Semantic equivalence of the Portuguese version of the Post-Traumatic Stress Disorder Checklist - Civilian Version (PCL-C) for the screening of post-traumatic stress disorder

Abstracts

INTRODUÇÃO: O transtorno do estresse pós-traumático (TEPT) é bastante prevalente, atingindo de 2 a 5% da população em alguns países. Seus portadores apresentam pior qualidade de vida, maior número de detenções e problemas legais, e utilizam os serviços de saúde com maior freqüência quando comparados a indivíduos não acometidos. Apesar do crescimento da violência urbana no Brasil, ainda não dispomos de nenhum instrumento adaptado para nossa língua que seja capaz de rastrear o TEPT. Este artigo pretende traduzir, adaptar e avaliar a aplicabilidade da versão em português da Post-Traumatic Stress Disorder Checklist - Civilian Version (PCL-C), uma escala auto-aplicável amplamente utilizada em todo o mundo para rastreamento do transtorno do estresse pós-traumático. MÉTODOS: A comprovação da equivalência semântica da versão em português da PCL-C foi feita através de quatro etapas: tradução; retradução; apreciação formal de equivalência e adaptação; e interlocução com a população-alvo. RESULTADOS: Foi criada uma versão em português da PCL-C que manteve o significado semântico da versão original e mostrou-se de fácil compreensão e aplicabilidade. DISCUSSÃO: A PCL-C foi escolhida para este estudo por ser um instrumento amplamente utilizado em países de língua inglesa e por possuir outras utilidades além do rastreamento do TEPT. A interlocução com a população-alvo, feita com um número relativamente pequeno de indivíduos (n = 21), mostrou que alguns participantes entenderam o termo "estresse" como uma rotina de vida cansativa. CONCLUSÃO: Uma vez obtida a equivalência semântica da versão em português da PCL-C, estudos posteriores deverão determinar suas características psicométricas para a população brasileira.

Transtorno do estresse pós-traumático; TEPT; PCL-C; instrumento de rastreamento; equivalência semântica

ORIGINAL ARTICLE

Semantic equivalence of the Portuguese version of the Post-Traumatic Stress Disorder Checklist — Civilian Version (PCL-C) for the screening of post-traumatic stress disorder^*

Equivalencia semántica de la versión en portugués de la Post-Traumatic Stress Disorder Checklist — Civilian Version (PCL-C) para el rastreo del trastorno de estrés pos-traumático

William Berger^I; Mauro Vitor Mendlowicz^II; Wanderson F. Souza^III; Ivan Figueira^IV

^IPsychiatrist, Master's course at the Psychiatric Institute, UFRJ (IPUB/UFRJ), Brazil

IIProfessor, Department of Psychiatry and Mental Health, Universidade Federal Fluminense (UFF), Brazil

^IIIAcademic of Psychology, Universidade Federal do Rio de Janeiro (UFRJ), Brazil

^IVProfessor, School of Medicine, Universidade Federal do Rio de Janeiro (UFRJ), Brazil

^{Correspondence}

ABSTRACT

BACKGROUND: The prevalence of post-traumatic stress disorder (PTSD) is high — it affects 2-5% of the population in some countries. These patients present worse quality of life, a higher number of detentions and legal problems, and use healthcare services more frequently than individuals without the disorder. Despite the growth of urban violence in Brazil, no instrument is currently available, in the Portuguese language, aimed at screening TEPT. The objective of this study was to translate, adapt and assess the applicability of the Portuguese version of the PTSD Checklist — Civilian Version (PCL-C), a self-administered scale for PTSD screening widely used in several countries.

METHODS: Semantic equivalence between the Portuguese version and the original PCL-C was assessed through four stages: translation; back translation; formal equivalence comparison and adaptation; and interlocution with the target population.

RESULTS: A Portuguese version for PCL-C was created preserving the meaning of the original version and showed to be easily applicable.

DISCUSSION: The PCL-C was chosen in this study because it is a widely used instrument in English-speaking countries and has others utilities than the screening of PTSD. The interlocution with the target population, carried out with a relatively low number of patients (n = 21), showed that some participants understood the term "stress" as referring to a stressful lifestyle.

CONCLUSIONS: Now that semantic equivalence of the Portuguese version of PCL-C was established, further studies are necessary in order to determine its psychometric properties for the Brazilian population.

Keywords: Post-traumatic distress disorder, PTSD, PCL-C, screening tool, semantic equivalence.

RESUMEN

INTRODUCCÍON: El trastorno de estrés postraumático (TEPT) es bastante común, afectando del 2 al 5% de la población en algunos países. Quienes lo padecen presentan una inferior calidad de vida, un mayor número de detenciones y problemas legales y recurren más frecuentemente a los servicios de salud que los individuos no afectados. A pesar del incremento de la violencia urbana en Brasil, todavía no disponemos de ningún instrumento adaptado a nuestro idioma que sea capaz de rastrear el TEPT. Este artículo pretende traducir, adaptar y evaluar la aplicabilidad de la versión en portugués de la Post-Traumatic Stress Disorder Checklist — Civilian Version (PCL-C), una escala auto-aplicable extensamente utilizada en todo el mundo para el rastreo del Trastorno de Estrés Postraumático.

MÉTODOS: Se comprobó la equivalencia semántica de la versión en portugués de la PCL-C a través de 4 etapas: traducción; re-traducción; apreciación formal de la equivalencia y adaptación; e interlocución con la población objetivo.

RESULTADOS: : Se creó una versión en Portugués de la PCL-C que mantuvo el significado semántico de la versión original y se presentó fácilmente comprensible y aplicable.

DEBATE: Se eligió la PCL-C para este estudio por ser un instrumento ampliamente utilizado en países de lengua inglesa y por tener otras utilidades más allá del rastreo del TEPT. La interlocución con la población objetivo, realizada con un número relativamente pequeño de individuos (n = 21), mostró que algunos participantes interpretaron el término "estrés" como una rutina fatigante de vida.

CONCLUSIÓN: Una vez que se obtenga la equivalencia semántica de la versión en portugués de la PCL-C, estudios posteriores deberán determinar sus características psicométricas para la población brasileña.

Palabras clave: Trastorno de estrés postraumático, TEPT, PCL-C, instrumento de rastreo, equivalencia semántica.

INTRODUCTION

Posttraumatic stress disorder (PTSD) was first recognized in the third edition of the Diagnostic and statistical manual for mental disorders of the American Psychiatry Association (DSM-III), in 1980.¹ It is defined as a reaction of intense fear, helplessness or horror when an individual experiences, witnesses or is confronted with one or more events that involve death, serious injury or threaten the physical integrity of self or others (criteria A for diagnosis). The DSM-IV also considers being informed of a diagnosis of a serious disease, involving risk of death, to be a stressor capable of triggering PTSD.^2-4 Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, have onset within six months of the event (although this is not obligatory as the ICD-10 accepts the existence of late-onset PTSD⁵) and last at least one month. There are three symptom groups: reexperiences (criterion B: distressing recollections; recurrent thoughts; dreams; flashbacks; etc.), avoidance behavior/emotional numbness (criterion C: avoidance of people, thoughts, activities or places which arouse recollections of the traumatic event; memory lapses; etc.) and increased arousal (criterion D: hypervigilance; insomnia; exaggerated startle response; etc.^2,5-7).

Individuals suffering from PTSD have worsened quality of life,^3,8 an increased number of arrests and legal problems,⁹ and use several health services with an increased frequency when compared with individuals without the disorder.^10,11 These factors indicate that PTSD does not only affect the sufferers themselves, but also the whole of society, increasing State expenditure on several different areas, such as health and security. If the increased level of violence in our country is further taken into account, the need for further studies of this disorder becomes clear. As a consequence, the need for new research instruments, adapted to our language (Brazilian Portuguese) that are easy to fill out and can be used with subjects with varying levels of education also becomes clear.

In some countries PTSD affects 2 to 5% of the general population,¹¹ and data suggest that the prevalence may be even higher in Brazil, due to the elevate prevalence of traumatic events in our country. For example, we have the third highest mortality rate by firearms among young people between 15 and 24 and we are world leaders in automobile accidents.¹² Despite this, and despite the significant personal and social impact that are inherent to PTSD, very few studies have been performed in Brazil.¹³ In our country, for example, we do not have an instrument that is capable of screening this disorder in Portuguese (taking into account Brazilian peculiarities) and has had its psychometric characteristics studied.

The current article will describe the method employed to test the semantic equivalence of a Portuguese version of a self-administered PTSD screening questionnaire, the Post-Traumatic Stress Disorder (PTSD) Checklist — Civilian Version (PCL-C), which comprises 17 items that assess the three symptom groups described above.¹⁴

METHODS

Original instrument

The PCL-C:¹⁴ An instrument developed in 1993 by Weathers, Litz, Huska and Keane, from the National Center for PTSD (USA), it exists in two versions: the PCL-M, specifically designed to assess the consequences of military experiences, and the PCL-C, designed for the civilian population, which assesses the consequences of a number of different types of traumatic experience. Both versions are based on the DSM-III-R diagnostic criteria for PTSD.¹⁵ To complete the questionnaire, the subject should gauge to what extent they have been disturbed by the symptoms described during the previous month, using a scale of severity from 1 to 5 (not at all to very much).¹⁴ The original version defines a score greater than or equal to 3 (average) for any of the 17 items as clinically significant. A diagnosis of PTSD is made if the subject presents, in addition to meeting criterion A, one clinically significant symptom from criterion B, three from C and two from D.

The original version of the PCL-C in English presents an internal consistency (alpha coefficient) of 0.90 for group B criteria, 0.89 for group C, 0.91 for group D, and 0.96 for all 17 items (values that are considered extremely high).¹⁴ The total item correlation varies from 0.52 to 0.80 when compared with the Mississipi scale. In the same study, the authors demonstrated a convergence validity of 0.85 between the two scales.¹⁴ Comparing the PCL with the Structured Clinical Interview for DSM-III-R (SCID), Weathers et. al. found a sensitivity of 0.82, specificity of 0.83 and a kappa index of 0.64.¹⁴ Strong correlations with other scales were also demonstrated, such as the Impact of Event Scale and the PK scale from the MMPI-2.¹⁴ In 1996 Blanchard et. al.¹⁶ published a study in which the psychometric properties of the PCL-C were evaluated with 40 victims of automobile accidents and sexual crimes. The instrument was compared with the Clinician Administered PTSD Scale (CAPS), which was used as the study reference.¹⁶ This revealed the PCL-C to have a correlation coefficient of 0.929 and diagnostic efficiency (a statistical measure derived from a 2 x 2 definition table including sensitivity, specificity, positive and negative predictive values, kappa, phi, odds ratio and likelihood ratio) of 0.9 in relation to the CAPS. Evaluating each item in turn, the authors found correlations varying from 0.386 to 0.788 and diagnostic efficiency greater than or equal to 0.7.¹⁶

Obtaining semantic equivalence

The semantic equivalence of the Portuguese version of the instrument was proven according to the model proposed by Reichenheim et al.,¹⁷ which consists of four distinct stages: translation, retranslation, formal appreciation of equivalence and discussion with the target population.

Translation: Two psychiatrists, highly experienced in the area and fluent in English, each produced an independent translation into Portuguese of the PCL-C, based on the original instrument in English, thus creating two versions of the same instrument (V1 and V2).

Retranslation: Two American citizens, both fluent in Portuguese and with higher education degrees (not related to healthcare) received either V1 or V2 and translated them from Portuguese to English, creating what we shall refer to as V3 and V4. The retranslations were done independently and the translators had no knowledge of the authors of V1 and V2.

Formal appreciation of equivalence and adaptation: In this stage the two new English versions (V3 and V4) were compared with the original of the PCL-C, noting whether the sentences had been rewritten with the same words (in their literal form) or if meaning had been retained (semantic equivalence). Based on these two criteria, and employing a Visual Analogue Scale (VAS), each sentence in V3 and V4 was awarded a mark from 0 to 100. Both comparison and grading of each item in V3 and V4 were performed by two further professionals connected with healthcare and both with experience in the use of a number of different psychometric scales. The first of these was a doctor with full residency in psychiatry and the second a psychology student. These professionals then compared the semantic equivalence of each sentence of V1 and V2 with the original version of the PCL-C and allocated each to one of the following categories: unchanged (UN), little different (LD), very different (VD) and completely different (CD).

For example, item 1 of the PCL-C, in the original version reads: "Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?" The first psychiatrist, translating into Portuguese created, as V1: "Memória, pensamentos e imagens repetitivos e perturbadores referentes a uma experiência estressante do passado?". Retranslation produced the V3 of this first item : "Memories, thoughts and repetitive and disturbing images about a stressful experience in the past?". This V3 was then compared with the first item of the original scale and was awarded a mark of 100 on the VAS and was graded "unchanged" (UN). When, however, the same process was repeated for V2 and V4, the item did not preserve its meaning with the same precision receiving 60 on the VAS and the label "little different" (LD). This process was repeated for all 17 items on the PCL-C. Depending on the score given to each item under analysis, the best version of each item in Portuguese was chosen (V1 and V2) to create a final version in this language. The authors allowed themselves, in certain cases, to select short extracts from V1 and V2 and amalgamate them, thus creating a new item containing the best parts of each. For item 12, they further allowed themselves to create a third version since neither V1 nor V2 were considered a satisfactory expression of the criterion tested for in the English original. In certain cases, minor grammatical corrections or semantic adaptations were also allowed.

Discussion with the target population: Once the final version in Portuguese of the PCL-C had been created (^{appendix 1}), in which even the original appearance of the instrument created by Weathers et al., was maintained, this was presented to 21 Brazilians, chosen by convenience, with a varying level of education and social status (11 individuals with a basic level, six medium and four higher). These people filled out the scale and were questioned as to their understanding of each item on the PCL-C and also whether they had any suggestions with respect of the instrument.

Figure 1 is a schematic depiction of all the methodology applied in this study.

RESULTS

With the application of the methodology described above, a Portuguese version was created of an instrument widely used and validated in many countries worldwide. The diagnostic criteria for PTSD and even the appearance of the original PCL-C in English were respected.

When the scale was presented to the study population, nobody exhibited any difficulty with its completion. When we requested the subjects to complete the scale with no explanation of what it aimed at measuring, practically all of them understood the term "situação de vida estressante", included in the initial instructions, to mean difficulties at work and not traumatic events.

DISCUSSION

The PCL-C was chosen for this study as being a PTSD screening instrument widely used by many different authors^{3,4,8-11,16,18-33} and which has undergone several validation studies of its psychometric properties, both in its original version in English and also in other languages.^{4,14,16,18,22,23,26,28,33,34} It has the benefit of being self-administered, i.e. it does not require an external examiner, in contrast with other existing instruments, such as the Clinician Administered PTSD Scale for DSM-IV (CAPS-DX)³⁵ and the SCID.³⁶ Two further PTSD screening instruments widely-used in many studies are the Davidson Trauma Scale (DST)³⁷ and the Post-Traumatic Stress Diagnostic Scale (PDS).³⁸ Nevertheless, we prefer to use the PCL-C for face validity, since it has been used in a wider spectrum of clinical situations, such as with primary care samples, cancer patients and other medical conditions in general.^{3,4,8,11,18,21,24,25,39}

The PCL-C has previously been studied and applied with populations that do not use the English language as their first language (as in studies conducted in Germany and with Hispanic communities in the USA, in its German and Spanish versions),^29,31,40 but there is not yet any study in Brazil that tests the semantic equivalence of a version adapted to our language together with its validity and reliability.

The instrument has more uses that just PTSD screening. For example, it has been used in clinical trials to evaluate response to treatments for the disorder, since the severity of the symptoms covered can be assessed continuously. It is merely necessary to change the description of symptoms from during the last month to during the last week and re-apply the scale weekly, for example.^14,20 The scale has also been used in a number of different countries with the aim of assessing the prevalence of PTSD after the diagnosis of serious illnesses, extremely aggressive treatments (such as chemotherapy and radiotherapy, for example) and even to test the progress and prognosis of patients with and without PTSD who have received these diagnoses.^{3,4,8,18,21,24,25}

One limitation of the present study is that the scale was applied to a relatively low number of people (n = 21), thus producing a possibility of spectrum bias. Discussion with the target population revealed that a considerable proportion of the sample understood the term "estresse" to refer to problems related to work and tiring daily routines (emotionally and physically). It is therefore imagined that a short introduction that put the object of study into context, as is included in the Structured Clinical Interview for DSM-IV (SCID),³⁶ would increase the sensitivity and specificity (already elevated) of the original instrument. Such a modification, however, would change the psychometric properties of the instrument, and therefore was not performed. Another possible solution for this problem would be to substitute the term "situações de vida estressantes", in the first part of the instrument's instructions, for "situações de vida traumatizantes".

Further studies with the PCL-C should be performed, since proof of semantic equivalence or face validity of a scale is just one of the stages of validating an instrument in any language. For an instrument to be of use in research it must offer good reliability (the capacity that an instrument has to arrive at the same diagnosis for a given patient or diagnosis group when features of the assessment are changed, such as interviewer or time of application) and validity (capture, identify or measure that which is proposed).⁴¹ Furthermore, sensitivity should be considered (the capacity to detect individuals suffering from the illness in question), as should specificity (the capacity to exclude individuals who are not affected). These factors have not yet been measured in relation to the application of the Portuguese version of the PCL-C to Brazilians. In an attempt to understand these psychometric properties of the scale as adapted for Portuguese, the authors of the present article are developing other studies with a much larger sample than that discussed here.

CONCLUSIONS

Despite its semantic equivalence having been proven, additional studies of the Portuguese version of the PCL-C, already in progress, should evaluate the psychometric characteristics of this instrument within the Brazilian population. For example, the diagnostic efficiency must be defined, against the SCID as gold standard, the test-restest reliability must be assessed and ROC curve methodology must be employed. Only then will the instrument have passed through all phases of its validation for the Brazilian population and be able to be widely utilized in our country.

Thus, with the creation of a version of the PCL-C adapted for the Brazilian population, the first stage of which (face validity) was initiated in this study, we will have an instrument that is capable to aid with diagnosis and observation of the progress of patients with a little-studied disorder which, probably, causes extreme suffering to innumerable Brazilians: post-traumatic stress disorder.

Acknowledgements

We are grateful to Penélope Alves Breglia for translating the abstract of this article into Spanish.

REFERENCES

Received on May 11, 2004.

Revised on June 1, 2004.

Approved on July 15, 2004.

Instruções:

Abaixo, há uma lista de problemas e de queixas que as pessoas às vezes apresentam como uma reação a situações de vida estressantes.

Por favor, indique o quanto você foi incomodado por estes problemas durante o último mês.

Por favor, marque 1 para "nada", 2 para "um pouco", 3 para "médio", 4 para "bastante" e 5 para "muito".

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APPENDIX 1:  PCL-C

*

This study was carried out at the Psychiatric Institute, UFRJ, Department of Psychiatry and Mental Health, Brazil.

Publication Dates

• Publication in this collection
  13 Sept 2005
• Date of issue
  Aug 2004

History

• Accepted
  15 July 2004
• Reviewed
  11 June 2004
• Received
  11 May 2004