Dsm5 Cross-cutting Symptom Measures

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 Excessive Co-Occurring Disorders Boundary Disputes between Disorders 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 Bipolar II disorder to fill the gap between Bipolar I and cyclothymia Mixed anxiety-depressive disorder to account for subthreshold cases of mood and anxiety disorders 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

22. 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

23. 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.

24. 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 .

25. 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

26. 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

27. 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 ”

28. 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

29. 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

30. 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

31. 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

32. 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