Most people first seek help for mental distress from someone they already know, often a primary care physician, clinic nurse, home health aide, or other practitioner whose training is outside mental health. In fact, most mental health care occurs outside the offices of mental health practitioners. To address the gap between the mental health training of non–mental health practitioners and the volume of mental health care they provide, DSM-5 offers screening tools—the Level 1 and Level 2 Cross-Cutting Symptom Measures—for use in either primary care or mental health settings. These brief, easy-to-read, paper-based tools can be completed before a clinical encounter, either by the patient or by someone who knows her well. The tools, which are available in Section III of DSM-5 and online at https://www.psychiatry.org/dsm5, can be reproduced and used, without additional permission, for clinical and research evaluations.

Each of these tools has a series of questions about recent symptoms (e.g., the Level 1 Cross-Cutting Symptom Measure—Adult asks, “During the past two [2] weeks, how much [or how often] have you avoided situations that make you anxious?”). These screening questions assess core symptoms for the major diagnoses. For example, for each Level 1 symptom statement, a patient or her caregiver will assess how much this bothered the patient using a 5-point scale: none (0), slight (1), mild (2), moderate (3), or severe (4). Each tool is designed to be easily scored. If a patient reports a clinically significant problem in any domain, you should consider a more detailed assessment tool (e.g., one designed for assessing anxiety).

The initial assessment to use with older adults is the Level 1 Cross-Cutting Symptom Measure—Adult, which contains 23 questions to be completed by the person seeking assessment before an initial evaluation or by the caregiver of an older adult. For most, but not all, of the symptom domains screened for in the Level 1 tool, there are separate Level 2 Cross-Cutting Symptom Measures for specific areas of concern, including depression, anger, mania, anxiety, somatic symptoms, sleep disturbances, repetitive thoughts and behaviors, and substance use.

Level 1 and 2 assessments initially help a practitioner identify and characterize the presenting problems. After the initial assessment, they can be used to help measure treatment response and progress toward recovery. The authors of DSM-5 suggest using the Cross-Cutting Symptom Measures at the first evaluation of a patient, in part to establish her baseline, and then revisiting that assessment periodically to assess her progress. These measures assess dimensions rather than diagnoses, which means they are not designed to tell the degree of likelihood of identifying a specific diagnosis. Their strength is that they allow you to track different symptom domains (e.g., the depressive symptoms of a patient with schizophrenia in addition to her psychotic symptoms).

Systematic use of these cross-cutting assessments will alert you to significant changes in a patient’s symptomatology and will provide measurable outcomes for treatment plans. They also may alert researchers to lacunae in the current diagnostic system.

For your convenience, the Level 1 tool appears in Figure 11–1. Practitioners using the Level 1 tool are encouraged to further explore all reports of problems with inattention, psychosis, substance use, and suicidal ideation or attempts, even those rated as 1 (slight). For the other domains, practitioners are encouraged to explore symptoms rated 2 (mild) or greater. The Level 2 measures are easily accessed online at https://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures.

Another way the authors of DSM-5 have attempted to improve the diagnostic system is by attending to the cultural specificity of mental distress and illness. Asking about a patient’s and caregiver’s cultural understanding of sickness and health is an efficient way to build a therapeutic alliance while gathering pertinent information (Lim 2015). In addition, performing a cultural assessment also personalizes the diagnosis, which increases its accuracy (Bäärnhielm and Scarpinati Rosso 2009). In Section III of DSM-5, “Cultural Formulation” (pp. 749–759), the authors discuss cultural syndromes, idioms of distress, and explanations of perceived causes.

Before we discuss using this cultural information in an interview, we should first define a few terms. A cultural syndrome is a group of clustered psychiatric symptoms specific to a particular culture or community. The syndrome may or may not be recognized as an illness by members of a community or by observers. A classic example is ataque de nervios, a syndrome of mental distress characterized by the sudden onset of intense fear, often experienced physically as a sensation of heat rising in the chest, that may result in aggressive or suicidal behavior (Lewis-Fernández et al. 2015). The syndrome is often associated with familial distress in Latino communities (Lizardi et al. 2009). A cultural idiom of distress, such as ataque de nervios, is a way of discussing mental distress or suffering shared by members of a particular community. Finally, a cultural explanation or perceived cause provides an explanatory model of why mental distress or illness occurs (American Psychiatric Association 2013). By its authors’ own admission, DSM-5 is one culturally shaped way of accounting for distress; the authors state, “The current formulation acknowledges that all forms of distress are locally shaped, including the DSM-5 disorders” (American Psychiatric Association 2013, p. 758). So how do you acknowledge the effects of culture on distress?

The Cultural Formulation Interview (CFI) is a structured tool, updated for DSM-5, to assess the influence of culture in a particular patient’s experience of distress. You can use the CFI at any time during an interview, but the authors of DSM-5 suggest using it when a patient seems disengaged, when you are struggling to reach a diagnosis, or when you are laboring to assess the dimensional severity of a diagnosis. Although use of the CFI has been studied mostly in immigrant communities (Martínez 2009), you should not limit its use to situations in which you perceive the patient as culturally different from yourself. You can use the CFI profitably in any setting because “cultural” accounts of why people get ill and why they return to health occur not only in immigrant communities but in all communities. Even when you believe that a person shares your own cultural account of illness and health, she may have a very different understanding of why people become ill and how they can become well. Furthermore, the CFI is the most patient-centered portion of DSM-5, and using it particularizes the diagnostic process.

The CFI is not a scored system of symptoms but rather a series of prompts to help you assess how a patient understands her distress, its etiology, its treatment, and the prognosis. The CFI can be incorporated into a diagnostic examination to personalize the diagnosis and build a therapeutic alliance. If you want to learn more about the CFI, you should review the materials in Section III of DSM-5 or read the DSM-5 Handbook on the Cultural Formulation Interview (Lewis-Fernández et al. 2015). The following is as an operationalized adaptation divided into five themes. Just as in the rest of this book, the italicized portions are interview prompts.

Related posts:

The 15-Minute Older Adult Diagnostic Interview Introduction The DSM-5 Older Adult Diagnostic Interview Psychoeducational Interventions Rating Scales and Alternative Diagnostic Systems Psychosocial Interventions

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