DSM-5 Cross-Cutting Symptom Measure: A Review

RebeccaAnne Edelman

2/25/18

CNS 736

Wake Forest University

The DSM-5 Level 1 Cross-Cutting Symptom Measure is a self-rated or guardian

rated, based on age of client, assessment tool to aid mental health counselors in

potentially identifying areas that should be further investigated during the client

assessment process. (American Psychiatric Association , "Online Assessment

Measures") Theses cross-cutting assessments are geared towards aiding counselors in finding

areas that may be significantly impacted for the clients and aid in building their treatment goals

and prognosis. (Bastiaens & Galus, "The DSM-5 Self-Rated Level 1 Cross-Cutting Symptom

Measure as a Screening Tool", 2017)

According to the American Psychiatric Association, the DSM-5 Cross-Cutting

Symptom Measure “may aid in a comprehensive mental status assessment by drawing

attention to symptoms that are important across diagnoses” (American Psychiatric

Association , "Online Assessment Measures"). In the Level 1 assessment, there are

thirteen areas focused on for adults and 12 for children/adolescents. Depending on the

severity rating in Level 1, there is an in-depth Level 2 assessment. Level 2 is far more

comprehensive than Level 1 and analyzes a frequency in which the client is bothered by

the presenting symptom. (Schmit & Balkin, Evaluating Emerging Measures in the DSM-

5 for Counseling Practice, 2014)

This symptom measure was created by the DSM-5 Task Force and Work Groups

to be apart of the intake process for each client seeking mental health evaluation and

treatment. The cross-cutting measures assess… “depression, anger, mania, anxiety,

somatic symptoms, sleep disturbance, psychosis, obsessive thoughts and behaviors,

cognition/memory problems in adults” (Clarke & Kuhl, DSM-5 cross-cutting symptom

measures: a step towards the future of psychiatric care?, 2014).

While the DSM-5 Cross-Cutting Symptom Measure does assess and measure a

variety of areas, it is not specific to any one disorder. The main means of this

assessment is to be used in the counseling environment for most clients to evaluate

symptoms of concern. (Jones, "Dimensional and Cross-Cutting Assessment in theDSM-

5", 2012) A large part of this transition into the Cross-Cutting Symptom Measure was to

create a new clinical perspective that breaks factors that are not bound by strict

categorical designations. “They are designed to be administered to all clients at the

initial evaluation to establish a baseline and on follow-up visits to monitor progress”

(Randall, "Book Review: Diagnostic and statistical manual of mental disorders", 2013)

In a multisite field trial, the DSM-5 Cross-Cutting symptom measure was completed by a

variety of adults and children. They were then reassessed after 2 weeks. The pooled

intraclass correlation coefficients were assessed at having a 95% confidence interval.

The results indicated that adults and adults responding for children were reliable

reports. However, children in themselves were not found to be reliable respondents.

“Clinicians rated psychosis with good reliability in adult patients but were less reliable in

assessing clinical domains related to psychosis in children and to suicide in all age

groups” (Narrow, et al., "DSM-5 Field Trials in the United States and Canada, Part III:

Development and Reliability Testing of a Cross-Cutting Symptom Assessment for DSM-

Symptom Measure to address symptoms in clients, but not diagnose.

Criticisms

Just like any assessment in counseling the DSM-5 Cross-Cutting Symptom

Measure is not perfect. The DSM-5 Cross-Cutting Symptom Measure has areas of

missing criteria, needs further research such as pilot studies, holds limitations for new

clients with lack of background information, and a few other shortcomings. The Level 2

measures are advocated for by the APA but when compared to the emotional and

behavioral symptoms that are part of the DSM-5 diagnosis, there are some critical areas

that are lacking. This assessment also focuses on symptoms vs diagnosis which if not

understood could cause issues for clients and counselors. (Schmit & Balkin, Evaluating

Emerging Measures in the DSM-5 for Counseling Practice, 2014)

Given that this assessment is also relatively new, there are not many reliability

reports released leaving the evidence from the assessment to be potentially

circumspect. (Schmit & Balkin, Evaluating Emerging Measures in the DSM-5 for

Counseling Practice, 2014)There is much more research that needs to be done regarding this

assessment. During pilot studies, clinicians raised concerns about timeliness and when

implementing this assessment with clients who they do not have a background of. This

assessment however is not intended screen for a specific disorder; yet clinicians seem to be

using it that way. (Clarke & Kuhl, DSM-5 cross-cutting symptom measures: a step towards the

future of psychiatric care?, 2014) The DSM-5 Cross-Cutting symptom measure is not intended

to be used as screening tool and this where clinicians may ethically misuse the symptom
measure. (Bastiaens & Galus, "The DSM-5 Self-Rated Level 1 Cross-Cutting Symptom

Measure as a Screening Tool", 2017) It is also important to note that not all Level 2 measures

have extensive reports or research. (Schmit & Balkin, Evaluating Emerging Measures in the

DSM-5 for Counseling Practice, 2014) Lack of evidence and support could cause concern when

using this assessment.

Some clinicians have also expressed concern about the symptom measure being

time consuming, overly complex, and laborious. Another labor and time concern is the

amount of time and work that goes into developing a new scale yet it is already

endorsed by the APA. The process includes numerous reviews and pilot testing and

there are concerns as to whether the DSM-5 Task Force has time and means to fully do

this. (Jones, "Dimensional and Cross-Cutting Assessment in the DSM-5", 2012) The

DSM-5 criteria is a large source when providing a diagnosis and counselors should be

cautious when interpreting measures that could be inconsistent with the diagnosis

criteria.

Advantages

The DSM-5 Cross-Cutting symptom measure is validated across the industry and

reports indicated “fairly strong psychometric properties” (Schmit & Balkin, Evaluating

Emerging Measures in the DSM-5 for Counseling Practice, 2014). One large advantage

is the symptom measure is in alignment with the “US Patient Protection and Affordable

Care Act and may offer a glimpse into what the future of psychiatric care will look like ”

(Clarke & Kuhl, DSM-5 cross-cutting symptom measures: a step towards the future of

psychiatric care?, 2014). This symptom measure also provides a way to reduce the
complexity of diagnosis, especially with comorbidity, by allowing counselors to get a

better picture for declivity with disorders to avoid forcing symptoms to fall in a category.

Another advantage is that it gives the client autonomy because it is self-report

and administered. (Clarke & Kuhl, DSM-5 cross-cutting symptom measures: a step

towards the future of psychiatric care?, 2014) This autonomy allows for the client to feel

involved rather than judged or uninvolved in their own life. This assessment is also

flexible and can be integrated across a variety of setting such as primary care settings

that offer behavioral health as well. (Randall, "Book Review: Diagnostic and statistical

manual of mental disorders", 2013) The assessment also allows the counselor to better

document a majority of the client’s presenting symptoms over time. (Jones,

"Dimensional and Cross-Cutting Assessment in the DSM-5", 2012) This information can

aid in building more specialized treatment plans and goals. This article also stated that a

symptom measure such as the DSM-5 Cross-Cutting Symptom Measure “could provide

a more specific and individualized profile description of a patient's psychopathology that

may in turn have more differentiated and specific treatment implications” (Jones,

"Dimensional and Cross-Cutting Assessment in the DSM-5", 2012).

Implications for counselors

This is a lot of information but what does it all mean in regards to counseling and

using this assessment? The current research is showing that this emerging measure is

inconsistent at this time and is based on “erratic reporting of psychometric information

and lack of alignment with diagnostic criteria, such as what was documented regarding

the disorder-specific severity measures” (Schmit & Balkin, Evaluating Emerging

measures are not useful. In fact, they are validated for clinical use but do lack some information

and should not be the only tool in diagnosis. (Schmit & Balkin, Evaluating Emerging Measures

in the DSM-5 for Counseling Practice, 2014) This tool can be used to highlight areas within each

client that are causing problems and may need further exploration and insight. (Schmit & Balkin,

Evaluating Emerging Measures in the DSM-5 for Counseling Practice, 2014)

This measure worked strongly with negative prediction in the areas of mania,

anxiety and psychosis symptoms. This allows a stronger sense of assurance in

identifying these symptoms in the counseling environment when used for addressing

the negative value.

Conclusion

The DSM-5 Cross-Cutting Symptom Measure while endorsed by the APA does

have its flaws. It is a reliable self-reporting tool and allows for clients to be

independently engaged in the assessment process. It also allows for a deeper look into

symptoms and possible categories they fall into for diagnosis purposes. Given that this

assessment has a Level 1 and Level 2 measure it allows for an in-depth look at the

symptoms a client is presenting. “The measures may be helpful in confirming clinical

impressions or identifying potential problem areas that warrant further exploration”

(Schmit & Balkin, Evaluating Emerging Measures in the DSM-5 for Counseling Practice,

2014).
 Works Cited

American Psychiatric Association . (n.d.). Online Assessment Measures. Retrieved

February, 2018, from

https://www.psychiatry.org/psychiatrists/practice/dsm/educational-

resources/assessment-measures

Bastiaens, L., & Galus, J. (2017). The DSM-5 Self-Rated Level 1 Cross-Cutting

Symptom Measure as a Screening Tool. Psychiatric Quarterly, 89(1), 111-115.

doi:10.1007/s11126-017-9518-7

Clarke, D. E., & Kuhl, E. A. (2014). DSM-5 cross-cutting symptom measures: a step

towards the future of psychiatric care? World Psychiatry, 13(3), 314-316.

doi:10.1002/wps.20154

Jones, K. D. (2012). Dimensional and Cross-Cutting Assessment in theDSM-5. Journal

of Counseling & Development, 90(4), 481-487. doi:10.1002/j.1556-

6676.2012.00059.x

Narrow, W. E., Clarke, D. E., Kuramoto, S. J., Kraemer, H. C., Kupfer, D. J., Greiner, L.,

& Regier, D. A. (2013). DSM-5 Field Trials in the United States and Canada, Part

III: Development and Reliability Testing of a Cross-Cutting Symptom Assessment

for DSM-5. American Journal of Psychiatry, 170(1), 71-82.

doi:10.1176/appi.ajp.2012.12071000

Randall, E. J. (2013, December 10). Book Review: Diagnostic and statistical manual of

mental disorders. Retrieved February, 2018, from

http://journals.sagepub.com.go.libproxy.wakehealth.edu/doi/full/10.1177/1049731

513501560#articleCitationDownloadContainer
Schmit, E. L., & Balkin, R. S. (2014). Evaluating Emerging Measures in the DSM-5 for

Counseling Practice. The Professional Counselor, 4(3), 216-231.

doi:10.15241/els.4.3.216