Dsm5 Cross-cutting Symptom Measures

DSM5Cross-Cutting

Symptom MeasuresDr (Maj) Ashutosh Ratnam

Overview • The Diagnostic Landscape before DSM5• The Felt Need for Cross-Cutting Symptom Measures• Conceptual Construct of Cross-Cutting Symptom

Measures• Theoretical Advantages • Cross-Cutting Symptom Measures as in DSM5• Field Trial • Lacunae & Critique • Summary

The Diagnostic Landscape before DSM5

• Each psychiatric clinical syndrome would ultimately be validated by its – Separation from other disorders – Common Clinical Course – Genetic Aggregation in Families – Further differentiation by future lab tests – Differential Response to Treatment (Kendler)

Robins E, Guze SB: Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 1970; 126:983–987


• …benefit in using explicit operational criteria to increase reliability in the absence of etiological understanding Stengel E: Classification of mental disorders. Bull World Health Organ 1959; 21:601–603

• “We are impressed by the remarkable advances in research and clinical practice that were facilitated by having explicit diagnostic criteria that produced greater reliability in diagnosis across clinicians and research investigators in many countries”

• D REGIER, The Conceptual Development of DSM-V, Am J Psychiatry 166:6, June 2009


• DSM-IV-TR (APA, 2000) used a categorical classification system that “divides mental disorders into types based on criterion sets with defining features” (p. xxxi)

• A categorical diagnosis has only two values– presence or absence of a disorder

• Members of a diagnostic group are assumed to be relatively similar– having specific symptoms that reflect the particular diagnosis

• Patient assessment uses a polythetic (i.e., checklist) approach– a minimum number of symptoms to receive a diagnosis

• KD Jones, Dimensional and Cross-Cutting Assessment in the DSM-5, Journal of Counseling & Development, October 2012, Volume 90

The Felt Need for Cross-Cutting Symptom Measures

• Patient populations, although appearing to have similar clinical presentations, are highly heterogeneous

• Categories often fail to identify/include significant aspects of symptomatology – they do not fit into the set of predetermined diagnostic

characteristicsMillon, T. (1991). Classification in psychopathology: Rationale, alternatives, and standards. Journal of

Abnormal Psychology, 100, 245–261.Regier, D. (2008). Dimensional approaches to psychiatric classification. In J. E. Helzer, H. C. Kraemer, R. F.

Krueger, H. U. Wittchen, P. J. Sirovatka, & D. A. Regier (Eds.), Dimensional approaches in diagnostic classification: Refining the research agenda for DSM-V (pp. xvii–xxiii). Washington, DC: American Psychiatric Association.

The Felt Need for Cross-Cutting Symptom Measures

• Heterogenicity • Categories failing to identify/include

symptomatology not fitting into diagnostic criteria sets

1. Excessive Co-Occurring Disorders 2. Boundary Disputes between Disorders

3. Excessive Use of NOS Categories

Excessive Co-Occurring Disorders • Data from more than 10,000 participants in the

Australian National Survey of Mental Health and Well-Being – 40% of the sample met the diagnostic criteria for more than

one current disorder• Andrews, G., Slade, T., & Issakidis, C. (2002). Deconstructing current comorbidity: Data from the

Australian National Survey of Mental Health and Well-Being. British Journal of Psychiatry, 181, 306–314. doi:10.1192/bjp.181.4.306

• In a survey of primary care patients, among individuals with the most severe ratings of depression, anxiety, or somatization, more than one-half in each syndrome group also had at least one, if not both, of the other two disorders

• Lowe B, Spitzer RL, Williams JBW, Mussell M, Schellberg D, Kroenke K: Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry 2008; 30:191–199

Excessive Co-Occurring Disorders

• “It seems that diagnostic comorbidity is the norm rather than the exception”

• Widiger, T. A., & Samuel, D. B. (2005). Diagnostic categories or dimensions? A question for the Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition. Journal of Abnormal Psychology, 114, 494–504. doi:10.1037/0021-843X.114.4.494

• Excessive incidence brings to question whether the comorbidity is – indeed the co-occurring presence of multiple mental

disorders – one disorder that is being given multiple diagnoses

Widiger, T. A., & Coker, L. A. (2003). Mental disorders as discrete clinical conditions: Dimensional versus categorical classification. In M. Hersen & S. M. Turner (Eds.), Adult psychopathology and diagnosis (pp. 3–35). Hoboken, NJ: Wiley.

Boundary Disputes between Disorders

• A categorical classification approach works best when “members of a diagnostic class are homogeneous” and “there are clear boundaries between classes” (DSMIV, APA, 2000, p. xxxi).

• Mental disorders are neither homogeneous nor divided by clear boundaries

• Most follow a continuous distribution– Individuals with anxiety are not merely anxious or not anxious

(with a clear boundary in between)– They experience infinite degrees of anxiety

Fauman, M. A. (2002). Study guide to the DSM-IV-TR. Washington, DC: American Psychiatric Publishing.

Boundary Disputes between Disorders • Attempts to delineate boundaries by addition of – new diagnoses– subtypes – specifiers

a) Bipolar II disorder to fill the gap between Bipolar I and cyclothymia

b) Mixed anxiety-depressive disorder to account for subthreshold cases of mood and anxiety disorders

c) Generalized subtype for social phobia when the feared situation includes most social situations

• Widiger, T. A., & Coker, L. A. (2003). Mental disorders as discrete clinical conditions: Dimensional versus categorical classification. In M. Hersen & S. M. Turner (Eds.), Adult psychopathology and diagnosis (pp. 3–35). Hoboken, NJ: Wiley.


Boundary Disputes between Disorders

• At times addition of new diagnoses/specifier worsened boundary problem

• The addition of the social phobia “generalized” specifier – accounted for patients with widespread social fears– also blurred the boundary with avoidant personality disorder

• Widiger, T. A., & Coker, L. A. (2003). Mental disorders as discrete clinical conditions: Dimensional versus categorical classification. In M. Hersen & S. M. Turner (Eds.), Adult psychopathology and diagnosis (pp. 3–35). Hoboken, NJ: Wiley.


Excessive Use of NOS Categories • “Each diagnostic class has at least one Not Otherwise

Specified (NOS) category and some classes have several NOS categories– The presentation conforms to the general guidelines for a mental

disorder in the diagnostic class, but the symptomatic picture does not meet the criteria for any of the specific disorders. Either • the symptoms are below the diagnostic threshold for one of the specific

disorders or • there is an atypical or mixed presentation

– The presentation conforms to a symptom pattern that has not been included in the DSM-IV Classification but that causes clinically significant distress or impairment

– There is uncertainty about etiology– There is insufficient opportunity for complete data collection (e.g.,

in emergency situations) or inconsistent or contradictory information, but there is enough information to place it within a particular diagnostic class”

Excessive Use of NOS Categories • “Because the NOS categories are considered residual categories, the

number of cases given NOS diagnoses should be modest in number”• Fairburn, C., Cooper, Z., Bahn, K., O’Connor, M., Doll, H., & Palmer, R. (2007). The severity and status of eating disorder

NOS: Implications for DSM-V. Behaviour Research and Therapy,45, 1705–1715.

• For some diagnostic categories the NOS category is used at least as often as any of the specific classifications.– Mood disorders (APA,2010)– Eating disorders (Fairburn et al., 2007)– Bipolar disorder (Cassano et al., 1999)– Personality disorders (Wilberg,Hummelen, Pedersen, & Karterud, 2008)

• NOS categories provide only general information, their usage results in a significant loss of diagnostic information

• First, M. B. (2010a). Clinical utility in the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). ProfessionalPsychology: Research and Practice, 41, 465–473.

Conceptual Construct of Cross-Cutting Symptom Measures

• “Conceptually, development ofDSM-5 sprang from a need to– reduce clinicians reliance on the “not otherwise

specified” category of many disorders, which is vague and contributes little to treatment planning

– develop more accurate criteria that improve diagnostic reliability

– integrate dimensional aspects of psychiatric disorders with the current categorical approach• so that the classification system more accurately represents

how symptoms manifest and present clinically”


• In rectifying this, DSM-5 leadership borrowed directly from general medicine the concept of the “review of systems,” brief questions allow physicians to assess a patient’s major organ systems for disturbances or dysfunctions – might signal a possible disorder – even otherwise might be in need of care

“DSM-5 is proposingto include a “mental review of systems”

in the form of a questionnaire that includes symptomsthat are known to cut across many if

not mostdiagnostic

categories and may be a source of

patient impairment, distress, or other

treatmentneed"


• “The general medical review of symptoms is crucial to detecting subtle changes in different organ systems that can facilitate diagnosis and treatment.

• A similar review of various mental functions can aid in a more comprehensive mental status assessment by drawing attention to – symptoms that may not fit neatly into the diagnostic

criteria suggested by the patient’s presenting symptoms– but may nonetheless be important to the individual’s

care” DSM5, APA

Theoretical Advantages • Clinical Advantages – Provide a more specific and individualized profile

description of a patient’s psychopathology• more differentiated and specific treatment

– Monitor treatment progress and improvements even if the symptoms do not disappear completely

– Self-report and self-administered nature of measures facilitates patient engagement in their own assessment and care• U.S. Patient Protection and Affordable Care Act’s recent

mandate that clinicians engage in patient-centered, measurement-based quality care

Theoretical Advantages• Research Advantages – Potential to allow clinicians and researchers to gain

better understanding of • how different combinations of cross-cutting symptoms at

varying levels of severity may present across diverse diagnoses• their potential impact on patient outcomes

– Provide psychiatry with a standardized way to communicate about comorbidity, remission, and recovery • lead to more customized treatments to match different

symptom profiles over time

DSM-5 cross-cutting symptom measures: a step towards the future of psychiatric care? DE CLARKE World Psychiatry 13:3 - October 2014

Cross-Cutting Symptom Measures as in DSM5

• Level 1 Cross-Cutting Symptom Measure – Adult Version • 23 Questions • Assessing 13 Psychiatric Domains

– Parent/Guardian Rated Version for children 6-17• 25 Questions • Assessing 12 Psychiatric Domains

– Children Self-reporting aged 11-17

• Each site focused on 4-7 diagnoses • Stratified Sampling – Stratification based on existing DSMIV diagnosis – If diagnosis new to DSM, then based on probability of

meeting criteria for new diagnosis • Sites enrolled – ‘fail safe’ sample of 50 pts per diagnosis– “other diagnosis” group with none of the study diagnosis

at that site

Field Trials – Medical/Academic• New York State Psychiatric

Institute, Columbia University Medical Center, New York

• Baystate Medical Center, Springfield, Mass

• Children's Hospital, Aurora, Colo

• Lucile Packard Children's Hospital, Stanford University in Stanford, Calif.

• Department of Veterans Affairs, Dallas

• University of California, Los Angeles

• University of Texas Health Science Center, San Antonio

• University of Pennsylvania, Philadelphia;

• Mayo Clinic, Rochester, Minn

• Centre for Addiction and Mental Health, Toronto

• The Menninger Clinic, Baylor College of Medicine, and the DeBakey VA Medical Center in Houston.

• Clinician Training – instructed to integrate the proposed DSM-5 criteria and measures

into their usual diagnostic practices rather than use structured research instruments

– instructed to use the information obtained in the cross-cutting symptom measures as potentially important clinical information that should be used to inform their clinical interviews• i.e. after reviewing the results of the completed measures, the clinicians

instructed to start the interview as usual with the chief complaint (which may not have corresponded to the highest-scoring domains on the cross-cutting symptom measures)

– to follow up on any areas of concern indicated in the cross-cutting symptom measures during the course of the interview

– cautioned that using the cross-cutting symptom measures solely as diagnostic screeners would defeat the purpose of the measures.

• Testing Methodology – The test (visit 1) and retest (visit 2) diagnostic interviews occurred anytime

from 4 hours to 14 days apart• clinicians were blind to the patient’s stratum assignment• clinicians who conducted the diagnostic interviews were blind to each other’s

ratings

• Before meeting with the assigned study clinician for the diagnostic interview, the patient, proxy respondent, or parent/guardian – provided demographic information – completed the relevant version of the DSM-5 cross-cutting symptom measures

on a tablet or laptop computer

• Before the start of the interview , Clinicians given – summary scores for each cross-cutting symptom domain with an interpretation – able to examine item-level scores for all measures

Field Trials Results • Level 1 Adult Reliabilities – All with ICC estimates of “good” or better except • Mania 1 (Sleeping less but still having a lot of energy?)• Mania 2 (Starting lots of projects or doing more risky things?)

• Level 1 Parents of Children under 11 – 19 of 25 items in good or excellent range – Questionable range • Anxiety item 3 (“cannot do things because of nervousness”)• Repetitive thoughts item 1 (“unpleasant thoughts, images or

urges entering mind”)

– Unacceptable reliability • Misuse of Legal Drugs

Field Trial Conclusion • “Initial psychometric findings for the DSM-5 cross-

cutting symptom measures show that a substantial majority of the level 1 and combined level 1 and 2 assessments demonstrated good or excellent test-retest reliability for adult, parent, and child respondents

• These results support the inclusion of these measures in the DSM-5 diagnostic assessment recommendations as a standardized source of clinical data, available to the clinician as a mental health review of systems”

Lacunae & Critique • In the DSM-5 pilot study, only a partial electronic version

was used (i.e., completion only), yet patients and clinicians still found the measures clinically useful

• The feasibility and clinical utility of the pencil-and-paper versions still need to be demonstrated, though the positive findings on their electronic counterparts bode well– Important for places in the U.S. and around the world that do not

have ready access to electronic technology

• “We anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred.” D Kupfer, D Reiger On the Spectrum, Nature Vol 496, Apr 13

Critique • Asperger’s syndrome is bundled together with a handful of related conditions

into the new category called autism-spectrum disorder• OCD, compulsive hair-pulling and other similar disorders are grouped together in

an obsessive–compulsive and related disorders category• “Though this should facilitate research into common vulnerabilities, it

probably won’t make much difference to treatment” D Rieger , On the Spectrum, Nature Vol 496, Apr 13

• Further refinements to the DSM-5 CC Symptom measures are warranted, as indicated by field trial testing

• The existing battery dovetails nicely with ongoing efforts supported by the National Institute of Mental Health’s Research Domain Criteria project – to better integrate basic science and neurobiology – including the use of

dimensional assessments of observable and neurological symptoms – into the psychiatric nosology

DSM-5 cross-cutting symptom measures: a step towards the future of psychiatric care? DE CLARKE World Psychiatry 13:3 - October 2014

Summary• Patient populations, although appearing to have similar

clinical presentations, are highly heterogeneous • Categories often fail to identify/include significant aspects of

symptomatology – they do not fit into the set of predetermined diagnostic

characteristics

• Categorical classification has resulted in – Excessive Co-Occurring Disorders – Boundary Disputes between Disorders – Excessive Use of NOS Categories

• NOS categories provide only general information, their usage results in a significant loss of diagnostic information

Summary• Cross cutting symptoms are a clinical reality and have – Clinical – Research advantages

• Substantial majority of level 1 and level 2 assessments demonstrate good/excellent test-retest reliability

• The existing crosscutting battery dovetails nicely with ongoing efforts supported by the National Institute ofMental Health’s Research Domain Criteria project – to better integrate basic science and neurobiology – including the

use of dimensional assessments of observable and neurological symptoms – into the psychiatric nosology

References • DSM-5 cross-cutting symptom measures: a step towards

the future of psychiatric care? DE CLARKE World Psychiatry 13:3 - October 2014D Rieger , On the Spectrum, Nature Vol 496, Apr 13

• DSM-5, American Psychiatric Association • A Research Agenda for DSM-V, APA • First, M. B. (2010a). Clinical utility in the revision of the

Diagnostic and Statistical Manual of Mental Disorders (DSM). ProfessionalPsychology: Research and Practice, 41, 465–473.

• KD Jones, Dimensional and Cross-Cutting Assessment in the DSM-5, Journal of Counseling & Development, October 2012, Volume 90

• Robins E, Guze SB: Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 1970; 126:983–987

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Dsm5 Cross-cutting Symptom Measures