Assessment Measures

A growing body of scientific evidence favors dimensional concepts in the diagnosis of mental disorders. The 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), the need for intermediate categories like schizoaffective disorder, high rates of comorbidity, frequent not-otherwise-specified (NOS) diagnoses, relative lack of utility in furthering the 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. Such an approach incorporates variations of features within an individual (e.g., differential severity of individual symptoms both within and outside of a disorder’s diagnostic criteria as measured by intensity, duration, or number of symptoms, along with other features such as type and severity of disabilities) rather than relying on a simple yes-or-no approach. For diagnoses for which all symptoms are needed for a diagnosis (a monothetic criteria set), different severity levels of the constituent symptoms may be noted. If a threshold endorsement of multiple symptoms is needed, such as at least five of nine symptoms for major depressive disorder (a polythetic criteria set), both severity levels and different combinations of the criteria may identify more homogeneous diagnostic groups.

A dimensional approach depending primarily on an individual’s subjective reports of symptom experiences along with the clinician’s interpretation is consistent with current diagnostic practice. It is expected that as our understanding of basic disease mechanisms based on pathophysiology, neurocircuitry, gene-environment interactions, and laboratory tests increases, approaches that integrate both objective and subjective patient data will be developed to supplement and enhance the accuracy of the diagnostic process.

Cross-cutting symptom measures modeled on general medicine’s review of systems can serve as an approach for reviewing critical psychopathological domains. The general medical review of systems 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 individual’s presenting symptoms, but may nonetheless be important to the individual’s care. The cross-cutting measures have two levels: Level 1 questions are a brief survey of 13 symptom domains for adult patients and 12 domains for child and adolescent patients. Level 2 questions provide a more in-depth assessment of certain domains. These measures were developed to be administered both at initial interview and over time to track the patient’s symptom status and response to treatment.

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. Some of the assessments are self-completed by the individual, while others require a clinician to complete. As with the cross-cutting symptom measures, these measures were developed to be administered both at initial interview and over time to track the severity of the individual’s disorder and response to treatment.

The World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0) was developed to assess a patient’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. The scale is self-administered and was developed to be used in patients with any medical disorder. 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 a patient’s disabilities.

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. These measures and additional dimensional assessments, including those for diagnostic severity, can be found online at www.psychiatry.org/dsm5.

Cross-Cutting Symptom Measures

Level 1 Cross-Cutting Symptom Measure

The DSM-5 Level 1 Cross-Cutting Symptom Measure is a patient- or informant-rated measure that assesses mental health 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 dementia), a knowledgeable adult informant may complete this measure. 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^1, ².

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 ³. 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 www.psychiatry.org/dsm5.

Scoring and interpretation. On 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 domain should be reviewed. However, a rating of mild (i.e., 2) or greater on any item within a domain, except for substance use, suicidal ideation, and psychosis, 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 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, 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.

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


Domain	Domain name	Threshold to guide further inquiry	DSM-5 Level 2 Cross-Cutting 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 behaviors	Mild or greater	Level 2—Repetitive Thoughts and 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. National Institute on Drug Abuse.^aAvailable at www.psychiatry.org/dsm5.

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. 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.

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


Domain	Domain name	Threshold to guide further inquiry	DSM-5 Level 2 Cross-Cutting Symptom Measure^a
I.	Somatic symptoms	Mild or greater	Level 2—Somatic Symptoms—Parent/Guardian of Child Age 6–17 (Patient Health Questionnaire–15 Somatic Symptom Severity Scale [PHQ-15])
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 behaviors	Mild or greater	None
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)
XII.	Suicidal ideation/suicide attempts	Yes	None
	Don’t Know	None

Note. National Institute on Drug Abuse.^aAvailable at www.psychiatry.org/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 www.psychiatry.org/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 at www.psychiatry.org/dsm5.

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.

References

1. Clarke DE, Narrow WE, Regier DA, et al: DSM-5 field trials in the United States and Canada, Part I: study design, sampling strategy, implementation, and analytic approaches. Am J Psychiatry 170(1):43–58, 2013 10.1176/appi.ajp.2012.12071000

2. Narrow WE, Clarke DE, Kuramoto SJ, 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-5. Am J Psychiatry 170(1):71–82, 2013 10.1176/appi.ajp.2012.12071000

3. Regier DA, Narrow WE, Clarke DE, et al: DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. Am J Psychiatry 170(1):59–70, 2013 10.1176/appi.ajp.2012.12071000 (Epub ahead of print)

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult

Name:________________________________________________________ Age: __________ Sex: [ ] Male [ ] Female 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) WEEKS, how much (or how often) have you been bothered by the following problems?	None Not at all	Slight Rare, less than a day or two	Mild Several days	Moderate More than half the days	Severe Nearly every day	Highest Domain Score (clinician)
I.	1.	Little interest or pleasure in doing things?	0	1	2	3	4
	2.	Feeling down, depressed, or hopeless?	0	1	2	3	4
II.	3.	Feeling more irritated, grouchy, angry than usual?	0	1	2	3	4
III.	4.	Sleeping less than usual, but still have a lot of energy?	0	1	2	3	4
	5.	Starting lots more projects than usual or doing more risky things than usual?	0	1	2	3	4
IV.	6.	Feeling nervous, anxious, frightened, worried, or on edge?	0	1	2	3	4
	7.	Feeling panic or being frightened?	0	1	2	3	4
	8.	Avoiding situations that make you anxious?	0	1	2	3	4
V.	9.	Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?	0	1	2	3	4
	10.	Feeling that your illnesses are not being taken seriously enough?	0	1	2	3	4
VI.	11.	Thoughts of actually hurting yourself?	0	1	2	3	4
VII.	12.	Hearing things other people couldn’t hear, such as voices even when no one was around?	0	1	2	3	4
	13.	Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?	0	1	2	3	4
VIII.	14.	Problems with sleep that affected your sleep quality over all?	0	1	2	3	4
IX.	15.	Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?	0	1	2	3	4
X.	16.	Unpleasant thoughts, urges, or images that repeatedly enter your mind?	0	1	2	3	4
	17.	Feeling driven to perform certain behaviors or mental acts over and over again?	0	1	2	3	4
XI.	18.	Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?	0	1	2	3	4
XII.	19.	Not knowing who you really are or what you want out of life?	0	1	2	3	4
	20.	Not feeling close to other people or enjoying your relationships with them?	0	1	2	3	4
XIII.	21.	Drink at least 4 drinks of any kind of alcohol in a single day?	0	1	2	3	4
	22.	Smoke any cigarettes, a cigar, or pipe, or use snuff or chewing tobacco?	0	1	2	3	4
	23.	Use any of the following 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)]?	0	1	2	3	4

Parent/Guardian-Rated DSM-5 Level 1 Cross-Cutting Symptom Measure—Child Age 6–17

Child’s Name:________________________________________________________ Age: __________ Sex: [ ] Male [ ] Female 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) WEEKS, how much (or how often) has your child…	None Not at all	Slight Rare, less than a day or two	Mild Several days	Moderate More than half the days	Severe Nearly every day	Highest Domain Score (clinician)
I.	1.	Complained of stomachaches, headaches, or other aches and pains?	0	1	2	3	4
	2.	Said he/she was worried about his/her health or about getting sick?	0	1	2	3	4
II.	3.	Had problems sleeping—that is, trouble falling asleep, staying asleep, or waking up too early?	0	1	2	3	4
III.	4.	Had problems paying attention when he/she was in class or doing his/her homework or reading a book or playing a game?	0	1	2	3	4
IV.	5.	Had less fun doing things than he/she used to?	0	1	2	3	4
	6.	Seemed sad or depressed for several hours?	0	1	2	3	4
V. and VI.	7.	Seemed more irritated or easily annoyed than usual?	0	1	2	3	4
	8.	Seemed angry or lost his/her temper?	0	1	2	3	4
VII.	9.	Starting lots more projects than usual or doing more risky things than usual?	0	1	2	3	4
	10.	Sleeping less than usual for him/her but still has lots of energy?	0	1	2	3	4
VIII.	11.	Said he/she felt nervous, anxious, or scared?	0	1	2	3	4
	12.	Not been able to stop worrying?	0	1	2	3	4
	13.	Said he/she couldn’t do things he/she wanted to or should have done because they made him/her feel nervous?	0	1	2	3	4
IX.	14.	Said that he/she heard voices—when there was no one there— speaking about him/her or telling him/her what to do or saying bad things to him/her?	0	1	2	3	4
	15.	Said that he/she had a vision when he/she was completely awake— that is, saw something or someone that no one else could see?	0	1	2	3	4
X.	16.	Said that he/she had 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?	0	1	2	3	4
	17.	Said he/she felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off?	0	1	2	3	4
	18.	Seemed to worry a lot about things he/she touched being dirty or having germs or being poisoned?	0	1	2	3	4
	19.	Said that he/she had to do things in a certain way, like counting or saying special things out loud, in order to keep something bad from happening?	0	1	2	3	4
	In the past TWO (2) WEEKS, has your child…
XI.	20.	Had an alcoholic beverage (beer, wine, liquor, etc.)?	Yes	No	Don’t Know
	21.	Smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco?	Yes	No	Don’t Know
	22.	Used drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?	Yes	No	Don’t Know
	23.	Used any medicine 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)?	Yes	No	Don’t Know
XII.	24.	In the past TWO (2) WEEKS, has he/she talked about wanting to kill himself/herself or about wanting to commit suicide?	Yes	No	Don’t Know
	25.	Has he/she EVER tried to kill himself/herself?	Yes	No	Don’t Know

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 ¹. 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 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^5, which predict functional abilities ³. In addition, scales for dimensional assessment of depression and mania are provided, which may alert clinicians to mood pathology. The severity of mood symptoms in psychosis has prognostic value ² and guides treatment ⁴.

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 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 may review all of the individual’s available information and, based on clinical judgment, select (with checkmark) the level that most accurately describes the severity of the individual’s condition. 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 guide decision making.

Reference

1. Barch DM, Carter CS, MacDonald AW ]3rd], et al: Context-processing deficit in schizophrenia: diagnostic specificity, 4-week course, and relationships to clinical symptoms. J Abnorm Psychol 112(1):132–143, 2003 12653421

2. Bowie CR, Reichenberg A, Patterson TL, et al: Determinants of real-world functional performance in schizophrenia subjects: correlations with cognition, functional capacity, and symptoms. Am J Psychiatry 163(3):418–425, 2006 16513862

3. Green MF, Kern RS, Heaton RK: Longitudinal studies of cognition and functional outcome in schizophrenia: implications for MATRICS. Schizophr Res 72(1):41–51, 2004 15531406

4. Peralta V, Cuesta MJ: Exploring the borders of the schizoaffective spectrum: a categorical and dimensional approach. J Affect Disord 108(1–2):71–86, 2009

5. Reichenberg A, Harvey PD, Bowie CR, et al: Neuropsychological function and dysfunction in schizophrenia and psychotic affective disorders. Schizophr Bull 35(5):1022–1029, 2009 18495643

Clinician-Rated Dimensions of Psychosis Symptom Severity

Name:________________________________________________________ Age: __________ Sex: [ ] Male [ ] Female 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 in the past seven (7) days.


Domain	0	1	2	3	4	Score
I. Hallucinations	Not present	Equivocal (severity or duration not sufficient to be considered psychosis)	Present, but mild (little pressure to act upon voices, not very bothered by voices)	Present and moderate (some pressure to respond to voices, or is somewhat bothered by voices)	Present and severe (severe pressure to respond to voices, or is very bothered by voices)
II. Delusions	Not present	Equivocal (severity or duration not sufficient to be considered psychosis)	Present, but mild (little pressure to act upon delusional beliefs, not very bothered by beliefs)	Present and moderate (some pressure to act upon beliefs, or is somewhat bothered by beliefs)	Present and severe (severe pressure to act upon beliefs, or is very bothered by beliefs)
III. Disorganized speech	Not present	Equivocal (severity or duration not sufficient to be considered disorganization)	Present, but mild (some difficulty following speech)	Present and moderate (speech often difficult to follow)	Present and severe (speech almost impossible to follow)
IV. Abnormal psychomotor behavior	Not present	Equivocal (severity or duration not sufficient to be considered abnormal psychomo-tor behavior)	Present, but mild (occasional abnormal or bizarre motor behavior or catatonia)	Present and moderate (frequent abnormal or bizarre motor behavior or catatonia)	Present and severe (abnormal or bizarre motor behavior or catatonia almost constant)
V. Negative symptoms (restricted emotional expression or avolition)	Not present	Equivocal decrease in facial expressivity, prosody, gestures, or self-initiated behavior	Present, but mild decrease in facial expressivity, prosody, gestures, or self-initiated behavior	Present and moderate decrease in facial expressivity, prosody, gestures, or self-initiated behavior	Present and severe decrease in facial expressivity, prosody, gestures, or self-initiated behavior
VI. Impaired cognition	Not present	Equivocal (cognitive function not clearly outside the range expected for age or SES; i.e., within 0.5 SD of mean)	Present, but mild (some reduction in cognitive function; below expected for age and SES, 0.5–1 SD from mean)	Present and moderate (clear reduction in cognitive function; below expected for age and SES, 1–2 SD from mean)	Present and severe (severe reduction in cognitive function; below expected for age and SES, >2 SD from mean)
VII. Depression	Not present	Equivocal (occasionally feels sad, down, depressed, or hopeless; concerned about having failed someone or at something but not preoccupied)	Present, but mild (frequent periods of feeling very sad, down, moderately depressed, or hopeless; concerned about having failed someone or at something, with some preoccupation)	Present and moderate (frequent periods of deep depression or hopelessness; preoccupation with guilt, having done wrong)	Present and severe (deeply depressed or hopeless daily; delusional guilt or unreasonable self-reproach grossly out of proportion to circumstances)
VIII. Mania	Not present	Equivocal (occasional elevated, expansive, or irritable mood or some restlessness)	Present, but mild (frequent periods of somewhat elevated, expansive, or irritable mood or restlessness)	Present and moderate (frequent periods of extensively elevated, expansive, or irritable mood or restlessness)	Present and severe (daily and extensively elevated, expansive, or irritable mood or restlessness)

Note. SD=standard deviation; SES=socioeconomic status.

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 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 dementia), a knowledgeable informant may complete the proxy-administered version of the measure, which is available at www.psychiatry.org/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. 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 uses 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.
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 www.who.int/classifications/icf/Pop_norms_distrib_IRT_scores.pdf.

Additional Scoring and Interpretation Guidance for DSM-5 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 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.

WHODAS 2.0
World Health Organization Disability Assessment Schedule 2.0
36-item version, self-administered

Patient Name: __________________ Age: _______ Sex: Male Female Date: ___________

This questionnaire asks about difficulties due to health/mental health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions thinking about how much difficulty you had doing the following activities. For each question, please circle only one response.


								Clinician Use Only
Numeric scores assigned to each of the items:		1	2	3	4	5	Raw Item Score	Raw Domain Score	Average Domin Score
In the last 30 days, how much difficulty did you have in:
Understanding and communicating
D1.1	Concentrating on doing something for ten minutes?	None	Mild	Moderate	Severe	Extreme or cannot do
D1.2	Remembering to do important things?	None	Mild	Moderate	Severe	Extreme or cannot do
D1.3	Analyzing and finding solutions to problems in day-to-day life?	None	Mild	Moderate	Severe	Extreme or cannot do
D1.4	Learning a new task, for example, learning how to get to a new place?	None	Mild	Moderate	Severe	Extreme or cannot do		30	5
D1.5	Generally understanding what people say?	None	Mild	Moderate	Severe	Extreme or cannot do
D1.6	Starting and maintaining a conversation?	None	Mild	Moderate	Severe	Extreme or cannot do
Getting around
D2.1	Standing for long periods, such as 30 minutes?	None	Mild	Moderate	Severe	Extreme or cannot do
D2.2	Standing up from sitting down?	None	Mild	Moderate	Severe	Extreme or cannot do
D2.3	Moving around inside your home?	None	Mild	Moderate	Severe	Extreme or cannot do		25	5
D2.4	Getting out of your home?	None	Mild	Moderate	Severe	Extreme or cannot do
D2.5	Walking a long distance, such as a kilometer (or	None	Mild	Moderate	Severe	Extreme or cannot do
Self-care
D3.1	Washing your whole body?	None	Mild	Moderate	Severe	Extreme or cannot do
D3.2	Getting dressed?	None	Mild	Moderate	Severe	Extreme or cannot do
D3.3	Eating?	None	Mild	Moderate	Severe	Extreme or cannot do		20	5
D3.4	Staying by yourself for a few days?	None	Mild	Moderate	Severe	Extreme or cannot do
Getting along with people
D4.1	Dealing with people you do not know?	None	Mild	Moderate	Severe	Extreme or cannot do
D4.2	Maintaining a friendship?	None	Mild	Moderate	Severe	Extreme or cannot do
D4.3	Getting along with people who are close to you?	None	Mild	Moderate	Severe	Extreme or cannot do		25	5
D4.4	Making new friends?	None	Mild	Moderate	Severe	Extreme or cannot do
D4.5	Sexual activities?	None	Mild	Moderate	Severe	Extreme or cannot do
In the last 30 days, how much difficulty did you have in:
Life activities-Household
D5.1	Taking care of your household responsibilities?	None	Mild	Moderate	Severe	Extreme or cannot do
D5.2	Doing most important household tasks well?	None	Mild	Moderate	Severe	Extreme or cannot do
D5.3	Getting all of the household work done that you needed to do?	None	Mild	Moderate	Severe	Extreme or cannot do		20	5
D5.4	Getting your household work done as quickly as needed?	None	Mild	Moderate	Severe	Extreme or cannot do
Life activities-School/Work
If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5-D5.8, below. Otherwise, skip to D6.1.
Because of your health condition, in the past 30 days, how much difficulty did you have in:
D5.5	Your day-to-day work/school?	None	Mild	Moderate	Severe	Extreme or cannot do
D5.6	Doing your most important work/school tasks well?	None	Mild	Moderate	Severe	Extreme or cannot do
D5.7	Getting all of the work done that you need to do?	None	Mild	Moderate	Severe	Extreme or cannot do		20	5
D5.8	Getting your work done as quickly as needed?	None	Mild	Moderate	Severe	Extreme or cannot do
Participation in society
In the past 30 days:
D6.1	How much of a problem did you have in joining in community activities (for example, festivities, religious, or other activities) in the same way as anyone else can?	None	Mild	Moderate	Severe	Extreme or cannot do
D6.2	How much of a problem did you have because of barriers or hindrances around you?	None	Mild	Moderate	Severe	Extreme or cannot do
D6.3	How much of a problem did you have living with dignity because of the attitudes and actions of others?	None	Mild	Moderate	Severe	Extreme or cannot do
D6.4	How much time did you spend on your health condition or its consequences?	None	Some	Moderate	A Lot	Extreme or cannot do		40	5
D6.5	How much have you been emotionally affected by your health condition?	None	Mild	Moderate	Severe	Extreme or cannot do
D6.6	How much has your health been a drain on the financial resources of you or your family?	None	Mild	Moderate	Severe	Extreme or cannot do
D6.7	How much of a problem did your family have because of your health problems?	None	Mild	Moderate	Severe	Extreme or cannot do
D6.8	How much of a problem did you have in doing things by yourself for relaxation or pleasure?	None	Mild	Moderate	Severe	Extreme or cannot do
General Disability Score (Total):								180	5

The World Health Organization has granted the Publisher permission for the reproduction of this instrument. This material can be reproduced without permission by clinicians for use with their own patients. Any other use, including electronic use, requires written permission from WHO.