The proposed inclusion of “Significant” in relation to adaptive functioning for 12.05 does little to clarify the indication that listing 12.05 is “only for” Intellectual Disability/Mental Retardation (as opposed to Borderline Intellectual Functioning). This should be revised to adaptive behaviors which are at least 2 or more standard deviations below the mean (consistent with the drafted criteria for Intellectual Disability under DSM-5 and would better reflect the desired increase in focus on adaptive behaviors consistent with current trends set by the AAIDD). Doing so would also allow for increased simplification of the listing and make it easier to align the listing with the proposal to use 2 standard deviations as a definition of a marked impairment (see pg 51342).

The requirement for having a valid MDI on listing 12.05 necessitates intellectual functioning 2 standard deviations below the mean. The proposed definition of marked suggests 2 standard deviations is a marked impairment. The proposed revisions to the B criteria includes the criterion “understand, remember and apply information.” It’s reasonable to assume that given these definitions of intellectual disability and a marked limitation each being 2 standard deviations below the mean, a valid MDI on 12.05 would automatically be a marked limitation on this B criterion domain.

The requirement for having an MDI on listing 12.05 also necessitates adaptive behaviors which are 2 standard deviations below the mean. The proposed definition of marked suggests 2 standard deviations is a marked impairment. The proposed revisions to the B criteria include “manage oneself” (as well as social functioning and concentrating which could also reflect domains of adaptive behavior deficits). Its reasonable to assume that given these definitions of intellectual disability and a marked limitation each being 2 standard deviations below the mean, a valid MDI on 12.05 would indicate adaptive behaviors which would be a marked limitation on one or all of these B criteria.

This makes the C (secondary impairment) and D (evaluating B criteria) listings under 12.05 unnecessary and potentially harmful (See Todd Finnerty, Psy.D.’s previous comments for additional discussion on this).

Dr. Finnerty’s Proposed Listing 12.05:

12.05 Intellectual Disability (formerly MR)

A. Intellectual Disability (formerly MR) originating prior to age 22 and as defined in 12.00B4, with mental incapacity evidenced by dependence upon others for personal needs (for example, toileting, eating, dressing, or bathing) and inability to follow directions, such that the use of standardized measures of intellectual functioning is precluded.

or

B. Intellectual Disability (formerly MR) originating prior to age 22 and as defined in 12.00B4, with a valid IQ score of 70 or less (as defined in 12.00B4d) on an individually administered standardized test of general intelligence having a mean of 100 and a standard deviation of 15 (see 12.00D4) along with concurrent deficits in adaptive functioning of at least two or more standard deviations below the mean.

***note, I went back and forth on whether we should include the word “approximately” prior to the IQ score of 70 or less and the 2 standard deviations below the mean for adaptive behaviors. It would likely be more scientifically accurate but I’m not sure how well it would guide adjudicators. I also have a website where I’m starting to put together some books and other resources at mildintellectualdisability.com and would welcome any suggestions for links, books or other articles.

In making revisions, the SSA should follow the guiding principles of simplification, flexibility and functioning. Changes related to these principles have a good chance of benefiting claimants, and the proposed changes do indeed follow these principles in many instances. Changes involving simplification can decrease the amount of time it takes to communicate a decision by eliminating redundancies in the mental health adjudicative process while focusing on functional factors which will help evaluate work related ability. Flexibility is an important principle due to the number of and changing nature of the underlying disorders. While the listings are based on DSM-IV-TR categories, significant revisions can be expected with the DSM-5 which is due for official publication in May, 2013.

I am in full agreement with the removal of the A criteria as the A criteria are redundant with the need to establish an MDI. They also are not comprehensive enough to cover all mental disorders which may be considered for a listing or which may arise out of the upcoming DSM-5. The resulting simplification can lead to additional time and cost-savings through the removal of the requirement to complete a PRTF. I applaud the proposal to remove the requirement for completion of a PRTF.

I applaud the proposed changes to the B criteria as well as the use of the C criteria for most listings. I agree with the removal of listing 12.09. 12.09 should have only been viewed as a theoretical listing and not one to be met, as we are instructed to rate limitations in the absence of 12.09 factors when possible or to essentially give the claimant the benefit of the doubt if this is not possible. In the instance where we had sufficient evidence to meet listing 12.09, a not severe or PRTF & MRFC based on remaining limitations from other impairments could have been performed with the evidence. Likewise, SSA should consider whether similar factors may be at work when predicting “Will not last” decisions making a “Will not last” finding on psych less common, in that we should have sufficient evidence to offer an assessment of their limitations at 12 months and communicate the finding in this manner.

Many of the proposed listing changes do arise out of consideration for these principles. However, the proposed changes to listing 12.05 fail to effectively harness the full power of the suggested principles of simplification, flexibility and functioning. This would be a missed opportunity to educate those involved in the adjudicative process as well as increase the efficiency and accuracy of decisions involving an MDI on listing 12.05.

Intellectual Disability
I disagree with the proposed change of “Mental Retardation” to “Intellectual Disability/Mental Retardation (ID/MR).” Given that the field, including the DSM-5, is moving away from the MR term and that the last “comprehensive revision” of the listings were done in 1985 and 1990, I recommend the complete removal of the term in headings and simply using “Intellectual Disability.” This will also save SSA the costs of later removing it completely from listing titles. There is no need for a long transition period where both terms are used simultaneously as the title of the listing, particularly when the reason for the removal is “negative connotations” associated with the MR term. Issues with familiarity with the term can be addressed by a brief narrative that could contain the term. In addition, the public will also benefit from the education generated by the SSA ‘taking sides” and choosing to use the Intellectual Disability term as opposed to presenting two equivalent terms despite admitting that one has “negative connotations.” The SSA will likely face similar issues with the many proposed name changes for DSM-5 and can not possibly incorporate every historical term that the public may or may not be familiar with in the title of their listings. The word “intellectual” is not a new one, nor are the listings requirements for IQ testing and adaptive behaviors. Just as many of the other listings have seen a simplification to an understandable narrative template this listing can as well. The American Association of Mental Retardation is now the American Association of Intellectual and Developmental Disabilities. The new DSM-5 for 2013 will remove the term Mental Retardation in favor of Intellectual Disability. The SSA should not be any further behind on this issue than it already is.

While SSA is to be commended for their proposed clarification of evidence required from the developmental period as well as an increased focus on adaptive behaviors, I also do not feel that the proposed rules go far enough in their revision of the 12.05 listings. While the proposed rules note that listing 12.05 is to be used only for intellectual disabilities, they continue to include a listing structure that is inconsistent, redundant and unnecessary.

The proposed rules note in the Federal Register that “We agreed with commenters who suggested that we use the definitions of “”marked”” and “”Extreme”” limitations” from the childhood disability recommendations (pg. 51338). Essentially by definition of an intellectual disability, an intellectual disability would involve marked limitations based on the proposed definition. An intellectual disability involves intellectual deficits which are 2 standard deviations below the mean and adaptive behavior deficits which are 2 standard deviations below the mean. On pg. 51342, the proposed rules suggest that we describe a “Marked” limitation as the “equivalent of functioning we would expect to find on standardized testing with scores that are at least two, but less than three, standard deviations below the mean.”

Therefore, the Intellectual Disability listing essentially indicates a need for 2 standard deviations on cognitive and adaptive behaviors to qualify as an MDI considered under the listing. Why is there a need for an evaluation of B criteria at all if our definition of marked limitations is cognitive and adaptive functioning below 2 standard deviations? The B criteria are redundant with the need to establish an MDI on 12.05 which would by definition involve marked adaptive behaviors.

If we are to use the provided definition of a marked limitation, the proposed changes to listing 12.05 do not go far enough. If someone satisfies the outlined criteria for an intellectual disability and an MDI on 12.05, by definition they meet our definition for a marked limitation. The rest is wasted adjudicative effort and introducing the potential for error. I recommend listing 12.05 simply guide adjudicators on the process of establishing an Intellectual Disability MDI with the assessment of both intellectual functioning and adaptive behaviors.

This suggests that evaluating for secondary impairments for 12.05 C would also be unnecessary.
One additional concern that can be brought up about listing 12.05 C as it stands is the potential for age discrimination. A wide range of etiologies of global cognitive deficit/ intellectual disability are recognized and can lead to an MDI relevant to listing 12.05. However, the listings currently require an onset prior to age 22 as it defines the developmental period. This would appear reasonable given how we conceptualize Intellectual Disability (though the DSM-IV-TR uses age 18 and an onset after age 18 but before 22 could lead to satisfying the listing but not the MR diagnosis from DSM-IV-TR). It is conceivable based on the structure of the listings however that one claimant could have an onset of global cognitive delay consistent with 12.05 and a secondary impairment and be a grant with an onset at age 21 and 11 months, however this same claimant could be a denial if the onset occurred just a short time later after their 22nd birthday. While the individual may have acquired “MR range” cognitive functioning and lost the ability to function adaptively to the point where they would fall 2 standard deviations below the mean, the construction of the listing does not automatically recognize this as a marked limitation despite the proposed definition of a marked limitation. If we assume they are not markedly limited as the listing allows, we could also assess for a secondary impairment if the onset is prior to age 22. This same person a short time later after age 22 would not have the same benefit of this assumption/expedient. Therefore this assumption and expedient should either also be included for global cognitive delay under listing 12.02 given that the major difference in some circumstances could hypothetically be age of onset, or we should simply recognize listing 12.05 C as an unnecessary, inconsistent communication that an MDI may meet our definition of Intellectual Disability as 2 standard deviations below the mean yet not meet our definition of a marked limitation as 2 standard deviations below the mean.

Concluding remarks

The SSA’s timing in reviewing the listing is an important one. The new edition of the DSM-5 in 2013 will bring in a terminology change to Mental Retardation as well as a number of other changes already in draft form at DSM5.org. The revised ICD will closely follow this in time. Simplifying and focusing on functioning has made a number of dramatic improvements and allowed for flexibility in dealing with changes to come in the field. However, this process must be further extended to the proposals for listing 12.05 if definitions are to be viewed as consistent with each other (ex: marked) and for the benefits of simplification to be truly realized and redundancies eliminated.

Proposed Revision of Reactive Attachment Disorder and addition of Disinhibited Social Engagement Disorder.

The proposal is to split off one group of kids previously diagnosed as RAD in to a new diagnosis.

The rationale presented for it indicates

“The new name is intended to describe the core of the disorder, which is less about diffuse or disinhibited attachment behaviors and
more about unmodulated and indiscriminate social behavior, especially initial approaches to and interaction with unfamiliar adults.” They also indicate it is more in keeping with ICD-10.

During the current revision process of DSM-5 there has been plenty of talk about the process itself. I myself can’t help but wonder what motivates individual scientists when it comes to evaluating the science behind mental disorders. While there has been plenty of talk related to conflicts of interest and the pharmaceutical industry, has sufficient attention been paid to potential conflicts with psychological testing publishers (and potential royalties from the sale of psychological tests)? Two Personality Disorders work group members have authored personality tests that include some scales that contain names which are  similar to the names that have been proposed as potential “facets” constructing the new DSM-5 personality disorder.

Drs Lee Anna Clark, Ph.D. and W. John Livesley. M.D., Ph.D. serve on the Personality Disorders workgroup of DSM-5 and are charged with helping to craft the future of personality disorder(s). According to Dr. Clark, they must navigate and work out “controversy within the Work Group” (see below). However, would having potential royalties from psychological testing related to the areas you’re commenting on create at least the appearance of impropriety (even if work group members could attend to and navigate any potential personal bias in their self-interest)?

Dr. Lee Anna Clark, Ph.D. currently has a grant from the University of Minnesota Press according to her disclosure statement (its not made clear in the statement if it is related to the SNAP-2): disclosure statement

The University of Minnesota Press is the publisher of Dr. Clark’s personality test, the SNAP-2. There is nothing related to any royalties she may or may not have earned or could potentially earn from the psychological test included in the disclosure statement.

SNAP-2

Per the disclosure statement “Dr. Lee Anna Clark has agreed that, from the time of approval through the publication of DSM-V, projected in 2012,(his/her) aggregate annual income derived from industry sources (excluding unrestricted research grants) will not exceed $10,000 in any calendar year.”

This in no way rules out any potential royalties that may be received for an increase in the use of the SNAP-2 or a revised version for research and clinical practice after the publication of DSM-5 (also DSM-5 has been pushed back to 2013 on an unrelated note).

For applied use, the SNAP-2 manual retails for $20, $1 per booklet with another $50 for the first time it is scored plus 50 cents for each scoring usage. SNAP-2 applied use pricing

Dr. W. John Livesley, M.D., Ph.D.’s disclosure statement only mentions past honoraria from AstraZeneca Pharmaceuticals, nothing related to any royalties he may or may not have earned from psychological testing (or may potentially earn).

Disclosure statement

“Dr. William J Livesley M.D.,Ph.D. has agreed that, from the time of approval through the publication of DSM-V, projected in 2012, (his/her) aggregate annual income derived from industry sources (excluding unrestricted research grants) will not exceed $10,000 in any calendar year.” However, this certainly does not rule out any royalties from the use of the DAPP-BQ in research and or practice after DSM-5.

John Livesley, MD is noted as the first author of the DAPP-BQ. There are multiple options for pricing of this psychological test:

DAPP BQ

The DAPP-BQ “examination kit” runs $180. This includes 10 fax in answer sheets. If you want 10 more fax in answer sheets that would cost you $160. You can get internet scoring cheaper with a Sigmatesting.com account: http://www.sigmaassessmentsystems.com/prices/dappbq.asp or you could purchase the scoring software for $125 and purchase coupons for additional scoring.

(Although for a limited time you can get a free electronic copy of the manual, it works, I just had mine e-mailed to me with an offer of a free trial of the DAPP-BQ on their online testing platform, SigmaTesting.com- I’m intrigued and will probably check it out.)

However, it is interesting that any royalties received from this are not necessarily viewed as a conflict of interest by the American Psychiatric Association (or perhaps they are unaware).  At least they are not included on these work group member’s disclosure statements.

The SNAP-2 includes “Trait and Temperament” scales and the website selling it notes it is intended for clinical use (not just a research tool).

SNAP scales

The names of the proposed facets are quite similar to the scales of the personality assessments authored by two of the work group members.

The scales of the SNAP-2 and the trait/facet system proposed for DSM-5 DSM-5 proposed facets share many similar names (ignoring correlations and the diagnostic scales and only looking at a nearly direct one to one relationship to scale name and facet and also ignoring the 5 retained personality disorder types):
The SNAP-2 scales and the proposed traits/facets each include:
Negative Emotionality (Negative Temperament), Manipulativeness, Aggression, Self-harm, Eccentric perceptions (Eccentricity), detachment (social detachment), impulsivity.

The DAPP-BQ includes scales with the same name of self-harm, cognitive dysregulation, affective lability (emotional lability), insecure attachment (separation insecurity), intimacy problems (intimacy avoidance), suspiciousness, oppositionality, submissiveness, narcissism, restricted affectivity (restricted expression).

This ignores that some of the other scales can be related in meaning to the additional scales despite having a more different name exs: Low Affiliation, introversion, stimulus seeking vs disinhibition, etc. Its also interesting that many of the names of the facets suggested for DSM-5 are different than those “normal” ones suggested for the Five-Factor Model Personality trait facets provided in Costa & Widiger’s 2nd ed of Personality Disorders and the Five-Factor Model of Personality.

It stands to reason that the authors of the SNAP-2 and DAPP-BQ worked hard on them and hope that their assessments do well regardless of monetary gain. The webpages selling them note they are intended for clinical use and therefore could see a wider audience if a new personality disorder system is implemented with similarly named facets. I have no knowledge of whether or not or how much these two specific authors, Dr. Clark and Dr. Livesley stand to gain from the sale of these psychological tests. However, shouldn’t this be disclosed  on the disclosure statement? This particularly since they have taken a prominent role working on the DSM-5 Personality Disorders workgroup and are authors listed on the DSM5.org website:

Ex: for the revisions of the general criteria for a personality disorder

http://www.dsm5.org/ProposedRevisions/Pages/RationaleforDefinitionandGeneralDiagnosticCriteriaforPersonalityDisorder.aspx

Dr. Livesley appears to stress identity problems in the piece he wrote, which is also assessed by the DAPP-BQ: http://www.dsm5.org/ProposedRevisions/Pages/RationaleforDefinitionandGeneralDiagnosticCriteriaforPersonalityDisorder.aspx

Dr. Clark co-authored the rationale for a six-domain trait dimensional diagnostic system

http://www.dsm5.org/ProposedRevisions/Pages/RationaleforaSix-DomainTraitDimensionalDiagnosticSystemforPersonalityDisorder.aspx

This section clearly spells out that “…the proposed specific trait facets were selected as representative based on existing measures of normal and abnormal personality, as well as recommendations by experts in personality assessment.” Apparently, the DAPP-BQ, and SNAP-2 were valued given the facet names. Sorry, if the only test in this area you had heard of before this was the NEO-PI-R

Some of the decision-makers deciding which “existing measures” to consider and how much weight to give them in relationship to the names of the facets proposed for use in DSM-5 actually authored two of the “existing measures.”

Drs Lee Anna Clark and W. John Livesley were also co-authors on a paper which was published in Psychological Assessment 21(3), 2009, pages 243-255 (An Integrative Dimensional Classification of Personality Disorder). The authors praise both the SNAP-2 and DAPP-BQ in the article and also review the praise of others for these assessments. The authors discuss how the SNAP-2 and DAPP-BQ can be used to assess the maladaptive personality traits which have been proposed in their personality disorder system. On page 247, the authors suggest that “One possible dimensional model for DSM-V is simply to retain the existing DSM-IV-TR diagnoses, but assess them dimensionally rather than categorically (Oldham & Skodol, 2000). However, using scales such as those of the DAPP-BQ and SNAP would provide profile descriptions that would be more differentiated and much less susceptible to construct and scale overlap…” Therefore, it would appear on arguing whether or not to continue to use the DSM-IV personality disorders, the authors used their assessments as the lead in to their argument. They note in the study how the “DAPP-BQ, and the SNAP could be well integrated within a common hierarchical structure in a manner that would be more efficient and easier to apply in general clinical practice than the existing diagnostic categories…” suggesting a desire to replace the personality disorder criteria you can assess with a clinical interview with the abstract personality traits you can best assess by administering the measures that these work group members will gladly sell to you (per score report).

Where is the cut off for medicating “normal” vs maladaptive personality traits?

Its also interesting to note that in this study they suggest the potential for medicating personality traits (not just maladaptive ones). On pg. 249 these work group members appear to “speculate” on potential treatments for personality traits themselves (as opposed to “disorder”). They review a study related to the pharmacological treatment of neuroticism and also note “There might be specific pharmacologic treatment implications for low conscientiousness (e.g. methylphenidates;…)” So basically if you have “low conscientiousness” you may qualify for a prescription for the controlled substance Ritalin. They also suggest that “Perhaps there will never be a pharmacotherapy for high conscientiousness…” (though I’ll speculate that a very high dose of an antipsychotic or benzodiazepine might do the trick).

Also check out Task-Force Member Dr. Andrew Skodol, M.D.’s rationale for types.
http://www.dsm5.org/ProposedRevisions/Pages/RationaleforProposingFiveSpecificPersonalityDisorderTypes.aspx He reviews Rottman et al. (2009) “…these findings indicate that personality traits in the absence of clinical context are too ambiguous for clinicians to interpret: although it may be possible to describe personality disorders in terms of the FFM, mentally translating personality traits back into syndromes or disorders is cognitively challenging.”

Its interesting that in the most recent, Winter, 2010 newsletter of the Society for A Science of Clinical Psychology Dr. Clark writes a column suggesting there continues to be disagreements among the work group on how to proceed with the personality disorders for DSM-5.

In the newsletter she described “controversy within the Work Group” between including types versus traits. She noted that some within the work group are arguing “against the inclusion of types.”

newsletter

She notes that “one easily can become blind to its problems and its complexities” in regards to working on a project such as DSM-5 for an extended period. She noted that Axis II is to be eliminated with Personality Disorder to be made a single diagnosis (thus Personality Disorder, borderline type or Personality Disorder, antisocial/psychopathic type; etc. vs simply Personality Disorder with some as yet to be determined mechanism for coding and/or communicating trait and facet profiles). It was suggested by Dr. Clark that a trait profile could be made for “all clients, regardless of whether they were diagnosed with PD.” She did not say however, that the SNAP-2 should be given to all clients.

The work group members are highly qualified for the tasks which they are doing, however it is strange to me that the disclosure statements focus on “Big Pharma” when at least in this instance, there appears to be no guidance for the field on interpreting what conflicts of interest may exist in relation to potential psychological testing royalties. However, to be clear I have no evidence that there is a conflict of interest or that authoring these psychological tests has played any role in the positions that these work group members have taken in resolving “controversy within the Work Group.”

Can personality disorders be reduced to the sum of their “parts?” Just thinking of myself, I might agree and say yes if the specific parts proposed were the ones included in a psychological test that I wrote and may or may not earn royalties from when DSM-5 is published. My primary question is not “is this happening?” It is ”shouldn’t this be something included on the disclosure statement regardless of whether it actually impacts work group members’ behaviors?”

There is still time to comment on the personality disorder proposals which are clearly still being discussed via http://www.dsm5.org

What do you think: types; traits & facets or a hybrid of the two? It doesn’t appear that you’ll get to keep your DSM-IV-TR Personality Disorders

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Learn more about depressive personality traits (and why depressive personality disorder is more useful than neuroticism) at http://www.depressivepersonality.com

In December, 2009 the American Psychiatric Association (http://www.psych.org) announced the one year delay of the official publication of the fifth edition of the Diagnostic and statistical manual of mental disorders until May, 2013.

The January 1st, 2010 issue of APA’s Psychiatric News noted “Proposed changes to the current diagnostic criteria will be posted on APA’s DSM-5 Web site at http://www.dsm5.org for public comments starting on January 20.”  [2010]

However today (1/15/10) I noticed that the DSM-5 website now reads: “Note: The new DSM5.org Web site, which will include proposed revisions and draft diagnostic criteria, has been rescheduled for launch on Wednesday, February 10, 2010.”

For more about me check out http://www.toddfinnerty.com

 However, I will most likley be discontinuing the tripod site and starting to post more general articles here. I maysummarize interesting articles or other things that appear interesting, so feel free to check back. If you’re on twitter follow @DrFinnerty http://twitter.com/DrFinnerty