term suggested was "ficou sabendo".The same suggestion was made and included for the answer to question 3. Second, the words "police" and "military" were initially translated to "polícia" and "militar", but for conceptual reasons they were changed to "polícia civil" and "polícia militar".
Still regarding the LEC-5, the item 1 showed a disagreement regarding cultural equivalence.According to the expert opinion, the example "deslizamento de terra" was included, since this kind of natural disaster is very frequent in our context.In the item 4, the expression "recreational activity" was adjusted from "atividade recreativa" to "atividade de lazer", and in the item 9 the words "uncomfortable/unwanted" were initially translated to "desconfortável/indesejada" but for conceptual reasons were changed to "constrangedora/não consentida".
Criterion A was evaluated in its totality, and three suggestions were made.Two of them were previously described (regarding the expression "learned about it" and the words "police" and "military") and were also incorporated.The third disagreement referred to the term "checked", which was denominated in the synthesis version as "marcou".It was suggested to change the term for the word "assinalou", which is more adequate to our context.About the instrument itself, in the items 1 and 6 the experts suggested to translate the word "memories" as "lembranças" and not "memórias", and in the item 7 the word "relacionadas" was included in the sentence "Evitar lembranças externas relacionadas à situação estressante" for semantic reasons.
In the items 8 and 10 there were two disagreements.First, the translation of the expression "trouble remembering" as "dificuldade para lembrar" was modified to "não conseguir lembrar".Second, in the item 10, the translation of the expression "someone else" was changed from "alguém" to "aos outros".Finally, in the item 13, the translation of the expression "cut off " was changed from "afastado" to "isolado" for idiomatic reasons.
After the conclusion of the consensus version and the introduction of the above mentioned suggestions, a pretesting study was performed with 10 subjects: four ambulatory patients from a psychiatric unit with PTSD diagnosis, and six subjects from the general population.Subjects (5 men/5 women) had a mean age of 41.5 years (dp = 15.07) and different educational backgrounds (20% elementary school, 40% high school, and 40% higher education).
Subjects did not show signs of discomfort and/or lack of motivation during the application of the scale.
The Brazilian version of the PCL-5 was well understood and accepted both linguistically and culturally by the sample, which did not make any suggestions for significant changes.Minor adjustments were made only in the item B of part 2 from Criterion A, which included adding the information "(item 1 a 17)" in a parenthesis after the affirmative "Se você vivenciou mais de um dos eventos da Parte 1", and underlying the information "mais incomoda" to facilitate both comprehension and evaluation by the subject.
The layout of the final version was maintained, and the transcultural adaptation of the PCL-5 for the Brazilian context was concluded.The instrument was denominated "Lista de Verificação do TEPT para o DSM-5 (PCL-5)" and can be found in the Annex in its three forms.
It should be noted that the form "Sem Critério A" (Annex 1) contains only a brief instruction and the 20 items that compose the instrument, and that it is appropriate to use when the experienced trauma has been evaluated by others means.The form "Com Critério A" (Annex 2) contains the definition of criterion A and examples of events that the subject could have experienced.The subject is asked to identify his/her worse fear and to evaluate if it fulfills criterion A. The form "Com lista de eventos de vida para o DSM-5 e Critério A" (Annex 3) contains the LEC-5, as well as the most detailed evaluation of criterion A. The last two forms should be used when there is a necessity to evaluate the Criterion A.

Conclusion
The transcultural adaptation of the PCL-5 for the Brazilian Portuguese followed a rigid and standardized protocol, having its face validity assessed by an expert group and by the target population.
The availability of this new version of the instrument for the Brazilian clinical and research context is highly important, since it is one of the most used instruments worldwide to assess PTSD, being adapted to different languages and cultures.
The PCL-5, in its three forms, can be freely used in the target population.Currently it is being psychometrically analyzed by our group, in clinical and non-clinical populations.

Table 1 .
Agreement percentage from the expert committee regarding the brief version (N = 3)