Is authoring psychological assessments related to personality disorders a potential conflict of interest for DSM-5 personality disorder workgroup membership?
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.
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).
“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:
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).
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
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
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.”
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?”