A presentation on the newly introduced cross-cutting symptom measures in DSM5. I'd made this as part of my psychiatry residency, and the article describes why the need came about, the process of formulating and testing the new cross-cutting system and the repercussions this will have on psychiatric practice

1. DSM5
Cross-Cutting
Symptom Measures
Dr (Maj) Ashutosh Ratnam

2. 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

3. 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

4. The Diagnostic Landscape before DSM5
• …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

5. The Diagnostic Landscape before DSM5
• 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

6. 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
characteristics
Millon, 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.

7. 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

8. 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

9. 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.

10. 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.

11. 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.
• 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

12. 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.
• 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

13. 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”

14. 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.

15. Conceptual Construct of Cross-Cutting Symptom
Measures
• “Conceptually, development of
DSM-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”

16. Conceptual Construct of Cross-Cutting Symptom
Measures
• 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

17. “DSM-5 is proposing
to include a “mental
review of systems”
in the form of a
questionnaire that
includes symptoms
that are known to
cut across many if
not most
diagnostic
categories and may
be a source of
patient impairment,
distress, or other
treatment
need"

18. Conceptual Construct of Cross-Cutting
Symptom Measures
• “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

19. 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

20. 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

21. 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

29. • 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

30. 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.

31. • 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.

32. • 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

37. 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

38. 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”

39. 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

40. 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

41. 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

42. 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

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