D ETERMINACIÓN DE R ECURSOS D IRECTOS

After determining whether the person meets criteria for a DSM-5 diagnosis, the evaluator should evaluate if there are any diagnostic subtypes or speci- fiers that apply. Under DSM-5’s diagnostic scheme, subtypes are mutually exclusive subgroupings within a particular diagnosis that are indicated by the manual’s instruction “specify whether” included in the diagnostic criteria. Under this definition, an individual cannot be diagnosed with two subtypes of a disorder. Examples of mental disorders that include mutually exclusive subtypes are illness anxiety disorder, encopresis, and narcolepsy [1(p21)].

In contrast to subtypes, DSM-5 specifiers are identified in the diagnos- tic set by the instruction “specify” or “specify if.” Specifier types include course specifiers (e.g., full or partial remission), severity specifiers, fre- quency specifiers, cross-cutting symptom specifiers, duration specifiers, descriptive feature specifiers (e.g., with poor insight), and environmental specifiers (e.g., in a controlled environment). Severity and course specifiers are only used to describe a person’s current presentation and only when the person meets full criteria for a diagnosis. When a person has an “other specified/unspecified” diagnosis, severity and course specifiers cannot be used. There are a variety of specifiers and their definitions and applications are summarized below [1(p22)].

Provisional specif ier

Under DSM-5, a diagnosis can also be recorded with the specifier “provi- sional” in two circumstances. First, when there is a “strong presumption”

that full diagnostic criteria will ultimately be met but there is not enough information available to make a diagnosis at the time of the evaluation [1 (p23)]. Consider the following example where a provisional disorder may be appropriate.

In this situation, the psychiatrist could record Michael’s diagnosis as fol- lows:  major depressive disorder (provisional). There may be presentations where the evaluator is struggling with whether to assign a “provisional” specifier diagnosis versus an “other specified/unspecified” diagnostic desig- nation. The main point to consider in this circumstance is DSM-5’s empha- sis on using the provisional specifier in situations in which there is a strong

presumption the person will meet criteria for the disorder. This contrasts

with the “other specified/unspecified” designation, which can be used in cir- cumstances where additional information does not (or is unlikely to) provide sufficient criteria or there remains general diagnostic uncertainty about the underlying etiology of the presenting symptoms.

Second, the provisional specifier may be used in situations in which the differential diagnosis depends exclusively on the illness duration. For exam- ple, a person who meets the duration criteria for schizophreniform disor- der (i.e., symptom duration more than one month but less than six months) would be diagnosed with “schizophreniform disorder, provisional.”

Severity specif iers

In DSM-5, the method of rating the severity of a mental disorder varies according to the disorder. For some disorders, the severity depends a speci- fied number of recorded symptoms. Substance use disorders, for example, are rated as either mild, moderate, or severe based on an established number of symptoms required for each severity level. In contrast, the severity level

VIGNETTE 1

Michael is a 39-year-old man who is taken to the emergency room after his wife found him nonresponsive in their bedroom as a result of an overdose of sleeping medication. His wife tells the emergency room psychiatrist that he has experienced severe insomnia, problems concen- trating at work, and social withdrawal over the past month. However, because he is nonresponsive, the psychiatrist cannot establish that he meets full criteria for major depressive disorder. How should the psy- chiatrist code Michael’s diagnosis?

determination of intellectual disability involves a more subjective assess- ment of the person’s adaptive functioning in three domains, without any clear cutoff scores, specified number of symptoms, or required assessment instrument. Many disorders (e.g., depressive disorders and bipolar and related disorders) are rated as “mild, moderate, or severe” depending on how many symptoms are present, the significance of symptoms, and the degree to which the symptoms impair the individual’s functioning [1 (p154, p188)]. Unlike substance use disorders, this rating method does not provide a spe- cific number of required criterion symptoms but does require an analysis of symptom severity and degree of disability. In this context, evaluators are likely to use disparate methods to evaluate symptom severity and disability as no particular assessment tools are mandated.

Section III of DSM-5 provides examples of “emerging measures” sug- gested for use in further clinical evaluation and research and to assess symptom severity. “Cross-cutting symptom measures” (Level 1 and Level 2)  are patient- or informant-rated measures used to assess a variety of men- tal health domains from a range of possible disorders. In contrast to cross-cutting symptom measures, “severity measures” are disorder-specific with criteria that generally correspond to the DSM-5 diagnostic criteria. DSM-5 discusses these severity measures, and the corresponding DSM-5 website provides specific severity disorder assessments. On the DSM-5 web- site, there are 10 self-report disorder-specific severity ratings for adults and 10 self-report disorder-specific severity ratings for children and adolescents. In addition, there are four clinician-rated disorder-specific severity ratings and two clinician-rated severity ratings that are not specific to any disor- der (e.g., ratings of nonsuicidal behavior and psychosis). All of these rating schemes are included in Section III, “emerging measures,” and therefore are not a mandatory component of assessment.

Evaluators who elect to use these assessment instruments should be famil- iar with the reliability and validity of these instruments and the evidence to support their use. In addition, many of these instruments have ratings that do not correspond to the DSM-5 criteria used to rate diagnosis severity. As an example, for the diagnosis of major depressive disorder, DSM-5 requires at least five depressive symptoms during the same 2-week period. According to DSM-5, the severity of depression is based on how many symptoms are present. In addition, seven of these symptoms must be present “nearly every day” over a 2-week time frame [1(p160–161)]. The suggested severity mea- sure for depression on the DSM-5 web site is one adapted from the Patient Health Questionnaire-9 (PHQ-9). In contrast to DSM-5 depression crite- ria, the PHQ-9 assesses symptoms over a 1-week period and severity levels depend on the frequency of each symptom (i.e., not at all, several days, more than half the days, and nearly every day). It is very possible to receive a rat- ing of “moderately severe depression” on the PHQ-9 but not even meet the

DSM-5 threshold to qualify for a diagnosis of depression. To prevent such conflicting and confusing results, it is recommended that the evaluator fol- low the DSM-5 diagnostic guidelines for rating severity included in the diag- nosis criteria set.

Psychosis severity specifier

The DSM-5 section titled “Schizophrenia Spectrum and Other Psychotic Disorders” includes the following mental disorders: delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffec- tive disorder, substance/medication-induced psychotic disorder, and psy- chotic disorder due to another medical condition. In each of these diagnostic criteria set, the manual instructs the evaluator to provide a “quantitative” evaluation of the following five major psychotic symptom categories: delu- sions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. DSM-5 also suggests that clinicians consider rating symptom severity for the week prior to the evaluation [1 (p97)].

For all psychotic disorders listed in Section II, the DSM-5 also references an assessment instrument titled “Clinician-Rated Dimensions of Psychosis Symptom Severity” (CRDPSS). However, the actual instrument is included in Section III, a section that includes emerging measures and models that have not yet been included as part of the required DSM-5 diagnostic crite- ria. Because severity of psychosis may be particularly relevant in a variety of forensic and clinical contexts, an understanding of the CRDPSS is impor- tant in determining the appropriateness of its use. This instrument mea- sures eight symptom dimensions that occur in individuals with psychotic disorders. The eight dimensions measured by this instrument include the five Criterion A symptoms of schizophrenia (hallucinations, delusions, dis- organized speech, abnormal psychomotor behavior, and negative symptoms)

plus impaired cognition, depression, and mania. The instrument’s authors

emphasize that symptom severity varies across individuals with psychosis thereby necessitating a dimensional assessment to measure this variability and to track the symptom course over time [3] .

This CRDPSS uses a 5-point Likert scale to rate each of eight symptom dimensions. The five possible ratings are as follows: 0=not present; 1=equivo- cal; 2=present, but mild; 3=present and moderate; and 4=present and severe. Although cutoff scores are not included in the DSM-5, in a separate publi- cation the instrument’s authors note that a score of 2 or higher “should be considered sufficient severity to fulfill a Criterion A diagnostic indicator for schizophrenia” [3 (p16)]. Barsh et al. [3] provide their own definitions of how to rate each dimension. For example, the severity of hallucinations and delu- sions depends on the degree to which the person feels pressured to respond

to the voices/delusions or is bothered by the voices/delusions. Other ques- tions typically asked by forensic examiners to evaluate the severity of hallu- cinations and delusions are not included in the rating. It is unclear from the DSM-5 manual or the literature how the authors chose the final factors to determine symptom severity, the evidence base to support their inclusion or exclusion of factors, and how the validity and reliability of this instrument was established (if at all).

Because of the limited research on the use of the CRDPSS, forensic evalu- ators can expect a rigorous cross-examination by knowledgeable attorneys if they use this instrument to rate the severity of psychotic disorders.

The evaluator may wish to consider the following options when evaluating psychotic disorders:

Option 1:  Because DSM-5 explicitly states that a severity rating is not required to make a schizophrenic spectrum disorder diagnosis, the examiner could chose to make the diagnosis without including the sever- ity specifier. However, the severity of a person’s psychosis is often very important in forensic and clinical contexts. An examiner who provides no quantitative assessment of psychosis severity may be limited on the degree of “quantitative” information they can provide relevant to key legal issues and relevant to determining the appropriate treatment and response to treatment. However, the evaluator could provide “qualitative” examples about the individual’s psychotic symptoms. For example, if a woman stabs her three children to death based on command hallucina- tions from her deceased mother that she must do so, the examiner could appropriately communicate that this woman’s psychotic symptoms are very severe when she is symptomatic.

Option 2: Because DSM-5 notes that psychosis severity is rated by a quan- titative assessment of delusions, hallucinations, disorganized speech, abnormal psychomotor behavior and negative symptoms, the evaluator could rate only the first five CRDPSS items (which corresponds to these five Criterion A  symptoms of schizophrenia). The caveats noted above about the known reliability and validity of this instrument and its use in a legal setting should be considered if this option is chosen.

Option 3: The evaluator could assess all eight dimensions of the CRDPSS even though not required to do so for purposes of rating severity. The caveats noted above about the known reliability and validity of this instrument and its use in a legal setting should be considered if this option is chosen.

Option 4:  The evaluator could choose not to use the CRDPSS and instead administer an alternate evidence-based assessment that has demon- strated efficacy in rating the five required psychotic dimensions.

Validated measures of psychotic symptom severity are available, and two of these are briefly summarized below.

The Positive and Negative Syndrome Scale (PANNS) is a well established and valid clinician-administered instrument used to measure the severity of schizophrenia symptoms [4] . The PANSS has good interrater reliability when rated by trained and well qualified examiners [4, 5]. The PANSS has 30 items accompanied by a specific definition and detailed anchoring crite- ria for seven rating points (ranging from 1=absent to 7=extreme). Ratings are generally made by assessing the person’s symptoms during the past week. The PANSS has three scales: the Positive Scale (P), Negative Scale (N), and General Psychopathology Scale (G). All five Criterion A symptoms that require a quantitative rating are well covered on the PANNS. In addition, the PANNS can yield a negative symptom factor score (NSFS) that includes five items from the negative scale and two items from the general psychopathol- ogy scale. This score has demonstrated good validity and test-retest reliabil- ity as a negative symptom assessment for patients with prominent negative or disorganized thought symptoms [6].

The Brief Psychiatric Rating Scale (BPRS) Expanded Version (4.0) is another commonly used instrument to assess psychiatric symptoms that include, but are not limited to, psychotic symptoms. There are 24 items on this instrument with some items rated based on the patient’s self-report, some items rated based on observed behavior, and some items rated on the basis of observed behavior and speech. The items are scored on a seven-point scale, with higher ratings equating with more severe symptoms. Although there is no unique scale to measure delusions, the BPRS includes an evalu- ation of specific types of delusions on various scales, including the somatic concern scale, guilt scale, grandiosity scale, suspiciousness scale, and unusual thought content scale [7] . As with the PANNS, this instrument evaluates symptom severity in the five required areas.

When deciding whether or not to use one of these validated instruments, the examiner should be aware of two caveats. First, the severity ratings are for a defined period of time (e.g., typically the past week). Consider the above example of the woman who stabbed her three children to death with an obvious history of severe psychosis. If she responds to treatment, her scores on the PANSS or BPRS could indicate that her symptoms are “mild” or “absent.” Although this may be useful clinical information and important to her current risk evaluation, this score alone would not accurately reflect the severity of her illness when she is not in clinical remission. In a foren- sic context, if an evaluator chooses to use a quantitative severity-rating instrument, it is highly recommended that they also provide a qualitative description of the person’s psychosis severity when they are symptomatic. Second, retrospective ratings of a person’s psychotic symptoms using the

PANNS or BPRS may be difficult and not consistent with the administration guidelines.

Although DSM-5 does not require a severity rating of cognitive impair- ment, depression, or mania for purposes of rating the severity of psychotic disorders, the CRDPSS includes these three dimensions. Rating the dimen- sion of impaired cognition on this instrument may prove to be particularly difficult. The instrument instructs the evaluator to assess the degree, if any, of reduction in cognitive function below the person’s expected age, socioeco- nomic status, and degree of standard deviation from the mean. No specific cognitive assessment instrument is cited or recommended to rate impaired cognition. The instrument’s authors provide the following guidance for eval- uators in rating this domain:

We would suggest that when possible, clinicians obtain a formal clinical neuropsychological assessment in individuals with psychosis to fully under- stand the nature and severity of their cognitive impairments . . . When it is not possible to obtain a full neuropsychological evaluation, a number of stud- ies have shown that several different brief assessment approaches provide clinically useful information concerning a patient’s general level of cognitive impairment . . . Such measures should be administered and scored by person- nel trained in the use of testing instruments and who are familiar with the expected influence of demographic factors . . . to ensure valid interpretation of observed scores relative to normative data . . . [3 (p18)]

The likelihood and availability of a formal clinical neuropsychological assess- ment will vary greatly depending on the treatment setting and purpose of treatment. Acute psychiatric inpatient units with short lengths of stay whose primary goal is to stabilize the patient are unlikely to have a full neuropsy- chological assessment immediately available or completed by the time of dis- charge. Likewise, many community outpatient centers and private practice clinics are unlikely to have a neuropsychologist available to help rate this domain for all of their patients with psychosis. Barsh et al. [3] acknowledge this limitation and note that if a formal assessment by trained personnel is not possible, then “the clinician should use the best available information to make a judgment about the client’s function, including the clinician’s inter- actions with the patient and/or reports of family members or clinical staff that regularly interact with the patient” [3 (p18)]. However, the instrument’s authors acknowledge the limited utility of this approach as they write, “. . . It is likely that without objective assessments, such ratings will have poor reli- ability and potentially low validity” [3 (p18)]. Although DSM-5 specifically references the use of the CRDPSS to measure psychosis severity, the DSM-5 also notes that additional investigation is needed to determine whether this instrument is helpful in providing treatment [1 (p90)]. Numerous validated

assessments of cognitive impairment are available and a review of these instruments is beyond the scope of this chapter.

“In remission” specif iers

DSM-5 provides the specifiers “in remission,” “in full remission,” or “in partial remission” for several, but not all, DSM-5 disorders. Definitions of “remission,” “full remission,” and “partial remission” vary depending on the specific diagnosis. One confusing application of the specifier “in full remission” is related to the Paraphilic Disorders. In the Paraphilic Disorders section, the “in full remission” specifier notes that the individual must not have engaged a “nonconsenting person” in their paraphilic interests, must not be distressed by their paraphilic interests, or must not demonstrate impairment resulting from their paraphilic interests for at least five years [1 (p687)]. This remission specifier is included in the description of every paraphilic disorder with the exception of pedophilic disorder. Therefore, an evaluator could logically conclude that the drafters of the paraphilic disor- ders criteria wanted to clearly communicate that a person with pedophilic disorder could never be in full remission. However, in the DSM-5 section titled “highlights of changes from DSM-IV to DSM-5,” the DSM-5 text specifically notes that the “in remission” specifier applies to all paraphilic disorders [1 (p816)]. It is unclear whether the remission specifier was mis-

takenly excluded in the text description of pedophilic disorder or whether

the sentence summarizing the changes from DSM-IV to DSM-5 mistakenly

included pedophilic disorder. This confusion is extremely problematic, par-

ticularly for forensic evaluators who are asked to provide status updates of sex offenders and their treatment response.

Cross-cutting symptom specif iers

A significant focus of DSM-5 is the recognition that various psychiatric symptoms are present in a variety of mental disorders. DSM-5 provides cer- tain symptom specifiers that may be used with multiple diagnoses. Two key examples of such cross-cutting symptom specifiers include “panic attack” and “catatonia.”

Panic attack specifier

DSM-5 specifically notes that a panic attack is not a mental disorder and cannot be coded as such. The panic attack specifier requires the presence of

four (or more) of 13 delineated symptoms that represent an abrupt surge of intense fear or discomfort from a calm or anxious state that peaks within minutes of onset. The panic attack specifier can apply to any DSM-5 men- tal disorder and some medical conditions, with the exception of panic dis-