It has appeared to me that the die was cast for the DSM-5 long before the revision process proper was ever underway. I’ve repeatedly mentioned the book A Research Agenda for DSM-V – the 2002 book that set the stage for two major conceptual changes: the inclusion of biological parameters and the addition of dimensional diagnostic criteria. That book was followed by a series of symposiums. While dimensional diagnosis was discussed in many of those conferences, there was one devoted to dimensional diagnosis specifically, and it was published as a separate book in 2007, Dimensional Approaches in Diagnostic Classification: Refining the Research Agenda for DSM-V. Both books are available piecemeal on the Internet. Here’s the reference to the chapter by Helena Chmura Kraemer, the statistician for the DSM-5 Revision:by HELENA CHMURA KRAEMERInternational Journal of Methods in Psychiatric Research. 2007 16[S1]: S8 – S15.
Abstract: An enhancement to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-V] is currently under consideration, one that would enhance both the reliability and validity of the Diagnostic and Statistical Manual [DSM] diagnoses: the addition of a dimensional adjunct to each of the traditional categorical diagnoses of the DSM. We first review the history and context of this proposal and define the concepts on which this dimensional proposal is based. The advantages of dimensional measures over categorical measures have long been known, but we here illustrate what is known with a theoretical and a practical demonstration of the potential effects of this addition. Possible objections to the proposal are discussed, concluding with some general criteria for implementing this proposal.
Like most of the book’s sections, it’s dripping with enthusiasm about the proposed dimensional additions to the DSM-5, mirroring Dr. David Kupfer’s later memo reported by Dr. Jane Costello in her DSM-5 resignation letter:
"…The tipping point for me was the memo from David and Darrell on February 18, 2009, stating “Thus, we have decided that one if not the major difference between DSM-IV and DSM-V will be the more prominent use of dimensional measures in DSM-V”, and going on to introduce an Instrument Assessment Study Group that will advise workgroups on the choice of old scale measures or the creation of new ones."
Dr. Helena Chmura Kraemer was a member of that Instrument Assessment Study Group along with Expert Advisors Drs. Robert Gibbons and Paul Pilkonis, two of the collaborators developing the computerized adaptive testing mentioned below. And all of this is background to two articles in the February American Journal of Psychiatry – an editorial by Drs. Helena Kraemer and Robert Freedman [the Journal’s editor] and the print publication of Dr. Gibbons et al’s paper on their CAT-ANX psychometric test.
American Journal of PsychiatryEditorialComputer Aids for the Diagnosis of Anxiety and Depressionby Helena Chmura Kraemer and Robert FreedmanThe publication of DSM-5 marked many examples of progress in psychiatric diagnosis, but two diagnoses, major depressive disorder and generalized anxiety disorder, the core dysfunctions that psychiatry addresses, did not change from DSM-IV to DSM-5. Yet, these two diagnoses had questionable test-retest reliability in the field tests, although paradoxically, high reliability for patients’ self rating. In this issue of the Journal, Gibbons et al. report on the development and initial testing of computerized adaptive testing to assess patients’ self-perception of their anxiety and depression.
In computerized adaptive testing, patients are first asked general questions, and then, based on their initial answers, additional questions are selected to increase the precision of assessment. A good clinician does the same, beginning with general questions and then, based on the answers to those questions, asking more specific questions until the diagnosis is reached. Use of the computer allows for many possible questions and for rapid selection of those most likely to be informative for a given patient. Similar techniques are used by giant online retailers to suggest additional items to buy after an initial purchase is made…
The Gibbons et al. approach is a truly outstanding contribution to measurement in medicine (particularly in psychiatry): it is novel and exciting, and it promises to improve the accuracy and cost-effectiveness of diagnosis both in clinical practice and in research…
by Robert D. Gibbons, Ph.D., David J. Weiss, Ph.D., Paul A. Pilkonis, Ph.D., Ellen Frank, Ph.D., Tara Moore, M.A., M.P.H., Jong Bae Kim, Ph.D., and David J. Kupfer, M.D.American Journal of Psychiatry. 2014 171:187–194.
Objective: The authors developed a computerized adaptive test for anxiety that decreases patient and clinician burden and increases measurement precision.Method: A total of 1,614 individuals with and without generalized anxiety disorder from a psychiatric clinic and community mental health center were recruited. The focus of the present study was the development of the Computerized Adaptive Testing–Anxiety Inventory (CAT-ANX). The Structured Clinical Interview for DSM-IV was used to obtain diagnostic classifications of generalized anxiety disorder and major depressive disorder.Results: An average of 12 items per subject was required to achieve a 0.3 standard error in the anxiety severity estimate and maintain a correlation of 0.94 with the total 431-item test score. CAT-ANX scores were strongly related to the probability of a generalized anxiety disorder diagnosis. Using both the Computerized Adaptive Testing–- Depression Inventory and the CAT-ANX, comorbid major depressive disorder and generalized anxiety disorder can be accurately predicted.Conclusions: Traditional measurement fixes the number of items but allows measurement uncertainty to vary. Computerized adaptive testing fixes measurement uncertainty and allows the number and content of items to vary, leading to a dramatic decrease in the number of items required for a fixed level of measurement uncertainty. Potential applications for inexpensive, efficient, and accurate screening of anxiety in primary care settings, clinical trials, psychiatric epidemiology, molecular genetics, children, and other cultures are discussed.
Putting aside any number of salient points for the moment, like:
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Dr. Kraemer’s tortured logic relating this test to the Field Trials above and to the potential usefulness of the test in clinical settings.
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Dr. Kraemer being a collaborator and author in the move to add dimensional diagnoses to the DSM-5.
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Dr. Kraemer being a frequent co-author with Dr. Kupfer during the DSM-5 process including the article reporting the Field Trials mentioned in the editorial.
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The use of NIMH funds to develop this commercial venture.
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The use of the academic journal articles [JAMA Psychiatry, Journal of Clinical Psychiatry, and now the American Journal of Psychiatry] to advertise this commercial venture.
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The validity of the CAT-ANX psychometric is untested in substantive clinical Field Trials.
… reviewing the timeline in the open letter to the APA…, there can be little doubt that the pairing of this editorial with this article is part of the long-planned launch of these computerized adaptive tests, developed by Dr. Gibbons and his business associates [including Dr. Kupfer, Chair of the DSM-5 Task Force]. Even though the dimensional parameters were not added to the DSM-5 main diagnostic criteria, they were included in Section III [a point Dr. Kupfer reminded us of recently – Section III of New Manual Looks to Future]. And these tests were clearly part of the dimensional initiative which is obviously still very much alive [from Kraemer, "Applications might easily be developed that could be used by patients in the waiting room, probably requiring less than 10 minutes of the patient’s time and none of clinician’s, producing a score that could be used in its dimensional form (the actual score and its measure of precision) or in categorical form (by selection of an appropriate cut point)"]. Obviously, screening is still part of the mix.
In the memo on this incident submitted to the APA Board of Trustees, Dr. Young wrote:
"Dr. Kupfer should have disclosed to APA his interest in PAI in 2012. Dr. Kupfer’s interest in PAI, which came after the decision had been made to include dimensional measures in DSM-5, did not influence DSM-5’s inclusion of dimensional measures for further study in Section 3. Interest in inclusion of these measures in DSM-5 began with conferences starting in 2003. If and when PAI develops a commercial product with CAT, it will not have any greater advantage than the dozens of dimensional measures currently being marketed by others."
Nobody I know thinks that Dr. Kupfer’s interest in PAI is why the dimensional measures were included in Section III, so I’m unclear what she’s talking about. What I think is that these computerized tests were commercialized to opportunize on the inclusion of dimensional measures in the full manual, and that moving them to Section III was a disappointment, but they carried on with their launch anyway. But that’s just my opinion. What rises beyond opinion is that this very significant longstanding Conflict of Interest was not declared in order to hide the commercial interests of everyone concerned with PAI. That is an ethical breach of major import and demands a full investigation by the Board of Trustees. To ignore it is to say that the APA has no Conflict of Interest policy – at least no Conflict of Interest policy that matters…
If diagnosis doesn’t matter — anything will do if the goal is to get the person on drugs — what’s the problem with a dimensional approach?
Less than 10 minutes of patient time for a diagnostic evaluation– and it doesn’t require a clinician to spend any time with the patient at all! Wonderful! So this is what Psychiatry has (or will) become? This is horrible. Unethical. Shameful.