DSM-5-TF Cross-Cutting Symptom Measure

DSM-5 Level 1 Cross-Cutting Symptom Measure

• A self- or informant-rated measure assessing domains important across psychiatric diagnoses
• Helps clinicians identify additional areas of inquiry impacting treatment and prognosis
• Tracks changes in symptom presentation over time

Domains Assessed

• 13 psychiatric domains, including:
  • Depression
  • Anger
  • Mania
  • Anxiety
  • Somatic Symptoms
  • Suicidal Ideation
  • Psychosis
  • Sleep Problems
  • Memory
  • Repetitive Thoughts and Behaviors
  • Dissociation
  • Personality Functioning
  • Substance Use

Measure Composition

• 23 questions in the adult version
• Each domain consists of 1-3 questions
• Items inquire about the level of bother or frequency of symptoms during the past 2 weeks

Administration

• Can be completed by the individual or a knowledgeable adult informant if the individual has impaired capacity (e.g., major neurocognitive disorder)

Measure's Reliability and Usefulness

• The measure was found to be clinically useful and reliable in the DSM-5 Field Trials conducted in adult clinical samples across the United States and Canada.
• Individuals' symptom ratings were shared with the clinician before meeting, facilitating communication during the clinical encounter.
• Clinicians in both major academic-medical research institutions and routine clinical practice settings found the measure clinically useful and feasible for integration into everyday clinical care and specialty clinical settings.
• Multiple studies have evaluated the psychometric properties of the adult self-rated version of the cross-cutting symptom measure in various populations.
• A large study of non-treatment-seeking college students across the United States demonstrated acceptable internal consistency and internal validity.

Parent/Guardian-Rated Version

• The parent/guardian-rated version of the measure is designed for children ages 6-17 and consists of 25 questions.
• The questions assess 12 psychiatric domains, including:
  • Depression
  • Anger
  • Irritability
  • Mania
  • Anxiety
  • Somatic symptoms
  • Inattention
  • Suicidal ideation/attempt

Psychiatric Symptom Measure

• Assessments include psychosis, sleep disturbance, repetitive thoughts and behaviors, and substance use.
• Ratings are based on the frequency or severity of symptoms over the past 2 weeks.
• The measure has been found to be clinically useful and reliable in pediatric clinical samples across the United States.

Administration

• Parent/guardian ratings are required for children of all ages.
• For children ages 11-17, clinicians may consider obtaining self-ratings from the child using the child-rated version of the measure.
• The child-rated version of the measure is available online at www.psychiatry.org/dsm5.

Scoring of Self-Rated Measures

• Each item is rated on a 5-point scale: 0 (none or not at all), 1 (slight or rare, less than a day or two), 2 (mild or several days), 3 (moderate or more than half the days), and 4 (severe or nearly every day)
• Clinicians should review scores on each item within a multi-item domain to identify the most problematic symptom
• A rating of mild (2) or greater on any item within a domain (except substance use, suicidal ideation, and psychosis) indicates the need for further assessment

Scoring Guidelines for Child Mental Health

Overview

• The guidelines describe how to use scores from a parent/guardian-rated mental health measure to determine if a more detailed assessment is necessary.
• The measure includes 25 items rated on a 5-point scale, with the exception of three items that are rated on a "Yes, No, or Don't Know" scale.

Scoring and Interpretation

• Most items are rated on a 5-point scale, ranging from 0 (none or not at all) to 4 (severe or nearly every day).
• Scores on the substance use, suicidal ideation, and psychosis domains are used to determine the need for further inquiry.
• A rating of 1 (slight or rare) or greater on any item within these domains may indicate a need for further assessment.
• For inattention and psychosis, scores are interpreted differently, with a rating of 1 (slight or rare) or greater used as an indicator for further inquiry.
• Suicide Attempt and Substance Abuse items are scored on a "Yes, No, or Don't Know" scale, with a rating of "Don't Know" indicating a need for further inquiry.

Threshold Scores

• Threshold scores for further inquiry are outlined in a table, indicating scores of 1+ for substance use, suicidal ideation, psychosis, and inattention, and "Don't Know" for suicide attempt and substance abuse.

Additional Assessment

• Depending on the score, a Level 2 cross-cutting symptom assessment may be needed, providing a more detailed evaluation of possible mental health concerns.
• Level 2 assessment includes domains such as substance use, suicidal ideation, psychosis, inattention, suicide attempt, and substance abuse.

Substance Use Items for Children

• Use of substance use items for children aged 11-17 years may lead to further probing of issues with the child
• This includes using the child-rated Level 2 Cross-Cutting Symptom Measure for the relevant domain

Clinician Guidance

• Clinicians should indicate the highest score on any item within a domain in the "Highest Domain Score" column
• Table 2 provides threshold scores that guide further inquiry for remaining domains

Child-Rated Version Guidelines

• Clinician instructions and guidelines for the child-rated version are similar to those of the parent/guardian-rated version
• Exception: "Don't Know" response categories are not present in the child-rated version
• Refer to www.psychiatry.org/dsm5 for more information

Level 2 Cross-Cutting Symptom Measures

• Threshold scores on Level 1 measures indicate a possible need for detailed clinical inquiry
• Level 2 measures provide in-depth information on potentially significant symptoms to inform diagnosis, treatment planning, and follow-up
• Level 2 measures are available online at www.psychiatry.org/dsm5
• Adult and pediatric versions are available online for most Level 1 symptom domains

Frequency of Use of the Cross-Cutting Symptom Measures

• Level 1 and relevant Level 2 measures can be completed at regular intervals to track change in symptom presentation over time
• Measures should be completed by the same knowledgeable informant for individuals with impaired capacity
• Measures should be completed by the same parent or guardian for children ages 6-17 years
• Consistently high scores on a particular domain may indicate significant and problematic symptoms that warrant further assessment, treatment, and follow-up
• Clinical judgment should guide decision making in using the cross-cutting symptom measures

Psychotic Disorders and Symptom Severity

• Psychotic disorders are heterogeneous, and symptom severity can predict aspects of the illness, such as cognitive and/or neurobiological deficits.
• Dimensional assessments capture meaningful variation in symptom severity, helping with treatment planning, prognostic decision-making, and research on pathophysiological mechanisms.

Clinician-Rated Dimensions of Psychosis Symptom Severity Measure

• The measure provides scales for dimensional assessment of primary symptoms of psychosis, including: • Hallucinations • Delusions • Disorganized speech • Abnormal psychomotor behavior • Negative symptoms
• The measure also includes a scale for dimensional assessment of cognitive impairment, which predicts functional abilities and prognosis.
• Scales for dimensional assessment of depression and mania are provided to identify co-occurring mood pathology.

Assessment and Rating

• The Clinician-Rated Dimensions of Psychosis Symptom Severity is an 8-item measure completed by the clinician during clinical assessment.
• Each item asks the clinician to rate the severity of each symptom as experienced by the individual when it was at its most severe during the past 7 days.

Scoring and Interpretation

• Ratings for each item on the measure are done on a 5-point scale with the following levels:
  • 0: none
  • 1: equivocal
  • 2: present, but mild
  • 3: present and moderate
  • 4: present and severe
• Each rating level has a symptom-specific definition to guide the clinician's judgment
• Clinicians review all available information and select the level that best describes the symptom severity based on clinical judgment

Frequency of Use

• The measure can be completed at regular intervals to track changes in symptom severity over time
• The frequency of use depends on the individual's symptom stability and treatment status
• Consistently high scores on a particular domain may indicate significant problems that require further assessment, treatment, and follow-up
• Clinical judgment should guide decision making when interpreting results

A self- or informant-rated measure that assesses domains important across psychiatric diagnoses, helping clinicians identify areas for further inquiry and track symptom changes.