{"id":43714,"date":"2014-02-06T12:14:38","date_gmt":"2014-02-06T17:14:38","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=43714"},"modified":"2014-02-07T12:17:18","modified_gmt":"2014-02-07T17:17:18","slug":"that-matters","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/02\/06\/that-matters\/","title":{"rendered":"that matters…"},"content":{"rendered":"
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<\/font><\/strong> – 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<\/a>. 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:<\/div>\n
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DSM categories and dimensions in clinical and research contexts<\/a><\/div>\n
by HELENA CHMURA KRAEMER<\/div>\n
International Journal of Methods in Psychiatric Research<\/font><\/strong>. 2007 16[S1]: S8 – S15.<\/div>\n
[full text on-line<\/a>]<\/div>\n


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Abstract<\/font><\/strong><\/u>: 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.<\/div>\n<\/blockquote>\n
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<\/a>:<\/div>\n
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"…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.<\/em>"<\/div>\n<\/blockquote>\n
Dr. Helena Chmura Kraemer was a member of that Instrument Assessment Study Group<\/em> 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<\/font><\/strong> – 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.<\/div>\n
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American Journal of Psychiatry<\/font><\/strong><\/div>\n
Editorial<\/font><\/strong><\/div>\n
Computer Aids for the Diagnosis of Anxiety and Depression<\/font><\/strong><\/div>\n
by Helena Chmura Kraemer and Robert Freedman<\/div>\n

The 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.<\/p>\n

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…<\/p>\n

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…<\/div>\n<\/blockquote>\n
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Development of the CAT-ANX: A Computerized Adaptive Test for Anxiety<\/a><\/div>\n
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.<\/div>\n
American Journal of Psychiatry<\/font><\/strong>. 2014 171:187–194.<\/div>\n

<\/p>\n

Objective<\/font><\/strong><\/u>: The authors developed a computerized adaptive test for anxiety that decreases patient and clinician burden and increases measurement precision.<\/div>\n
Method<\/font><\/strong><\/u>: 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.<\/div>\n
Results<\/font><\/strong><\/u>: 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.<\/div>\n
Conclusions<\/font><\/strong><\/u>: 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.<\/div>\n<\/blockquote>\n
Putting aside any number of salient points for the moment, like: <\/div>\n