{"id":45280,"date":"2014-03-31T18:57:18","date_gmt":"2014-03-31T22:57:18","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=45280"},"modified":"2014-04-02T12:09:34","modified_gmt":"2014-04-02T16:09:34","slug":"the-summer-of-09-five-years-later","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/03\/31\/the-summer-of-09-five-years-later\/","title":{"rendered":"the summer of 09 – five years later…"},"content":{"rendered":"
In October 2012, I first read the article below and blogged about it  [speaking of forests…<\/a>]. That was before the Board of Trustees of the APA met in December and finalized what was going to be included in the DSM-5. While this article was published in print after the DSM-5 was already on its way to the printer, it appeared on-line several months before. In fact, it was originally submitted the previous summer after being partially<\/em> presented at the May 2012 APA Annual Meeting. So I assume it was written under the assumption that the Cross-Cutting Dimensions would be included in the DSM-5. Back then, it helped me finally realize that the Task Force leaders didn’t believe in the neoKraepelinian model any more. They were over Robins and Guze. They’d said it repeatedly, but I hadn’t heard it to the extent they meant it. No wonder they didn’t do the Revision they were assigned to do. They had other fish to fry. But as I was preparing this, my first-ever 1boringoldman DSM-5 one year anniversary series<\/em> [the summer of 09…<\/a>, the endless summer [of 09]…<\/a>], I read it in a different light: <\/div>\n
\n
DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses and Analytic Approaches<\/a><\/div>\n
by Darrel A. Regier, William E. Narrow, Diana E. Clarke, Helena C. Kraemer, S. Janet Kuramoto, Emily A. Kuhl, and David J. Kupfer<\/div>\n
American Journal of Psychiatry.<\/font><\/strong> 2013 170:59-70.<\/div>\n
[full text on-line<\/a>] <\/div>\n

… Emil Kraepelin, who pioneered the separation of schizophrenic and affective psychoses into separate diagnostic groups in 1898, noted later in a 1920 publication — prescient in its anticipation of a current polygenetic environmental interaction model of mental disorders — that the strict separation of these categorical diagnoses was not supported. We are now coming to the end of the neoKraepelinian 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.<\/p>\n

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 “although most sciences start with a categorical classification of their subject matter, they often replace this with dimensions as more accurate measurements become possible”.<\/p>\n

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."<\/div>\n<\/blockquote>\n

At the time this was written, the Task Force had given up on the attempt to add in biological parameters to the DSM-5 [Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5<\/a>], but their hopes for the cross-cutting dimensions were still alive<\/font><\/strong><\/em>. I had taken  cross-cutting dimensions<\/font><\/strong><\/em> to mean symptoms that crossed diagnostic entities, but I think there was more to it. They were actually looking for anything that could be measured or quantified<\/font><\/strong><\/em>, like the kind of thing Madhukar Trivedi was so obsessed with – called measurement based care<\/em>. Reading it now, it seems as if the practice they were planning for psychiatrists was modeled on the Clinical Trial motif [rather than the other way around], and the measurement would be like those in Clinical Trials –  a psychometric of some kind – as in the example above. In fact, we know that’s what they meant from Jane Costello’s DSM-5 resignation letter [summer of 09]:<\/p>\n\n\n
03\/27\/2009<\/td>\nDr. Jane Costello resigns from the DSM-5 Child and Adolescent Disorders workgroup<\/a>. In her letter of resignation<\/a>, she said:
"…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>" <\/td>\n<\/tr>\n<\/table>\n

When I look at my timeline of the Affair d’Kupfer<\/a>, it seems impossible not to conclude that their company with its Computerized Adaptive Testing had been planned to take advantage of the addition of dimensional measures to the DSM-5 from the very start. Insider trading, profiteering, whatever you want to call it, it’s a huge conflict of interest. So one part of my reading of this article was that it strengthened my suspicions of unethical play by Dr. Kupfer and his colleagues.<\/p>\n

And while I’ve never been in love with the DSM-anything, it seems to me as if something kind of sleazy went on here that needs to see the light of day. This agenda for the DSM-5 was set over a decade ago. It was at a time when Steven Hyman was Director of the NIMH. And, as a matter of fact, Darrell Regier, who later became Co-Chair of the DSM-5 Task Force was coming to the end of a 25 year career at the NIMH. So somewhere around 2002, Steven Hyman agreed for the NIMH to go in with the APA to fund a long series of symposia based of their agenda for the DSM-V\/5; Darrell Regier went from the NIMH to APIRE [American Psychiatric Institute for Research and Education<\/a>] part of the American Psychiatric Foundation<\/a> where he has primarily worked on the DSM-5; they published the A Research Agenda for the DSM-5<\/a>; and, oh yeah, Dr. Robert Gibbons began to work on his CAT psychometrics funded by the NIMH. It now appears to me that there was a grand plan here – a grand plan to use the DSM-5 Revision to effect a major paradigm shift in psychiatry just like the DSM-III had been used in 1980 – a grand plan hatched by the power players at the NIMH, the APA, and the APF. History was going to repeat itself.<\/p>\n

So no wonder they tried to wave off Drs. Spitzer and Frances. Those guys were still thinking about categories and reliability. They didn’t want their input. They wanted them to get out of the way of the new version of the new psychiatry. No wonder they spent so little time looking at the categories that were in need of work. They weren’t interested in descriptive categories anymore. Little surprise that they appointed an Instrument Assessment Study Group<\/em> to come up with ways to measure dimensions<\/em>. That was the plan in the first place. And perhaps it also explains the most striking feature of this DSM-5 Task Force. They were impervious to infuence from anything – huge changes in the climate of psychiatry, scandals galore, a major rebellion in the public forum, the exit of  PHARMA from the scene, failed Field Trials. Nothing had any impact on their course. They were on a predefined mission. <\/p>\n

And they’re still at it. Steven Hyman is back from a sabbatical as Harvard’s provost, now Directing the Stanley Center<\/a>. Along with Tom Insel, he supports the NIMH RDoC, a clone of the DSM-5’s dimensions<\/em>. And everything Hyman writes recently ends with some way of "luring" PHARMA back to CNS drug development [and supporting the academic-pharmaceutical complex]. They had a dream for the new century and they tried like hell to make it work – clinical neuroscience with measurement based care. Algorithms for treatment defined by clinical trials using dimensions. The idea was behind the great trials from Hyman’s era at the NIMH [STAR*D, CATIE, etc]; it drove the DSM-5 Revision effort for it’s lifespan; and it didn’t work… <\/div>\n","protected":false},"excerpt":{"rendered":"

In October 2012, I first read the article below and blogged about it  [speaking of forests…]. That was before the Board of Trustees of the APA met in December and finalized what was going to be included in the DSM-5. While this article was published in print after the DSM-5 was already on its way […]<\/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-45280","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45280","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=45280"}],"version-history":[{"count":15,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45280\/revisions"}],"predecessor-version":[{"id":45321,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/45280\/revisions\/45321"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=45280"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=45280"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=45280"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}