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

The DSM-5-TR Level 1 Cross-Cutting Symptom Measure is a 23-item self- or informant-rated screener from the American Psychiatric Association that checks 13 mental health domains in adults, so clinicians can see which areas need a closer look ^[1].

Foundational context

The Level 1 Cross-Cutting Measure was developed and tested in the DSM-5 field trials to improve early identification of symptoms that span diagnostic boundaries ^[1]. Traditional categorical diagnoses can obscure comorbidity or evolving symptom pictures; the Level 1 Measure brings those patterns into view through a brief, structured self-report.

In the field trials it showed good test-retest reliability in adult clinical samples ^[1], and clinicians and clients in routine practice found it clinically useful ^[2].

What does the DSM-5-TR Level 1 measure?

The Level 1 Measure screens symptoms across 13 mental health domains, including depression, anxiety, sleep problems, trauma-related symptoms, psychosis, dissociation, substance use, and more. Each item captures symptom severity over the past two weeks on a 0–4 scale (“None” → “Severe”).

Instructions to clinicians

The DSM-5-TR Level 1 Cross-Cutting Symptom Measure is a self- or informant-rated measure that assesses mental health domains that are important across psychiatric diagnoses. It is intended to help clinicians identify additional areas of inquiry that may have significant impact on the individual’s treatment and prognosis. In addition, the measure may be used to track changes in the individual’s symptom presentation over time.

This adult version of the measure consists of 23 questions that assess 13 psychiatric domains, including depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use. Each item inquires about how much (or how often) the individual has been bothered by the specific symptom during the past 2 weeks.

If the individual is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a knowledgeable adult informant may complete the measure. The measure was found to be clinically useful and to have good test-retest reliability in the DSM-5-TR Field Trials that were conducted in adult clinical samples across the United States and in Canada.

How do you give the DSM-5-TR Level 1?

The adult Level 1 measure is completed by the client, usually before the clinical interview, in about 5–10 minutes. Each of the 23 items asks how much (or how often) the person has been bothered by a symptom during the past 2 weeks. If the individual is of impaired capacity and unable to complete the form, a knowledgeable adult informant may complete it instead, ideally the same informant at follow-up.

• Suitable for intake, triage, and monitoring
• Complements targeted assessment workflows
• Helps identify comorbidity early
• Works across mental health and primary care settings
• Requires follow-up assessment for elevated domains

The DSM-5-TR Level 2 Cross-Cutting Symptom Measures may be used to provide more detailed information on the symptoms associated with some of the Level 1 domains. Domain-specific scales such as the PHQ-9 for depression, the GAD-7 for anxiety and the AUDIT for alcohol use can also follow up an elevated domain.

How do you score and interpret the DSM-5-TR Level 1?

Scoring structure

Each item on the measure 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.

Additional inquiry is based on the highest score on any item within a domain, so the clinician is asked to indicate that score in the “Highest Domain Score” column.

A rating of mild (i.e., 2) or greater on any item within a domain (except for substance use, suicidal ideation, and psychosis) may serve as a guide for additional inquiry and follow up to determine if a more detailed assessment for that domain is necessary.

For substance use, suicidal ideation, and psychosis, a rating of slight (i.e., 1) or greater on any item within the domain may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is needed.

• Items scored 0–4
• No total score
• Interpretation is domain-specific

Clinical meaning

• Any nonzero suicidal ideation → prompt clinical follow-up
• Mild symptoms (score of 1) may still be clinically relevant when persistent or impairing

Frequency of use

To track change in the individual’s symptom presentation over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status. For individuals with impaired capacity, it is preferable that the same knowledgeable informant completes the measures at follow-up appointments.

Consistently high scores on a particular domain may indicate significant and problematic symptoms for the individual that might warrant further assessment, treatment, and follow-up. Clinical judgment should guide decision making.

Psychometric properties

• Field trials. In the DSM-5 Field Trials (seven adult sites in the United States and Canada), test-retest reliabilities of the adult cross-cutting items were generally good to excellent; retest interviews were 4 hours to 2 weeks apart ^[1].
• Routine practice. In routine clinical practice field trials (621 clinicians, 1,269 clients), 52% of adult clients reported the cross-cutting measures would help their clinicians better understand their symptoms ^[2].
• Japanese validation. In a Japanese general-population sample, the total score showed high internal consistency, test-retest reliability and convergent validity, but several individual items had low test-retest reliability and the measure mainly captured internalizing symptoms ^[3].

Limitations

• Not diagnostic; only flags areas of concern
• Some domains (SI, psychosis) require immediate clinical assessment
• Limited depth per domain (1–3 items each)
• Relies on client self-report, which may be influenced by insight, mood, or context
• Several individual items showed low test-retest reliability in a Japanese general-population sample ^[3]