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

842

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 self-rated, 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
[Link]/dsm5.

843

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.

844

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
 Threshold to guide DSM-5 Level 2 Cross-Cutting
Domain Domain name further inquiry Symptom Measure
a

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 Mild or greater Level 2—Repetitive Thoughts and
behaviors 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.
a
Available at [Link]/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 academic-medical 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 non-
treatment-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
[Link]/dsm5.

845

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
Domain Domain name further inquiry Symptom 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 Mild or greater None
behaviors
XI. Substance use Yes Level 2—Substance Use—Parent/Guardian
of Child Age 6–17 (adapted from the
NIDA-modified ASSIST)
Don’t Know NIDA-modified ASSIST (adapted)—Child-
Rated (age 11–17 years)
 Threshold to guide DSM-5 Level 2 Cross-Cutting
Domain Domain name further inquiry Symptom Measurea

XII. Suicidal ideation/suicide Yes None

attempts
Don’t Know None
Note. NIDA = National Institute on Drug Abuse.
a
Available at [Link]/dsm5.

Scoring and [Link] 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

846

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 [Link]/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 in-depth information on potentially significant symptoms to
inform diagnosis, treatment planning, and follow-up. They are available online at
[Link]/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.

847

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) None Slight Mild Moderate Severe Highest
WEEKS, how much (or how Not Rare, Several More Nearly Domain
often) have you been at all less days than half every Score
bothered by the following than a the days day (clinician)
problems? day or
two
I. 1. Little interest or pleasure in 0 1 2 3 4
doing things?
2. Feeling down, depressed, or 0 1 2 3 4
hopeless?
II. 3. Feeling more irritated, grouchy, 0 1 2 3 4
angry than usual?
III. 4. Sleeping less than usual, but 0 1 2 3 4
still have a lot of energy?
5. Starting lots more projects than 0 1 2 3 4
usual or doing more risky
things than usual?
IV. 6. Feeling nervous, anxious, 0 1 2 3 4
frightened, worried, or on
edge?
7. Feeling panic or being 0 1 2 3 4
frightened?
8. Avoiding situations that make 0 1 2 3 4
you anxious?
V. 9. Unexplained aches and pains 0 1 2 3 4
(e.g., head, back, joints,
abdomen, legs)?
10. Feeling that your illnesses are 0 1 2 3 4
not being taken seriously
enough?
VI. 11. Thoughts of actually hurting 0 1 2 3 4
yourself?

848 12. Hearing things other people 0 1 2 3 4

couldn’t hear, such as voices
VII. even when no one was
around?
13. Feeling that someone could 0 1 2 3 4
hear your thoughts, or that
you could hear what another
person was thinking?
VIII. 14. Problems with sleep that 0 1 2 3 4
affected your sleep quality
overall?
IX. 15. Problems with memory (e.g., 0 1 2 3 4
learning new information) or
with location (e.g., finding
your way home)?
X. 16. Unpleasant thoughts, urges, or 0 1 2 3 4
images that repeatedly enter
your mind?
17. Feeling driven to perform 0 1 2 3 4
certain behaviors or mental
acts over and over again?
XI. 18. Feeling detached or distant 0 1 2 3 4
from yourself, your body,
 your physical surroundings,
or your memories?
Not knowing who you really
XII. 19. are or what you want out of 0 1 2 3 4
life?

20. Not feeling close to other 0 1 2 3 4

people or enjoying your
relationships with them?
XIII. 21. Drink at least 4 drinks of any 0 1 2 3 4
kind of alcohol in a single
day?
22. Smoke any cigarettes, a cigar, 0 1 2 3 4
or pipe, or use snuff or
chewing tobacco?
23. Use any of the following 0 1 2 3 4
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)]?

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) None Slight Mild Moderate Severe Highest
WEEKS, how much (or how Not at Rare, Several More Nearly Domain
often) has your child… all less days than half every Score
than a the days day (clinician)
day or
two
I. 1. Complained of 0 1 2 3 4
stomachaches,
headaches, or other
aches and pains?
2. Said he/she was worried 0 1 2 3 4
about his/her health or
about getting sick?
II. 3. Had problems sleeping— 0 1 2 3 4
 that is, trouble falling
asleep, staying asleep,
or waking up too early?
III. 4. Had problems paying 0 1 2 3 4
attention when he/she
was in class or doing
his/her homework or
reading a book or
playing a game?
IV. 5. Had less fun doing things 0 1 2 3 4
than he/she used to?
6. Seemed sad or depressed 0 1 2 3 4
for several hours?
V. 7. Seemed more irritated or 0 1 2 3 4
andVI. easily annoyed than
usual?
8. Seemed angry or lost 0 1 2 3 4
his/her temper?
VII. 9. Starting lots more projects 0 1 2 3 4
than usual or doing
more risky things than
usual?
10. Sleeping less than usual 0 1 2 3 4
for him/her but still has
lots of energy?
VIII. 11. Said he/she felt nervous, 0 1 2 3 4
anxious, or scared?
12. Not been able to stop 0 1 2 3 4
worrying?
13. Said he/she couldn’t do 0 1 2 3 4
things he/she wanted to
or should have done
because they made
him/her feel nervous?

850 14. Said that he/she heard 0 1 2 3 4

voices—when there
IX. was no one there—
speaking about him/her
or telling him/her what
to do or saying bad
things to him/her?
15. Said that he/she had a 0 1 2 3 4
vision when he/she was
completely awake—that
is, saw something or
someone that no one
else could see?
X. 16. Said that he/she had 0 1 2 3 4
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?
17. Said he/she felt the need 0 1 2 3 4
to check on certain
hi d
 things over and over
again, like whether a
door was locked or
whether the stove was
turned off?
18. Seemed to worry a lot 0 1 2 3 4
about things he/she
touched being dirty or
having germs or being
poisoned?
19. Said that he/she had to do 0 1 2 3 4
things in a certain way,
like counting or saying
special things out loud,
in order to keep
something bad from
happening?
In the past TWO (2) WEEKS, has your child …
XI. 20. Had an alcoholic beverage ❑ Yes ❑ No ❑ Don’t Know
(beer, wine, liquor,
etc.)?
21. Smoked a cigarette, a ❑ Yes ❑ No ❑ Don’t Know
cigar, or pipe, or used
snuff or chewing
tobacco?
22. Used drugs like ❑ Yes ❑ No ❑ Don’t Know
marijuana, cocaine or
crack, club drugs (like
ecstasy), hallucinogens
(like LSD), heroin,
inhalants or solvents
(like glue), or
methamphetamine (like
speed)?
23. Used any medicine ❑ Yes ❑ No ❑ Don’t Know
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)?
XII. 24. In the past TWO (2) ❑ Yes ❑ No ❑ Don’t Know
WEEKS, has he/she
talked about wanting to
kill himself/herself or
about wanting to
commit suicide?
25. Has he/she EVER tried to ❑ Yes ❑ No ❑ Don’t Know
kill himself/herself?

851

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 Clinician-Rated 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.

852

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 0 1 2 3 4 Score
I. Hallucinations ❑ Not ❑ Equivocal (severity or ❑ Present, but ❑ Present and ❑ Present and
present duration not sufficient to be mild (little moderate severe (severe
considered psychosis) pressure to act (some pressure to
upon voices or pressure to respond to voices
other types of respond to or other types of
hallucinations, voices or other hallucinations, or
not very types of is very bothered
bothered by hallucinations, by
hallucinations) or is hallucinations)
somewhat
bothered by
hallucinations)
II. Delusions ❑ Not ❑ Equivocal (severity or ❑ Present, but ❑ Present and ❑ Present and
present duration not sufficient to be mild (little moderate severe (severe
considered psychosis) pressure to act (some pressure to act
upon pressure to act upon delusional
delusional upon beliefs, or is very
beliefs, not delusional bothered by such
very bothered beliefs, or is beliefs)
by such somewhat
beliefs) bothered by
such beliefs)
III. Disorganized ❑ Not ❑ Equivocal (severity or ❑ Present, but ❑ Present and ❑ Present and
speech present duration not sufficient to be mild (some moderate severe (speech
considered disorganization) difficulty (speech often almost
following difficult to impossible to
speech) follow) follow)
IV. Abnormal ❑ Not ❑ Equivocal (severity or ❑ Present, but ❑ Present and ❑ Present and
psychomotor present duration not sufficient to be mild moderate severe (abnormal
behavior considered abnormal (occasional (frequent or bizarre motor
psychomotor behavior) abnormal or abnormal or behavior or
bizarre motor bizarre motor catatonia almost
behavior or behavior or constant)
catatonia) catatonia)

853 ❑ Not ❑ Equivocal decrease in ❑ Present, but ❑ Present and ❑ Present and
present facial expressivity, prosody, mild decrease moderate severe decrease
V. Negative gestures, or self-initiated in facial decrease in in facial
symptoms behavior expressivity, facial expressivity,
(restricted prosody, expressivity, prosody,
emotional gestures, or prosody, gestures, or self-
expression or self-initiated gestures, or initiated behavior
avolition) behavior self-initiated
behavior
VI. Impaired ❑ Not ❑ Equivocal (cognitive ❑ Present, but ❑ Present and ❑ Present and
cognition present function not clearly outside mild (some moderate severe (severe
the range expected for age reduction in (clear reduction in
or SES; i.e., within 0.5 SD cognitive reduction in cognitive
of mean) function; cognitive function; below
below function; expected for age
expected for below and SES, > 2 SD
age and SES, expected for from mean)
0.5–1 SD from age and SES,
mean) 1–2 SD from
mean)
VII. Depression ❑ Not ❑ Equivocal (occasionally ❑ Present, but ❑ Present and ❑ Present and
present feels sad, down, depressed, mild (frequent moderate severe (deeply
or hopeless; concerned periods of (frequent depressed or
about having failed feeling very periods of hopeless daily;
someone or at something sad, down, deep delusional guilt
but not preoccupied) moderately depression or or unreasonable
depressed, or hopelessness; self-reproach
hopeless; preoccupation grossly out of
 hopeless; preoccupation grossly out of
concerned with guilt, proportion to
about having having done circumstances)
failed wrong)
someone or at
something,
with some
preoccupation)
VIII. Mania ❑ Not ❑ Equivocal (occasional ❑ Present, but ❑ Present and ❑ Present and
present elevated, expansive, or mild (frequent moderate severe (daily and
irritable mood or some periods of (frequent extensively
restlessness) somewhat periods of elevated,
elevated, extensively expansive, or
expansive, or elevated, irritable mood or
irritable mood expansive, or restlessness)
or irritable mood
restlessness) or
restlessness)
Note. SD = standard deviation; SES = socioeconomic status.

854

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 [Link]/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

WHODAS 2.0 summary scores. 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 domain scores. WHODAS 2.0 produces domain-specific scores for six
different functioning domains: cognition, mobility, self-care, getting along, life
activities (household and work/school), and participation.
WHODAS 2.0 population norms. 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 [Link]/classifications/icf/Pop_norms_distrib_IRT_scores.pdf.

855

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.

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