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A growing body of scientific evidence favors dimensional concepts in the diagnosis of mental disorders. The limitations of a categorical approach to diagnosis include the failure to find zones of rarity between diagnoses (i.e., delineation of mental disorders from one another by natural boundaries), the need for intermediate categories like schizoaffective disorder, high rates of comorbidity, frequent not-otherwise-specified (NOS) diagnoses, relative lack of utility in furthering the identification of unique antecedent validators for most mental disorders, and lack of treatment specificity for the various diagnostic categories.
From both clinical and research perspectives, there is a need for a more dimensional approach that can be combined with DSM’s set of categorical diagnoses. Such an approach incorporates variations of features within an individual (e.g., differential severity of individual symptoms both within and outside of a disorder’s diagnostic criteria as measured by intensity, duration, or number of symptoms, along with other features such as type and severity of disabilities) rather than relying on a simple yes-or-no approach. For diagnoses for which all symptoms are needed for a diagnosis (a monothetic criteria set), different severity levels of the constituent symptoms may be noted. If a threshold endorsement of multiple symptoms is needed, such as at least five of nine symptoms for major depressive disorder (a polythetic criteria set), both severity levels and different combinations of the criteria may identify more homogeneous diagnostic groups.
A dimensional approach depending primarily on an individual’s subjective reports of symptom experiences along with the clinician’s interpretation is consistent with current diagnostic practice. It is expected that as our understanding of basic disease mechanisms based on pathophysiology, neurocircuitry, gene-environment interactions, and laboratory tests increases, approaches that integrate both objective and subjective patient data will be developed to supplement and enhance the accuracy of the diagnostic process.
Cross-cutting symptom measures modeled on general medicine’s review of systems can serve as an approach for reviewing critical psychopathological domains. The general medical review of systems is crucial to detecting subtle changes in different organ systems that can facilitate diagnosis and treatment. A similar review of various mental functions can aid in a more comprehensive mental status assessment by drawing attention to symptoms that may not fit neatly into the diagnostic criteria suggested by the individual’s presenting symptoms, but may nonetheless be important to the individual’s care. The cross-cutting measures have two levels: Level 1 questions are a brief survey of 13 symptom domains for adult patients and 12 domains for child and adolescent patients. Level 2 questions provide a more in-depth assessment of certain domains. These measures were developed to be administered both at initial interview and over time to track the patient’s symptom status and response to treatment.
Severity measures are disorder-specific, corresponding closely to the criteria that constitute the disorder definition. They may be administered to individuals who have received a diagnosis or who have a clinically significant syndrome that falls short of meeting full criteria for a diagnosis. Some of the assessments are self-completed by the individual, while others require a clinician to complete. As with the cross-cutting symptom measures, these measures were developed to be administered both at initial interview and over time to track the severity of the individual’s disorder and response to treatment.
The World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0) was developed to assess a patient’s ability to perform activities in six areas: understanding and communicating; getting around; self-care; getting along with people; life activities (e.g., household, work/school); and participation in society. The scale is self-administered and was developed to be used in patients with any medical disorder. It corresponds to concepts contained in the WHO International Classification of Functioning, Disability and Health. This assessment can also be used over time to track changes in a patient’s disabilities.
This chapter focuses on the DSM-5 Level 1 Cross-Cutting Symptom Measure (adult self-rated and parent/guardian versions); the Clinician-Rated Dimensions of Psychosis Symptom Severity; and the WHODAS 2.0. Clinician instructions, scoring information, and interpretation guidelines are included for each. These measures and additional dimensional assessments, including those for diagnostic severity, can be found online at www.psychiatry.org/dsm5.
Cross-Cutting Symptom Measures
The DSM-5 Level 1 Cross-Cutting Symptom Measure is a patient- or informant-rated measure that assesses mental health domains that are important across psychiatric diagnoses. It is intended to help clinicians identify additional areas of inquiry that may have significant impact on the individual’s treatment and prognosis. In addition, the measure may be used to track changes in the individual’s symptom presentation over time.
The adult version of the measure consists of 23 questions that assess 13 psychiatric domains, including depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use (Table). Each domain consists of one to three questions. Each item inquires about how much (or how often) the individual has been bothered by the specific symptom during the past 2 weeks. If the individual is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a knowledgeable adult informant may complete this measure. The measure was found to be clinically useful and to have good reliability in the DSM-5 field trials that were conducted in adult clinical samples across the United States and in Canada(Clarke et al. 2013;Narrow et al. 2013).
Level 1 Cross-Cutting Symptom Measure Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure: 13 domains, thresholds for further inquiry, and associated DSM-5 Level 2 measures
The parent/guardian-rated version of the measure (for children ages 6–17) consists of 25 questions that assess 12 psychiatric domains, including depression, anger, irritability, mania, anxiety, somatic symptoms, inattention, suicidal ideation/attempt, psychosis, sleep disturbance, repetitive thoughts and behaviors, and substance use (Table). Each item asks the parent or guardian to rate how much (or how often) his or her child has been bothered by the specific psychiatric symptom during the past 2 weeks. The measure was also found to be clinically useful and to have good reliability in the DSM-5 field trials that were conducted in pediatric clinical samples across the United States(Narrow et al. 2013). For children ages 11–17, along with the parent/guardian rating of the child’s symptoms, the clinician may consider having the child complete the child-rated version of the measure. The child-rated version of the measure can be found online at www.psychiatry.org/dsm5.
On the adult self-rated version of the measure, each item is rated on a 5-point scale (0=none or not at all; 1=slight or rare, less than a day or two; 2=mild or several days; 3=moderate or more than half the days; and 4=severe or nearly every day). The score on each item within a domain should be reviewed. However, a rating of mild (i.e., 2) or greater on any item within a domain, except for substance use, suicidal ideation, and psychosis, may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is necessary, which may include the Level 2 cross-cutting symptom assessment for the domain (see ). For substance use, suicidal ideation, and psychosis, a rating of slight (i.e., 1) or greater on any item within the domain may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is needed. As such, indicate the highest score within a domain in the “Highest domain score” column. Table outlines threshold scores that may guide further inquiry for the remaining domains.
Scoring and interpretation Parent/guardian-rated DSM-5 Level 1 Cross-Cutting Symptom Measure for child age 6–17: 12 domains, thresholds for further inquiry, and associated Level 2 measures
On the parent/guardian-rated version of the measure (for children ages 6–17), 19 of the 25 items are each rated on a 5-point scale (0=none or not at all; 1=slight or rare, less than a day or two; 2=mild or several days; 3=moderate or more than half the days; and 4=severe or nearly every day). The suicidal ideation, suicide attempt, and substance abuse items are each rated on a “Yes, No, or Don’t Know” scale. The score on each item within a domain should be reviewed. However, with the exception of inattention and psychosis, a rating of mild (i.e., 2) or greater on any item within a domain that is scored on the 5-point scale may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is necessary, which may include the Level 2 cross-cutting symptom assessment for the domain (see Table). For inattention or psychosis, a rating of slight or greater (i.e., 1 or greater) may be used as an indicator for additional inquiry. A parent or guardian’s rating of “Don’t Know” on the suicidal ideation, suicide attempt, and any of the substance use items, especially for children ages 11–17 years, may result in additional probing of the issues with the child, including using the child-rated Level 2 Cross-Cutting Symptom Measure for the relevant domain. Because additional inquiry is made on the basis of the highest score on any item within a domain, clinicians should indicate that score in the “Highest Domain Score” column. Table outlines threshold scores that may guide further inquiry for the remaining domains.
Level 2 Cross-Cutting Symptom Measures
Any threshold scores on the Level 1 Cross-Cutting Symptom Measure (as noted in Tables 1 and 2 and described in “Scoring and Interpretation” indicate a possible need for detailed clinical inquiry. Level 2 Cross-Cutting Symptom Measures provide one method of obtaining more in-depth information on potentially significant symptoms to inform diagnosis, treatment planning, and follow-up. They are available online at www.psychiatry.org/dsm5. Tables 1 and 2 outline each Level 1 domain and identify the domains for which DSM-5 Level 2 Cross-Cutting Symptom Measures are available for more detailed assessments. Adult and pediatric (parent and child) versions are available online for most Level 1 symptom domains at www.psychiatry.org/dsm5.
Frequency of Use of the Cross-Cutting Symptom Measures
To track change in the individual’s symptom presentation over time, the Level 1 and relevant Level 2 cross-cutting symptom measures may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. For individuals with impaired capacity and for children ages 6–17 years, it is preferable for the measures to be completed at follow-up appointments by the same knowledgeable informant and by the same parent or guardian. Consistently high scores on a particular domain may indicate significant and problematic symptoms for the individual that might warrant further assessment, treatment, and follow-up. Clinical judgment should guide decision making.
References: Frequency of Use of the Cross-Cutting Symptom Measures
· Clarke DE , Narrow WE , Regier DA , et al: DSM-5 field trials in the United States and Canada, Part I: study design, sampling strategy, implementation, and analytic approaches. Am J Psychiatry 170(1):43–58, 2013 10.1176/appi.ajp.2012.12071000[Abstract]
· Narrow WE , Clarke DE , Kuramoto SJ , et al: DSM-5 field trials in the United States and Canada, Part III: development and reliability testing of a cross-cutting symptom assessment for DSM-5. Am J Psychiatry 170(1):71–82, 201310.1176/appi.ajp.2012.12071000
· Regier DA , Narrow WE , Clarke DE , et al: DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. Am J Psychiatry 170(1):59–70, 2013 10.1176/appi.ajp.2012.12071000 (Epub ahead of print)[Abstract]
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult
Parent/Guardian-Rated DSM-5 Level 1 Cross-Cutting Symptom Measure—Child Age 6–17
Clinician-Rated Dimensions of Psychosis Symptom Severity
As described in the chapter “Schizophrenia Spectrum and Other Psychotic Disorders,” psychotic disorders are heterogeneous, and symptom severity can predict important aspects of the illness, such as the degree of cognitive and/or neurobiological deficits(Barch et al. 2003). Dimensional assessments capture meaningful variation in the severity of symptoms, which may help with treatment planning, prognostic decision-making, and research on pathophysiological mechanisms. The Clinician-Rated Dimensions of Psychosis Symptom Severity provides scales for the dimensional assessment of the primary symptoms of psychosis, including hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, and negative symptoms. A scale for the dimensional assessment of cognitive impairment is also included. Many individuals with psychotic disorders have impairments in a range of cognitive domains(Reichenberg et al. 2009), which predict functional abilities(Green et al. 2004). In addition, scales for dimensional assessment of depression and mania are provided, which may alert clinicians to mood pathology. The severity of mood symptoms in psychosis has prognostic value (Bowie et al. 2006)and guides treatment(Peralta and Cuesta 2009).
The Clinician-Rated Dimensions of Psychosis Symptom Severity is an 8-item measure that may be completed by the clinician at the time of the clinical assessment. Each item asks the clinician to rate the severity of each symptom as experienced by the individual during the past 7 days.
Scoring and Interpretation
Each item on the measure is rated on a 5-point scale (0=none; 1=equivocal; 2=present, but mild; 3=present and moderate; and 4=present and severe) with a symptom-specific definition of each rating level. The clinician may review all of the individual’s available information and, based on clinical judgment, select (with checkmark) the level that most accurately describes the severity of the individual’s condition. The clinician then indicates the score for each item in the “Score” column provided.
Frequency of Use
To track changes in the individual’s symptom severity over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant further assessment, treatment, and follow-up. Clinical judgment should guide decision making.
References: Frequency of Use
· Barch DM , Carter CS , MacDonald AW 3rd , et al: Context-processing deficit in schizophrenia: diagnostic specificity, 4-week course, and relationships to clinical symptoms. J Abnorm Psychol 112(1):132–143, 2003
· Bowie CR , Reichenberg A , Patterson TL , et al: Determinants of real-world functional performance in schizophrenia subjects: correlations with cognition, functional capacity, and symptoms. Am J Psychiatry 163(3):418–425, 2006
· Green MF , Kern RS , Heaton RK : Longitudinal studies of cognition and functional outcome in schizophrenia: implications for MATRICS. Schizophr Res 72(1):41–51, 2004
· Peralta V , Cuesta MJ : Exploring the borders of the schizoaffective spectrum: a categorical and dimensional approach. J Affect Disord 108(1–2):71–86, 2009
· Reichenberg A , Harvey PD , Bowie CR , et al: Neuropsychological function and dysfunction in schizophrenia and psychotic affective disorders. Schizophr Bull 35(5):1022–1029, 2009
Clinician-Rated Dimensions of Psychosis Symptom Severity
World Health Organization Disability Assessment Schedule 2.0
The adult self-administered version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a 36-item measure that assesses disability in adults age 18 years and older. It assesses disability across six domains, including understanding and communicating, getting around, self-care, getting along with people, life activities (i.e., household, work, and/or school activities), and participation in society. If the adult individual is of impaired capacity and unable to complete the form (e.g., a patient with dementia), a knowledgeable informant may complete the proxy-administered version of the measure, which is available at www.psychiatry.org/dsm5. Each item on the self-administered version of the WHODAS 2.0 asks the individual to rate how much difficulty he or she has had in specific areas of functioning during the past 30 days.
WHODAS 2.0 Scoring Instructions Provided by WHO
WHODAS 2.0 summary scores
There are two basic options for computing the summary scores for the WHODAS 2.0 36-item full version.
Simple: The scores assigned to each of the items—“none” (1), “mild” (2), “moderate” (3), “severe” (4), and “extreme” (5)—are summed. This method is referred to as simple scoring because the scores from each of the items are simply added up without recoding or collapsing of response categories; thus, there is no weighting of individual items. This approach is practical to use as a hand-scoring approach, and may be the method of choice in busy clinical settings or in paper-and-pencil interview situations. As a result, the simple sum of the scores of the items across all domains constitutes a statistic that is sufficient to describe the degree of functional limitations.
Complex: The more complex method of scoring is called “item-response-theory” (IRT)–based scoring. It takes into account multiple levels of difficulty for each WHODAS 2.0 item. It takes the coding for each item response as “none,” “mild,” “moderate,” “severe,” and “extreme” separately, and then uses a computer to determine the summary score by differentially weighting the items and the levels of severity. The computer program is available from the WHO Web site. The scoring has three steps:
· Step 1—Summing of recoded item scores within each domain.
· Step 2—Summing of all six domain scores.
· Step 3—Converting the summary score into a metric ranging from 0 to 100 (where 0 = no disability; 100 = full disability).
WHODAS 2.0 domain scores
WHODAS 2.0 produces domain-specific scores for six different functioning domains: cognition, mobility, self-care, getting along, life activities (household and work/school), and participation.
WHODAS 2.0 population norms
For the population norms for IRT-based scoring of the WHODAS 2.0 and for the population distribution of IRT-based scores for WHODAS 2.0, please see www.who.int/classifications/icf/Pop_norms_distrib_IRT_scores.pdf.
Additional Scoring and Interpretation Guidance for DSM-5 Users
The clinician is asked to review the individual’s response on each item on the measure during the clinical interview and to indicate the self-reported score for each item in the section provided for “Clinician Use Only.” However, if the clinician determines that the score on an item should be different based on the clinical interview and other information available, he or she may indicate a corrected score in the raw item score box. Based on findings from the DSM-5 Field Trials in adult patient samples across six sites in the United States and one in Canada, DSM-5 recommends calculation and use of average scores for each domain and for general disability. The average scores are comparable to the WHODAS 5-point scale, which allows the clinician to think of the individual’s disability in terms of none (1), mild (2), moderate (3), severe (4), or extreme (5). The average domain and general disability scores were found to be reliable, easy to use, and clinically useful to the clinicians in the DSM-5 Field Trials. The average domain score is calculated by dividing the raw domain score by the number of items in the domain (e.g., if all the items within the “understanding and communicating” domain are rated as being moderate, then the average domain score would be 18/6 = 3, indicating moderate disability). The average general disability score is calculated by dividing the raw overall score by number of items in the measure (i.e., 36). The individual should be encouraged to complete all of the items on the WHODAS 2.0. If no response is given on 10 or more items of the measure (i.e., more than 25% of the 36 total items), calculation of the simple and average general disability scores may not be helpful. If 10 or more of the total items on the measure are missing but the items for some of the domains are 75%–100% complete, the simple or average domain scores may be used for those domains.
Frequency of use
To track change in the individual’s level of disability over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant further assessment and intervention.