Köhne article Flashcards
The Relationist Turn in Understanding Mental Disorders
- from essentialism to embracing dynamic and complex relations
(article)
He said that it is a very long and complicated article, so we just need to understand the core topics that are mentioned
These topics can be found in the next flashcard
What should we focus on in the article?
(from video)
(we must focus on the understanding of the following points, but not go into detail)
Core points:
- Essentialism
- Blinding effects
- Having one model is problematic
(make sure to understand core problems)
Alternatives:
> Dimensional traits and HiTOP
> Network approach
> Transdiagnostic approach
(make sure to understand approaches and their short-comings)
Personalized approaches:
~ Precision psychiatry
~ Personalized psychiatry
~ Person-centered psychiatry
(make sure to understand the differences)
Toward integration:
* Group level
* Individual level
(make sure to understand why the author thinks the difference between levels are important and how the discussed methods in this paper can contribute to these different levels)
Core points
Essentialism
- what is essentialism?
- what are the criticisms of the DSM-V?
Essentialism: view that human beings have an essence that is important to their identity
Criticisms:
- lack of solid empirical basis
> arbitrary boundaries
- extreme heterogeneity among patients who share the same DSM classification
- arbitrary diagnostic thresholds
- limited validity, reliability, loss of information and diagnostic instability
Core points
Blinding effect
- the categorical model seems to be based on an essentialist causal hypothesis
- this means that according to a categorical model (e.g. DSM), mental disorders originate from a biological cause, or derive from an essence of some sort
- in simple words, the DSM assumes that there is an underslying dysfunction behind every disorder, and the symptoms are just the consequence
the role of neuro research on the essentialist veiw
- much research has been conducted, and clinical patients do have a different brain compared to healthy brains
- however, it is not clear whether this is a cause or correlation
- after years of research, the “underlying dysfunction” has still not been found
what is the main take-away from the blinding effect?
- DSM oversimplifies mental health, and doesn’t take into consideration the possibility of symptoms causing each other, without an underlying dysfunction
- all treatments are based on the DSM classification, and there is no real evidence that manualized treatments are better than non-manualized ones
Core points
Having one model is problematic
- DSM is serving many goals at the same time
> e.g. practical, clinical, research, treatment, … - different levels require different extents of complexity, which means that having all the levels in one apparatus (DSM) is problematic
Alternatives
Dimensional traits and HiTOP
- dimensional traits approach
- much empirical evidence in favor, and do not meet the above criticisms
- what are dimensional traits approaches based on?
- what do these theories explain?
- Latent trait theory
> underlying, unobservable traits influence behavior
> e.g. extraversion→ sociability and talkativeness - Common etiology models
> different traits or behaviors might arise from shared underlying causes (e.g. genetic or environmental factors)
These theories explain:
→ why personality is measured on a spectrum
→ how underlying biological or psychological factors contribute to trait development
- e.g. GAD and MDD can be explained by higher order factor like “internalizing pathology”
what is the P-factor?
- general psychopathology dimension
- symptoms or syndromes that occur at the same time occur because of this factor
Dimensional approaches to personality
> DSM’s new section
- different dimensional models have been created to explain personality, such as the 5-factor model
- some propose a different amount of factors, but the clusters that resurface are always similar
- the DSM has included a dimensional approach section (“Emerging Measures and Models”)
> this promises hope, because it shifts from categorical to dimensional frameworks
Dimensional traits and HiTOP
- the HiTOP
- what are its aims?
(the Hierarchical Taxonomy of Psycho-pathology)
1. aim to create a classification system for mental health that is empirically grounded
→ this means that it is based on measurable data (quantitative)
2. aim to avoid reification
→ this means that they want to avoid treating abstract concepts as if they are fixed, real entities
- they want to emphasize that mental disorders are on a continuous dimension (not distinct, separate conditions)
the HiTOP
- the hierarchy, from bottom to top
- Symptoms
> e.g. lack of energy
2.1 Components
> related symptoms manifestation
> e.g. fear of eating in front of others
2.2 Maladaptive traits
> e.g. perfectionism
3 Syndromes
> related components and trait dimensions (e.g. social anxiety)
4 Subfactors
> group of closely related syndromes (e.g. fear)
5. Spectra
> internalizing, dishinibition, antagonism, thought disorder, detachment, somatoform
6. Super spectra
> e.g. the P-factor
HiTOP vs DSM
- HiTOP consists of bottom-up discoveries of patterns and categories, achieved through the variance and covariance of symptoms and syndromes, with many data samples
→ this means that the HiTOP has empirical fundaments - in DSM, the syndrome level is described, but in order to facilitate communication
! therefore, we should abandon the DSM diagnoses because there is no empirical support
So, what makes the HiTOP a strong model?
- it lumps and splits
> it combines into one (broad spectrum) and separates the many particulars (signs and symptoms) - empirical fundament
- hierarchy
- dimensionality of personality and its psychopathology
the HiTOP: clinical vs research aim
- its aim is both clinical and research
- there is still discussion on whether it will be applicable to psychiatric practice
> psychiatric practice is more aligned with categorical models, compared to psychological practice - HiTOP will outperform categorical models when it comes to clinical decision making
> it will treat characteristics common to multiple conditions and the patient’s relevant dimensions - it already has psychological tests ready (e.g. Scale of Assessment for Negative Symptoms) that are waiting to be implemented
Cons of HiTOP
- the essentialist perspective
- there is no clear reason as to why we should cluster symptoms and syndromes based on similarities and differences
- there is also no clear reason as to why/how a particular cluster would explain a set of particulars
- factor analysis shows clusters of psychopathology, but fails to prove the existence of a latent factor
Both models are informed by essentialism
> categorical: it describes psychopathology
> dimensional: it explains psychopathology
Alternatives
Network approach
- the core
- Aims:
- provide better understanding of process behind mental disorders
- optimally organize existing treatments, and create new ones - Mental disorders: “problems of living”
> this shows deviation from mental disorders as “disease concepts” - Central disease mechanisms will not be found because they do not exist
What are the 5 principles of the Network theory?
1- Mental disorders are complex systems
> multifactorial in: consitution, etiology and causal background
2- Symptoms are a result of (bi) directional causal connections between symptoms
> neurobiological factors are still important because they impact certain symptoms
> symptoms are not caused by latent factor
3- The covariance of mental symptoms follows a network structure
> syndromes do exist and can be explained by a strong causal relationship between symptoms
> this cluster of causally connected symptoms forms a new homeostasis
> many feedback loops can be active
> no sharp boundaries between syndromes → comorbidity is obvious
4- Hysteresis: even when trigger that activated the network dies out, the network becomes self-sustaining and gets stuck in active state
> this forms distinctive feature of healthy vs disorders individuals
5- Symptom-component correspondance
> the symptom clusters resemble the categories of syndromes of the traditional diagnostic categories
Network theory- the come-back of reductionism
- it does not treat DSM disorders as fixed and real, with a single underlying cause
- it also doesn’t assume that DSM categories represent distinct biological entities
- however, it still relies on DSM symptoms to describe mental disorders
→ this means that it still frames mental disorders in terms of DSM criteria, even if it doesn’t fully agree with how the DSM organizes them
! conclusion: essentialism, reductionism and disease concept slip back through the back door
how can we know what to include in the network models?
- the current demarcation is based on the DSM
- we should take into account interacting layers → biological, psychological and sociocultural
- we need both etiological perspective, and working mechanism
> etiology: explains the origin and cause of constellation of symptoms
> working mechanism: causal mechanisms within constellation of symptoms
From Network theory to the Transdiagnostic approach
- clarifying symptom centrality
- network theory, nonreductionist at heart, should transcend a mere symptom-based account
Clarifying symptom centrality, :
- we might be able to find target symptoms and decrease comorbidity
- it might be unproven essentialist prejudice
Alternatives
Transdiagnostic approach
- how did they come about?
- do they work?
- originated through the contact with patients
- started with the observation that disorder-specific CBT gave incomplete overview of the maintaining factors of eating disorders, which then failed to explain their comorbidities
- throughout different years, maintaining factors were discovered across different disorders, which created all sorts of transdiagnostic approaches
> analyses show that transdiagnostic approaches are efficacious and outperform control conditions
Transdiagnostic approach - Solution to a Taxonomical problem
There are different transdiagnostic approaches
- Latent trait theory: transdiagnostic approach + common mechanisms of etiology
> e.g. anxiety and depression share common latent process like “negative affectivity”
- Medical conceptualization: common disruptions in specific brain systems should explain a variety of mental disorders
- CBT variant: focus on common effective ingredients of CBT
> explains mental disorders by disturbed cognitive and behavioral processes
→ this is just to show that there are many existing transdiagnostic models, but a clear and coherent one is still missing
