Other Conditions That May Be a Focus of Clinical Attention 725
membership) in a specific category. Typically , such categories include gender or gender
identity, race, ethnicity, religion,  sexual orientation, country of  origin, political beliefs, dis-
ability status, caste, social status , weight, and physical appearance.
V62.9 (Z60.9) Unspecified Problem Related to Social Environment
This category should be used when there is a pr oblem related to the individual’s social en-
vironment other than as specified above.
Problems Related to Crime or Interaction
 With the Legal System
V62.89 (Z65.4)   Victim of Crime
V62.5 (Z65.0) Conviction in Civil or Criminal Proceedings Without Imprisonment
V62.5 (Z65.1) Imprisonment or Other Incarceration
V62.5 (Z65.2) Problems Related to Release From Prison
V62.5 (Z65.3) Problems Related to Other Legal Circumstances
Other Health Service Encounters for
Counseling and Medical Advice
V65.49 (Z70.9) Sex Counseling
This category should be used when the indi vidual seeks counseling related to sex educa-
tion, sexual behavior, sexual orientation, sexual attitudes (embarrassment, timidity), oth-
ers’ sexual behavior or orientation (e.g., spou se, partner, child), sexu al enjoyment, or any
other sex-related issue.
V65.40 (Z71.9) Other Counseling or Consultation
This category should be used when counseling is provided or advice/consultation is
sought for a problem that is not specified above or elsewhere in this chapter. Examples in-
clude spiritual or religious counseling, dietar y counseling, and counseling on nicotine use.


clude spiritual or religious counseling, dietar y counseling, and counseling on nicotine use.
Problems Related to Other Psychosocial, Personal,
and Environmental Circumstances
V62.89 (Z65.8) Religious or Spiritual Problem
This category can be used when the focus of clinical attention is a religious or spiritual
problem. Examples include distressing experi ences that involve lo ss or questioning of
faith, problems associated with conversion to a new faith, or questioning of spiritual val-
ues that may not necessarily be related to an organized church or religious institution.
V61.7 (Z64.0) Problems Related to Unwanted Pregnancy
V61.5 (Z64.1) Problems Related to Multiparity
V62.89 (Z64.4) Discord With Social Service Provider, Including Probation Officer,
Case Manager, or Social Services Worker
V62.89 (Z65.4) Victim of Terrorism or Torture
V62.22 (Z65.5) Exposure to Disaster, War, or Other Hostilities
V62.89 (Z65.8) Other Problem Related to Psychosocial Circumstances
V62.9 (Z65.9) Unspecified Problem Related to Un specified Psychosocial Circum-
stances


726 Other Conditions That May Be a Focus of Clinical Attention
Other Circumstances of Personal History
V15.49 (Z91.49) Other Personal History of Psychological Trauma
V15.59 (Z91.5) Personal History of Self-Harm
V62.22 (Z91.82) Personal History of Military Deployment
V15.89 (Z91.89) Other Personal Risk Factors
V69.9 (Z72.9) Problem Related to Lifestyle
This category should be used when a lifestyle pr oblem is a specific focus of treatment or di-
rectly affects the course, prognosis, or treatmen t of a mental or other medical disorder. Ex-
amples of lifestyle problems include lack of physical exercise, inappropriate diet, high-risk
sexual behavior, and poor sleep hygiene. A prob lem that is attributable to a symptom of a
mental disorder should not be coded unless that problem is a specific focus of treatment or
directly affects the course, prognosis, or treatmen t of the individual. In such cases, both the
mental disorder and the lifesty le problem should be coded.
V71.01 (Z72.811) Adult Antisocial Behavior
This category can be used when the focus of c linical attention is adult antisocial behavior
that is not due to a mental disorder (e.g., conduct disorder , antisocial personality disor-
der). Examples include the behavior of some pr ofessional thieves, racketeers, or dealers in
illegal substances.
V71.02 (Z72.810) Child or Adolescent Antisocial Behavior
This category can be used when the focus of clinical attention is antisocial behavior in a
child or adolescent that is no t due to a mental disorder (e.g ., intermittent explosive disor-
der, conduct disorder). Examples include isol ated antisocial acts by children or adoles-


der, conduct disorder). Examples include isol ated antisocial acts by children or adoles-
cents (not a pattern of antisocial behavior).
Problems Related to Access to Medical
and Other Health Care
V63.9 (Z75.3) Unavailability or Inaccessibility of Health Care Facilities
V63.8 (Z75.4) Unavailability or Inaccessibility of Other Helping Agencies
Nonadherence to Medical Treatment
V15.81 (Z91.19) Nonadherence to Medical Treatment
This category can be used when the focus of clinical attention is nonadherence to an im-
portant aspect of treatment for a mental diso rder or another medica l condition. Reasons
for such nonadherence may include discomfort  resulting from treatment (e.g., medication
side effects), expense of treatment, personal value judgments or religious or cultural be-
liefs about the proposed treatment, age-related debility, and the presence of a mental dis-
order (e.g., schizophrenia, personality disorder ). This category should be used only when
the problem is sufficiently severe to warrant independent clinical attention and does not
meet diagnostic criteria fo r psychological factors affect ing other medical conditions.
278.00 (E66.9) Overweight or Obesity
This category may be used when overweight or  obesity is a focus of clinical attention.
V65.2 (Z76.5) Malingering
The essential feature of malingering is the inte ntional production of false or grossly exag-
gerated physical or psychologi cal symptoms, motivated by external incentives such as
avoiding military duty, avoiding work, obta ining financial compensation, evading crimi-
nal prosecution, or obtaining drugs. Under some circumstances, malingering may repre-


Other Conditions That May Be a Focus of Clinical Attention 727
sent adaptive behavior—for example, feigni ng illness while a captive of the enemy during
wartime. Malingering should be strongly suspected if any combination of the following is
noted:
1. Medicolegal context of presentation (e.g., th e individual is referred by an attorney to
the clinician for examination, or the indivi dual self-refers while litigation or criminal
charges are pending).
2. Marked discrepancy between the individual’s  claimed stress or disability and the ob-
jective findings and observations.
3. Lack of cooperation during the diagnostic evaluation and in complying with the pre-
scribed treatment regimen.
4. The presence of antisocial personality disorder.
Malingering differs from factitious disorder  in that the motiva tion for the symptom
production in malingering is an external ince ntive, whereas in factit ious disorder external
incentives are absent. Malingering is differen tiated from conversion  disorder and somatic
symptom–related mental disorders by the inte ntional production of symptoms and by the
obvious external incentives assoc iated with it. Definite evidence of feigning (such as clear
evidence that loss of function is present du ring the examination but not at home) would
suggest a diagnosis of factitious  disorder if the individual’s apparent aim is to assume the
sick role, or malingering if it is to obtain an incentive, such as money.
V40.31 (Z91.83) Wandering Associated With a Mental Disorder
This category is used for individuals with a mental disorder whose desire to walk about
leads to significant clinical management or safety concerns. For example, individuals with
major neurocognitive or neurodevelopmental disorders may experience  a restless urge to


major neurocognitive or neurodevelopmental disorders may experience  a restless urge to
wander that places them at risk for falls and causes them to leave supervised settings with-
out needed accompaniment. This category excl udes individuals whose intent is to escape
an unwanted housing situation (e.g., childre n who are running away from home, patients
who no longer wish to remain in the hospital) or those who walk or pace as a result of med-
ication-induced akathisia.
Coding note: First code associated mental disorder  (e.g., major neurocognitive disor-
der, autism spectrum disorder), then co de V40.31 (Z91.83) wandering associated with
[specific mental disorder].
V62.89 (R41.83) Borderline Intellectual Functioning
This category can be used when an individual’s borderline intellectual functioning is the fo-
cus of clinical attention or has an impact on the individual’s treatmen t or prognosis. Differ-
entiating borderline intellectual functioning and mild intellectual disability (intellectual
developmental disorder) requires careful asse ssment of intellectual and adaptive functions
and their discrepanc ies, particularly in the presence of co-occurring mental disorders that
may affect patient compliance with standardized  testing procedures (e.g., schizophrenia or
attention-deficit/hyperactivity diso rder with severe impulsivity).


SECTION III
Emerging Measures and Models
Assessment Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .733
Cross-Cutting Symptom Measures . . . . . . . . . . . . . . . . . . . . . . . . . . .734
DSM-5 Self-Rated Level 1 Cross-Cutting
Symptom Measure—Adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . .738
Parent/Guardian-Rated DSM-5 Level 1 Cross-Cutting
Symptom Measure—Child Age 6–17  . . . . . . . . . . . . . . . . . . . .740
Clinician-Rated Dimensions of Psycho sis Symptom Severity . . . . . .742
World Health Organization Disability Assessment Schedule 2.0
(WHODAS 2.0) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .745
Cultural Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .749
Cultural Formulation Interview (CFI). . . . . . . . . . . . . . . . . . . . . . . . . . .750
Cultural Formulation Interview (CFI)—Informant Version . . . . . . . . . .755


Alternative DSM-5 Model for Personality Disorders . . . . . . . . . . . . . . . .761
Conditions for Further Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .783
Attenuated Psychosis Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . .783
Depressive Episodes With Short-Duration Hypomania  . . . . . . . . . . .786
Persistent Complex Bereavement Disorder  . . . . . . . . . . . . . . . . . . . .789
Caffeine Use Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .792
Internet Gaming Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .795
Neurobehavioral Disorder Associated With
Prenatal Alcohol Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .798
Suicidal Behavior Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .801
Nonsuicidal Self-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 self/informant-rated
measure that serves as a review of systems across mental disorders. A clini-
cian-rated severity scale for schizophrenia and other psychotic disorders also
is provided, as well as the World He alth 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 m odel 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 self-injury.


733 Assessment
 Measures
A growing body  of scientific evidence favors dimensional concepts in the diagnosis
of mental disorders. The limitations of a cate gorical 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 in termediate 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 specif icity for the various di agnostic categories.
From both clinical and research perspectiv es, there is a need for a more dimensional
approach that can be combined with DSM’s se t of categorical diagnoses. Such an approach
incorporates variations of features within an in dividual (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, su ch 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 ho mogeneous 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


diagnostic practice. It is expected that as  our understanding of basic disease mechanisms
based on pathophysiology, neurocircuitry, ge ne-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 simi lar 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 cr iteria 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 ar e a brief survey of 13 symptom domains for
adult patients and 12 domains for child and ad olescent 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 ov er time to track the patient’s symptom status
and response to treatment.
Severity measures  are disorder-specific, corresponding closely to the criteria that consti-
tute the disorder definition. They may be ad ministered to individuals who have received
a diagnosis or who have a clinically signific ant syndrome that falls short of meeting full
criteria for a diagnosis. Some of the assess ments 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.


734 Assessment Measures
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 participat ion 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 WH O International Classification  of Functioning, Disability
and Health. This assessment can also be used over time to track changes in a patient’s dis-
abilities.
This chapter focuses on the DSM-5 Leve l 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. Cl inician 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-Cuttin g Symptom Measure
The DSM-5 Level 1 Cross-Cuttin g Symptom Measure is a patien t- or informant-rated mea-
sure that assesses mental health domains th at are important across psychiatric diagnoses.
It is intended to help clinicians identify addi tional areas of inquiry that may have signifi-
cant impact on the individual’s treatment and prognosis. In addition, the measure may be
used to track changes in the individu al’s symptom presentation over time.
The adult version of the measure consists of  23 questions that assess 13 psychiatric do-


The adult version of the measure consists of  23 questions that assess 13 psychiatric do-
mains, including depression, an ger, mania, anxiety, somatic symptoms, suicidal ideation,
psychosis, sleep problems, memo ry, repetitive thoughts and behaviors, dissociation, per-
sonality functioning, and substance use (Table 1). Each domain consists of one to three
questions. Each item inquires about how mu ch (or how often) the individual has been
bothered by the specific symptom during the p ast 2 weeks. If the individual is of impaired
capacity and unable to complete the form (e .g., an individual with dementia), a knowl-
edgeable adult informant may complete this measure. The measure was found to be clin-
ically 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.
The parent/guardian-rated ver sion of the measure (for childr en ages 6–17) consists of
25 questions that assess 12 psychiatric domain s, including depression, anger, irritability,
mania, anxiety, somatic symptoms, inattent ion, suicidal ideation/attempt, psychosis,
sleep disturbance, repetitive thoughts and behaviors, an d substance use (Table 2). Each
item asks the parent or guardian to rate ho w 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 ha ve 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 sympto ms, 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, ex cept for substance use, suicidal ideation, and


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, ex cept 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 as-
sessment for the domain (see Table 1). For substa nce use, suicidal idea tion, and psychosis, a


Assessment Measures 735
rating of slight (i.e., 1) or greater on any item  within the domain may serve as a guide for ad-
ditional inquiry and follow-up to determine if a more detailed a ssessment 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.
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 mo re than half the days; and 4=severe or nearly
every day). The suicidal ideation, suicide atte mpt, 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 re-
viewed. However, with the exception of inattentio n 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 determin e 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 beTABLE 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 nameThreshold to guide


Level 2 measures
Domain Domain nameThreshold to guide
further inquiryDSM-5 Level 2 Cross-Cutting Symptom
Measurea
I. Depression Mild or greater Lev el 2—Depression—Adult (PROMIS
Emotional Distress—Short Form)
II. Anger Mild or greater Level  2—Anger—Adult (PROMIS Emo-
tional 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 Le vel 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 behaviorsMild or greater Level 2—Repetitive Thoughts and
Behaviors—Adult (Florida Obsessive-
Compulsive Inventory [FOCI] Severity
Scale)
XI. Dissociation Mild or greater None
XII. Personality
functioningMild or greater None
XIII. Substance use Slight or greater L evel 2—Substance Us e—Adult (adapted
from the NIDA-Modified ASSIST)
Note. NIDA=National Institute on Drug Abuse.


Note. NIDA=National Institute on Drug Abuse.
aAvailable at www.ps ychiatry.org/dsm5.


736 Assessment Measures
used as an indicator for additional inquiry. A parent or guardian’s ra ting of “Don’t Know” on
the suicidal ideation, suicide a ttempt, and any of the substance use items, especially for chil-
dren 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. Be-
cause additional inquiry is made on the basis of the highest score on any item within a do-
main, 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 nameThreshold to guide
further inquiryDSM-5 Level 2 Cross-Cutting Symptom
Measurea
I. Somatic symptoms Mild or greater Le vel 2—Somatic Symptoms—Parent/Guard-
ian of Child Age 6–17 (Patient Health
Questionnaire–15 Somatic Symptom Sever-
ity Scale [PHQ-15])
II. Sleep problems Mild or greater Lev el 2—Sleep Disturbance—Parent/Guard-
ian 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 Pel-
ham, Version IV [SNAP-IV])
IV. Depression Mild or greater Level 2—Depression—Parent/Guardian of


IV. Depression Mild or greater Level 2—Depression—Parent/Guardian of
Child Age 6–17 (PROMIS Emotional Dis-
tress—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 behaviorsMild 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 attemptsYes None
Don’t Know None
Note. NIDA=National Institute on Drug Abuse.
aAvailable at www.ps ychiatry.org/dsm5.


Assessment Measures 737
Level 2 Cross-Cuttin g 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 Cr oss-Cutting Symptom Measures provide one method of obtain-
ing more in-depth information on potentially significant symptoms to inform diagnosis,
treatment planning, and follow-up. They ar e 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 assess-
ments. 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 sympto m presentation over time , the Level 1 and rel-
evant Level 2 cross-cutting symptom measures  may be completed at regular intervals as
clinically indicated, depending on the stab ility of the individual’s symptoms and treat-
ment status. For individuals with impaired capacity and for children ages 6–17 years, it is
preferable for the measures to be comple ted 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 signif icant and problematic sy mptoms for the indi-
vidual that might warrant further assessment, treatment, and follow-up. Clinical judg-
ment should guide decision making.


738 Assessment MeasuresDSM-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 th e individual? _________________________ hours/week
Instructions:  The questions below ask about things that might have bothered you. For each question, circle the nu mber that best describes ho w 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
allSlight
Rare, less than
a day or twoMild
Several
daysModerate
More than
half the daysSevere
Nearly
every dayHighest
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, gr ouchy, 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, frig htened, 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


Assessment Measures 739VII. 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 affect ed your sleep quality over all? 0 1 2 3 4
IX. 15. Problems with memory (e.g., lear ning 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 certai n behaviors or mental acts over
and over again?0 1 2 3 4
XI. 18. Feeling detached or distant from yourself, your body, your phys-
ical 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?01 23 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


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), hallucinogen s (like LSD), heroin, inhalants
or solvents (like glue), or  methamphetamine (like speed)]?0 1 2 3 4


740 Assessment MeasuresParent/Guardian-Rated DSM-5 Level 1 Cros s-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 t he past TWO (2) WEEKS.
During the past TWO (2) WEEKS,  how much (or how often) has your
child…None
Not at
allSlight
Rare, less than
a day or twoMild
Several
daysModerate
More than
half the daysSevere
Nearly
every dayHighest
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 hi s/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?01 23 4
III. 4.Had problems paying attention when he/she was in class or
doing his/her homework or read ing 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


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?01 23 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


Assessment Measures 741IX. 14. Said that he/she heard voices—when there was no one there—
speaking about him/her or tellin g him/her what to do or say-
ing bad things to him/her?01 23 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?01 23 4
X.16. Said that he/she had thoughts that kept coming into his/her
mind that he/she would do so mething 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 chec k 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 lo ud, 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


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


742 Assessment Measures
Clinician-Rated Dimensions of
Psychosis Symptom Severity
As described in the chapter “Schizophrenia  Spectrum and Other Psychotic Disorders,”
psychotic disorders are hetero geneous, and symptom severity  can predict important as-
pects of the illness, such as the degree of cogn itive and/or neurobiological deficits. Dimen-
sional assessments capture meaningful variation in the severity of symptoms, which may
help with treatment planning, prognostic decision-making, and research on pathophysi-
ological mechanisms. The Clinician-Rated Dimensions of Psychosis Symptom Severity
provides scales for the dimensional assessment  of the primary symptoms of psychosis, in-
cluding hallucinations, delusions, disorganiz ed speech, abnormal psychomotor behavior,
and negative symptoms. A scale for the dimensional assessment of cognitive impairment
is also included. Many individuals with psyc hotic disorders have im pairments in a range
of cognitive domains, which predict functional abilities. In addition, scales for dimensional
assessment of depression and mania are provided , which may alert clinicians to mood pa-
thology. The severity of mood symptoms in psychosis has prognostic value and guides
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 sy mptom as experienced by the individual during
the past 7 days.
Scoring and Interpretation
Each item on the measure is rated on a 5-poin t scale (0=none; 1=equivocal; 2=present, but
mild; 3=present and moderate; and 4=present and severe) with a sy mptom-specific defi-


nition of each rating level. The clinician may review all of the individual’s available infor-
mation and, based on clinical judgment, select (with checkmark) the level that most
accurately describes the severity of the indivi dual’s condition. The clinician then indicates
the score for each item in the “Score” column provided.
Frequency of Use
To track changes in the indi vidual’s symptom severity over time, the measure may be
completed at regular intervals as clinically in dicated, depending on the stability of the in-
dividual’s symptoms an d treatment status. Consistently high scores on a particular do-
main may indicate significant and problematic areas for the individual that might warrant
further assessment, treatment, and follow-up.  Clinical judgment should guide decision
making.


Assessment Measures 743Clinician-Rated Dimensions of  Psychosis Symptom Severity
Name:______________________________________ ______ Age: __________ Sex: [ ] Male [ ] Female  Date:________________
Instructions:  Based on all the information you have on the individual and usin g your clinical judgment, please rate (with checkmark) the pre sence and severity
of the following symptoms as experienced by the in dividual 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 psy-
chosis)❑ Present, but mild (lit-
tle 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 psy-
chosis)❑ Present, but mild (lit-
tle pressure to act
upon delusional
beliefs, not very both-
ered 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 dis-
organization)❑ Present, but mild


to be considered dis-
organization)❑ Present, but mild
(some difficulty fol-
lowing speech)❑ Present and moderate
(speech often difficult
to follow)❑ Present and severe
(speech almost impos-
sible to follow)
IV.  Abnormal psychomo-
tor 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 behav-
ior or catatonia)❑ Present and severe
(abnormal or bizarre
motor behavior or
catatonia almost con-
stant)
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, pros-
ody, gestures, or self-
initiated behavior❑ Present and moderate
decrease in facial
expressivity, pros-
ody, gestures, or self-
initiated behavior❑ Present and severe
decrease in facial
expressivity, pros-
ody, gestures, or self-
initiated behavior


744 Assessment Measures Domain 0 1 2 3 4 Score
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 (occasion-
ally feels sad, down,
depressed, or hope-
less; concerned about
having failed some-
one or at something
but not preoccupied)❑ Present, but mild (fre-
quent periods of feel-
ing very sad, down,
moderately
depressed, or hope-
less; concerned about
having failed some-
one or at something,
with some preoccupa-
tion)❑ Present and moderate
(frequent periods of
deep depression or
hopelessness; preoc-
cupation with guilt,
having done wrong)❑ Present and severe
(deeply depressed or
hopeless daily; delu-
sional guilt or unrea-
sonable self-reproach
grossly out of propor-
tion to circumstances)


sonable self-reproach
grossly out of propor-
tion to circumstances)
VIII. Mania ❑ Not present ❑ Equivocal (occasional
elevated, expansive,
or irritable mood or
some restlessness)❑ Present, but mild (fre-
quent 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.


Assessment Measures 745
World Health Organization
 Disability Assessment Schedule 2.0
The adult self-administered vers ion of the World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 2.0) is a 36-item measur e that assesses disability in adults age 18
years and older. It assesses disability across six domains, including understanding and
communicating, getting around, self-care, gett ing along with people, life activities (i.e.,
household, work, and/or school activities), an d participation in society. If the adult indi-
vidual is of impaired capacity and unable to complete the form (e.g., a patient with demen-
tia), 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 withou t recoding or collaps-
ing of response categories; thus, there is no we ighting of individual items. This approach is


practical to use as a hand-scoring approach, and may be the method of choice in busy clin-
ical 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 suff icient 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 mu ltiple levels of diffic ulty for each WHODAS
2.0 item. It takes the coding for each item response as “none,” “mild,” “moderate,” “se-
vere,” 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 pro-
gram 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 in to 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, mobilit y, self-care, getting along, life activities
(household and work/school), and participation.
WHODAS 2.0 population norms. For the population norms fo r 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/clas sifications/icf/Pop_norms_distrib_IRT_scores.pdf.


Additional Scoring and Inte rpretation Guidance for
DSM-5 Users
The clinician is asked to review the individu al’s response on each item on the measure
during the clinical interview and to indicate th e self-reported score for each item in the sec-
tion 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 avail-


746 Assessment Measures
able, 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 si x 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 comparab le 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 averag e 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 cal-
culated by dividing the raw overall score by nu mber of items in the measure (i.e., 36). The
individual should be encouraged to complete a ll of the items on the WHODAS 2.0. If no re-
sponse 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 measur e are missing but the items for some of the do-
mains are 75%–100% complete, the simple or aver age domain scores may be used for those
domains.


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 trea tment status. Consistently high scores on a
particular domain may indicate significant and problematic areas for the individual that
might warrant further assessment and intervention.


Assessment Measures 747
WHODAS 2.0
World Health Organization Disability Assessment Schedule 2.0
36-item version, self-administered
3DWLHQW1DPH BBBBBBBBBBBBBBBBBBBBBBB$JH BBBBBB  6H[0DOH)HPDOH ' D W H BBBBBBBBBBBBB
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.
 ClinicianUse
Only
Numeric scores assigned to each of the items: 1 2 3 4 5
Raw Item
Score
Raw
Domain
Score
Average
Domain
Score In the last 30 days, how much difficulty did you have in:
Understanding and communicating
D1.1 Concentrating on doing so mething for ten minutes?  None Mild Moderate Severe Extreme or
cannot do

____
30

____
5
 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


D1.4 Learning a new task, for example, learning how to
get to a new place?  None Mild Moderate Severe Extreme or
cannot do
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

____
25

____
5
 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
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
equivalent)?  None Mild Moderate Severe Extreme or
cannot do
Self-care
D3.1 Washing your whole body?  None Mild Moderate Severe Extreme or
cannot do

____
20

____
5
 D3.2 Getting dressed?  None Mild Moderate Severe Extreme or
cannot do
D3.3 Eating?  None Mild Moderate Severe Extreme or
cannot do
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

____
25

____


cannot do

____
25

____
5
 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
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


748 Assessment Measures
 ClinicianUse
Only
Numeric scores assigned to each of the items: 1 2 3 4 5
Raw Item
Score
Raw
Domain
Score
Average
Domain
Score In the last 30 days, how much difficulty did you have in:
Life activities ͶHousehold
D5.1 Taking care of your household responsibilities?  None Mild Moderate Severe Extreme or
cannot do

____
20

____
5
 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
D5.4 Getting your household work done as quickly as
needed?  None Mild Moderate Severe Extreme or
cannot do
Life activities ͶSchool/Work
If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5 ʹD5.8, 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

____
20

____
5
 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


cannot do
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

____
40

____
5
 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
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): ____


cannot do
General Disability Score (Total): ____
180 ____
5
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UHTXLUHVZULWWHQSHUPLVVLRQIURP:+2 © World Health Organization, 2012. All rights reserved. Measuring health and disability: manual for WHO Disability
Assessment Schedule (WHODAS 2.0), World Health Organization, 2010, Geneva.
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.


749Cultural
 Formulation
Understanding the cultural  context of illness experience is essential for effec-
tive diagnostic assessment and clinical management. Culture  refers to systems of knowl-
edge, concepts, rules, and practices that ar e learned and transmitted across generations.
Culture includes language, religion and spirit uality, family structur es, life-cycle stages,
ceremonial rituals, and customs, as well as moral and legal systems. Cultures are open,
dynamic systems that undergo continuous ch ange over time; in the contemporary world,
most individuals and groups are exposed to mu ltiple cultures, which they use to fashion
their own identities and make sense of experi ence. These features of culture make it cru-
cial not to overgeneralize cultur al information or stereotype groups in terms of fixed cul-
tural traits.
Race  is a culturally constructed category of identity that divides humanity into groups
based on a variety of superficia l physical traits attributed to  some hypothetical intrinsic,
biological characteristics. Racial categories an d constructs have varied widely over history
and across societies. The construct of race has no consistent biological definition, but it is
socially important because it supports racial ideologies, racism, discrimination, and social
exclusion, which can have strong negative effe cts on mental health. There is evidence that
racism can exacerbate many psychiatric disord ers, contributing to poor outcome, and that
racial biases can affect diagnostic assessment.
Ethnicity is a culturally constructed group identity used to define peoples and communi-
ties. It may be rooted in a common history, geography, language, religion, or other shared
characteristics of a group, which distinguish th at group from others. Ethnicity may be self-
assigned or attributed by out siders. Increasing mobility, inte rmarriage, and intermixing of


cultures has defined new mixed, multiple, or hybrid ethnic identities.
Culture, race, and ethnicity are related to economic inequities, racism, and discrimina-
tion that result in health disparities. Cultural , ethnic, and racial identities can be sources of
strength and group support that enhance resilie nce, but they may also lead to psycholog-
ical, interpersonal, and intergen erational conflict or difficultie s in adaptation that require
diagnostic assessment.
Outline for Cultural Formulation
The Outline for Cultural Formulation introduc ed in DSM-IV provided  a framework for as-
sessing information about cultural features of an individu al’s mental health problem and
how it relates to a social and cultural context and history. DS M-5 not only includes an up-
dated version of the Outline but also presents  an approach to assessment, using the Cul-
tural Formulation Interview (CFI), which has been field-tested for diagnostic usefulness
among clinicians and for acceptability among patients.
The revised Outline for Cultur al Formulation calls for syst ematic assessment of the fol-
lowing categories:
•Cultural identity of the individual:  Describe the individual’s racial, ethnic, or cultural
reference groups that may influence his or he r relationships with others, access to re-


750 Cultural Formulation
sources, and developmental and current chal lenges, conflicts, or predicaments. For im-
migrants and racial or ethnic minorities, th e degree and kinds of involvement with both
the culture of origin and the ho st culture or majority cultur e should be noted separately.
Language abilities, preferences,  and patterns of use are relevant for identifying difficul-
ties with access to care, social integration, and the need fo r an interprete r. Other clini-
cally relevant aspects of identity may in clude religious affiliation, socioeconomic
background, personal and family places of  birth and growing up, migrant status, and
sexual orientation.
•Cultural conceptualizations of distress:  Describe the cultural constructs that influence
how the individual experiences, understands, and communicates his or her symptoms
or problems to others. These constructs may include cultural syndromes, idioms of dis-
tress, and explanatory models or perceived causes. The level of severity and meaning of
the distressing experiences shou ld be assessed in relation to the norms of the individ-
ual’s cultural reference groups. Assessment of coping and help-seeking patterns should
consider the use of profession al as well as traditional, alternative, or complementary
sources of care.
•Psychosocial stressors and cultural feat ures of vulnerability and resilience:  Identify
key stressors and supports in the individual ’s social environment (which may include
both local and distant events) and the role of religion, family, and other social networks
(e.g., friends, neighb ors, coworkers) in providing emotional, instrumental, and infor-
mational support. Social stressors and social  supports vary with cultural interpreta-
tions of events, family structure, developm ental tasks, and social context. Levels of


functioning, disability, and resilience should be  assessed in light of the individual’s cul-
tural reference groups.
•Cultural features of the relationship between the individual and the clinician:  Iden-
tify differences in culture, language, and social status between an individual and clini-
cian that may cause difficulties in communication and may influence diagnosis and
treatment. Experiences of racism and discri mination in the larger society may impede
establishing trust and safety in the clinical  diagnostic encounter. Effects may include
problems eliciting symptoms, misunderstanding of the cultural and clinical signifi-
cance of symptoms and behaviors, and diffi culty establishing or maintaining the rap-
port needed for an effe ctive clinical alliance.
•Overall cultural assessment:  Summarize the implications of the components of the cul-
tural formulation identified in  earlier sections of the Ou tline for diagnosis and other
clinically relevant issues or problems as well as appropriate management and treat-
ment intervention.
Cultural Formulation Interview (CFI)
The Cultural Formulation Interview (CFI) is a set of 16 questions that clinicians may use to
obtain information during a me ntal health assessment about the impact of culture on key
aspects of an individual’s clinical presentation and care. In the CFI, culture  refers to
• The values, orientations, kn owledge, and practices that individuals derive from mem-
bership in diverse social groups (e.g., et hnic groups, faith communities, occupational
groups, veterans groups).
• Aspects of an individual’s background, de velopmental experiences, and current social
contexts that may affect his or her perspe ctive, such as geographical origin, migration,
language, religion, sexual orie ntation, or race/ethnicity.


language, religion, sexual orie ntation, or race/ethnicity.
• The influence of family, friends, and ot her community members (the individual’s social
network ) on the individual’s illness experience.


Cultural Formulation 751
The CFI is a brief semistructured  interview for systematically assessing cultural factors
in the clinical encounter that may be used with any individual. The CFI focuses on the in-
dividual’s experience and the so cial contexts of the clinical problem. The CFI follows a per-
son-centered approach to cult ural assessment by eliciting information from the individual
about his or her own views and those of others in his or her social network. This approach
is designed to avoid stereotyping, in that each  individual’s cultural knowledge affects how
he or she interprets illness experience and gu ides how he or she seeks help. Because the
CFI concerns the individual’s personal views, there are no right or wrong answers to these
questions. The interview follows and is available online at www.psychiatry.org/dsm5.
The CFI is formatted as two text columns. The left-hand column contains the instruc-
tions for administering the CFI and describes the goals for each interview domain. The
questions in the right-hand column illustrate how to explore these domains, but they are
not meant to be exhaustive. Follow-up question s may be needed to clarify individuals’ an-
swers. Questions may be rephrased as needed. Th e CFI is intended as a guide to cultural as-
sessment and should be used flexibly to maintain a natural flow of the interview and rapport
with the individual.
The CFI is best used in conjunction with  demographic information obtained prior to
the interview in order to tailor the CFI ques tions to address the in dividual’s background
and current situation. Specific demographic do mains to be explored with the CFI will vary
across individuals and settings. A comprehens ive assessment may include place of birth,


across individuals and settings. A comprehens ive assessment may include place of birth,
age, gender, racial/ethnic origin, marital stat us, family composition,  education, language
fluencies, sexual orientation, religious or sp iritual affiliation, occupation, employment, in-
come, and migration history.
The CFI can be used in the initial assessment of individuals in all clinical settings, regard-
less of the cultural background of the individual or of the clinician. Individuals and clini-
cians who appear to share the same cultural background may nevertheless differ in ways
that are relevant to care. The CFI may be used in its entirety, or components may be incor-
porated into a clinical evaluation as needed. The CFI may be es pecially helpful when there is
• Difficulty in diagnostic assessment owing to  significant differences in the cultural, re-
ligious, or socioeconomi c backgrounds of clinician and the individual.
• Uncertainty about the fit between culturally distinctive symptoms and diagnostic criteria.
• Difficulty in judging illness severity or impairment.
• Disagreement between the individual an d clinician on the course of care.
• Limited engagement in and adherenc e to treatment by the individual.
The CFI emphasizes four domains of assessmen t: Cultural Definition of the Problem
(questions 1–3); Cultural Perceptions of Caus e, Context, and Support (questions 4–10); Cul-
tural Factors Affecting Self-Coping and Past Help Seeking (questions 11–13); and Cultural
Factors Affecting Current Help Seeking (questions 14–16). Both the person-centered process
of conducting the CFI and the information it el icits are intended to enhance the cultural va-
lidity of diagnostic assessmen t, facilitate treatment planning , and promote the individual’s


lidity of diagnostic assessmen t, facilitate treatment planning , and promote the individual’s
engagement and satisfaction. To  achieve these goals, the info rmation obtained from the CFI
should be integrated with all other available clinical material into a comprehensive clinical
and contextual evaluation. An In formant version of the CFI can be used to collect collateral
information on the CFI domains from  family members or caregivers.
Supplementary modules have b een developed that expand on each domain of the CFI
and guide clinicians who wish to explore th ese domains in greater depth. Supplementary


Supplementary modules have b een developed that expand on each domain of the CFI
and guide clinicians who wish to explore th ese domains in greater depth. Supplementary
modules have also been developed for specific populations, such as children and adoles-
cents, elderly individuals, and immigrants and refugees. These supplementary modules
are referenced in the CFI under the pertin ent subheadings and are available online at
www.psychiatry.org/dsm5.


752 Cultural Formulation
Cultural Formulation Interview (CFI)
Supplementary modules used to  expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWERINSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED.
The following questions aim to clarify key aspects of
the presenting clinical pr oblem from the point of
view of the individual and other members of the
individual’s social network (i.e., family, friends, or
others involved in current problem). This includes
the problem’s meaning, potential sources of help,
and expectations for services.INTRODUCTION FOR THE INDIVIDUAL:
I would like to understand the problems that
bring you here so that I can help you more
effectively. I want to know about your  experi-
ence and ideas. I will ask some questions
about what is going on  and how you are deal-
ing with it. Please remember there are no
right or wrong answers.
CULTURAL DEFINITION OF THE PROBLEM
CULTURAL  DEFINITION  OF THE PROBLEM
(Explanatory Model, Level of Functioning)
Elicit the individual’s view  of core problems and key
concerns.
Focus on the individual’s own way of understand-
ing the problem.
Use the term, expression, or brief description elicited
in question 1 to identify the problem in subsequent
questions (e.g., “your conflict with your son”).1. What brings you here today?
IF INDIVIDUAL GIVES FEW DETAILS OR
ONLY MENTIONS SYMPTOMS OR A
MEDICAL DIAGNOSIS, PROBE:
People often understand their problems in
their own way, which may be similar to or
different from how doctors describe the


their own way, which may be similar to or
different from how doctors describe the
problem. How would you describe your
problem?
Ask how individual frames the problem for members
of the social network.2. Sometimes people have different ways of
describing their problem to their family,
friends, or others in their community. How
would you describe your problem to them?
Focus on the aspects of the problem that matter most
to the individual.3. What troubles you mo st about your prob-
lem?
CULTURAL PERCEPTIONS OF CA USE, CONTEXT, AND SUPPORT
CAUSES
(Explanatory Model, Social Network, Older Adults)
This question indicates the meaning of the condition
for the individual, which may be relevant for clin-
ical care.4. Why do you think this is happening to
you? What do you think are the causes of
your [PROBLEM]?
Note that individuals may identify multiple causes,
depending on the facet of the problem they are con-
sidering.PROMPT FURTHER IF REQUIRED:
Some people may explain their problem as
the result of bad things that happen in their
life, problems with others, a physical ill-
ness, a spiritual reason, or many other
causes.
Focus on the views of memb ers of the in dividual’s
social network. These may be diverse and vary from
the individual’s.5. What do others in your family, your
friends, or others in your community think
is causing your [PROBLEM]?


Cultural Formulation 753
STRESSORS  AND  SUPPORTS
(Social Network, Caregivers, Psychosocial Stre ssors, Religion and Spirituality, Immigrants and
Refugees, Cultural Identity, Older Adults, Coping and Help Seeking)
Elicit information on the individual’s life context,
focusing on resources, social supports, and resil-
ience. May also probe other supports (e.g., from co-
workers, from participation in religion or spiritu-
ality).6. Are there any kinds of support that make
your [PROBLEM] better, such as support
from family, friends, or others?
Focus on stressful aspects of the individual’s envi-
ronment. Can also probe,  e.g., relationship prob-
lems, difficulties at work or school, or
discrimination.7. Are there any kinds of stresses that make
your [PROBLEM] worse, such as difficul-
ties with money, or family problems?
ROLE OF CULTURAL  IDENTITY
(Cultural Identity, Psychosocial Stressors, Relig ion and Spirituality, Immigrants and Refugees,
Older Adults, Children and Adolescents)
Sometimes, aspects of people’s back-
ground or identity can make their [PROB-
LEM] better or worse. By background or
identity,  I mean, for example, the commu-
nities you belong to, the languages you
speak, where you or your family are from,
your race or ethnic background, your gen-
der or sexual orientation, or your faith or
religion.
Ask the individual to reflect  on the most salient ele-
ments of his or her cult ural identity. Use this


ments of his or her cult ural identity. Use this
information to tailor questions 9–10 as needed.8. For you, what are the most important
aspects of your back ground or identity?
Elicit aspects of identity that make the problem bet-
ter or worse.
Probe as needed (e.g., cl inical worsening as a result
of discrimination due to  migration status, race/
ethnicity, or sexual orientation).9. Are there any aspects of your background
or identity that make a difference to your
[PROBLEM]?
Probe as needed (e.g., migration-related problems;
conflict across generations or due to gender roles).10. Are there any aspects of your background
or identity that are causing other concerns
or difficulties for you?
CULTURAL FACTORS AFFECTING SELF- COPING AND PAST HELP SEEKING
SELF-COPING
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers,
Psychosocial Stressors)
Clarify self-coping for the problem. 11. Sometimes people have various ways of
dealing with problems like [PROBLEM].
What have you done on your own to cope
with your [PROBLEM]?Cultural Formulation Interview (CFI) (continued)
Supplementary modules used to  expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWERINSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED.


754 Cultural Formulation
PAST HELP SEEKING
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Care givers, Psychosocial
Stressors, Immigrants and Refu gees, Social Network, Clinician-Patient Relationship)
Elicit various sources of help (e.g., medical care,
mental health treatment,  support groups, work-
based counseling, folk healing, religious or spiri-
tual counseling, other form s of traditional or alter-
native healing).
Probe as needed (e.g., “What other sources of help
have you used?”).
Clarify the indivi dual’s experience and regard for
previous help.12. Often, people look for help from many dif-
ferent sources, including different kinds of
doctors, helpers, or healers. In the past,
what kinds of treatment, help, advice, or
healing have you sought for your [PROB-
LEM]?
PROBE IF DOES NOT DESCRIBE USE-
FULNESS OF HELP RECEIVED:
What types of help or treatment were most
useful? Not useful?
BARRIERS
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Psychosocial Stressors, Immi-
grants and Refugees, Social Network, Clinician-Patient Relationship)
Clarify the role of social barriers to help seeking,
access to care, and problems engaging in previous
treatment.
Probe details as needed (e.g., “What got in the
way?”).13. Has anything prevented you from getting
the help you need?
PROBE AS NEEDED:
For example, money, work or family com-
mitments, stigma or discrimination, or lack
of services that unde rstand your language
or background?


of services that unde rstand your language
or background?
CULTURAL FACTORS AFFECT ING CURRENT HELP SEEKING
PREFERENCES
(Social Network, Caregivers, Re ligion and Spirituality, Older Adults, Coping and Help Seeking)
Clarify individual’s cu rrent perceived needs and
expectations of he lp, broadly defined.
Probe if individual lists only one source of help (e.g.,
“What other kinds of help would be useful to you
at this time?”).Now let’s talk some more about the help
you need.
14. What kinds of help do you think would be
most useful to you at this time for your
[PROBLEM]?
Focus on the views of the social network regarding
help seeking.15. Are there other kinds of help that your fam-
ily, friends, or other people have suggested
would be helpful for you now?
CLINICIAN -PATIENT  RELATIONSHIP
(Clinician-Patient Relationship, Older Adults)
Elicit possible concerns abou t the clinic or the clini-
cian-patient relationship, including perceived rac-
ism, language barriers, or cultural differences that
may undermine goodwill, communication, or care
delivery.
Probe details as needed (e.g., “In what way?”).
Address possible barriers to care or concerns about
the clinic and the clinician-patient relationship
raised previously.Sometimes doctors and patients misunder-
stand each other because they come from
different backgrounds or have different
expectations.
16. Have you been concerned about this and is
there anything that we can do to provide
you with the care you need?Cultural Formulation Interview (CFI) (continued)
Supplementary modules used to  expand each CFI subtopic are noted in parentheses.


Supplementary modules used to  expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWERINSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED.


Cultural Formulation 755
Cultural Formulation Interview (CFI)—Informant Version
The CFI–Informant Version co llects collateral information from an informant who is
knowledgeable about the clinical problems and life circumstances of the identified indi-
vidual. This version can be used to suppleme nt information obtained  from the core CFI or
can be used instead of the core CFI when the individual is unable to provide information—
as might occur, for example, with children or  adolescents, floridly  psychotic individuals,
or persons with cognitive impairment.
Cultural Formulation Interv iew (CFI)—Informant Version
GUIDE TO INTERVIEWERINSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED.
The following questions aim to clarify key aspects of
the presenting cl inical problem from the infor-
mant’s point of view. Th is includes the problem’s
meaning, potential sources of help, and expecta-
tions for services.INTRODUCTION FOR THE INFORMANT:
I would like to understand the problems that
bring your family me mber/friend here so
that I can help you and him/her more effec-
tively. I want to know about your  experience
and ideas. I will ask some questions about
what is going on and how you and your fam-
ily member/friend are dealing with it. There
are no right or wrong answers.
RELATIONSHIP WITH THE PATIENT
Clarify the informant’s rela tionship with the indi-
vidual and/or the individual’s family.1. How would you describe your relationship
to [INDIVIDUAL OR TO FAMILY]?
PROBE IF NOT CLEAR:
How often do you see [INDIVIDUAL]?
CULTURAL DEFINITION OF THE PROBLEM


CULTURAL DEFINITION OF THE PROBLEM
Elicit the informant’s view  of core problems and key
concerns.
Focus on the informant’s way of understanding the
individual’s problem.
Use the term, expression, or brief description elicited
in question 1 to identify the problem in subsequent
questions (e.g., “her conflict with her son”).2. What brings your family member/friend
here today?
IF INFORMANT GIVES FEW DETAILS OR
ONLY MENTIONS SYMPTOMS OR A
MEDICAL DIAGNOSIS, PROBE:
People often understand problems in their
own way, which may be similar or differ-
ent from how doctors describe the prob-
lem. How would you describe
[INDIVIDUAL’S] problem?
Ask how informant frames the problem for members
of the social network.3. Sometimes people have different ways of
describing the problem to family, friends,
or others in their community. How would
you describe [INDIVIDUAL’S] problem to
them?
Focus on the aspects of the problem that matter most
to the informant.4. What troubles you most about [INDIVID-
UAL’S] problem?


756 Cultural Formulation
CULTURAL PERCEPTIONS OF CA USE, CONTEXT, AND SUPPORT
CAUSES
This question indicates the meaning of the condition
for the informant, which may be relevant for clini-
cal care.
Note that informants may identify multiple causes
depending on the facet of the problem they are con-
sidering.5. Why do you think this is happening to
[INDIVIDUAL]? What do  you think are the
causes of his/her [PROBLEM]?
PROMPT FURTHER IF REQUIRED:
Some people may explain the problem as the
result of bad things that happen in their life,
problems with others, a physical illness, a
spiritual reason, or many other causes.
Focus on the views of me mbers of the in dividual’s
social network. These may be diverse and vary
from the informant’s.6. What do others in [INDIVIDUAL’S] fam-
ily, his/her friends, or others in the com-
munity think is causing [INDIVIDUAL’S]
[PROBLEM]?
STRESSORS  AND  SUPPORTS
Elicit information on the individual’s life context,
focusing on resources, so cial supports, and resil-
ience. May also probe oth er supports (e.g., from co-
workers, from participation in religion or spiritu-
ality).7. Are there any kinds of supports that make
his/her [PROBLEM] better, such as from
family, friends, or others?
Focus on stressful aspects of  the individual’s environ-
ment. Can also probe, e.g., relationship problems, dif-
ficulties at work or school, or discrimination.8. Are there any kinds of stresses that make


his/her [PROBLEM] worse, such as diffi-
culties with money, or family problems?
ROLE OF CULTURAL  IDENTITY
Sometimes, aspects of people’s background
or identity can make the [PROBLEM] better
or worse. By background or identity,  I mean,
for example, the commun ities you belong to,
the languages you speak, where you or your
family are from, your race or ethnic back-
ground, your gender or sexual orientation,
and your faith or religion.
Ask the informant to reflect on the most salient ele-
ments of the individual’s cu ltural identity. Use this
information to tailor questions 10–11 as needed.9. For you, what are the most important
aspects of [INDIVIDUAL’S] background or
identity?
Elicit aspects of identity that make the problem bet-
ter or worse.
Probe as needed (e.g., cl inical worsening as a result
of discrimination due to  migration status, race/
ethnicity, or sexual orientation).10. Are there any aspects of [INDIVIDUAL’S]
background or identity that make a differ-
ence to his/her [PROBLEM]?
Probe as needed (e.g., migration-related problems;
conflict across generations or due to gender roles).11. Are there any aspects of [INDIVIDUAL’S]
background or identity that are causing
other concerns or difficulties for him/her?Cultural Formulation Interv iew (CFI)—Informant Version (continued)
GUIDE TO INTERVIEWERINSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED.


Cultural Formulation 757
CULTURAL FACTORS AFFECTING SELF- COPING AND PAST HELP SEEKING
SELF-COPING
Clarify individual’s self-coping for the problem. 12. Sometimes people have various ways of
dealing with problems like [PROBLEM].
What has [INDIVIDUAL] done on his/her
own to cope with his/her [PROBLEM]?
PAST HELP SEEKING
Elicit various sources of help (e.g., medical care,
mental health treatment,  support groups, work-
based counseling, folk healing, religious or spiri-
tual counseling, other alternative healing).
Probe as needed (e.g., “What other sources of help
has he/she used?”).
Clarify the indivi dual’s experience and regard for
previous help.13. Often, people also look for help from many
different sources, including different kinds
of doctors, helpers, or healers. In the past,
what kinds of treatment, help, advice, or
healing has [INDIVIDUAL] sought for his/
her [PROBLEM]?
PROBE IF DOES NOT DESCRIBE USE-
FULNESS OF HELP RECEIVED:
What types of help or treatment were most
useful? Not useful?
BARRIERS
Clarify the role of social barriers to help-seeking,
access to care, and problems engaging in previous
treatment.14.  Has anything prevented [INDIVIDUAL]
from getting the help he/she needs?
Probe details as needed (e.g., “What got in the
way?”).PROBE AS NEEDED:
For example, money, work or family com-
mitments, stigma or discrimination, or lack
of services that understand his/her lan-
guage or background?


of services that understand his/her lan-
guage or background?
CULTURAL FACTORS AFFECT ING CURRENT HELP SEEKING
PREFERENCES
Clarify individual’s cu rrent perceived needs and
expectations of help, broadly defined, from the
point of view of the informant.
Probe if informant lists only one source of help (e.g.,
“What other kinds of help would be useful to
[INDIVIDUAL] at this time?”).Now let’s talk about the help [INDIVID-
UAL] needs.
15. What kinds of help would be most useful to
him/her at this time for his/her [PROB-
LEM]?
Focus on the views of the social network regarding
help seeking.16. Are there other kinds of help that [INDI-
VIDUAL’S] family, friends, or other people
have suggested would be helpful for him/
her now?
CLINICIAN -PATIENT  RELATIONSHIP
Elicit possible concerns abou t the clinic or the clini-
cian-patient relationship, including perceived rac-
ism, language barriers, or cultural differences that
may undermine goodwill, communication, or care
delivery.
Probe details as needed (e.g., “In what way?”).
Address possible barriers to care or concerns about
the clinic and the clinician-patient relationship
raised previously.Sometimes doctors and patients misunder-
stand each other because they come from
different backgrounds or have different
expectations.
17. Have you been concerned about this, and is
there anything that we can do to provide
[INDIVIDUAL] with the care he/she
needs?Cultural Formulation Interv iew (CFI)—Informant Version (continued)


GUIDE TO INTERVIEWERINSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED.


758 Cultural Formulation
Cultural Concepts of Distress
Cultural concepts of distress  refers to ways that cultural groups experience, understand, and
communicate suffering, behavioral problems, or troubling thoughts and emotions. Three
main types of cultural concepts may be distinguished. Cultural syndromes  are clusters of
symptoms and attributions that tend to co -occur among individuals in specific cultural
groups, communities, or contexts and that ar e recognized locally as coherent patterns of
experience. Cultural idioms of distress  are ways of expressing distress that may not involve
specific symptoms or syndromes, but that pr ovide collective, shared ways of experiencing
and talking about personal or social concerns . For example, everyday talk about “nerves”
or “depression” may refer to widely varying forms of suffe ring without mapping onto a
discrete set of symptoms, syndrome, or disorder. Cultural explanations  or perceived causes
are labels, attributions, or features of an ex planatory model that indicate culturally recog-
nized meaning or etiology for symptoms, illness, or distress.
These three concepts—syndromes, idioms, and explanations—are more relevant to
clinical practice than the older formulation culture-bound syndrome. Specifically, the term
culture-bound syndrome  ignores the fact that clinically important cultural differences often
involve explanations or experience of distress  rather than culturally distinctive configura-
tions of symptoms. Furthermore, the term culture-bound  overemphasizes the local partic-
ularity and limited distribution  of cultural concepts of di stress. The current formulation
acknowledges that all  forms of distress are locally shaped, including the DSM disorders.
From this perspective, many DSM diagnoses can be understood as operationalized proto-
types that started out as cultural syndromes, and became widely accepted as a result of


types that started out as cultural syndromes, and became widely accepted as a result of
their clinical and research utilit y. Across groups there remain  culturally patterned differ-
ences in symptoms, ways of talking about dist ress, and locally perceived causes, which are
in turn associated with coping strategies and patterns of help seeking.
Cultural concepts arise from local folk or  professional diagnost ic systems for mental
and emotional distress, and they may also re flect the influence of biomedical concepts.
Cultural concepts have four key featur es in relation to the DSM-5 nosology:
• There is seldom a one-to-one correspondence of any cultural concept with a DSM diag-
nostic entity; the correspondence is more lik ely to be one-to-many in either direction.
Symptoms or behaviors that might be sort ed by DSM-5 into several disorders may be
included in a single folk concept, and diverse presentations that might be classified by
DSM-5 as variants of a single disorder may be  sorted into several distinct concepts by an
indigenous diagnostic system.
• Cultural concepts may apply to a wide range of severity, including presentations that
do not meet DSM criteria for any mental disorder. For example, an individual with acute
grief or a social predicament may use the same idiom of distress or display the same
cultural syndrome as another individual  with more severe psychopathology.
• In common usage, the same cultural term frequently denotes more than one type of
cultural concept. A familiar example may be the concept of “depression,” which may
be used to describe a syndrome (e.g., major depressive disorder), an idiom of distress
(e.g., as in the common expression “I feel depressed”), or a perceived cause (similar to
“stress”).
• Like culture and DSM itself, cultural concepts  may change over time in response to both


• Like culture and DSM itself, cultural concepts  may change over time in response to both
local and global influences.
Cultural concepts are important to ps ychiatric diagnosis for several reasons:
•To avoid misdiagnosis:  Cultural variation in symptoms and in explanatory models as-
sociated with these cultural co ncepts may lead clinicians to  misjudge the severity of a


Cultural Formulation 759
problem or assign the wrong diagnosis (e.g., unfamiliar spiritual explanations may be
misunderstood as psychosis).
•To obtain useful clinical information:  Cultural variations in symptoms and attribu-
tions may be associated with particular fe atures of risk, res ilience, and outcome.
•To improve clinical rapport and engagement:  “Speaking the language of the patient,”
both linguistically and in terms of his or her dominant concepts and metaphors, can re-
sult in greater communication and satisfac tion, facilitate treatment negotiation, and
lead to higher rete ntion and adherence.
•To improve therapeutic efficacy:  Culture influences the psychological mechanisms of
disorder, which need to be understood and addressed to improve clinical efficacy. For
example, culturally specific catastrophic co gnitions can contribute to symptom escala-
tion into panic attacks.
•To guide clinical research:  Locally perceived connections  between cultural concepts
may help identify patterns of comorbidity and underlying biological substrates.
•To clarify the cu ltural epidemiology:  Cultural concepts of distress are not endorsed
uniformly by everyone in a given culture. Distinguishing syndromes, idioms, and ex-
planations provides an approach for studying the distribution of cultural features of ill-
ness across settings and regions, and over time. It also suggests qu estions about cultural
determinants of risk, course, and outcome in clinical and community settings to en-
hance the evidence base of cultural research.
DSM-5 includes information on cultural conc epts in order to improve the accuracy of
diagnosis and the comprehensiveness of clinical assessment. Clinical assessment of indi-
viduals presenting with thes e cultural concepts should determine whether they meet
DSM-5 criteria for a spec ified disorder or an other specified or unspecified  diagnosis. Once the


disorder is diagnosed, the cultural terms and explanations should be included in case for-
mulations; they may help clarify symptoms and etiological a ttributions that could other-
wise be confusing. Individuals whose sympto ms do not meet DSM criteria for a specific
mental disorder may still expect  and require treatment; this should be assessed on a case-
by-case basis. In addition to the CFI and its supplementary modules, DSM-5 contains the
following information and tools that may be useful when integrating cultural information
in clinical practice:
•Data in DSM-5 criteria and text for specific disorders:  The text includes information
on cultural variations in prevalence, sy mptomatology, associate d cultural concepts,
and other clinical aspects. It is important to emphasize that there is no one-to-one cor-
respondence at the categorical level between  DSM disorders and cultural concepts. Dif-
ferential diagnosis for individuals must th erefore incorporate in formation on cultural
variation with information elicited by the CFI.
•Other Conditions That May Be a Focus of Clinical Attention: Some of the clinical con-
cerns identified by the CFI may correspond to V codes or Z code s—for example, accul-
turation problems, parent-child relational pr oblems, or religious or spiritual problems.
•Glossary of Cultural Concepts of Distress:  Located in the Appendix, this glossary pro-
vides examples of well-studied cultural concepts of distress  that illustrate the relevance
of cultural information for c linical diagnosis and s ome of the interrelationships among
cultural syndromes, idioms of di stress, and causal explanations.


761Alternative DSM-5 Model for
Personality Disorders
The current approach  to personality disorders appe ars in Section II of DSM-5,
and an alternative model developed for DSM-5 is presented here in Section III. The inclu-
sion of both models in DSM-5 reflects the de cision of the APA Board of Trustees to pre-
serve continuity with current clinical practi ce, while also introducing a new approach that
aims to address numerous shor tcomings of the current approa ch to personality disorders.
For example, the typical patient meeting criter ia for a specific personality disorder fre-
quently also meets criteria for other personalit y disorders. Similarly, other specified or un-
specified personality disorder is  often the correct (but mostly  uninformative) diagnosis, in
the sense that patients do not tend to present with patterns of symptoms that correspond
with one and only one personality disorder.
In the following alternative DSM-5 model, personality disorders are characterized by
impairments in personality functioning  and pathological personality traits.  The specific
personality disorder diagnoses that may be derived from this model include antisocial,
avoidant, borderline, narcissis tic, obsessive-compulsive, an d schizotypal personality dis-
orders. This approach also includes a diagno sis of personality disorder—trait specified
(PD-TS) that can be made when a personality disorder is considered  present but the crite-
ria for a specific disorder are not met.
General Criteria for Personality Disorder
General Criteria for Personality Disorder
The essential features of a personality disorder are
A. Moderate or greater impairment in personality (self/interpersonal) functioning.
B. One or more pathological personality traits.
C. The impairments in personality functioning and the individual’s personality trait expres-
sion are relatively inflexible and pervasive across a broad range of personal and social
situations.


situations.
D. The impairments in personality functioning and the individual’s personality trait expres-
sion are relatively stable across time, with onsets that can be traced back to at least
adolescence or early adulthood.
E. The impairments in personality functioning and the individual’s personality trait expres-
sion are not better explained by another mental disorder.
F. The impairments in personality functioning and the individual’s personality trait expres-
sion are not solely attributable to the physiological effects of a substance or another
medical condition (e.g., severe head trauma).
G. The impairments in personality functioning and the individual’s personality trait expres-
sion are not better understood as normal for an individual’s developmental stage or so-
ciocultural environment.


762 Alternative DSM-5 Model for Personality Disorders
A diagnosis of a personality disorder requires  two determinations: 1) an assessment of
the level of impairment in personality functi oning, which is needed for Criterion A, and 2)
an evaluation of pathological personality trai ts, which is required for Criterion B. The im-
pairments in personality functioning and person ality trait expression are relatively inflex-
ible and pervasive across a broad range of pers onal and social situations (Criterion C);
relatively stable across time, with onsets that can be traced back to at least adolescence or
early adulthood (Criterion D); not better explained by another mental disorder (Criterion
E); not attributable to the effects of a substance or another medical condition (Criterion F);
and not better understood as normal for an individual’s developmental stage or sociocul-
tural environment (Criterion G). All Section II I personality disorders described by criteria
sets, as well as PD-TS, meet these general criteria, by definition.
Criterion A: Level of Personality Functioning
Disturbances in self  and interpersonal  functioning constitute the core of personality psy-
chopathology and in this alternative diagnostic  model they are evaluated on a continuum.
Self functioning involves identity and sel f-direction; interpersonal functioning involves
empathy and intimacy (see Table 1). The Level of Personality Functioning Scale (LPFS; see
Table 2, pp. 775–778) uses each of these elements to differentiate five levels of impairment,
ranging from little or no impair ment (i.e., healthy, adaptive functioning; Level 0) to some
(Level 1), moderate (Level 2), severe (Lev el 3), and extreme (Level 4) impairment.
Impairment in personality functioning predicts the presence of a personality disorder,


Impairment in personality functioning predicts the presence of a personality disorder,
and the severity of impairment predicts whet her an individual has more than one person-
ality disorder or one of the more typically se vere personality disorders. A moderate level
of impairment in personality functioning is re quired for the diagnosis of a personality dis-
order; this threshold is based on empirical ev idence that the moderate level of impairment
maximizes the ability of clinicians to accurate ly and efficiently identify personality disor-
der pathology.
Criterion B: Pathological Personality Traits
Pathological personality traits are organized into five broad domain s: Negative Affectiv-
ity, Detachment, Antagonism, Disinhibition, and Psychoticism. Within the five broad trait
domains  are 25 specific trait facets  that were developed initially  from a review of existing
trait models and subsequently through iterat ive research with samples of persons who
sought mental health services. The full trait taxonomy is presented in Table 3 (see pp. 779–
781). The B criteria for the spec ific personality disorders comp rise subsets of the 25 traitTABLE 1 Elements of personality functioning
Self:
1. Identity:  Experience of oneself as unique, with clear boundaries between self and others; sta-
bility of self-esteem and accuracy of self-apprai sal; capacity for, and ability to regulate, a
range of emotional experience.
2. Self-direction:  Pursuit of coherent and meaningful short-term and life goals; utilization of
constructive and prosocial internal standards of behavior; ability to self-reflect productively.
Interpersonal:
1.Empathy:  Comprehension and appreciation of others’ experiences and motivations; tolerance
of differing perspectives; understanding the effects of one’s own behavior on others.


of differing perspectives; understanding the effects of one’s own behavior on others.
2. Intimacy:  Depth and duration of connection with ot hers; desire and capa city for closeness;
mutuality of regard reflected in interpersonal behavior.


Alternative DSM-5 Model for Personality Disorders 763
facets, based on meta-analytic reviews and empi rical data on the relationships of the traits
to DSM-IV personality disorder diagnoses.
Criteria C and D: Perv asiveness and Stability
Impairments in personality functioning an d pathological pers onality traits are relatively  per-
vasive across a range of personal and social contexts, as personality is defined as a pattern of
perceiving, relating to, and thinking about the environm ent and oneself. The term relatively
reflects the fact that all except the most extr emely pathological personalities show some de-
gree of adaptability. The pattern in personality disorders is maladaptive and relatively inflex-
ible, which leads to disabilities in social, o ccupational, or other important pursuits, as
individuals are unable to modify their thinking or behavior, even in th e face of evidence that
their approach is not working. The impairments in functioning and personality traits are also
relatively  stable. Personality traits—the dispositions  to behave or feel in certain ways—are
more stable than the symptomatic expressions of  these dispositions, but personality traits can
also change. Impairments in personality fu nctioning are more stable than symptoms.
Criteria E, F, and G: Al ternative Explanations for
Personality Pathology (D ifferential Diagnosis)
On some occasions, what appears to be a pe rsonality disorder may be better explained by
another mental disorder, the effects of a subs tance or another medica l condition, or a nor-
mal developmental stage (e.g., adolescence, late  life) or the individu al’s sociocultural en-
vironment. When another ment al disorder is present, the diagnosis of a personality
disorder is not made, if the manifestations of  the personality disorder clearly are an ex-