L5: Dimensional Taxonomy (HiTOP)

Question 1

What is essentialism?

Answer 1

the fact that psychiatry is rooted within the medical discipiline, and accordingly understands psychopathology as a structural, (epi)genetic, cellular, molecular, or other underyling disturbance that is located inside the body/brain
theres implicit essentialism in the DSM

Question 2

How does essentialism relate to DSM?

Answer 2

its implicit
“mental disorder is syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behaviour that reflects a dysfunction in the psych, bio, or dev process underlying mental functioning

Question 3

What are the core ideas of essentialism?

Answer 3

1. theres an underlying cause that explains the occurence of all symptoms of a cluster of symptoms
2. mental disorders are defined by these clusteres of symptoms
3. clusters of symptoms are independent from each other because they have a different cause (categorical taxonomy)

Question 4

What are the blinding effects of essentialism?

Answer 4

this view negates the possibility that mental disorders may be unique in presentation & etiology per person:
- alternative perspectives: blinds us to alternerative explanations of mental disorders
- context: may be blind to the context surrounding symptoms
- meaning
- social construction
- individual variation: may blind us to the fact that ppl just vary on certain traits, doesnt mean they have an undelrying mental disorder
- personal understanding

Question 5

What are the issues with essentialism?

Answer 5

1. aribitrary cut-offs instead of empirical basis: a )within syndromes, ex: meet 5 out of 9 symptoms b) between syndromes (lots of overlap between some)
2. Heterogeneity within syndromes: a) of symptoms: many different profiles (ppl) meet the same syndrome but very different symptoms b) of causes (ex: BPD could be from trauma, substance abuse, difficult current context etc)
3. Co-occurence (“comorbidity”): a) of syndromes (many BPD patients also meet depression, PTSD etc) b) of causes (one cause can lead to many different syndromes so many syndromes have common causes like trauma)
4. Continuity of personality & psychopathology (spectrum from momentary/episode/changeable/what you have <-> pervasive/persistent/unchangeable/who you are is less and less big (less distinct between what is a permanent syndrome like BPD and what is a temporary one like MDD)

Question 6

Why is having one model problematic?

Answer 6

categorical model is serving many parties & goals simultaneously (administartion, policy making, treatment, research etc)
while every level requires a different level of simplification vs precise representation, description at pop. level vs description at individual level
psychiatry needs more than one model so that it can be served both
- as a science
- as a practical, clinical discipline

Question 7

What were proposed solutions for the problems of essentialism (and thus of having only one model)?

Answer 7

• Dimensional trait model (starting in the 90s) like HiTOP
• the Network approach
• the Transdiagnostic approach
• the Personalized approach

Question 8

How did we get to HiTOP?

Answer 8

1. psychiatric epidemiology: research into prevalence showed that comorbidity was super common
2. questionnaire research in clinical & dev psych: bottom up disocveries of patterns & syndromes
3. personality trait research: showed continuity between traits and psych problems
4. psychometrics

Question 9

What is the dimensional trait model?

Answer 9

• models grounded in empirical data & do not meet most of the essentialism critiques
• idea: need to think in continua about psychopathology
• spectrum of personality traits (as variants of normal personality) and its pathlogy (varying in severity) with an assumed underlying factor
• so symptoms and/or syndromes that occur at the same time are understood to co-occur because of this underlying facotr

Question 10

What are some dimensional trait models?

Answer 10

1. 5 Factor Model: of normal personality functioning (Openness, Conscientiousness, Extraversion, Agreeableness, Neuroticism)
2. Personality psychopathology five: positive emotionality, aggressiveness, constraint, negative emotionality, psychoticism)
3. Dimensional trait model proposed for DSM: negative affectivity, detachment, psychoticism, antagonism, disinhibition
4. HiTOP: Hierarchical Taxonomy of Psychopathology

Question 11

How does a dimensional trait approach work in steps?

Answer 11

1. dimensionalize syndromes (instead of no depression to major depression with a cutoff of symptoms in the middle, we make a spectrum from low to high depressivity based on amount of symptoms)
2. Factor analyze multiple syndromes: like social anxiety, MDD, PTSD overlap a lot so then we get the “internalizing spectrum”
3. Factor analyze large sets of symptoms: put all DSM symptoms into one group and do hierarchical factor analysis on it all -> you get HiTOP
4. Joint factor analysis of Five Factor Model (peronality) and Alternative Model of Personality Syndromes and see how both relate to each other and to HiTOP

Question 12

What is HiTOP?

Answer 12

Hierarchical Taxonomy of Psychopathology
- aims to produce a tonomy that integrates & reflects quantitative outcomes in the area of mental health
- want to hypothesize and build an empirical classification system for psychopathology
- consists of hierarchically organised dimensions which start at the narrowest level of “symptoms” (particular signs) and moves up to the broadest level of “super spectra” (very broad dimesnions of multiple spectra)
- 6 spectra: internalizing, disinhibition, antagonism, thought disorder, detachment, and somatoform

Question 13

What are shortcomings of the dimensional approach in general? Is it really “beyond” essentialism?

Answer 13

• questionable whether it can really serve psychiatry as a practical, clinical discpiline: can we really make clinical decisions without categories & cut-offs? doesnt really solve the arbitrary cutoff critique
• still problematic assumption of inferring a latent marker or substrate (aka underlying function/structure) from similarities/differences in appearances (morphology) (like the term internalizing pathology)

Question 14

For what goals should we use dimensional taxonomy (HiTOP)? what are the pros basically

Answer 14

• empirically grounded taxonomy
• more adequate representation of dimensionality & heterogeneity
• continuity w epiodemiological reseach

Question 15

What is the network approach?

Goal, Underlying Idea, Central Principles

Answer 15

Goal: better understand the processes behind mental disorderes and to optimally organise existing treatment interventions and develop new ones
Underlying idea: believes that there is no underlying central disease mechanism, rather they see mental disorders as “problems of living”
Central principles
- mental disorders are complex systems. symptoms are the results of connections petween symptoms (second principle) rather than as the result of a common cause (latent disease entity). mental disorder are made up of symptoms, not the cause of them.
- neurbio factors can still influence some symptoms but dont explain it all
- the covariance of mental symptoms follows a network structure: syndromes (clusters of symptoms) do esist & can be explained by strong causal relationships between the symptoms (so many feedback loops can be active)
- Hysteresis principle
- Symptom component correspondence principle

Question 16

What is the idea of hysteresis?

Answer 16

the idea that in the network approach even when the trigger for activation of the network has subsided, the network becomes self-sustaining, and gets stuck in its active state

Question 17

What is the “symptom-component correspondence’ principle?

Answer 17

the idea in network theory, that symptoms are actually just components of one big network, but they have found common network structures of symptoms that roughly align with some diagnoses

Question 18

What are the shortcomings of the network approach?

Answer 18

reductionism still there!
- still implicity assumes that mental disorders can be described in terms of DSM symptoms (so they are using reductionism, essentialism, and a disease concept)
- network approach says that mental disorders are “problems of living” so many things could be included, so what determines what to include in the network as symptoms?
- but in reality the network approach uses mainly DSM symptoms as network components, instead of using an “open methodology”

Question 19

What is reductionism vs essentialism vs disease concept

Answer 19

reductionism: tries to simplify complex problems by breaking them down into smaller parts
essentialism: looks for the essential, underlying quality that defines a mental disorder
disease concept: sees mental disorders as similar to physical diseases w clear causes & treatments

Question 20

How did the transdiagnostic approach come about?

Answer 20

originated from contact w patients
clinicans observed that disorder specific CBT based on the DSM categories, missed some essential maintaining mechanisms of all EDs. this lack may explain the high comorbidity amongst the EDs as well

Question 21

What is the transdiagnostic approach?

Answer 21

an approach that focuses on broad factors and mechanisms that are seen in multiple DSM diagnoses, and constructs treatments around this, rather than around specific disorders
(ex: treatment around emotional regulation, self esteem, etc)
- has many different models and approaches within itself

Question 22

What are the pros of the transdiagnostic approach?

Answer 22

• it transcends taxonomical problem: addresses common factors across diagnoses, offering a more comprehensive treatment approach
• its bottom-up: it orginitated from clinical patient observation, allowing for factors to be introduced that transcend the DSM restrictions: it broadens our symptom conceptualization of mental disorders

Question 23

What are the shortcomings of the transdiagnostic appraoch?

Answer 23

may just be a “lumping approach”, its not really diagnostic since its just combining multiple DSM diagnoses and giving treatment to it all together

Question 24

for what goals should we use categorical taxonomy (DSM)?

Answer 24

• continuity with research tradition in psych
• communication w society
• status as a medical professional
• reimbursement by health insurance

Question 25

For what goals should we use case conceptualization?

Answer 25

• explanatory hypotheses
• applying psych theory
• learning clinical reasoning
• using clinical expertise
• developing a treatment rationale

Question 26

For what goals should we use the personal recovery approach?

Answer 26

• intersubjective understanding
• collaboration
• first person perspective
• promoting personal recovery
• hope, meaning, identity

Question 27

What are the 3 sub-approaches of the personalized approach?

Answer 27

1. precision psychiatry
2. personalized psychiatry
3. person centered psychiatry

Question 28

What is precision psychiatry?

Answer 28

to tailor treatments to personal biological stratifiers in psychiatry (not really to each individual, but at such high exactness in measurements so that its basically personalized)
- patients w the same disorder category (similar profiles) can differ a lot from each other in terms of bio associations, so we need to adjust
- assumes that psych, social, and other dimensions of a mental disorder will be represented and found in our body/brain

Question 29

What are the shortcomings of precision psychiatry?

Answer 29

• in reality, we are still far from finding biomedical tests that could inform clinical practice for mental health
• theres essentialism here again: to assume that psych & social dimensions of mental health will be represented in our body/brain
• concerns on whether this is the best use of healthcare (some health problems may be better tackled on a group level than an individual level)
• this focus on personal bio markers takes away focus on how important the therapeutic relationship is for improvement

Question 30

What is personalized psychiatry?

Answer 30

• n=1 approach
  each individual patient is unique in terms of etiology, expression, treatment response, and prognosis so we should focus on the unique homeostasis within individuals
• so we have to make personalized theories about a person and his/her mental disorder & use the according technologies

Question 31

What are some technologies used for personalized psychiatry? How does it work?

Answer 31

Ecological Momentary Assessment (EMA), symptoms, emotions, events, context, and behaviour are repeatedly assessed in real time during the day
it generates “big” time series data on a single individual by sampling real time experiences
provides insight into the relationship between problems & behaviour & context etc, so can inform treatment

Question 32

What are the pros of personalized psychiatry?

Answer 32

it focuses on symptoms rather than syndromes, focus on individuals rather than groups, and focuses on dynamics rather than a static position of mental disorders
- seems to benefit patients directly
- can inform group interventions

Question 33

What are the shortcomings of personalized psychiatry?

Answer 33

• doubts about how much complexity this method can really allow (can we quantify & measure everything about mental disorders)
• can unmotivated patients also engage with this method
• can it really be made personal/feel personal to the patient (we need human contact)

Question 34

What is person-centered psychiatry?

Answer 34

• propagated by recovery movement
• idea: whole person + their context + needs should be focus of clinical care
• here a diagnosis becomes personalized “co-construction/co-narration” of a patients needs in relation to their resources
• allows for non reductionist, personally meaningful appraoch

Question 35

What are the shortcomings of the person-centered psychiatry approach?

Answer 35

• radically deviates from current models so risks losing communication with that & becoming somewhat one-dimensional

Question 36

What is the group vs individual level of psychiatry?

Answer 36

principles that different models (dimensional, categorical, personalized etc) serve different purposes
individual: clinical purposes
group: research & practical purposes (like administration, communication, reimbursement etc)

Question 37

What is the distinction between “diagnosis” and “DSM diagnosis” in psychiatry?

Answer 37

DSM diagnosis: a taxonomy that aims to represent the actual state of affairs, but doesnt do this (reification issue: ppl think a DSM diagnosis means this is the only and whole truth, while its actually a limited symptom conception at the nomothetic (general) level)
- limited symptom definition
- not very complex (since only includes a cluster of symptoms)
- concerns a grouping so its not created to embed the very particular
- important for practical reasons
diagnosis: precise conception of a mental problem at the ideographic (aka individual) level
- symptom transcending definition
- complex (can include attachment, personality, context, system etc as well as symptoms)
- important for treatment

Question 38

Why is the difference between individual and group level in psychiatry important to author?

Answer 38

because they both require different methods & models

Question 39

What (parts of) methods are best for the group level?

Answer 39

• DSM is the current sued
  but 3 other TAXONOMIES have been proposed
  1. HiTOP: gives more nuance, but this nuance might stand in the way of it serving practical issues (but should it use DSM terms?)
  2. Transdiagnostic approach: if we lump multiple categories together it could serve practical purposes & remove some reification. or it could help develop a taxonomy based on patients needs which may help psychological interventions, but not psychiatric ones
  3. Person centered approach: wants to abandon taxonomy altogther but this would not help at the group level. to meet client needs, we can eliminate obscure terms from our taxonomy & use more neutral descriptions)

Question 40

What (part of) personalized/dimensional methods are best for the individual level?

Answer 40

WHOLENESS, PERSONALIZED, COMPLEX, DYNAMIC
- scale up symptom level (rather than syndrome level) & include contextual, somatic, and psychological levels into our conception of mental disorder at the individual level
- network theory: idiosyncratic (n=1), dynamic networks that fit the complexity of patients problems but lacks inclusivity & misses symptom transcending factors
- understanding connectedness between symptoms
- Person centered approaches: understanding personal meaning (phenomonology) & therapeutic relationships importance

overall we should thrive for nonessentialist & non reductionist bottom up appraoch