what’s in dsm-5 dsm 5 diagnoses and numbers xiii-xl summary of changes from iv -preface how the...
TRANSCRIPT
Whatrsquos in DSM-5bull DSM 5 diagnoses and numbers xiii-xlbull summary of changes from IV -prefacebull How the DSM 5 was developed-Intro 5-19bull Further description of major changes-intro
5-19bull How to use the manual 19-24bull Diagnostic codes and diagnostic criteria for
every diagnosis pp31-715bull Dimensional assessment measures 733-748bull Dimensional assessment of personality
disorders 761-783bull Focus on cultural assessment 749-760bull Cultural formulation interviews 749-760bull Conditions for further study 783-808bull Highlight of all changes from DSM-IV to
DSM 5 PP 809 ndash 816bull Glossary of mental terms 817-832bull Glossary of cultural concepts of distress
833-838bull DSM crosswalks for ICD-9 and ICD 10 863-
897
WHY CHANGE
bull DSM-IVrsquos organizational structure failed to reflect shared features or symptoms of related disorders and diagnostic groups (like psychotic disorders with bipolar disorders or internalizing (depressive anxiety somatic) and externalizing (impulse control conduct substance use) disorders
bullDSM-IV Thin on Culture
bullDid not represent or integrate the latest findings from neuroscience genetics and cognitive research
bullMulti axial structure was out of line with the rest of medicine
bullGlobal assessment of functioning was an unreliable measure
bullDecision trees did not increase inter-rater reliability
Other problems
bull Separates diagnoses from treatmentbull Diagnosis has become an end in itself (billability amp pressure
for scientific determinism)bull Minimizes TIME as a major factor in making diagnosesbull Minimizes emergent symptomsbull Minimizes lack of symptom clarity as an issuebull Ignores internal unobservablesbull Funnels tx focus to symptom negation rather than well-beingbull Forces clinician to make immediate diagnosesbull Forces clinician to more severe DX
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
WHY CHANGE
bull DSM-IVrsquos organizational structure failed to reflect shared features or symptoms of related disorders and diagnostic groups (like psychotic disorders with bipolar disorders or internalizing (depressive anxiety somatic) and externalizing (impulse control conduct substance use) disorders
bullDSM-IV Thin on Culture
bullDid not represent or integrate the latest findings from neuroscience genetics and cognitive research
bullMulti axial structure was out of line with the rest of medicine
bullGlobal assessment of functioning was an unreliable measure
bullDecision trees did not increase inter-rater reliability
Other problems
bull Separates diagnoses from treatmentbull Diagnosis has become an end in itself (billability amp pressure
for scientific determinism)bull Minimizes TIME as a major factor in making diagnosesbull Minimizes emergent symptomsbull Minimizes lack of symptom clarity as an issuebull Ignores internal unobservablesbull Funnels tx focus to symptom negation rather than well-beingbull Forces clinician to make immediate diagnosesbull Forces clinician to more severe DX
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bull DSM-IVrsquos organizational structure failed to reflect shared features or symptoms of related disorders and diagnostic groups (like psychotic disorders with bipolar disorders or internalizing (depressive anxiety somatic) and externalizing (impulse control conduct substance use) disorders
bullDSM-IV Thin on Culture
bullDid not represent or integrate the latest findings from neuroscience genetics and cognitive research
bullMulti axial structure was out of line with the rest of medicine
bullGlobal assessment of functioning was an unreliable measure
bullDecision trees did not increase inter-rater reliability
Other problems
bull Separates diagnoses from treatmentbull Diagnosis has become an end in itself (billability amp pressure
for scientific determinism)bull Minimizes TIME as a major factor in making diagnosesbull Minimizes emergent symptomsbull Minimizes lack of symptom clarity as an issuebull Ignores internal unobservablesbull Funnels tx focus to symptom negation rather than well-beingbull Forces clinician to make immediate diagnosesbull Forces clinician to more severe DX
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bullDSM-IV Thin on Culture
bullDid not represent or integrate the latest findings from neuroscience genetics and cognitive research
bullMulti axial structure was out of line with the rest of medicine
bullGlobal assessment of functioning was an unreliable measure
bullDecision trees did not increase inter-rater reliability
Other problems
bull Separates diagnoses from treatmentbull Diagnosis has become an end in itself (billability amp pressure
for scientific determinism)bull Minimizes TIME as a major factor in making diagnosesbull Minimizes emergent symptomsbull Minimizes lack of symptom clarity as an issuebull Ignores internal unobservablesbull Funnels tx focus to symptom negation rather than well-beingbull Forces clinician to make immediate diagnosesbull Forces clinician to more severe DX
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bullDid not represent or integrate the latest findings from neuroscience genetics and cognitive research
bullMulti axial structure was out of line with the rest of medicine
bullGlobal assessment of functioning was an unreliable measure
bullDecision trees did not increase inter-rater reliability
Other problems
bull Separates diagnoses from treatmentbull Diagnosis has become an end in itself (billability amp pressure
for scientific determinism)bull Minimizes TIME as a major factor in making diagnosesbull Minimizes emergent symptomsbull Minimizes lack of symptom clarity as an issuebull Ignores internal unobservablesbull Funnels tx focus to symptom negation rather than well-beingbull Forces clinician to make immediate diagnosesbull Forces clinician to more severe DX
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bullMulti axial structure was out of line with the rest of medicine
bullGlobal assessment of functioning was an unreliable measure
bullDecision trees did not increase inter-rater reliability
Other problems
bull Separates diagnoses from treatmentbull Diagnosis has become an end in itself (billability amp pressure
for scientific determinism)bull Minimizes TIME as a major factor in making diagnosesbull Minimizes emergent symptomsbull Minimizes lack of symptom clarity as an issuebull Ignores internal unobservablesbull Funnels tx focus to symptom negation rather than well-beingbull Forces clinician to make immediate diagnosesbull Forces clinician to more severe DX
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bullGlobal assessment of functioning was an unreliable measure
bullDecision trees did not increase inter-rater reliability
Other problems
bull Separates diagnoses from treatmentbull Diagnosis has become an end in itself (billability amp pressure
for scientific determinism)bull Minimizes TIME as a major factor in making diagnosesbull Minimizes emergent symptomsbull Minimizes lack of symptom clarity as an issuebull Ignores internal unobservablesbull Funnels tx focus to symptom negation rather than well-beingbull Forces clinician to make immediate diagnosesbull Forces clinician to more severe DX
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Other problems
bull Separates diagnoses from treatmentbull Diagnosis has become an end in itself (billability amp pressure
for scientific determinism)bull Minimizes TIME as a major factor in making diagnosesbull Minimizes emergent symptomsbull Minimizes lack of symptom clarity as an issuebull Ignores internal unobservablesbull Funnels tx focus to symptom negation rather than well-beingbull Forces clinician to make immediate diagnosesbull Forces clinician to more severe DX
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bull There have been no no established zones of rarity between diagnosis (much symptom overlap)
bull Law-like biological markers have not yet been found
bull Categorical measurement (depressed vs NOT depressed) doesnrsquot capture clinical variance
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
DSM III amp IV limits
Focus on only what is observable limits diagnostic possibilities
Limited number of observable signs amp symptoms(12 to 19 symptoms )
Because law-like biomarkers have not been foundElements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM = diagnostic confusion
Simple counting of the number of symptoms in Order to make a diagnosis DOES NOT WORK
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
DSM III amp IV ndash problems with measuringLimited number of observable signs and Symptoms Elements that cannot be seen directlyare excluded This is exactly the opposite of medicine which strives to see below the surface
Limited number of observable signssymptoms But 400 diagnoses in DSM
1 Problem = under- determination of diagnosisConsequences = - boundary problems (paris)
- false positives - rise of comorbidity
- problems of differential dx - one size fits all diagnoses - only agreement on most severe
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
The relationship between Categorical Dx comorbidity and increased reliability
bull 1 no major depression 2 major depressionbull 1 No generalized anxiety 2 generalized anxiety
Depression1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
None minimal mild minor moderate major severe maximal
1 2 3 4 5 6 7 8General anxiety
Categorical measurement increases potential for inter-rater reliability 50 chance of inter-rater reliability
Fewer choices = easier= less information = more possibility of making mistake = inflated comorbidity
Categorical measures = No clinical variance amp no diagnostic thresholdDecreasing variance increases potential for inter rater reliability and increases potential for specious comorbidity
Dimensional measure inter-rater reliability lower = 12
More choices = harder= more infoSubtle distinctions lessPotential for speciouscomorbidity
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bull DSM III amp IV turned assessment into yesno decision trees
bull Inflated comorbiditybull Inflated inter-rater reliability (but did not
increase it)bull Never established true biological markersbull Reduced the rigorousness of good assessment
in the name of clinical utility
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
DSM 51 Emphasizes dimensional measurement2 Provides World Health Organization measure
of overall well-being3 Does away with Axes4 Focuses more on culture5 Attempts to ldquoRe-organizerdquo diagnostic
categories according to what we now (think we)know
6 Attempts to ldquore-grouprdquo individual diagnoses according to what we now (think we) know
7 Includes crosswalks with ICD-9 and ICD 10httpwwwdsm5orgPagesDefaultaspx
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
1 Dimensional measureshttpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
bull Allows clinician opportunity to ldquofine tunerdquo diagnosis
bull Captures diagnostic complexitybull Should reduce inflated comorbidity By allowing
inclusion of crosscutting symptoms (such as anxiety) within other diagnoses
bull Focuses assessment on crosscutting symptomsbull Creates severity specifier for many diagnosesbull Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms are on a continuum
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bull DSM 5 adds dimensional measures WITHOUT abandoning categorical measures
bull Criteria are basically the same as they were in the DSM-IV
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Crosscutting symptoms(symptoms that can occur across many DXs)
bull Captures symptom comorbidity without diagnostic comorbidity
bull Cross-cutting symptom measures may aid in a comprehensive mental status assessment by drawing attention to symptoms that are important across diagnoses They are intended to help identify additional areas of inquiry that may guide treatment and prognosis The cross-cutting measures have two levels Level 1 questions are a brief survey of 13 domains for adult patients and 12 domains for child and adolescent patients and Level 2 questions provide a more in-depth assessment of certain domains
httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measuresLevel1
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
During the past TWO (2) WEEKS how much (or how often) have you been bothered by the following problems
None
Not atall
Slight
Rare lessthan a day
or two
Mild
Severaldays
Moderate
More thanhalf the days
Severe
Nearlyevery day
Highest
DomainScore
(clinician)
I 1 Little interest or pleasure in doing things 0 1 2 3 4
2 Feeling down depressed or hopeless 0 1 2 3 4
II 3 Feeling more irritated grouchy or angry than usual 0 1 2 3 4
III 4 Sleeping less than usual but still have a lot of energy 0 1 2 3 4
5 Starting lots more projects than usual or doing more risky things than usual0 1 2 3 4
IV 6 Feeling nervous anxious frightened worried or on edge 0 1 2 3 4
7 Feeling panic or being frightened 0 1 2 3 4
8 Avoiding situations that make you anxious 0 1 2 3 4
V 9 Unexplained aches and pains (eg head back joints abdomen legs) 0 1 2 3 4
10 Feeling that your illnesses are not being taken seriously enough 0 1 2 3 4
VI 11 Thoughts of actually hurting yourself 0 1 2 3 4
VII 12 Hearing things other people couldnrsquot hear such as voices even when no
one was around
0 1 2 3 4
13 Feeling that someone could hear your thoughts or that you could hear what another person was thinking
0 1 2 3 4
VIII 14 Problems with sleep that affected your sleep quality over all 0 1 2 3 4
IX 15 Problems with memory (eg learning new information) or with location(eg finding your way home)
0 1 2 3 4
X 16 Unpleasant thoughts urges or images that repeatedly enter your mind 0 1 2 3 4
17 Feeling driven to perform certain behaviors or mental acts over and over again 0 1 2 3 4
XI 18 Feeling detached or distant from yourself your body your physical surroundings or your memories
0 1 2 3 4
XII 19 Not knowing who you really are or what you want out of life 0 1 2 3 4
20 Not feeling close to other people or enjoying your relationships with them 0 1 2 3 4
XIII 21 Drinking at least 4 drinks of any kind of alcohol in a single day 0 1 2 3 4
22 Smoking any cigarettes a cigar or pipe or using snuff or chewing tobacco 0 1 2 3 4
23 Using any of the following medicines ON YOUR OWN that is without a doctorrsquos prescription in greater amounts or longer than prescribed [eg painkillers (like Vicodin) stimulants (like Ritalin or Adderall) sedatives or tranquilizers (like sleeping pills or Valium) or drugs like marijuana cocaine or crack club drugs (like ecstasy) hallucinogens (like LSD) heroin
inhalants or solvents (like glue) or methamphetamine (like speed)]
0 1 2 3 4
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom MeasuremdashAdult
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS
1 POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)2 GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH CLINET3 CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS BUT NOT NECESSARILY QUALIFY FOR ITS OWN DXDEPRESSIONANXIETYSOMATIC SYMPTOMSSLEEP ISSUES ETC
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
level II measures(Dimensional)
bull Level II crosscutting measuresndash Focus on one specific domainndash Provides a more varied clinical profile within that
domainndash Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries (For example in my dealing with major depression with a co-occurring anxiety disorder or major depression with anxious features
ndash Provides clinical verification before diagnosis
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Level 2 measures of symptoms
bull Level 2 questions provide a more in-depth assessment of certain domains httpwwwpsychiatryorgpracticedsmdsm5online-assessment-measures Level2
bull Level 2 is given as a specific follow up once the clinician is lsquoorientedrsquo in a symptomatic direction they are focused WITHIN a specific symptom domain
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Level 2 Cross-Cutting Symptom MeasuresFor AdultsLEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShort Form)LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashAdult (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])LEVEL 2mdashSubstance UsemdashAdult (Adapted from the NIDA-Modified ASSIST)
For Parents of Children Ages 6ndash17LEVEL 2mdashSomatic SymptommdashParentGuardian of Child Age 6ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashParentGuardian of Child Age 6ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashInattentionmdashParentGuardian of Child Age 6ndash17 (Swanson Nolan and Pelham version IV [SNAP-IV])LEVEL 2mdashDepressionmdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashDepressionmdashParent Item Bank)LEVEL 2mdashAngermdashParentGuardian of Child Age 6ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashParent)LEVEL 2mdashIrritabilitymdashParentGuardian of Child Age 6ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashParentGuardian of Child Age 6ndash17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashParentGuardian of Child Age 6ndash17 (Adapted from PROMIS Emotional DistressmdashAnxietymdashParent Item Bank)LEVEL 2mdashSubstance UsemdashParentGuardian of Child Age 6ndash17 (Adapted from the NIDA-Modified ASSIST)
For Children Ages 11ndash17LEVEL 2mdashSomatic SymptommdashChild Age 11ndash17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])LEVEL 2mdashSleep DisturbancemdashChild Age 11ndash17 (PROMISmdashSleep DisturbancemdashShort Form)LEVEL 2mdashDepressionmdashChild Age 11ndash17 (PROMIS Emotional DistressmdashDepressionmdashPediatric Item Bank)LEVEL 2mdashAngermdashChild Age 11ndash17 (PROMIS Emotional DistressmdashCalibrated Anger MeasuremdashPediatric)LEVEL 2mdashIrritabilitymdashChild Age 11ndash17 (Affective Reactivity Index [ARI])LEVEL 2mdashManiamdashChild Age 11ndash17 (Altman Self-Rating Mania Scale [ASRM])LEVEL 2mdashAnxietymdashChild Age 11ndash17 (PROMIS Emotional DistressmdashAnxietymdashPediatric Item Bank)LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashChild Age 11ndash17 (Adapted from the Childrenrsquos Florida Obsessive Compulsive Inventory [C-FOCI] Severity Scale)LEVEL 2mdashSubstance UsemdashChild Age 11ndash17 (Adapted from the NIDA-Modified ASSIST)
List of all the level 2 (disorder specific) cross-cutting symptom measures
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Domain Domain Name Threshold to guidefurther inquiry
DSM-5 Level 2 Cross-Cutting Symptom Measure available online
I Depression Mild or greater LEVEL 2mdashDepressionmdashAdult (PROMIS Emotional DistressmdashDepressionmdashShortForm)1
II Anger Mild or greater LEVEL 2mdashAngermdashAdult (PROMIS Emotional DistressmdashAngermdashShort Form)1
III Mania Mild or greater LEVEL 2mdashManiamdashAdult (Altman Self-Rating Mania Scale)IV Anxiety Mild or greater LEVEL 2mdashAnxietymdashAdult (PROMIS Emotional DistressmdashAnxietymdashShort Form)1
V Somatic Symptoms Mild or greater LEVEL 2mdashSomatic SymptommdashAdult (Patient Health Questionnaire 15 SomaticSymptom Severity [PHQ-15])
VI Suicidal Ideation Slight or greater NoneVII Psychosis Slight or greater NoneVIII Sleep Problems Mild or greater LEVEL 2mdashSleep Disturbance - Adult (PROMISmdashSleep DisturbancemdashShort Form)1
IX Memory Mild or greater NoneX Repetitive Thoughts
and BehaviorsMild or greater LEVEL 2mdashRepetitive Thoughts and BehaviorsmdashAdult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI Dissociation Mild or greater NoneXII Personality
FunctioningMild or greater None
XIII Substance Use Slight or greater LEVEL 2mdashSubstance AbusemdashAdult (adapted from the NIDA-modified ASSIST)
Table 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure domains thresholds for further inquiry and associated Level 2 measures for adults ages 18 and over
Hypothetically scores on our client using level I crosscutting symptoms indicated the following areas circled
b
b
b
b
b
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt worthless q 1 q 2 q 3 q 4 q 5
2 I felt that I had nothing to look forward to q 1 q 2 q 3 q 4 q 5
3 I felt helpless q 1 q 2 q 3 q 4 q 5
4 I felt sad q 1 q 2 q 3 q 4 q 5
5 I felt like a failure q 1 q 2 q 3 q 4 q 5
6 I felt depressed q 1 q 2 q 3 q 4 q 5
7 I felt unhappy q 1 q 2 q 3 q 4 q 5
8 I felt hopeless q 1 q 2 q 3 q 4 q 5 TotalPartial Raw Score
Prorated Total Raw Score T-Score
LEVEL 2mdashDepressionmdashAdult PROMIS Emotional DistressmdashDepressionmdashShort Form Name Age Sex Male Female Date_ If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquono interest or pleasure in doing thingsrdquo andor ldquofeeling down depressed or hopelessrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
During the past TWO (2) WEEKS about how often did you use any of the followingmedicines ON YOUR OWN that is without a doctorrsquos prescription in greater amountsor longer than prescribed
Clinician
Use
One ortwo days
Severaldays
More thanhalf the days
Nearlyevery day
Item Score Not at all
a Painkillers (like Vicodin) q 0 q 1 q 2 q 3 q 4 b Stimulants (like Ritalin Adderall) q 0 q 1 q 2 q 3 q 4 c Sedatives or tranquilizers (like sleeping
pills or Valium)q 0 q 1 q 2 q 3 q 4
Or drugs like
d Marijuana q 0 q 1 q 2 q 3 q 4 e Cocaine or crack q 0 q 1 q 2 q 3 q 4 f Club drugs (like ecstasy) q 0 q 1 q 2 q 3 q 4 g Hallucinogens (like LSD) q 0 q 1 q 2 q 3 q 4 h Heroin q 0 q 1 q 2 q 3 q 4 i Inhalants or solvents (like glue) q 0 q 1 q 2 q 3 q 4 j Methamphetamine (like speed) q 0 q 1 q 2 q 3 q 4
Total Score
LEVEL 2mdashSubstance UsemdashAdult Adapted from the NIDA-Modified ASSIST Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquousing medicines on your own without a doctorrsquos prescription or in greater amounts or longer than prescribed andor using drugs like marijuana cocaine or crack andor other drugsrdquo at a slight or greater level of severity The questions below ask how often you (the individual receiving care) have used these medicines andor substances during the past 2 weeks Please respond to each item by marking (P or x) one box per row
Useless for alcohol Perhaps ADS
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Clinician Use
During the past 7 days how much have you been bothered by any of the following problems Item Score
Not bothered at all
0
Bothered a little
1
Bothered a lot
2
1 Stomach pain 2 Back pain 3 Pain in your arms legs or joints (knees hips etc) 4 Menstrual cramps or other problems with
your periods WOMEN ONLY
5 Headaches 6 Chest pain 7 Dizziness 8 Fainting spells 9 Feeling your heart pound or race 10 Shortness of breath 11 Pain or problems during sexual intercourse 12 Constipation loose bowels or diarrhea 13 Nausea gas or indigestion 14 Feeling tired or having low energy 15 Trouble sleeping
TotalPartial Raw Score Prorated Total Raw Score (if 1-3 items left unanswered)
LEVEL 2mdashSomatic SymptommdashAdult PatientAdapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15) Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ldquounexplained aches and painsrdquo andor ldquofeeling that your illnesses are not being taken seriously enoughrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
Level 2 cross-cutting scale for Somatic symptoms - Adult
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
ClinicianUse
In the past SEVEN (7) DAYS
ItemScore Never Rarely Sometimes Often Always
1 I felt fearful q 1 q 2 q 3 q 4 q 5
2 I felt anxious q 1 q 2 q 3 q 4 q 5
3 I felt worried q 1 q 2 q 3 q 4 q 5
4 I found it hard to focus on anything
other than my anxietyq 1 q 2 q 3 q 4 q 5
5 I felt nervous q 1 q 2 q 3 q 4 q 5
6 I felt uneasy q 1 q 2 q 3 q 4 q 5
7 I felt tense q 1 q 2 q 3 q 4 q 5
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashAnxietymdashAdult PROMIS Emotional DistressmdashAnxietymdashShort Form Name Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual In a typical week approximately how much time do you spend with the individual hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks you (individual receiving care) have been bothered by ldquofeeling nervous anxious frightened worried or on edgerdquo ldquofeeling panic or being frightenedrdquo andor ldquoavoiding situations that make you anxiousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
In the past SEVEN (7) DAYS my child said that heshe hellip
Clinician use
Never1
almost never2
Sometimes3
Often4
Almost always5
Item score
1 Felt like something awful might happen
2 Felt nervous 3 Felt scared 4 Felt worried 5 Worried about what could happen to himher
6 Worried when heshe went to bed at night
7 Got scared really easy
8 Was afraid of going to school 9 Worried when heshe was at home
10 Worried when heshe was away from home
Totalpartial raw score Prorated total raw score T-score
Instructions to parentguardian On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past 2 weeks your child receiving care has been bothered by ldquofeeling nervous anxious or scaredrdquo ldquonot being able to stop worryingrdquo andor ldquocouldnrsquot do things heshe wanted to or should have done because they made himher feel nervousrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past 7 days Please respond to each item by marking ( or x) one box per row
Level 2 cross-cutting scale for anxiety in children ndash parent filled
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
ClinicianUse
In the past SEVEN (7) DAYS Not at all A little bit Somewhat Quite a bit Very much 1 My sleep was restless q 1 q 2 q 3 q 4 q 5
2 I was satisfied with my sleep q 5 q 4 q 3 q 2 q 1
3 My sleep was refreshing q 5 q 4 q 3 q 2 q 1
4 I had difficulty falling asleep q 1 q 2 q 3 q 4 q 5
In the past SEVEN (7) DAYS
Never Rarely Sometimes Often Always 5 I had trouble staying asleep q 1 q 2 q 3 q 4 q 5
6 I had trouble sleeping q 1 q 2 q 3 q 4 q 5
7 I got enough sleep q 5 q 4 q 3 q 2 q 1
In the past SEVEN (7) DAYS
Very Poor Poor Fair Good Very good 8 My sleep quality was q 5 q 4 q 3 q 2 q 1
TotalPartial Raw Score Prorated Total Raw Score
T-Score
LEVEL 2mdashSleep DisturbancemdashAdult PROMISmdashSleep DisturbancemdashShort FormName Age Sex q Male q Female Date If the measure is being completed by an informant what is your relationship with the individual receiving care In a typical week approximately how much time do you spend with the individual receiving care hoursweek Instructions to patient On the DSM-5 Level 1 cross-cutting questionnaire that you just completed you indicated that during the past2 weeks you (the individual receiving care) have been bothered by ldquoproblems with sleep that affected your sleep quality over allrdquo at a mild or greater level of severity The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days Please respond to each item by marking (P or x) one box per row
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
DIMENSIONAL SEVERITY MEASURES
bull In addition to a diagnosis DSM MEASURES SEVERITY OF MANY DIAGNOSIS
bull SEVERITY HAS NEVER BEEN CONSISTENTLY MEASURED IN DSM UNTIL NOWndash ONE EITHER WAS PSYCHOTIC OR ONE WAS NOTndash THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Severity - The DSM uses 2 methods of assessing severity depending on the diagnosis
Method 1 involves using a specific dimensional measure or scale Called ldquodisorder specific severity measuresrdquo These can be find on the DSM 5 website under online assessment measures (DIMENSIONAL SCALE )
Method 2 involves counting the number of symptoms and rating severity based on number of symptoms For example lsquomild alcohol use Disorder = 2 ndash 3 symptoms moderate alcohol use disorder = 4 ndash 5 symptoms severe alcohol use Disorder= presence of 6 or more symptoms (Total number of diagnostic crtieria)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Disorder-Specific Severity Measures For AdultsSeverity Measure for DepressionmdashAdult (Patient Health Questionnaire [PHQ-9])Severity Measure for Separation Anxiety DisordermdashAdultSeverity Measure for Specific PhobiamdashAdultSeverity Measure for Social Anxiety Disorder (Social Phobia)mdashAdultSeverity Measure for Panic DisordermdashAdultSeverity Measure for AgoraphobiamdashAdultSeverity Measure for Generalized Anxiety DisordermdashAdultSeverity of Posttraumatic Stress SymptomsmdashAdult (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashAdult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashAdult (Brief Dissociative Experiences Scale [DES-B])For Children Ages 11ndash17Severity Measure for DepressionmdashChild Age 11ndash17 (PHQ-9 modified for Adolescents [PHQ-A]mdashAdapted)Severity Measure for Separation Anxiety DisordermdashChild Age 11ndash17Severity Measure for Specific PhobiamdashChild Age 11ndash17Severity Measure for Social Anxiety Disorder (Social Phobia)mdashChild Age 11ndash17Severity Measure for Panic DisordermdashChild Age 11ndash17Severity Measure for AgoraphobiamdashChild Age 11ndash17Severity Measure for Generalized Anxiety DisordermdashChild Age 11ndash17Severity of Posttraumatic Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey PTSD Short Scale [NSESS])Severity of Acute Stress SymptomsmdashChild Age 11ndash17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])Severity of Dissociative SymptomsmdashChild Age 11ndash17 (Brief Dissociative Experiences Scale [DES-B])Clinician-RatedClinician-Rated Severity of Autism Spectrum and Social Communication DisordersClinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant DisorderClinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
This document is found on page 743 of the DSMIt allows the clinician to rate all of the salient dimensionsthat might be present in a disorder on the schizophrenia spectrum - IN TERMS OF SEVERITY - using Likert scale to rate the dimensions
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
A Five or more of the following symptoms of been present during the same two-week period and represent a change from previous functioning at least one of the symptoms is either depressed mood or loss of interest or pleasure
1 Depressed mood most of the day nearly every day as indicated by subjective reporter observation Yes or no2 Marked diminished interest or pleasure in all our almost all activities Most of the day nearly every day Yes or no3 Significant weight loss when not dieting or weight gain or decrease in appetite nearly every day Yes or no4 Insomnia or hypersomnia nearly every day Yes or no5 Psychomotor agitation or retardation nearly every day Yes or no6 Fatigue or loss of energy nearly every day Yes or no7 Feelings of worthlessness or excessive or inappropriate guilt Yes or no8 Diminished ability to think or concentrate or indecisiveness nearly every day Yes or no9 Recurrent thoughts of death or recurrent suicidal ideation or suicide attempt Yes or no
B The symptoms cause clinically significant distress or impairment Yes or noC The episode is not attributable to the physiological effects of a substance or another medical condition Yes or noD The occurrence of the major depressive disorder is not better explained by schizoaffective schizophrenia schizophreniform or anything else on the schizophrenia spectrum Yes or noE There has never been a manic episode or hypomanic episode Yes or no
DSM 5 criteria for major depression
1 Lead with level I crosscutting symptom measures to assess all symptom domains
2 Follow-up with level II crosscutting measures in order to capture clinical nuances and potential comorbid
3 Move to categories and check off criteria
4 Assess severity
Psycho-social HX MSE
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
ClinicianUse
Item score
Not at all
Several
days
Morethan half the days
Nearlyevery day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down depressed or hopeless 0 1 2 3 3 Trouble falling or staying asleep or sleeping too much 0 1 2 3 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourselfmdashor that you are a failure orhave let yourself or your family down
0
1
2
3
7Trouble concentrating on things such as reading the newspaper or watching television
0
1
2
3
8
Moving or speaking so slowly that other people could havenoticed Or the oppositemdashbeing so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
TotalPartial Raw Score Prorated Total Raw Score (if 1-2 items left unanswered)
Adapted from the Patient Health Questionnairendash9 (PHQ-9) depressionName Age Sex Male q Female q Date Instructions Over the last 7 days how often have you been bothered by any of the following problems
Levels of depressive symptoms severity PHQ-9 ScoreNoneMild depressionModerate depression Moderately severe depression Severe depression
0-45-910-1415-1920-27
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Method 2 for severity
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
A Problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12 month period
1 Alcohol taken in larger amount (need more for increased effect)2 Persistent desire or efforts to quit Using alcohol3 Time spent to obtain use recover from effects Of alcohol4 Cravings Or urges to use Alcohol5 Failure to fulfill significant roles6 Continued use Alcohol despite persistent and recurrent problems7 Important socialoccupational activities are reduced8 Recurrent use Of alcohol in physically hazardous situations9 Use Of alcohol continues despite knowledge of impact of the problem10 Tolerance as defined by a Increased amounts needed to achieve intoxication
or b Diminished effect Of alcohol11 Withdrawal From alcohol
Alcohol use disorder
SeverityMild = presence of 2-3 symptoms moderate = presence of four ndash five symptomssevere = presence of six or more symptoms
Course specifiersearly remission = after full criteria were l previously met none of the criteria met for at least three months but less than 12 (with the exception of craving)In sustained remission = after full criteria were previously met none exists except craving during the period of 12 months or more
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
2 NO MORE GAFWHODAS
bull DSM IV-TR- HAD SOMETHING CALLED THE GLOBAL ASSESSMENT OF FUNCTIONINGndash THE ONLY DIMENSIONAL MEASURE IN THE DSM IV
TRndash USED BY CLINICIAN COMPLETELY UNRELIABLE AND
NOT VALIDbull REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATAndash THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
DSM 5 recommends the following
1 Assess symptom severityseverity of diagnosis-use severity scales
2 Use dimensional scales or standardized scales whenever possible
3 Assess suicidality capacity for self harm or harming others- use separate assessment protocol
4 Use World Health Organization disability assessment scale to assess social and self-care functioning
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
WHODAS 20
bull Based on the International Classification of Functioning Disability and Health (ICF)
bull Applicable to any health conditionbull Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
see pages 745 to 748 in DSM 5
WHODAS Assesses the following six areas1 Understanding and communicating2 Getting around3 Self-care4 Getting along with people5 Life activities6 Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES
DOES NOT TARGET SPECIFIC DISEASE SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASEWHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D11 Concentrating on doing something for ten minutes
1 2 3 4 5
D12 Remembering to do important things 1 2 3 4 5
D13 Analysing and finding solutions to problems in day-to-day life
1 2 3 4 5
D14 Learning a new task for example learning how to get to a new place
1 2 3 4 5
D15 Generally understanding what people say
1 2 3 4 5
D16 Starting and maintaining a conversation
1 2 3 4 5
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D21 Standing for long periods such as 30 minutes
1 2 3 4 5
D22 Standing up from sitting down 1 2 3 4 5
D23 Moving around inside your home 1 2 3 4 5
D24 Getting out of your home 1 2 3 4 5
D25 Walking a long distance such as a kilometre [or equivalent]
1 2 3 4 5
Domain 1 Cognition
Domain 2 Mobility
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
In the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D31 Washing your whole body 1 2 3 4 5
D32 Getting dressed 1 2 3 4 5
D33 Eating 1 2 3 4 5
D34 Staying by yourself for a few days 1 2 3 4 5
In the past 30 days how much difficulty did you have in None Mild Moderate Severe Extreme or cannot do
D41 Dealing with people you do not know 1 2 3 4 5D42 Maintaining a friendship 1 2 3 4 5D43 Getting along with people who are close to you 1 2 3 4 5
D44 Making new friends 1 2 3 4 5D45 Sexual activities 1 2 3 4 5
Domain 3 Self-care
Domain 4 Getting along with people
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D51 Taking care of your household responsibilities 1 2 3 4 5
D52 Doing your most important household tasks well 1 2 3 4 5
D53 Getting all the household work done that you needed to do
1 2 3 4 5
D54 Getting your household work done as quickly as needed 1 2 3 4 5
Because of your health condition in the past 30 days how much difficulty did you have in
None Mild Moderate Severe Extreme or cannot do
D55 Your day-to-day workschool 1 2 3 4 5D56 Doing your most important workschool tasks well 1 2 3 4 5
D57 Getting all the work done that you need to do 1 2 3 4 5
D58 Getting your work done as quickly as needed 1 2 3 4 5
D59 Have you had to work at a lower level because of a health condition No 1Yes 2
D510 Did you earn less money as the result of a health condition No 1Yes 2
Domain 5 LIFE ACTIVITIES
Domain 5 WORK OR SCHOOL ACTIVITIES
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
In the past 30 days None Mild Moderate Severe Extreme or cannot do
D61 How much of a problem did you have joining in community activities (for example festivities religious or other activities) in the same way as anyone else can
1 2 3 4 5
D62 How much of a problem did you have because of barriers or hindrances in the world around you
1 2 3 4 5
D63 How much of a problem did you have living with dignity because of the attitudes and actions of others
1 2 3 4 5
D64 How much time did you spend on your health condition or its consequences
1 2 3 4 5
D65 How much have you been emotionally affected by your health condition
1 2 3 4 5
D66 How much has your health been a drain on the financial resources of you oryour family
1 2 3 4 5
D67 How much of a problem did your family have because of your health problems
1 2 3 4 5
D68 How much of a problem did you have in doing things by yourself for relaxation or pleasure
1 2 3 4 5
Domain 6 Participation
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
bull If WHODAS is used place results at the very end of assessment after psychosocial stressors
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
3 How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I II and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Axis IV - psychosocial and environmental factors - are now covered through an expanded set of V codes V codes allow clinicians to indicate other conditions that may be a focus of clinical attention or affect diagnosis course prognosis or treatment of a mental disorder
Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and disability for individual disorders Change to the World Health Organization Disability Assessment Schedule (WHO DAS 20) Taken from Northstar behavioral health system
httpwwwnorthstarbehavioralcomOverview20of20DSM20520changes20HO20Version20for20Web208-13-13pdf
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
All diagnoses are considered primary diagnosis
bull All diagnoses are listed consecutively (no distinction between diagnosis previously listed on axis I axis II or axis III)
bull List diagnosis that is the reason for visit 1st
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment (Patient continues to drink while on
antidepressants and does not take antidepressants regularly)
bull If the principal diagnosis that is a reason for visit is a mental disorder caused by a medical condition the medical condition is listed 1st
Primary-Parkinsons disease-moderate with tremors and newly developed postural instability (scored 3 on Hoehn and Yahr)
Primary-Reason for visit 29622 major depressive disorder single episode moderate
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Case example ndash for listing of DXJohn is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit smoking 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he has been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so According to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Parkinsonrsquos disease-recently upgraded to moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
V codes -psychosocial stressorsGreatly expanded in the DSM 5
bull V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or injury
bull V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect the diagnosis course prognosis or treatment of the mental disorder
bull First Incorporated in the DSM-III
bull Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
1 Focus or need for clinical attention (along with the billable diagnosis) Can be a
primary diagnosis
2 Psychosocial stressors - Conditions that affect the mental health diagnosis andor contribute to the
development or exacerbation of the DX
3 Other issues circumstances conditions that need attention or affect the diagnosis
course and outcome of treatment)
Use V codes To indicate
V codes (codes V01ndashV91) are used to describe encounters with circumstances other than formal mental disorder diagnoses disease or
injury
V codes are taken from the ICD Their conditions and problems that may be the focus of clinical attention or that otherwise might affect
the diagnosis course prognosis or treatment of the mental disorder
First Incorporated in the DSM-III
Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
Code in the following ways
1 As a Focus or need for clinical attention = Place code as a comorbid diagnosis or as another primary diagnosis
2 As a Psychosocial Environmental stressor = Place code as A stressor at the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years He quit 5 years ago after being diagnosed with Parkinsons disease Over the last 5 years Johns ability to perform physical activity has progressively deteriorated Although John reports bouts of depression beginning in adolescence and continuing throughout his adult life he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinsonrsquos) Since that time he is been on several antidepressant medications most recently Remeron John reports that he has been a regular drinker since his days in college Although he denies it his alcohol use according to his wife has increased since his diagnosis of Parkinsons However upon evaluation both john and his wife agree that he drinks no more than 3 times per week ndash usually a six pack Although John has been advised to discontinue drinking he has not done so And according to both John and his wife He misses his medication anywhere from 1 to 3 times per week
About 3 months ago john fell while at home His wife at first thought it was a result of his drinking According to John he noticed that he was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of Parkinsonrsquos
Despite advice to the contrary John has become progressively more sedentary and has discontinued all forms of exercise About 1 month ago Johns employers required that John start working part-time and consider filing for early Social Security According to them Johns ability to work has diminished They too noted that he was having difficulty walking For the last 3 weeks John has met all of the criteria for a severe episode of major depression
Primary diagnosis
Primary-reason for visit 29633 major depressive disorder recurrent severe
Primary- Medical condition Chronic Obstructive Pulmonary Disease moderate
Primary-30500 alcohol use disorder mild
Primary -v1581 non-adherence to medical treatment Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
v27800 ndash Obesity
v699 - Problems related to lifestyle Johns diet and his progressive sedentary behavior along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
v6229 - Other problems related to employment John has recently had his work hours cut in half
WHODAS raw score = 98 domain averages Cognition = 1none mobility = 4 severe self-care = 2 mild getting along with others = 2 mild Life activities = 25 mild- moderate work activities = 3 moderate participation = 35moderate- severe
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
4 A cultural frameworkThe DSM and cultural formulation
bull DSM calls for systematic cultural assessment in these areas1 Cultural identity of the individual-describe reference group that might
influence his or her relationships resources developmental and current challenges
2 Cultural conceptualization of distress-describe constructs that influence how the individual experiences understands and communicates symptoms or problems to others
3 Psychosocial stressors and cultural features of vulnerability and resilience-identify key stressors and supports in the individual social environment role of religion family and other social
4 Cultural features or influencing factors of the relationship between the individual and clinician-Identify differences that may cause difficulties in communication and may influence diagnosis
5 Overall cultural assessment-summarize the implications of the components of the cultural formulation identified earlier (DSM 5 pp749-750)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
DSM and the cultural formulation interview
bull 16 questions used to obtain information about the impact of culture on key aspects of a persons clinical presentation
bull Assesses 4 areas1 Cultural definition of the problem (Q1 ndash 3)2 Cultural perceptions of cause context and support (Q4 ndash
10)3 Culture of factors affecting self coping and past help
seeking (Q 11 ndash 134 Cultural factors affecting current help seeking (Q 14 ndash 16)
This page and the 3 following are reprinted from the DSM 5 website at psychiatryorg Please see provisions for copying at the bottom of the slides
5 Overall organization of disorders
Neuro developmental Bipolar
Schizophrenia Depressive
Anxiety
Obsessive-compulsive and related
Trauma related
Dissociative
Somatic symptom related
Feeding and eating disorders
Sexual dysfunctions
Sleep wake disorders
Elimination disorders
Substance related and addictive disorders
Disruptive impulse control disorders
Neurocognitive disorders
Personality disorder
Gender dysphoria
Paraphilia disorders
Others
Younger Older
The progression from younger to older in the DSM is general and there are specific disorders such as some early childhood feeding disorders that clearly occur later
Initial occurrence
DSM categories organized over developmental lifespan
Neuro developmental
Bipolar
Schizophrenia Depressive
Anxiety
Obsessive-compulsive and related
Trauma related
Dissociative
Somatic symptom related
Feeding and eating disorders
Sexual dysfunctions
Sleep wake disorders
Elimination disorders
Substance related and addictive disorders
Disruptive impulse control disorders
Neurocognitive disorders
Personality disorder
Gender dysphoria
Paraphilia disorders
Others
These distinctions have some strong validation from recent neuro-scientific and genetic research
DSM categories organized using empirically validated common factors
Neural commonalities
ExternalizingSymptomfactors
PhysiologicalSymptomfactors
InternalizingSymptomfactors
Bio-geneticsimilarfactors
6 Highlight of specific changes in diagnosis
Gonebull Disorders usually evident in infancy childhood and adolescencebull Factitious disorders and malingeringbull adjustment disorders (now included in trauma and stress-related
disorders)bull NOS Diagnosis for all categories
Addedbull neurodevelopmental disordersbull obsessive-compulsive and related disorders (moved out of anxiety)bull trauma and stress-related disorders (moved out of anxiety)bull Disruptive impulse control and conduct related disordersbull Specified and ldquoUnspecified disorder for all diagnosesbull Suicide risk is now specified for 25 diagnosis Changedbull Delirium dementia and cognitive disorders = neurocognitive
disordersbull psychotic disorders = schizophrenia spectrum and other psychotic
disordersbull mood disorders = bipolar and related disorders amp depressive
disorders bull somatoform disorders = somatic symptom and related disorders
Neuro developmental disorders 1 The term mental retardation has been changed to intellectual disability2 The term phonological disorders has been changed to communication disorders
1 A new diagnosis of socialpragmatic communication disorder has been added here2 childhood onset fluency disorder new name for stuttering3 Speech sound disorder is new name for phonological disorder
3 Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers disorder autism and pervasive developmental disorder Severity measures are included
4 Several changes have been made to the diagnostic criteria for attention deficit hyperactive disorder
5 Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics disorder disorder of written expression and learning disorder NOS
6 Language disorder combines expressive and mixed receptive expressive into one7 Symptom onset for ADHD was extended to before age 12 Subtypes eliminated and
replaced by specifiers now allowed to make a comorbid diagnosis with ASD Symptom criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other psychotic disorders
1 The spectrum seems to emphasize degrees of psychosis2 Change in criteria for schizophrenia now requires at least one
criteria to be either a Delusions b Hallucinations or c Disorganized speech
3 Subtypes of schizophrenia were eliminated4 Dimensional measures of symptom severity are now included5 Schizoaffective disorder has been reconceptualized6 Delusional disorder no longer requires the presence of ldquonon-
bizarre in delusions There is now specifier for bizarre delusions
7 Schizotypal personality disorder is now considered part of the spectrum
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
5 Overall organization of disorders
Neuro developmental Bipolar
Schizophrenia Depressive
Anxiety
Obsessive-compulsive and related
Trauma related
Dissociative
Somatic symptom related
Feeding and eating disorders
Sexual dysfunctions
Sleep wake disorders
Elimination disorders
Substance related and addictive disorders
Disruptive impulse control disorders
Neurocognitive disorders
Personality disorder
Gender dysphoria
Paraphilia disorders
Others
Younger Older
The progression from younger to older in the DSM is general and there are specific disorders such as some early childhood feeding disorders that clearly occur later
Initial occurrence
DSM categories organized over developmental lifespan
Neuro developmental
Bipolar
Schizophrenia Depressive
Anxiety
Obsessive-compulsive and related
Trauma related
Dissociative
Somatic symptom related
Feeding and eating disorders
Sexual dysfunctions
Sleep wake disorders
Elimination disorders
Substance related and addictive disorders
Disruptive impulse control disorders
Neurocognitive disorders
Personality disorder
Gender dysphoria
Paraphilia disorders
Others
These distinctions have some strong validation from recent neuro-scientific and genetic research
DSM categories organized using empirically validated common factors
Neural commonalities
ExternalizingSymptomfactors
PhysiologicalSymptomfactors
InternalizingSymptomfactors
Bio-geneticsimilarfactors
6 Highlight of specific changes in diagnosis
Gonebull Disorders usually evident in infancy childhood and adolescencebull Factitious disorders and malingeringbull adjustment disorders (now included in trauma and stress-related
disorders)bull NOS Diagnosis for all categories
Addedbull neurodevelopmental disordersbull obsessive-compulsive and related disorders (moved out of anxiety)bull trauma and stress-related disorders (moved out of anxiety)bull Disruptive impulse control and conduct related disordersbull Specified and ldquoUnspecified disorder for all diagnosesbull Suicide risk is now specified for 25 diagnosis Changedbull Delirium dementia and cognitive disorders = neurocognitive
disordersbull psychotic disorders = schizophrenia spectrum and other psychotic
disordersbull mood disorders = bipolar and related disorders amp depressive
disorders bull somatoform disorders = somatic symptom and related disorders
Neuro developmental disorders 1 The term mental retardation has been changed to intellectual disability2 The term phonological disorders has been changed to communication disorders
1 A new diagnosis of socialpragmatic communication disorder has been added here2 childhood onset fluency disorder new name for stuttering3 Speech sound disorder is new name for phonological disorder
3 Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers disorder autism and pervasive developmental disorder Severity measures are included
4 Several changes have been made to the diagnostic criteria for attention deficit hyperactive disorder
5 Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics disorder disorder of written expression and learning disorder NOS
6 Language disorder combines expressive and mixed receptive expressive into one7 Symptom onset for ADHD was extended to before age 12 Subtypes eliminated and
replaced by specifiers now allowed to make a comorbid diagnosis with ASD Symptom criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other psychotic disorders
1 The spectrum seems to emphasize degrees of psychosis2 Change in criteria for schizophrenia now requires at least one
criteria to be either a Delusions b Hallucinations or c Disorganized speech
3 Subtypes of schizophrenia were eliminated4 Dimensional measures of symptom severity are now included5 Schizoaffective disorder has been reconceptualized6 Delusional disorder no longer requires the presence of ldquonon-
bizarre in delusions There is now specifier for bizarre delusions
7 Schizotypal personality disorder is now considered part of the spectrum
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Neuro developmental Bipolar
Schizophrenia Depressive
Anxiety
Obsessive-compulsive and related
Trauma related
Dissociative
Somatic symptom related
Feeding and eating disorders
Sexual dysfunctions
Sleep wake disorders
Elimination disorders
Substance related and addictive disorders
Disruptive impulse control disorders
Neurocognitive disorders
Personality disorder
Gender dysphoria
Paraphilia disorders
Others
Younger Older
The progression from younger to older in the DSM is general and there are specific disorders such as some early childhood feeding disorders that clearly occur later
Initial occurrence
DSM categories organized over developmental lifespan
Neuro developmental
Bipolar
Schizophrenia Depressive
Anxiety
Obsessive-compulsive and related
Trauma related
Dissociative
Somatic symptom related
Feeding and eating disorders
Sexual dysfunctions
Sleep wake disorders
Elimination disorders
Substance related and addictive disorders
Disruptive impulse control disorders
Neurocognitive disorders
Personality disorder
Gender dysphoria
Paraphilia disorders
Others
These distinctions have some strong validation from recent neuro-scientific and genetic research
DSM categories organized using empirically validated common factors
Neural commonalities
ExternalizingSymptomfactors
PhysiologicalSymptomfactors
InternalizingSymptomfactors
Bio-geneticsimilarfactors
6 Highlight of specific changes in diagnosis
Gonebull Disorders usually evident in infancy childhood and adolescencebull Factitious disorders and malingeringbull adjustment disorders (now included in trauma and stress-related
disorders)bull NOS Diagnosis for all categories
Addedbull neurodevelopmental disordersbull obsessive-compulsive and related disorders (moved out of anxiety)bull trauma and stress-related disorders (moved out of anxiety)bull Disruptive impulse control and conduct related disordersbull Specified and ldquoUnspecified disorder for all diagnosesbull Suicide risk is now specified for 25 diagnosis Changedbull Delirium dementia and cognitive disorders = neurocognitive
disordersbull psychotic disorders = schizophrenia spectrum and other psychotic
disordersbull mood disorders = bipolar and related disorders amp depressive
disorders bull somatoform disorders = somatic symptom and related disorders
Neuro developmental disorders 1 The term mental retardation has been changed to intellectual disability2 The term phonological disorders has been changed to communication disorders
1 A new diagnosis of socialpragmatic communication disorder has been added here2 childhood onset fluency disorder new name for stuttering3 Speech sound disorder is new name for phonological disorder
3 Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers disorder autism and pervasive developmental disorder Severity measures are included
4 Several changes have been made to the diagnostic criteria for attention deficit hyperactive disorder
5 Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics disorder disorder of written expression and learning disorder NOS
6 Language disorder combines expressive and mixed receptive expressive into one7 Symptom onset for ADHD was extended to before age 12 Subtypes eliminated and
replaced by specifiers now allowed to make a comorbid diagnosis with ASD Symptom criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other psychotic disorders
1 The spectrum seems to emphasize degrees of psychosis2 Change in criteria for schizophrenia now requires at least one
criteria to be either a Delusions b Hallucinations or c Disorganized speech
3 Subtypes of schizophrenia were eliminated4 Dimensional measures of symptom severity are now included5 Schizoaffective disorder has been reconceptualized6 Delusional disorder no longer requires the presence of ldquonon-
bizarre in delusions There is now specifier for bizarre delusions
7 Schizotypal personality disorder is now considered part of the spectrum
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Neuro developmental
Bipolar
Schizophrenia Depressive
Anxiety
Obsessive-compulsive and related
Trauma related
Dissociative
Somatic symptom related
Feeding and eating disorders
Sexual dysfunctions
Sleep wake disorders
Elimination disorders
Substance related and addictive disorders
Disruptive impulse control disorders
Neurocognitive disorders
Personality disorder
Gender dysphoria
Paraphilia disorders
Others
These distinctions have some strong validation from recent neuro-scientific and genetic research
DSM categories organized using empirically validated common factors
Neural commonalities
ExternalizingSymptomfactors
PhysiologicalSymptomfactors
InternalizingSymptomfactors
Bio-geneticsimilarfactors
6 Highlight of specific changes in diagnosis
Gonebull Disorders usually evident in infancy childhood and adolescencebull Factitious disorders and malingeringbull adjustment disorders (now included in trauma and stress-related
disorders)bull NOS Diagnosis for all categories
Addedbull neurodevelopmental disordersbull obsessive-compulsive and related disorders (moved out of anxiety)bull trauma and stress-related disorders (moved out of anxiety)bull Disruptive impulse control and conduct related disordersbull Specified and ldquoUnspecified disorder for all diagnosesbull Suicide risk is now specified for 25 diagnosis Changedbull Delirium dementia and cognitive disorders = neurocognitive
disordersbull psychotic disorders = schizophrenia spectrum and other psychotic
disordersbull mood disorders = bipolar and related disorders amp depressive
disorders bull somatoform disorders = somatic symptom and related disorders
Neuro developmental disorders 1 The term mental retardation has been changed to intellectual disability2 The term phonological disorders has been changed to communication disorders
1 A new diagnosis of socialpragmatic communication disorder has been added here2 childhood onset fluency disorder new name for stuttering3 Speech sound disorder is new name for phonological disorder
3 Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers disorder autism and pervasive developmental disorder Severity measures are included
4 Several changes have been made to the diagnostic criteria for attention deficit hyperactive disorder
5 Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics disorder disorder of written expression and learning disorder NOS
6 Language disorder combines expressive and mixed receptive expressive into one7 Symptom onset for ADHD was extended to before age 12 Subtypes eliminated and
replaced by specifiers now allowed to make a comorbid diagnosis with ASD Symptom criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other psychotic disorders
1 The spectrum seems to emphasize degrees of psychosis2 Change in criteria for schizophrenia now requires at least one
criteria to be either a Delusions b Hallucinations or c Disorganized speech
3 Subtypes of schizophrenia were eliminated4 Dimensional measures of symptom severity are now included5 Schizoaffective disorder has been reconceptualized6 Delusional disorder no longer requires the presence of ldquonon-
bizarre in delusions There is now specifier for bizarre delusions
7 Schizotypal personality disorder is now considered part of the spectrum
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
6 Highlight of specific changes in diagnosis
Gonebull Disorders usually evident in infancy childhood and adolescencebull Factitious disorders and malingeringbull adjustment disorders (now included in trauma and stress-related
disorders)bull NOS Diagnosis for all categories
Addedbull neurodevelopmental disordersbull obsessive-compulsive and related disorders (moved out of anxiety)bull trauma and stress-related disorders (moved out of anxiety)bull Disruptive impulse control and conduct related disordersbull Specified and ldquoUnspecified disorder for all diagnosesbull Suicide risk is now specified for 25 diagnosis Changedbull Delirium dementia and cognitive disorders = neurocognitive
disordersbull psychotic disorders = schizophrenia spectrum and other psychotic
disordersbull mood disorders = bipolar and related disorders amp depressive
disorders bull somatoform disorders = somatic symptom and related disorders
Neuro developmental disorders 1 The term mental retardation has been changed to intellectual disability2 The term phonological disorders has been changed to communication disorders
1 A new diagnosis of socialpragmatic communication disorder has been added here2 childhood onset fluency disorder new name for stuttering3 Speech sound disorder is new name for phonological disorder
3 Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers disorder autism and pervasive developmental disorder Severity measures are included
4 Several changes have been made to the diagnostic criteria for attention deficit hyperactive disorder
5 Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics disorder disorder of written expression and learning disorder NOS
6 Language disorder combines expressive and mixed receptive expressive into one7 Symptom onset for ADHD was extended to before age 12 Subtypes eliminated and
replaced by specifiers now allowed to make a comorbid diagnosis with ASD Symptom criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other psychotic disorders
1 The spectrum seems to emphasize degrees of psychosis2 Change in criteria for schizophrenia now requires at least one
criteria to be either a Delusions b Hallucinations or c Disorganized speech
3 Subtypes of schizophrenia were eliminated4 Dimensional measures of symptom severity are now included5 Schizoaffective disorder has been reconceptualized6 Delusional disorder no longer requires the presence of ldquonon-
bizarre in delusions There is now specifier for bizarre delusions
7 Schizotypal personality disorder is now considered part of the spectrum
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Gonebull Disorders usually evident in infancy childhood and adolescencebull Factitious disorders and malingeringbull adjustment disorders (now included in trauma and stress-related
disorders)bull NOS Diagnosis for all categories
Addedbull neurodevelopmental disordersbull obsessive-compulsive and related disorders (moved out of anxiety)bull trauma and stress-related disorders (moved out of anxiety)bull Disruptive impulse control and conduct related disordersbull Specified and ldquoUnspecified disorder for all diagnosesbull Suicide risk is now specified for 25 diagnosis Changedbull Delirium dementia and cognitive disorders = neurocognitive
disordersbull psychotic disorders = schizophrenia spectrum and other psychotic
disordersbull mood disorders = bipolar and related disorders amp depressive
disorders bull somatoform disorders = somatic symptom and related disorders
Neuro developmental disorders 1 The term mental retardation has been changed to intellectual disability2 The term phonological disorders has been changed to communication disorders
1 A new diagnosis of socialpragmatic communication disorder has been added here2 childhood onset fluency disorder new name for stuttering3 Speech sound disorder is new name for phonological disorder
3 Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers disorder autism and pervasive developmental disorder Severity measures are included
4 Several changes have been made to the diagnostic criteria for attention deficit hyperactive disorder
5 Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics disorder disorder of written expression and learning disorder NOS
6 Language disorder combines expressive and mixed receptive expressive into one7 Symptom onset for ADHD was extended to before age 12 Subtypes eliminated and
replaced by specifiers now allowed to make a comorbid diagnosis with ASD Symptom criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other psychotic disorders
1 The spectrum seems to emphasize degrees of psychosis2 Change in criteria for schizophrenia now requires at least one
criteria to be either a Delusions b Hallucinations or c Disorganized speech
3 Subtypes of schizophrenia were eliminated4 Dimensional measures of symptom severity are now included5 Schizoaffective disorder has been reconceptualized6 Delusional disorder no longer requires the presence of ldquonon-
bizarre in delusions There is now specifier for bizarre delusions
7 Schizotypal personality disorder is now considered part of the spectrum
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Neuro developmental disorders 1 The term mental retardation has been changed to intellectual disability2 The term phonological disorders has been changed to communication disorders
1 A new diagnosis of socialpragmatic communication disorder has been added here2 childhood onset fluency disorder new name for stuttering3 Speech sound disorder is new name for phonological disorder
3 Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers disorder autism and pervasive developmental disorder Severity measures are included
4 Several changes have been made to the diagnostic criteria for attention deficit hyperactive disorder
5 Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics disorder disorder of written expression and learning disorder NOS
6 Language disorder combines expressive and mixed receptive expressive into one7 Symptom onset for ADHD was extended to before age 12 Subtypes eliminated and
replaced by specifiers now allowed to make a comorbid diagnosis with ASD Symptom criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other psychotic disorders
1 The spectrum seems to emphasize degrees of psychosis2 Change in criteria for schizophrenia now requires at least one
criteria to be either a Delusions b Hallucinations or c Disorganized speech
3 Subtypes of schizophrenia were eliminated4 Dimensional measures of symptom severity are now included5 Schizoaffective disorder has been reconceptualized6 Delusional disorder no longer requires the presence of ldquonon-
bizarre in delusions There is now specifier for bizarre delusions
7 Schizotypal personality disorder is now considered part of the spectrum
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Schizophrenia spectrum and other psychotic disorders
1 The spectrum seems to emphasize degrees of psychosis2 Change in criteria for schizophrenia now requires at least one
criteria to be either a Delusions b Hallucinations or c Disorganized speech
3 Subtypes of schizophrenia were eliminated4 Dimensional measures of symptom severity are now included5 Schizoaffective disorder has been reconceptualized6 Delusional disorder no longer requires the presence of ldquonon-
bizarre in delusions There is now specifier for bizarre delusions
7 Schizotypal personality disorder is now considered part of the spectrum
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Bipolar and related disorders
bull Diagnosis must now include both changes in mood and changes in activityenergy level
bull Some particular conditions can now be diagnosed under other specified bipolar and related disordersldquo
bull An anxiety specifier has now been includedbull Attempts made to clarify definition of
hypomania However it was not successful
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Depressive disorders
bull New diagnosis included = disruptive mood dysregulation disorderrdquo-use for children up to age 18
bull New diagnosis included = premenstrual dysphoric disorderldquo
bull What used to be called dysthymic disorder is now persistent depressive disorderldquo
bull Bereavement is no longer excluded ndash used to be an exclusion for 2 months
bull New specifiers such as mixed features And anxious distress
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Obsessive-compulsive and related disorders
bull A completely new diagnostic grouping categorybull Hoarding disorder-new diagnosisbull Excoriation (skin picking) disorder-new diagnosisbull Substance induced obsessive-compulsive disorder-
new diagnosisbull Trichotillomania now called hair pulling disorderbull Tic specifier has been addedbull Muscle dysphoria is now a specifier within body
dysmorphic disorder
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Trauma and stress related disorders
bull For diagnosis of acute stress disorder it must be specified whether the traumatic events were experienced directly or indirectly
bull Adjustment disorders (a separate class in the DSM-IV) are included here as various types of responses to stress
bull Major changes in the criteria for the diagnosis of PTSD
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Anxiety disordersbull Obsessive-compulsive disorder has been moved out of
this categorybull PTSD has been moved out of this categorybull Acute stress disorder has been moved out of this categorybull Changes in criteria for specific phobia and social anxiety
have been madebull Panic attacks can now be used as a specifier within any
other disorder in the DSMbull Separation anxiety disorder has been moved to this groupbull Selective mutism has been moved to this group
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Dissociative disorders
bull Depersonalization disorder has been relabeled ldquoDepersonalizationDerealization disorderldquo
bull Dissociative fugue is no longer a separate diagnosis but is now specifier within the diagnosis of dissociative amnesialdquo
bull Changes in criteria for the diagnosis of dissociative identity disorder
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Somatic symptom and related disorders
bull This is a new name for what was previously called somatoform disordersldquo
bull The number of diagnoses in this category has been reduced The diagnoses of somatization disorder hypochondriasis pain disorder and undifferentiated somatoform disorder have all been removed
bull Illness anxiety disorder has been an added diagnosis and replaces hypochondriasis
bull Factitious disorder is now included in this group
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Feeding and eating disorders
bull Binge eating disorder is now included as a separate diagnosis
bull also includes a number of diagnosis that were previously included in a DSM-IV TR in the chapter disorders usually 1st diagnosed during infancy childhood and adolescenceldquondash Pica and rumination disorder are 2 examples
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Elimination disordersbull Originally classified in chapters on childhood and infancy
Now have separate classification
bull Primary insomnia renamed insomnia disorderlaquobull Narcolepsy now distinguished from other forms of
hypersomniabull Breathing related sleep disorders have been broken into
3 separate diagnosesbull Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
Sleep wake disorders
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Sexual dysfunctionsbull Some gender related sexual dysfunctions have been
outedbull Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
bull New diagnostic class and the DSM 5bull Include separate classifications for children
adolescents and adultsbull The construct of gender has replaced the construct of
sex
Gender dysphoria
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Disruptive impulse control and conduct disorders
bull New diagnostic grouping and DSM 5bull Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct disorder oppositional defiant disorder with a group previously known as impulse control disorders not otherwise classified
bull Oppositional defiant disorder now has 3 subtypesbull Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Substance related and addictive disorders
bull The distinctions between substance abuse and substance dependence are no longer madendash Now includes criteria for intoxication withdrawal
and substance induced disordersbull Now includes gambling disorderbull Cannabis and caffeine withdrawal are now
new disorders
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Neuro-cognitive disorders
bull New diagnostic groupbull Dementia and amnestic disorder are included
in this new groupbull Mild NCD is a new diagnosis
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Personality disorders
Nothing changes
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
DSM 5 promised major changes in criteria
bull Promised dimensional focusbull Promised reduction in number of personaliity
disorders to fivebull Changes did not occurbull Dimensional focus for personality disorders
was moved to section 3
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Primary Criteria in DSM 5(Unchanged from DSM-IV TR)
A Enduring pattern of inner experience amp behavior that deviates markedly from expectations of the culture This pattern is manifested in 2 or more of the following areas
A Cognition B Affect C Interpersonal D Impulse control
B Inflexible amp pervasive across situationC Distress or impairment in social occupational
interpersonalhellipD Long-standing (back to adolescence or early adulthood)
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Dimensional classification of personality disorders
bull Authors of DSM 5 had planned to use dimensional measures to diagnose personality disorders
bull They plan to reduce personality disorders from 10 to 5
bull This changed in a closed-door meetingbull Dimensional measures are now in section 3
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-
Proposed changes in assessment of PDs Two broad dimensions
Overall personality functioning
5 BroadPathological Trait Domains
self Interpersonal
IdentitySelf direction
Empathy Intimacy
Negative affectivity
Detachment Antagonism Disinhibition Psychoticism
- Whatrsquos in DSM-5
- Why change
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Other problems
- Slide 9
- DSM III amp IV limits
- DSM III amp IV ndash problems with measuring
- The relationship between Categorical Dx comorbidity and increa
- Slide 13
- DSM 5
- 1 Dimensional measures httpwwwpsychiatryorgpracticedsm
- Slide 16
- Crosscutting symptoms (symptoms that can occur across many DXs)
- Slide 18
- Slide 19
- Slide 20
- level II measures(Dimensional)
- Level 2 measures of symptoms
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- DIMENSIONAL SEVERITY MEASURES
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Method 2 for severity
- Alcohol use disorder
- 2 NO MORE GAF WHODAS
- DSM 5 recommends the following
- WHODAS 20
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- 3 How to chart without axes
- Slide 48
- All diagnoses are considered primary diagnosis
- Case example ndash for listing of DX
- V codes -psychosocial stressors Greatly expanded in the DSM 5
- Use V codes To indicate
- Code in the following ways
- Slide 54
- 4 A cultural framework The DSM and cultural formulation
- DSM and the cultural formulation interview
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- 5 Overall organization of disorders
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Neuro developmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
- Anxiety disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Elimination disorders
- Sexual dysfunctions
- Disruptive impulse control and conduct disorders
- Substance related and addictive disorders
- Neuro-cognitive disorders
- Personality disorders
- DSM 5 promised major changes in criteria
- Primary Criteria in DSM 5 (Unchanged from DSM-IV TR)
- Dimensional classification of personality disorders
- Proposed changes in assessment of PDs Tw
-