Nonsuicidal SeIf-Injury ..................................... 803
This section contains tools and techniques to enhance the clinical deci- sion-making process, understand the cultural context of mental disorders, and recognize emerging diagnoses for further study. It provides strategies to en- hance clinical practice and new criteria to stimulate future research, represent- ing a dynamic DSM-5 that will evolve with advances in the field.
Among the tools in Section III is a Level 1 cross—cutting seIf/informant-rated measure that serves as a review of systems across mental disorders. A clini- is provided, as well as the World Health Organization Disability Assessment
Schedule, Version 2 (WHODAS 2.0). Level 2 severity measures are available online (www.psychiatry.org/dsm5) and may be used to explore significant re- sponses to the Level 1 screen. A comprehensive review of the cultural context of mental disorders, and the Cultural Formulation Interview (CFI) for clinical use, are provided.
Proposed disorders for future study are provided, which include a new model for the diagnosis of personality disorders as an alternative to the estab- lished diagnostic criteria; the proposed model incorporates impairments in per- sonality functioning as well as pathological personality traits. Also included are new conditions that are the focus of active research, such as attenuated psy- chosis syndrome and nonsuicidal seIf-injury.
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 fail- ure 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 dis- order, high rates of comorbidity, frequent not—otherwise—specified (NOS) diagnoses, relative lack of utility in furthering the identification of unique antecedent validators for most men- tal 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 indi— vidual 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 se- verity 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.
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 med- ical 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.