(For Frequently Asked Questions about the use of dimensional assessments in DSM-5, please see here.)
Overview of the Use of Dimensions in DSM-5
Dimensional assessments are being proposed for inclusion with existing categorical diagnoses in DSM-5 to provide a basis for measurement-based care. The principal goal is to provide additional information that assists the clinician in assessment, treatment planning, and treatment monitoring.
Some dimensional assessments may be useful before a formal diagnostic evaluation is conducted, such as assessing for depression in primary care, identifying features like suicidal ideation, or rating personality traits; some may be useful for refining the diagnosis; others may be specific measures useful once a diagnosis is established, such as severity ratings of the condition that could be used to establish a baseline measure of severity and then track its change over time. A full range of dimensional assessments is being considered for recommendation to clinicians and other users of DSM-5, and the technology may extend from paper-based self-report questionnaires through computerized adaptive testing. These various assessments and instruments may have value in many settings, including primary care and specialized care clinics. Many of these dimensional assessments will be specific for a given disorder, but an effort to assess factors that may be relevant in any patient’s treatment is also being undertaken.
Proposed dimensional assessments will be tested for feasibility and acceptability during DSM-5 field trials.
Cross-cutting Assessment
Providing clinicians a method to measure cross-cutting areas relevant across disorders was one of the recommendations by the DSM research planning conference on Dimensional Assessment, and the DSM-5 Spectrum Study Group. The aim of this assessment is to provide quantitative measures of important clinical areas that will be relevant beyond any set of syndromal criteria. It is designed to be used at an initial evaluation to establish a baseline, and on follow-up visits to track changes. It does not relate to any specific disorder and does not serve as a screening test for DSM disorders. It relies whenever possible on self-report ratings by a patient or informant.
This cross-cutting assessment addresses factors not necessarily included in the diagnostic criteria of a specific disorder but that may be relevant for prognosis, treatment planning, assessment of outcome, or refinement of diagnosis. The assessment is intended for use with most patients in most clinical settings and should be suitable for use before or during an initial clinical examination. They are called “cross-cutting” in the sense that these measures cut across the boundaries of any single disorder. They represent domains that are commonly seen and monitored in patients, regardless of their initial clinical presentation or subsequent diagnosis. Examples include measurement of depressed mood, anxiety, substance use, or sleep problems for all patients seen in a practice or clinic. The intent is to provide clinicians a brief, simple way to obtain ratings for such important areas over time regardless of the specific disorder.
Initial discussions by the DSM-5 Task Force and the Diagnostic Assessment Instruments Study Group yielded a list of emphasized essential characteristics of this cross-cutting assessment, including that they:
1. are useful in clinical practice;
2. are brief, simple to read, and simple to evaluate;
3. can be completed by the patient or an informant, rather than a clinician, whenever possible;
4. provide coverage suitable for most patients in most clinical settings; and
5. use ratings on a 5-point scale, with 0 indicating absence of the problem.
The framework for this assessment rests on a brief set of items that each link to a more thorough inquiry on that item if warranted:
- The initial items assessing the cross-cutting domains (called “Level 1” assessments) could be administered on a single sheet of paper or single computer screen, with each domain scored for 0 to 4 rating with appropriate anchor points.
- If any of the domains is rated as being “clinically significant” (easy rules for determining this are specified), additional questions would be asked (called “Level 2” assessments) for more precision on that domain. We wish to emphasize, however, that cross-cutting dimensions should not be used to limit the clinician's subsequent diagnostic assessment of the patient, as cross-cutting dimensions do not correspond to all of the diagnoses that are likely to be in DSM-5. Limiting a clinical evaluation to only those domains covered by cross-cutting dimensions may cause clinicians to miss disorders that need to be identified and treated.
The “Level 1” assessments consist of 1 to 3 items for each major domain to be assessed. A second set of “Level 2” assessment consists of the items that would be triggered for rating if a “Level 1” item scored in a clinically significant range. Drafts of proposed “Level 1” assessment scales for adults and for children and adolescents have been prepared in the process of planning field trials. A draft of cross-cutting “Level 1” items for adults can be found here. If any of these “Level 1” items indicates a level of concern, the patient or informant is asked to rate a fuller set of items related to that specific domain. For adults, this further inquiry on “Level 2” will use either clinician-rated measures or measures developed as part of an initiative on patient assessment underway at the National Institutes of Health.
As part of a roadmap for clinical research, the NIH began an effort to produce a Patient-Reported Outcome Measurement Information System™ (PROMIS) that
“aims to revolutionize the way patient-reported outcome tools are selected and employed . . . . PROMIS™ aims to develop ways to measure patient-reported symptoms . . . . across a wide variety of chronic diseases and conditions.” (www.nihpromis.org)
PROMIS™ has developed assessments for a number of clinical domains that have been identified by the DSM-5 Task Force as areas on which quantitative ratings would be useful for this cross-cutting assessment. One advantage for using the scales developed by the PROMIS™ initiative is that they are short. Further, the initiative has developed computerized adaptive testing methods that can be used to establish a patient’s rating by comparison to national norms with as few questions as possible. For the DSM-5 field trials, a simpler approach, using the paper and pencil fixed-item “short forms” for each PROMIS™ domain, will be available although a computer assisted version may also be used. The short forms focus on a single domain, such as depressed mood, and use a set of questions identified using item response theory to place an individual’s response along a unidimensional continuum based on population norms. Relevant short forms that could be included in DSM-5 include the scales for depressed mood, anxiety, anger, sleep problems, and perhaps fatigue and pain impact.
At present, the PROMIS™ system includes child or adolescent scales for depressed mood, anxiety, and anger with additional scales on attention under development. However, these scales are not as well-developed for the geriatric population. In addition, some key areas are missing (e.g., substance use) from the PROMIS™ system; some PROMIS™ measures may not correspond well to the relevant DSM-5 domain (e.g., use of Pain Impact or Fatigue for somatic symptom ratings); and some clinical areas may not be ideally suited to a patient-report system (e.g., Psychosis). However, the opportunity to work with NIH on further development of the system and implementation in clinical practice is one the Task Force is excited to pursue.
Dimensional Assessments for Children and Adolescents
As with adult populations, cross-cutting “Level 1” assessments will be used to broadly assess in children and adolescents areas of clinical importance not necessarily captured within a single disorder’s diagnostic criteria. These assessments can be designated as “Level 1 P” when rated by the child or youth patient’s self-report, “Level 1 I” when rated by an informant, and “Level 1 C” when rated by a clinician. A similar naming structure could be used for “Level 2” questionnaires. The same measures could be used in a mental health professional’s waiting room to increase the efficiency and comprehensiveness of the initial evaluation by mental health clinicians, or in pediatric practices or in clinics attended by mothers to identify untreated children/youth.
Examples of Assessments
To view the preliminary draft adult “Level 1” assessments, click here.
To view adult “Level 2” assessment for depression, click here.
To view adult “Level 2” assessment for anxiety, click here.
To view adult “Level 2” assessment for anger, click here.
To view pediatric “Level 2” assessment for depression, click here.
To view pediatric “Level 2” assessment for anxiety, click here.
To view pedatric “Level 2” assessment for anger, click here.
References
Helzer JE, Kraemer HC, Krueger RF, Wittchen H-U, Sirovatka PJ, Regier DA: Dimensional Approaches in Diagnostic Classification: Refining the Research Agenda for DSM-V. Arlington, VA, American Psychiatric Association, 2008.
PROMIS: Patient-Reported Outcome Measurement Information System™ . www.nihpromis.org