Skip to main content

01 - Assessment Measures

Assessment Measures

841

Assessment Measures A growing body of scientific evidence favors dimensional concepts in the diagnosis of mental disorders. Limitations of a categorical approach to diagnosis include the failure to find zones of rarity between diagnoses (i.e., delineation of mental disorders from one another by natural boundaries), need for intermediate categories like schizoaffective disorder, high rates of comorbidity, need for frequent use of other or unspecified diagnoses, relative lack of utility in furthering identification of unique antecedent validators for most mental disorders, and lack of treatment specificity for the various diagnostic categories. From both clinical and research perspectives, there is a need for a more dimensional approach that can be combined with DSM’s set of categorical diagnoses to better capture the heterogeneity in the presentation of various mental and substance use disorders. Such an approach allows clinicians or others to better communicate particular variation of features that apply to presentations that meet criteria for a disorder. Such features include differential severity of individual symptoms (including symptoms that are part of the diagnostic features as well as those that are associated with the disorder) as measured by intensity, duration, and impact on functioning. This combined approach also allows clinicians or others to identify conditions that do not meet criteria for a disorder but are severe and disabling and in need of treatment. It is expected that as the understanding of basic disease mechanisms for mental and substance use disorders based on pathophysiology, neurocircuitry, and gene-environment interactions increases, more objective measures of psychopathology will be incorporated into the diagnostic criteria sets to enhance their accuracy. Until such time, a dimensional approach depending primarily on an individual’s subjective reports of symptom experiences along with the clinician’s interpretation is highlighted by current psychiatric evaluation guidelines as an important step in enhancing diagnostic practice. Cross-cutting symptom measures, modeled on general medicine’s review of systems, can serve as an approach for reviewing critical psychopathological domains across age groups and diagnoses. The general medical review of systems—a list of questions arranged by organ systems—is crucial to detecting signs and symptoms of dysfunction and disease with which the individual may or may not present that can facilitate diagnosis and treatment. A similar review of various mental systems (or domains), which is the goal of the cross-cutting symptom measures, can aid in a more comprehensive mental status assessment of individuals at the initial evaluation. The review of mental systems can systematically draw attention to signs and symptoms of other domains of mental health and functioning that may be important to the individual’s care. The cross-cutting measures have two levels of inquiry: Level 1 uses 1 to 3 questions for each of 13 symptom domains for adults (self-rated) and 12 domains for children (ages 6–17, parent rated) and adolescents (child rated, ages 11–17) to identify emerging signs and symptoms. Level 2 questions provide a more in-depth assessment of certain domains (e.g., depression, anxiety, mania, anger, irritability, somatic symptoms). These measures are developed to be administered

both at initial interview and at follow-up visits. Thus, use of these measures can form key aspects of measurement-based care, the process by which standardized assessment tools are administered and results used to track individuals’ progress over time to guide a more precise plan of care. Use of these measures ultimately aims to inform measurement-based care by identifying areas of emerging symptoms and concerns as well as supporting ongoing symptom monitoring, treatment adjustment, and outcomes critical to the provision of quality care for individuals with mental and substance use disorders. As a result, these cross-cutting symptom measures have been identified as important components of psychiatric diagnostic assessment in clinical practice guidelines. Severity measures are disorder-specific, corresponding closely to the criteria that constitute the disorder definition. They may be administered to individuals who have received a diagnosis or who have a clinically significant syndrome that falls short of meeting full criteria for a diagnosis (e.g., use of the Clinician-Rated Dimensions of Psychosis Symptom Severity in individuals whose symptoms meet criteria for schizophrenia). Some of the assessments are selfrated, while others are rated by the clinician based on observation of the individual. As with the cross-cutting symptom measures, these measures can be administered both at initial interview and over time to track the severity of the individual’s disorder and response to treatment. These assessments help operationalize symptom frequency, intensity, or duration; overall symptom severity; or symptom type (e.g., depression, anxiety, sleep disturbance) for many, though not all, DSM-5 diagnoses (e.g., generalized anxiety disorder, social anxiety disorder, psychotic disorders, posttraumatic stress disorder, autism spectrum disorder, and social (pragmatic) communication disorder). Data obtained from use of these disorder-specific measures can assist with diagnosis and inform symptom monitoring and treatment planning. The World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0) was developed by the World Health Organization to assess an individual’s ability to perform activities in six areas: understanding and communicating; getting around; self-care; getting along with people; life activities (e.g., household, work/school); and participation in society. This version of the scale is self-administered and was developed for individuals with any medical condition, not just mental disorders. It corresponds to concepts contained in the WHO International Classification of Functioning, Disability and Health. This assessment can also be used over time to track changes in an individual’s level of functioning. Assessment of functioning is a key aspect of psychiatric diagnostic assessment given that most DSM-5 criteria sets include a requirement that the disturbance causes clinically significant distress or impairment in functioning. Individuals with mental disorders are more likely to have severe impairment in functioning (i.e., communicating or understanding; getting along with others; carrying out daily activities at work, home, or school; participating in social activities) compared to individuals with chronic medical conditions. In addition, many individuals seek help for mental disorders because of the direct impact of their disorders on functional impairment across multiple domains and settings. Functional impairment may impact prognosis across diagnoses and, if residual functional impairment remains after symptoms subside, can lead to recurrence or relapse for conditions such as major depressive disorder and anxiety disorders. This chapter focuses on the DSM-5 Level 1 Cross-Cutting Symptom Measure (adult self-

rated and parent/guardian versions); the Clinician-Rated Dimensions of Psychosis Symptom Severity; and the WHODAS 2.0. Clinician instructions, scoring information, and interpretation guidelines are included for each. Description of the child-rated version is not included in print given the overall similarity in items, scoring, and clinician instructions and guidelines with the parent/guardian-rated version. These measures, including the child-rated version, and additional dimensional assessments, such as those for diagnostic severity, can be found online at www.psychiatry.org/dsm5. Cross-Cutting Symptom Measures Level 1 Cross-Cutting Symptom Measure The DSM-5 Level 1 Cross-Cutting Symptom Measure is a self- or informant-rated measure that assesses domains that are important across psychiatric diagnoses. It is intended to help clinicians identify additional areas of inquiry that may have significant impact on the individual’s treatment and prognosis. In addition, the measure may be used to track changes in the individual’s symptom presentation over time. The adult version of the measure consists of 23 questions that assess 13 psychiatric domains, including depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use (Table 1). Each domain consists of one to three questions. Each item inquires about how much (or how often) the individual has been bothered by the specific symptom during the past 2 weeks. If the individual is of impaired capacity and unable to complete the form (e.g., an individual with major neurocognitive disorder), a knowledgeable adult informant may complete this measure. TABLE 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure: 13 domains, thresholds for further inquiry, and associated DSM-5 Level 2 measures Domain Domain name Threshold to guide further inquiry DSM-5 Level 2 Cross-Cutting Symptom Measurea I. Depression Mild or greater Level 2—Depression—Adult (PROMIS Emotional Distress—Short Form) II. Anger Mild or greater Level 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form) III. Mania Mild or greater Level 2—Mania—Adult (Altman Self-Rating Mania Scale [ASRM]) IV. Anxiety Mild or greater Level 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form) V. Somatic symptoms Mild or greater Level 2—Somatic Symptom—Adult (Patient Health Questionnaire–15 [PHQ-15] Somatic Symptom Severity Scale)

VI. Suicidal ideation Slight or greater None VII. Psychosis Slight or greater None VIII. Sleep problems Mild or greater Level 2—Sleep Disturbance—Adult (PROMIS Sleep Disturbance—Short Form) IX. Memory Mild or greater None X. Repetitive thoughts and behaviors Mild or greater Level 2—Repetitive Thoughts and Behaviors— Adult (Florida Obsessive-Compulsive Inventory [FOCI] Severity Scale) XI. Dissociation Mild or greater None XII. Personality functioning Mild or greater None XIII. Substance use Slight or greater Level 2—Substance Use—Adult (adapted from the NIDA-Modified ASSIST) Note. NIDA = National Institute on Drug Abuse. aAvailable at www.psychiatry.org/dsm5. The measure was found to be clinically useful and to have good reliability in the DSM-5 Field Trials that were conducted in adult clinical samples across the United States and in Canada. In the DSM-5 Field Trials, in which the individual’s symptom ratings were shared with the clinician before meeting, individuals reported that the results from the measure helped facilitate communication during the clinical encounter. Similarly, clinicians in both major academicmedical research institutions as well as routine clinical practice settings found the measures clinically useful and feasible for integration into everyday clinical care as well as specialty clinical settings. In addition to results from the DSM-5 Field Trials, several studies have evaluated the psychometric properties of the adult self-rated version of the cross-cutting symptom measure in a variety of populations. For example, findings from a large study of nontreatment-seeking college students across the United States demonstrated acceptable internal consistency and internal validity. The parent/guardian-rated version of the measure (for children ages 6–17) consists of 25 questions that assess 12 psychiatric domains, including depression, anger, irritability, mania, anxiety, somatic symptoms, inattention, suicidal ideation/attempt, psychosis, sleep disturbance, repetitive thoughts and behaviors, and substance use (Table 2). Each item asks the parent or guardian to rate how much (or how often) his or her child has been bothered by the specific psychiatric symptom during the past 2 weeks. The measure was also found to be clinically useful and to have good reliability in the DSM-5 Field Trials that were conducted in pediatric clinical samples across the United States. For children ages 11–17, along with the parent/guardian rating of the child’s symptoms, the clinician may consider having the child complete the child-rated version of the measure. The child-rated version of the measure can be found online at www.psychiatry.org/dsm5. TABLE 2 Parent/guardian-rated DSM-5 Level 1 Cross-Cutting Symptom Measure for child age 6–17: 12 domains, thresholds for further inquiry, and associated Level 2 measures Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom

Scoring and interpretation. Domain Domain name further inquiry Measurea I. Somatic symptoms Mild or greater Level 2—Somatic Symptoms—Parent/Guardian of Child Age 6–17 (Patient Health Questionnaire–15 [PHQ-15] Somatic Symptom Severity Scale) II. Sleep problems Mild or greater Level 2—Sleep Disturbance—Parent/Guardian of Child Age 6–17 (PROMIS Sleep Disturbance— Short Form) III. Inattention Slight or greater Level 2—Inattention—Parent/Guardian of Child Age 6–17 (Swanson, Nolan, and Pelham, Version IV [SNAP-IV]) IV. Depression Mild or greater Level 2—Depression—Parent/Guardian of Child Age 6–17 (PROMIS Emotional Distress— Depression—Parent Item Bank) V. Anger Mild or greater Level 2—Anger—Parent/Guardian of Child (PROMIS Calibrated Anger Measure—Parent) VI. Irritability Mild or greater Level 2—Irritability—Parent/Guardian of Child (Affective Reactivity Index [ARI]) VII. Mania Mild or greater Level 2—Mania—Parent/Guardian of Child Age 6–17 (Altman Self-Rating Mania Scale [ASRM]) VIII. Anxiety Mild or greater Level 2—Anxiety—Parent/Guardian of Child Age 6–17 (PROMIS Emotional Distress—Anxiety —Parent Item Bank) IX. Psychosis Slight or greater None X. Repetitive thoughts and behaviors Mild or greater None XI. Substance use Yes Level 2—Substance Use—Parent/Guardian of Child Age 6–17 (adapted from the NIDAmodified ASSIST) Don’t Know NIDA-modified ASSIST (adapted)—Child-Rated (age 11–17 years) XII. Suicidal ideation/suicide attempts Yes None Don’t Know None Note. NIDA = National Institute on Drug Abuse. aAvailable at www.psychiatry.org/dsm5. On the adult self-rated version of the measure, each item is rated on a 5-point scale (0 = none or not at all; 1 = slight or rare, less than a day or two; 2 = mild or several days; 3 = moderate or more than half the days; and 4 = severe or nearly every day). The score on each item within a multi-item domain should be reviewed by the clinician, especially if a Level 2 cross-cutting symptom assessment is not indicated, to understand which specific symptom within a domain is most problematic (e.g., auditory hallucinations or thought broadcasting for the psychosis domain) to help guide further inquiry. However, a rating of mild (i.e., 2) or greater on any item within a domain, except for substance use, suicidal ideation, and psychosis, strongly suggests the need for additional inquiry and follow-up to determine if a more detailed assessment is necessary, which

may include the Level 2 cross-cutting symptom assessment for the domain (see 1). For substance use, suicidal ideation, and psychosis, a rating of slight (i.e., 1) or greater on any item within the domain may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is needed. As such, the rater should indicate the highest score within a domain in the “Highest domain score” column. Table 1 outlines threshold scores that may guide further inquiry for the remaining domains. On the parent/guardian-rated version of the measure (for children ages 6–17), 19 of the 25 items are each rated on a 5-point scale (0 = none or not at all; 1 = slight or rare, less than a day or two; 2 = mild or several days; 3 = moderate or more than half the days; and 4 = severe or nearly every day). The suicidal ideation, suicide attempt, and substance abuse items are each rated on a “Yes, No, or Don’t Know” scale. The score on each item within a domain should be reviewed by the clinician to understand which specific symptom within a domain is most problematic (e.g., visual or auditory hallucination on the psychosis domain) to help guide further inquiry. However, with the exception of inattention and psychosis, a rating of mild (i.e., 2) or greater on any item within a domain that is scored on the 5-point scale may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is necessary, which may include the Level 2 cross-cutting symptom assessment for the domain (see Table 2). For inattention or psychosis, a rating of slight or greater (i.e., 1 or greater) may be used as an indicator for additional inquiry. A parent or guardian’s rating of “Don’t Know” on the suicidal ideation, suicide attempt, and any of the substance use items, especially for children ages 11–17 years, may result in additional probing of the issues with the child, including using the child-rated Level 2 Cross-Cutting Symptom Measure for the relevant domain. Because additional inquiry is made on the basis of the highest score on any item within a domain, clinicians should indicate that score in the “Highest Domain Score” column. Table 2 outlines threshold scores that may guide further inquiry for the remaining domains. The clinician instructions and guidelines for the child-rated version are similar to those of the parent/guardian-rated version described above with the exception of the “Don’t Know” response categories, which are not present in the child-rated version (see www.psychiatry.org/dsm5). Level 2 Cross-Cutting Symptom Measures Any threshold scores on the Level 1 Cross-Cutting Symptom Measure (as noted in Tables 1 and 2 and described in “Scoring and Interpretation”) indicate a possible need for detailed clinical inquiry. Level 2 Cross-Cutting Symptom Measures provide one method of obtaining more indepth information on potentially significant symptoms to inform diagnosis, treatment planning, and follow-up. They are available online at www.psychiatry.org/dsm5. Tables 1 and 2 outline each Level 1 domain and identify the domains for which DSM-5 Level 2 Cross-Cutting Symptom Measures are available for more detailed assessments. Adult and pediatric (parent and child) versions are available online for most Level 1 symptom domains. Frequency of Use of the Cross-Cutting Symptom Measures To track change in the individual’s symptom presentation over time, the Level 1 and relevant Level 2 cross-cutting symptom measures may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. For individuals with impaired capacity and for children ages 6–17 years, it is preferable for the

measures to be completed at follow-up appointments by the same knowledgeable informant and by the same parent or guardian. Consistently high scores on a particular domain may indicate significant and problematic symptoms for the individual that might warrant further assessment, treatment, and follow-up. Clinical judgment should guide decision making. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult Name:______________________________________ Age: __________ 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? _________________________ hours/week Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) I.

  1. Little interest or pleasure in doing things? 1 3

  2. Feeling down, depressed, or hopeless? 1 3 II.

  3. Feeling more irritated, grouchy, angry than usual? 1 3 III.

  4. Sleeping less than usual, but still have a lot of energy? 1 3

  5. Starting lots more projects than usual or doing more risky things than usual? 1 3 IV.

  6. Feeling nervous, anxious, frightened, worried, or on edge? 1 3

  7. Feeling panic or being frightened? 1 3

  8. Avoiding situations that make you anxious? 1 3 V.

  9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 1 3

  10. Feeling that your illnesses are not being taken seriously enough? 1 3 VI.

  11. Thoughts of actually hurting yourself? 1 3 848 VII.

  12. Hearing things other people couldn’t hear, such as voices even when no one was around? 1 3

  13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? 1 3 VIII.

  14. Problems with sleep that affected your sleep quality overall? 1 3 IX.

  15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? 1 3 X.

  16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? 1 3

  17. Feeling driven to perform certain behaviors or mental acts over and over again? 1 3 XI.

  18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? 1 3 XII.

  19. Not knowing who you really are or what you want out of life? 1 3

  20. Not feeling close to other people or enjoying your relationships with them? 1 3 XIII.

  21. Drink at least 4 drinks of any kind of alcohol in a single day? 1 3

  22. Smoke any cigarettes, a cigar, or pipe, or use snuff or chewing tobacco? 1 3

  23. Use any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., 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)]? 1 3 849 Parent/Guardian-Rated DSM-5 Level 1 Cross-Cutting Symptom Measure—Child Age 6–17

Child’s Name:________________ Age: __________ Date:_____________ Relationship to the child: ___________________________________ Instructions (to parent or guardian of child): The questions below ask about things that might have bothered your child. For each question, circle the number that best describes how much (or how often) your child has been bothered by each problem during the past TWO (2) WEEKS. During the past TWO (2) WEEKS, how much (or how often) has your child… None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) I.

  1. Complained of stomachaches, headaches, or other aches and pains? 1 3
  2. Said he/she was worried about his/her health or about getting sick? 1 3 II.
  3. Had problems sleeping—that is, trouble falling asleep, staying asleep, or waking up too early? 1 3 III.
  4. Had problems paying attention when he/she was in class or doing his/her homework or reading a book or playing a game? 1 3 IV.
  5. Had less fun doing things than he/she used to? 1 3
  6. Seemed sad or depressed for several hours? 1 3 V. andVI.
  7. Seemed more irritated or easily annoyed than usual? 1 3
  8. Seemed angry or lost his/her temper? 1 3 VII.
  9. Starting lots more projects than usual or doing more risky things than usual? 1 3
  10. Sleeping less than usual for him/her but still has lots of energy? 1 3 VIII.
  11. Said he/she felt nervous, anxious, or scared? 1 3
  12. Not been able to stop worrying? 1 3
  13. Said he/she couldn’t do things he/she wanted to or should have done because they made him/her feel nervous? 1 3 850 IX.
  14. Said that he/she heard voices— when there was no one there— speaking about him/her or telling him/her what to do or saying bad things to him/her? 1 3
  15. Said that he/she had a vision when he/she was completely awake 1 3

—that is, saw something or someone that no one else could see? X. 16. Said that he/she had thoughts that kept coming into his/her mind that he/she would do something bad or that something bad would happen to him/her or to someone else? 1 3 17. Said he/she felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off? 1 3 18. Seemed to worry a lot about things he/she touched being dirty or having germs or being poisoned? 1 3 19. Said that he/she had to do things in a certain way, like counting or saying special things out loud, in order to keep something bad from happening? 1 3 In the past TWO (2) WEEKS, has your child … XI. 20. Had an alcoholic beverage (beer, wine, liquor, etc.)? ❑ Yes ❑ No ❑ Don’t Know 21. Smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco? ❑ Yes ❑ No ❑ Don’t Know 22. Used drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)? ❑ Yes ❑ No ❑ Don’t Know 23. Used any medicine without a doctor’s prescription (e.g., painkillers [like Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers [like sleeping pills or Valium], or steroids)? ❑ Yes ❑ No ❑ Don’t Know XII. 24. In the past TWO (2) WEEKS, has he/she talked about wanting to kill himself/herself or about wanting to commit suicide? ❑ Yes ❑ No ❑ Don’t Know 25. Has he/she EVER tried to kill himself/herself? ❑ Yes ❑ No ❑ Don’t Know Clinician-Rated Dimensions of Psychosis Symptom Severity As described in the chapter “Schizophrenia Spectrum and Other Psychotic Disorders,” psychotic disorders are heterogeneous, and symptom severity can predict important aspects of the illness,

such as the degree of cognitive and/or neurobiological deficits. Dimensional assessments capture meaningful variation in the severity of symptoms, which may help with treatment planning, prognostic decision-making, and research on pathophysiological mechanisms. The ClinicianRated Dimensions of Psychosis Symptom Severity measure provides scales for the dimensional assessment of the primary symptoms of psychosis, including hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, and negative symptoms. A scale for the dimensional assessment of cognitive impairment is also included. Many individuals with psychotic disorders have impairments in a range of cognitive domains, which predict functional abilities and prognosis. In addition, scales for dimensional assessment of depression and mania are provided, which may alert clinicians to co-occurring mood pathology. The severity of mood symptoms in psychosis has prognostic value and can guide treatment. The Clinician-Rated Dimensions of Psychosis Symptom Severity is an 8-item measure that may be completed by the clinician at the time of the clinical assessment. Each item asks the clinician to rate the severity of each symptom as experienced by the individual when it was at its most severe during the past 7 days. Scoring and Interpretation Each item on the measure is rated on a 5-point scale (0 = none; 1 = equivocal; 2 = present, but mild; 3 = present and moderate; and 4 = present and severe) with a symptom-specific definition of each rating level. The clinician reviews all of the individual’s available information and, based on clinical judgment, selects (with checkmark) the level that most accurately describes the severity of the symptom domain. The clinician then indicates the score for each item in the “Score” column provided. Frequency of Use To track changes in the individual’s symptom severity over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant further assessment, treatment, and follow-up. Clinical judgment should always guide decision making. Clinician-Rated Dimensions of Psychosis Symptom Severity Name:______________________________________ Age: __________ Date:________________ Instructions: Based on all the information you have on the individual and using your clinical judgment, please rate (with checkmark) the presence and severity of the following symptoms as experienced by the individual, when each symptom was at its most severe, in the past seven (7) days. Domain 1 3 Score I. Hallucinations ❑ Not present ❑ Equivocal (severity or duration not sufficient to be considered psychosis) ❑ Present, but mild (little pressure to act upon voices or other types of hallucinations, not very ❑ Present and moderate (some pressure to respond to voices or other types of hallucinations, ❑ Present and severe (severe pressure to respond to voices or other types of hallucinations, or is very bothered

II. Delusions ❑ Not ❑ Equivocal (severity or present duration not sufficient to be considered psychosis) ❑ Not ❑ Equivocal (severity or III. Disorganized speech present duration not sufficient to be considered disorganization) ❑ Not ❑ Equivocal (severity or IV. Abnormal psychomotor behavior present duration not sufficient to be considered abnormal psychomotor behavior) ❑ Not ❑ Equivocal decrease in present facial expressivity, prosody, gestures, or selfinitiated behavior V. Negative symptoms (restricted emotional expression or avolition) ❑ Not ❑ Equivocal (cognitive VI. Impaired cognition present function not clearly outside the range expected for age or SES; i.e., within 0.5 SD of mean) VII. Depression ❑ Not ❑ Equivocal (occasionally present feels sad, down, depressed, or hopeless; concerned about having failed someone or at something but not preoccupied) VIII. Mania ❑ Not ❑ Equivocal (occasional present elevated, expansive, or irritable mood or some restlessness) bothered by hallucinations) or is somewhat bothered by hallucinations) by hallucinations) ❑ Present, but ❑ Present and ❑ Present and mild (little pressure to act upon delusional beliefs, not very bothered by such beliefs) moderate (some pressure to act upon delusional beliefs, or is somewhat bothered by such beliefs) severe (severe pressure to act upon delusional beliefs, or is very bothered by such beliefs) ❑ Present, but ❑ Present and ❑ Present and mild (some difficulty following speech) moderate (speech often difficult to follow) severe (speech almost impossible to follow) ❑ Present, but ❑ Present and ❑ Present and mild (occasional abnormal or bizarre motor behavior or catatonia) moderate (frequent abnormal or bizarre motor behavior or catatonia) severe (abnormal or bizarre motor behavior or catatonia almost constant) ❑ Present, but ❑ Present and ❑ Present and mild decrease in facial expressivity, prosody, gestures, or selfinitiated behavior moderate decrease in facial expressivity, prosody, gestures, or selfinitiated behavior severe decrease in facial expressivity, prosody, gestures, or self-initiated behavior ❑ Present, but ❑ Present and ❑ Present and mild (some reduction in cognitive function; below expected for age and SES, 0.5–1 SD from mean) moderate (clear reduction in cognitive function; below expected for age and SES, 1–2 SD from mean) severe (severe reduction in cognitive function; below expected for age and SES, > 2 SD from mean) ❑ Present, but ❑ Present and ❑ Present and mild (frequent periods of feeling very sad, down, moderately depressed, or hopeless; concerned about having failed someone or at something, with some preoccupation) moderate (frequent periods of deep depression or hopelessness; preoccupation with guilt, having done wrong) severe (deeply depressed or hopeless daily; delusional guilt or unreasonable selfreproach grossly out of proportion to circumstances) ❑ Present, but ❑ Present and ❑ Present and mild (frequent periods of somewhat elevated, expansive, or irritable mood or restlessness) moderate (frequent periods of extensively elevated, expansive, or irritable mood severe (daily and extensively elevated, expansive, or irritable mood or restlessness)

WHODAS 2.0 summary scores. WHODAS 2.0 domain scores. or restlessness) Note. SD = standard deviation; SES = socioeconomic status. World Health Organization Disability Assessment Schedule 2.0 The adult self-administered version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a 36-item measure that assesses disability in adults age 18 years and older. It has been validated across numerous cultures worldwide and demonstrated sensitivity to change. It assesses disability across six domains, including understanding and communicating, getting around, self-care, getting along with people, life activities (i.e., household, work, and/or school activities), and participation in society. If the adult individual is of impaired capacity and unable to complete the form (e.g., a patient with major neurocognitive disorder), a knowledgeable informant may complete the proxy-administered version of the measure, which is available at www.psychiatry.org/dsm5. Each item on the self-administered version of the WHODAS 2.0 asks the individual to rate how much difficulty he or she has had in specific areas of functioning during the past 30 days. WHODAS 2.0 Scoring Instructions Provided by WHO There are two basic options for computing the summary scores for the WHODAS 2.0 36-item full version. Simple: The scores assigned to each of the items—“none” (1), “mild” (2), “moderate” (3), “severe” (4), and “extreme” (5)—are summed for a maximum total raw score of 180. This method is referred to as simple scoring because the scores from each of the items are simply added up without recoding or collapsing of response categories; thus, there is no weighting of individual items. This approach is practical to use as a hand-scoring approach, and may be the method of choice in busy clinical settings or in paper-and-pencil interview situations. As a result, the simple sum of the scores of the items across all domains constitutes a statistic that is sufficient to describe the degree of functional limitations. Complex: The more complex method of scoring is called “item-response-theory” (IRT)– based scoring. It takes into account multiple levels of difficulty for each WHODAS 2.0 item. It takes the coding for each item response as “none,” “mild,” “moderate,” “severe,” and “extreme” separately, and then requires a computer to determine the summary score by differentially weighting the items and the levels of severity. The computer program is available from the WHO Web site. The scoring has three steps: Step 1—Summing of recoded item scores within each domain (i.e., for each item, the response options 1–5 are converted to a rate of 0–4, leading to a total raw score of 144). Step 2—Summing of all six domain scores. Step 3—Converting the summary score into a metric ranging from 0 to 100 (where 0 = no disability; 100 = full disability). WHODAS 2.0 produces domain-specific scores for six different functioning domains: cognition, mobility, self-care, getting along, life activities (household and

WHODAS 2.0 population norms. work/school), and participation. For the population norms for IRT-based scoring of the WHODAS 2.0 and for the population distribution of IRT-based scores for WHODAS 2.0, please see www.who.int/classifications/icf/Pop_norms_distrib_IRT_scores.pdf. Additional Scoring and Interpretation Guidance for DSM-5-TR Users The clinician is asked to review the individual’s response on each item on the measure during the clinical interview and to indicate the self-reported score for each item in the section provided for “Clinician Use Only.” However, if the clinician determines that the score on an item should be different based on the clinical interview and other information available, he or she may indicate a corrected score in the raw item score box. Based on findings from the DSM-5 Field Trials in adult patient samples across six sites in the United States and one in Canada, DSM-5-TR recommends calculation and use of average scores for each domain and for general disability. The average scores are comparable to the WHODAS 5-point scale, which allows the clinician to think of the individual’s disability in terms of none (1), mild (2), moderate (3), severe (4), or extreme (5). The average domain and general disability scores were found to be reliable, easy to use, and clinically useful to the clinicians in the DSM-5 Field Trials. The average domain score is calculated by dividing the raw domain score by the number of items in the domain (e.g., if all the items within the “understanding and communicating” domain are rated as being moderate, then the average domain score would be 18/6 = 3, indicating moderate disability). The average general disability score is calculated by dividing the raw overall score by number of items in the measure (i.e., 36). The individual should be encouraged to complete all of the items on the WHODAS 2.0. If no response is given on 10 or more items of the measure (i.e., more than 25% of the 36 total items), calculation of the simple and average general disability scores may not be helpful. If 10 or more of the total items on the measure are missing but the items for some of the domains are 75%–100% complete, the simple or average domain scores may be used for those domains. Frequency of Use To track change in the individual’s level of disability over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant further assessment and intervention.

857

858

No comments to display

Back to top