{"id":31197,"date":"2012-12-20T19:36:55","date_gmt":"2012-12-21T00:36:55","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=31197"},"modified":"2012-12-20T20:01:16","modified_gmt":"2012-12-21T01:01:16","slug":"speaking-of-forests","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/12\/20\/speaking-of-forests\/","title":{"rendered":"speaking of forests&#8230;"},"content":{"rendered":"<div align=\"justify\"><em>Forest Plots<\/em> are a useful way to display information when multiple items are compared by a single measurement variable &#8211; in this case, the DSM-5 Diagnoses [ordinate, y-axis] are compared by the kappa <em>inter-rater reliability<\/em> variable [abscissa, x-axis] from the DSM-5 Field Trials. These first two plots show the kappa values separated by diagnosis and site [with 95% Confidence limits as the horizontal line]. The adults are on top with children and adolescents below:<\/div>\n<div align=\"center\"><img decoding=\"async\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/dsm-5-field-trials.gif\" \/><\/div>\n<div align=\"center\"><img decoding=\"async\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/child-field-trials-3.gif\" \/><\/div>\n<div align=\"justify\">In the lead-up to the presentation of the Field Trial results, there was something of a debate between Dr. Frances, DSM-IV leader, and the DM-5 leaders. The issues were:<\/div>\n<ul><sup><strong>        <\/p>\n<li>The Task Force cancelling one of the two planned sets of Field Trials<\/li>\n<li>The actual interpretations of the kappa values<\/li>\n<li>Whether the DSM-IV and DSM-5 kappas were comparable<\/li>\n<p>       <\/strong><\/sup><\/ul>\n<div align=\"justify\">Below, these plots are color coded to show the difference in their standards [the yellow band being &quot;questionable&quot;]. Again Adults on top, children below:<\/div>\n<div align=\"center\"><img decoding=\"async\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/field-trials.gif\" \/><\/div>\n<div align=\"justify\">I&#8217;ve said all I need to say about the results of the Field Trials. They look even less reliable in kids than adults, and the adult results didn&#8217;t look very good. Musing about that, I re-read the conclusion to the article. This was right at the end: <\/div>\n<blockquote>\n<div align=\"center\"><a href=\"http:\/\/ajp.psychiatryonline.org\/data\/Journals\/AJP\/0\/appi.ajp.2012.12070999.pdf\" target=\"_blank\"><u><strong><font color=\"#200020\">DSM-5  Field Trials in the United States and Canada, Part II: Test-Retest  Reliability of Selected Categorical Diagnoses and Analytic Approaches<\/font><\/strong><\/u><\/a><br \/>                                   <sup>by   Darrel A. Regier, William E. Narrow, Diana E. Clarke, Helena C.  Kraemer, S. Janet Kuramoto, Emily A. Kuhl, and David J. Kupfer<\/sup><br \/>                                   <strong><font color=\"#004400\">American Journal of Psychiatry.<\/font><\/strong> 2012 October 30, <strong><font color=\"#200020\">AJP in Advance<\/font><\/strong><\/div>\n<p>  <\/p>\n<div align=\"justify\"><sup><strong>&quot;<font color=\"#660022\">&#8230; Emil Kraepelin, who pioneered the separation of schizophrenic and affective psychoses into separate diagnostic groups in 1898, noted later in a 1920 publication&mdash; prescient in its anticipation of a current polygenetic environmental interaction model of mental disorders&mdash;that the strict separation of these categorical diagnoses was not supported. We are now coming to the end of the neo- Kraepelinian era initiated in the U.S. by Robins and Guze with a renewed appreciation of both the benefits and limitations of a strict categorical approach to mental disorder diagnosis.<\/font><\/strong><\/sup><\/div>\n<p align=\"justify\"><sup><strong>The ultimate goal is to build on the progress achieved with categorical diagnoses by continuing with longitudinal follow-up of patients with these diagnoses, incorporating cross-cutting dimensional measures judiciously into the diagnoses where they prove useful, and in some cases recommending simple external tests [such as a cognitive test for mild neurocognitive disorder] that might improve the reliability and move toward a more mature scientific understanding of mental disorders. A noted philosopher of science, Carl Hempel, observed that &ldquo;although most sciences start with a categorical classification of their subject matter, they often replace this with dimensions as more accurate measurements become possible&rdquo;.<\/strong><\/sup><\/p>\n<div align=\"justify\"><sup><strong>Clinicians think dimensionally and adjust treatments to target different symptom expressions in patients who may have the same categorical diagnosis. The intent of DSM-5 is to provide a diagnostic structure that will more fully support such dimensional assessments with diagnostic criteria revisions, specifiers, and cross-cutting symptom domain assessments. The goal is to support better measurement-based care and treatment outcome assessment in an era when quality measurement and personalized medicine will require new diagnostic approaches.&quot;<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">As I read that first paragraph, I felt like I understood something that has bothered me through this whole process. I haven&#8217;t understood why the DSM-III and DSM-IV framers and the DSM-5 Task Force have been at such odds. I got the trees &#8211; the various issues that have come up along the way and I&#8217;ve had plenty to say about that. But I think I missed the forest. It&#8217;s so easy to get caught up in the details and miss the big picture, then when it becomes a bit clearer, you wonder why you didn&#8217;t see it in the first place. This is the forest: &quot;<strong><font color=\"#660022\">We are now coming to the end of the neo-Kraepelinian era<\/font><\/strong>.&quot; The framers of the DSM-5 don&#8217;t <em><strong><font color=\"#200020\">believe in<\/font><\/strong><\/em> the neo-Kraepelinian Revolution of 1980 any more. That explains a lot of things:<\/div>\n<ul><sup><strong>  <\/p>\n<li>\n<div align=\"justify\">Why they locked Robert Spitzer out of their process<\/div>\n<\/li>\n<li>\n<div align=\"justify\">Why the&#8217;ve never really responded to Dr. Frances<\/div>\n<\/li>\n<li>\n<div align=\"justify\">Why they&#8217;ve occupied themselves with quirky diagnoses<\/div>\n<\/li>\n<li>\n<div align=\"justify\">Why they didn&#8217;t really revise the current manual<\/div>\n<\/li>\n<li>\n<div align=\"justify\">Why they&#8217;re willing to accept these lousy Field Trials<\/div>\n<\/li>\n<li>\n<div align=\"justify\">Why they keep talking about things like <em>cross-cutting<\/em> and <em>dimensional<\/em><\/div>\n<\/li>\n<li>\n<div align=\"justify\">Why they&#8217;ve barreled ahead in the face of such negativity<\/div>\n<\/li>\n<p>  <\/strong><\/sup><\/ul>\n<div align=\"justify\">The framers of the DSM-5 are over it. I don&#8217;t know why I didn&#8217;t notice that. They said it in their research agenda book ten years ago. They wanted to put psychiatry on a genetic\/biological basis and it didn&#8217;t work. They apparently felt they had to fight the good fight to do that &#8211; shut out the reactionaries. Well they fought the good fight, ignored a lot of the refinements needed in the DSM-IV, and waited for <em>something<\/em> that would move psychiatry in the direction they <strike>wanted<\/strike> expected it to move &#8211; the <em>something<\/em> never came so they turned their hopes to the RDoC at the NIMH. In spite of their un-success in moving the DSM-5 in the direction they <strike>wanted<\/strike> expected it to go, hope springs eternal:<\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong>The intent of DSM-5 is to provide a diagnostic structure that will  more fully support such dimensional assessments with diagnostic criteria  revisions, specifiers, and cross-cutting symptom domain assessments.  The goal is to support better measurement-based care and treatment  outcome assessment in an era when quality measurement and personalized  medicine will require new diagnostic approaches.<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">I&#8217;ve known they had a bad case of future think, but it didn&#8217;t occur to me that the framers of the DSM-5 had given up on the very system they were in charge of revising, or that they saw the neo-Kraepelinian era as being at its end. If that wasn&#8217;t true before they started, it&#8217;s guaranteed to be true now. I think this is an example of the proverb, &quot;<strong><font color=\"#200020\">don&#8217;t put the cart before the horse<\/font><\/strong>&quot;. And in doing that, they&#8217;ve made one hell of a mess&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Forest Plots are a useful way to display information when multiple items are compared by a single measurement variable &#8211; in this case, the DSM-5 Diagnoses [ordinate, y-axis] are compared by the kappa inter-rater reliability variable [abscissa, x-axis] from the DSM-5 Field Trials. These first two plots show the kappa values separated by diagnosis and [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-31197","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/31197","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=31197"}],"version-history":[{"count":30,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/31197\/revisions"}],"predecessor-version":[{"id":31231,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/31197\/revisions\/31231"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=31197"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=31197"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=31197"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}