Case Study

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Life Events Checklist for DSM-5 (LEC-5)

Interview Version

Version date: 12 April 2018

Reference: Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013). The Life Events Checklist for DSM-5 (LEC-5) – Interview. [Measurement instrument]. Available from https://www.ptsd.va.gov

URL: https://www.ptsd.va.gov/professional/ assessment/te-measures/life_events_checklist.asp

Note: This is a fillable form. You may complete it electronically.

Study:

ID#:

Rater:

Date:

This page intentionally left blank

__________________________________________________________________________________________________

Father?

__________________________________________________________________________________________________

Siblings?

__________________________________________________________________________________________________

Other caretakers?

__________________________________________________________________________________________________

How did your parents (adults you grew up with) get along? (Yelling? Fighting? Violence?)

_________________________________________________________________________________________________

__________________________________________________________________________________________________

How was discipline handled? (Who handled it? What did it consist of?)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Were you ever treated in a cold, unemotional way? (By whom? What was that like? How old were you? How often?)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

LEC– 5 Interview

In a few minutes I’m going to ask you more about the questionnaire you filled out on stressful events in your life. But before I do that I want to ask you a few questions about what it was like for you growing up.

Who did you live with? (Who took care of you?)

What stands out for you about growing up? (Anything particularly good? Particularly bad?)

What was your relationship like with your:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

What stands out for you about growing up? (Anything particularly good? Particularly bad?)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

What was your relationship like with your:

Mother?

Father?

Siblings?

Other caretakers?

How did your parents (adults you grew up with) get along? (Yelling? Fighting? Violence?)

How was discipline handled? (Who handled it? What did it consist of?)

Were you ever treated in a cold, unemotional way? (By whom? What was that like? How old were you? How often?)

Page 1 of 12LEC-5 Interview (12 April 2018) National Center for PTSD

___________

Page 2 of 12

Did you ever feel rejected by someone you grew up with? (By whom? What was that like? How old were you? How

often?)

Were you ever criticized unfairly or told that you were no good or worthless? (By whom? What was that like? How

old were you? How often?)

Were you ever made to feel ashamed or humiliated? (By whom? What was that like? How old were you? How

often?)

Were you ever neglected or left to fend for yourself (e.g., left alone, left without food, kept out of the house)?

(By whom? What was that like? How old were you? How often?)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Were you ever criticized unfairly or told that you were no good or worthless? (By whom? What was that like? How

old were you? How often?)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Were you ever made to feel ashamed or humiliated? (By whom? What was that like? How old were you? How

often?)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Were you ever neglected or left to fend for yourself (e.g., left alone, left without food, kept out of the house)?

(By whom? What was that like? How old were you? How often?)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

RATE EMOTIONAL ABUSE SEVERITY

(1=none 2=minimal/subthreshold 3=definite/threshold 4=harsh/severe)

LEC-5 Interview (12 April 2018) National Center for PTSD

Page 3 of 12

Getting back to the questionnaire about stressful events, what I’m going to do now is go over the different events you said you experienced and ask you to tell me very briefly about what happened. If it’s something that happened more than once I want you to think about the WORST time.

You said you:

Item 1: Natural disaster Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

Item 2: Fire or explosion Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

LEC-5 Interview (12 April 2018) National Center for PTSD

Page 4 of 12

You also said you:

Item 3: Transportation accident Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

Item 4: Serious accident at work, home, or during recreational activity Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

LEC-5 Interview (12 April 2018) National Center for PTSD

Page 5 of 12

You also said you:

Item 5: Exposure to toxic substance Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

Item 6: Physical assault Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

LEC-5 Interview (12 April 2018) National Center for PTSD

___________

Page 6 of 12

You also said you:

Item 7: Assault with a weapon Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

IF THE RESPONDENT ENDORSES ANY TYPE OF PHYSICAL ASSAULT OR HARSH PHYSICAL DISCIPLINE, ASK:

As you look back on it, do you think that what happened to you [CITE PHYSICAL ASSAULT EXPERIENCES] would be considered physical abuse? (Why or why not? What about by today’s standards? How so?)

RATE PHYSICAL ABUSE SEVERITY

(1=none 2=minimal/subthreshold 3=definite/threshold 4=harsh/severe)

LEC-5 Interview (12 April 2018) National Center for PTSD

___________

Page 7 of 12

You also said you:

Item 8: Sexual assault Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

Item 9: Other unwanted or uncomfortable sexual experience Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

IF THE RESPONDENT ENDORSES ANY TYPE OF SEXUAL ASSAULT OR OTHER UNCOMFORTABLE SEXUAL EXPERIENCE, ASK:

As you look back on it, do you think that what happened to you [CITE SEXUAL ASSAULT EXPERIENCES] would be considered sexual abuse? (Why or why not? What about by today’s standards? How so?)

RATE SEXUAL ABUSE SEVERITY

(1=none 2=minimal/subthreshold 3=definite/threshold 4=harsh/severe)

LEC-5 Interview (12 April 2018) National Center for PTSD

Page 8 of 12

You also said you:

Item 10: Combat or exposure to a war-zone Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

Item 11: Captivity Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

LEC-5 Interview (12 April 2018) National Center for PTSD

Page 9 of 12

You also said you:

Item 12: Life-threatening illness or injury Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

Item 13: Severe human suffering Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

LEC-5 Interview (12 April 2018) National Center for PTSD

Page 10 of 12

You also said you:

Item 14: Sudden violent death Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Were you seriously injured? Was your life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

Item 15: Sudden accidental death Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Were you seriously injured? Was your life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

LEC-5 Interview (12 April 2018) National Center for PTSD

Page 11 of 12

You also said you:

Item 16: Serious injury, harm, or death you caused to someone else Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

Item 17: Another very stressful event or experience Experienced / Witnessed / Learned about / Job-related / Not sure

What happened? (How old were you? How were you involved? Who else was involved? Was anyone seriously injured or killed? Was anyone’s life in danger? How many times did this happen?)

Exposure type:

____ Experienced ____ Witnessed ____ Learned about ____ Exposed to aversive details

Life threat? NO YES (self ___ other ___ )

Serious injury? NO YES (self ___ other ___ )

Criterion A met? NO PROBABLE YES

Number of times ____________

LEC-5 Interview (12 April 2018) National Center for PTSD

Page 12 of 12

DETERMINE THE WORST EVENT FOR USE ON THE CAPS-5: (Which of these events would you say was the worst overall? Which one bothers you the most currently or has caused you the most problems?)

IF NO EVENTS ENDORSED ON CHECKLIST: (Has there ever been a time when your life was in danger or you were seriously injured or harmed? What about experiencing some type of sexual violence?)

IF NO: (What about a time when you were threatened with death or serious injury, even if you weren’t actually injured or harmed?)

IF NO: (What about witnessing something like this happen to someone else or finding out that it happened to someone close to you?)

IF NO: (What about being exposed to something like this as part of your job?)

IF NO: (What would you say are some of the most stressful experiences you have had over your life?)

For the rest of the interview, I want you to keep (EVENT) in mind as I ask you about different problems it may have caused you. You may have had some of these problems before, but for this interview we’re going to focus just on the past month. For each problem I’ll ask if you’ve had it in the past month, and if so, how often and how much it bothered you.

ADMINISTER CAPS-5

LEC-5 Interview (12 April 2018) National Center for PTSD

1. Number of times_3:
2. Number of times_4:
3. Study:
4. ID:
5. Rater:
6. Date:
7. How did your parents get along:
8. Were you ever treated in a cold unemotional way:
9. Mother:
10. Father:
11. Siblings:
12. Did you ever feel rejected by someone you grew up with:
13. Were you ever made to feel ashamed or humiliated:
14. Were you ever neglected or left to fend for yourself:
15. Natural Disaster:
16. Other caretakers:
17. Were you ever criticized unfairly or told that you were no good or worthless:
18. Abuse Severity:
19. Emotional Severity:
20. Toxic Substance:
21. Physical Assault:
22. Weapon Assault:
23. Sexual Assault:
24. Uncomfortable Sexual Experience:
25. Warzone Exposure:
26. Captivity:
27. Ilness or Injury:
28. Human Suffering:
29. Sudden Violent Death:
30. Sudden Accidental Death:
31. Serious Injury:
32. Sexual Assault Severity:
33. Life Threat1: Off
34. Injury1: Off
35. Criterion1: Off
36. Fire or Explosion:
37. Life Threat2: Off
38. Injury2: Off
39. Criterion2: Off
40. Serious Accident:
41. Transportation Accident:
42. Life Threat 3: Off
43. Serious Injury 3: Off
44. Criterion 3: Off
45. Life Threat 4: Off
46. Serious Injury 4: Off
47. Criterion 4: Off
48. Life Threat5: Off
49. Injury5: Off
50. Life Threat6: Off
51. Injury6: Off
52. Check Box1_1: Off
53. Check Box1_2: Off
54. Check Box1_3: Off
55. Check Box2_1: Off
56. Check Box2_2: Off
57. Check Box2_3: Off
58. Check Box2_4: Off
59. Check Box3_1: Off
60. Check Box3_2: Off
61. Check Box3_3: Off
62. Check Box3_4: Off
63. Check Box4_1: Off
64. Check Box4_2: Off
65. Check Box4_3: Off
66. Check Box4_4: Off
67. Life Threat7: Off
68. Check Box7_2: Off
69. Check Box7_1: Off
70. Injury7: Off
71. Check Box7_3: Off
72. Check Box7_4: Off
73. Criterion7: Off
74. Number of times_7:
75. Check Box5_1: Off
76. Check Box5_2: Off
77. Check Box5_3: Off
78. Check Box5_4: Off
79. Number of times5:
80. Check Box6_1: Off
81. Check Box6_2: Off
82. Check Box6_3: Off
83. Check Box6_4: Off
84. Number of times_6:
85. Life Threat8: Off
86. Injury8: Off
87. Life Threat9: Off
88. Injury9: Off
89. Check Box1_4: Off
90. Check Box8_1: Off
91. Check Box8_3: Off
92. Check Box8_2: Off
93. Check Box8_4: Off
94. Check Box9_1: Off
95. Check Box9_2: Off
96. Check Box9_3: Off
97. Check Box9_4: Off
98. Life Threat10: Off
99. Injury10: Off
100. Criterion10: Off
101. Life Threat11: Off
102. Injury11: Off
103. Criterion11: Off
104. Check Box10_1: Off
105. Check Box10_3: Off
106. Check Box10_2: Off
107. Check Box10_4: Off
108. Check Box11_1: Off
109. Check Box11_3: Off
110. Check Box11_2: Off
111. Check Box11_4: Off
112. Life Threat12: Off
113. Injury12: Off
114. Criterion12: Off
115. Life Threat13: Off
116. Injury13: Off
117. Criterion13: Off
118. Criterion6: Off
119. Criterion5: Off
120. Check Box12_1: Off
121. Check Box12_2: Off
122. Check Box12_3: Off
123. Check Box12_4: Off
124. Number of times12:
125. Check Box13_1: Off
126. Check Box13_2: Off
127. Check Box13_3: Off
128. Check Box13_4: Off
129. Number of times_13:
130. Life Threat14: Off
131. Injury14: Off
132. Criterion14: Off
133. Life Threat15: Off
134. Injury15: Off
135. Criterion15: Off
136. Check Box14_1: Off
137. Check Box14_2: Off
138. Check Box14_3: Off
139. Check Box14_4: Off
140. Number of times14:
141. Check Box15_1: Off
142. Check Box15_2: Off
143. Check Box15_3: Off
144. Check Box15_4: Off
145. Number of times_15:
146. Life Threat16: Off
147. Check Box16_1: Off
148. Check Box16_2: Off
149. Injury16: Off
150. Check Box16_3: Off
151. Check Box16_4: Off
152. Criterion16: Off
153. Number of times16:
154. Life Threat17: Off
155. Check Box17_1: Off
156. Check Box17_2: Off
157. Injury17: Off
158. Check Box17_3: Off
159. Check Box17_4: Off
160. Criterion17: Off
161. Number of times_17:
162. Stressful Event:
163. Determine the Worst Event:
164. If No Events Endorsed on Checklist:
165. If No:
166. If No2:
167. If No3:
168. If No4:
169. ET1_Experienced: Off
170. ET1_Witnessed: Off
171. ET1_LearnedAbout: Off
172. ET1_Exposed: Off
173. ET2_Experienced: Off
174. ET2_Witnessed: Off
175. ET2_LearnedAbout: Off
176. ET2_Exposed: Off
177. ET4_Experienced: Off
178. ET4_Witnessed: Off
179. ET4_LearnedAbout: Off
180. ET4_Exposed: Off
181. ET5_Experienced: Off
182. ET5_Witnessed: Off
183. ET5_LearnedAbout: Off
184. ET5_Exposed: Off
185. ET6_Experienced: Off
186. ET6_Witnessed: Off
187. ET6_LearnedAbout: Off
188. ET6_Exposed: Off
189. ET7_Experienced: Off
190. ET7_Witnessed: Off
191. ET7_LearnedAbout: Off
192. ET7_Exposed: Off
193. ET8_Experienced: Off
194. ET8_Witnessed: Off
195. ET8_LearnedAbout: Off
196. ET8_Exposed: Off
197. ET9_Experienced: Off
198. ET9_Witnessed: Off
199. ET9_LearnedAbout: Off
200. ET9_Exposed: Off
201. ET11_Experienced: Off
202. ET11_Witnessed: Off
203. ET11_LearnedAbout: Off
204. E11_Exposed: Off
205. ET10_Experienced: Off
206. ET10_Witnessed: Off
207. ET10_LearnedAbout: Off
208. ET10_Exposed: Off
209. ET13_Experienced: Off
210. ET13_Witnessed: Off
211. ET13_LearnedAbout: Off
212. ET13_Exposed: Off
213. ET12_Experienced: Off
214. ET12_Witnessed: Off
215. ET12_LearnedAbout: Off
216. ET12_Exposed: Off
217. ET15_Experienced: Off
218. ET15_Witnessed: Off
219. ET15_LearnedAbout: Off
220. ET15_Exposed: Off
221. ET14_Experienced: Off
222. ET14_Witnessed: Off
223. ET14_LearnedAbout: Off
224. ET14_Exposed: Off
225. ET17_Experienced: Off
226. ET17_Witnessed: Off
227. ET17_LearnedAbout: Off
228. ET17_Exposed: Off
229. ET3_Experienced: Off
230. ET3_Witnessed: Off
231. ET3_LearnedAbout: Off
232. ET3_Exposed: Off
233. ET16_Experienced: Off
234. ET16_Witnessed: Off
235. ET16_LearnedAbout: Off
236. ET16_Exposed: Off
237. Number of times_2:
238. Number of times1:
239. Who did you live with:
240. What stands out for you about growing up:
241. How was discipline handled:
242. Number of times8:
243. Number of times_9:
244. Number of times10:
245. Number of times_11: