E14. Robert Krueger – Empirically-based Diagnosis and Categorisation

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Today we speak with Professor Robert Krueger, Distinguished McKnight University Professor, Hathaway Distinguished Professor, and the Director of Clinical Training in the Department of Psychology at the University of Minnesota. Professor Krueger’s work spans the fields of personality and personality disorders, psychometrics, and genetics, and is centred on developing an empirically-based system of grouping and delineating psychopathology.

This is a topic that I think is important to the way we think about mental health and conduct research into it. And I couldn’t hope to have to have a more qualified guest to discuss the topic with. Professor Krueger was a member of the DSM-5 Personality and Personality Disorders Work group, and is an architect of the Hierarchical Taxonomy of Psychopathology a new, dimensional classification system of psychiatric problems.

Show Notes

1:20 – On Robert’s background

2:55 – On the problems associated with the DSM diagnostic procedure

5:05 – How did we end up with the DSM given how readily the associated problems are observed, and given the transdiagnostic approach of early psychotherapists?

8:20 – On the pendulum swinging back the other way now.

11:50 – An outline of the HiTOP (Hierarchical Taxonomy Of Psychopathology) approach to diagnosis and categorisation.

17:20 – On why traditional categorical diagnoses appear in the HiTOP?

22:25 – On the similarities and differences of Research Domain Criteria (RDoC)

26:40 – On other approaches to deriving an empirically derived nosology, apart from HiTOP and RDoC.

28:55 – Will the shift to an empirically derived nosology be a big change for clinicians?

33:20 – Thinking about an example involving multiple diagnoses, from a HiTOP perspective.

37:15 – Does the move toward an empirically derived nosology have any implications for debates around the over-pathologising of normal human experience?

41:00 – What advice does he have for students?

2:00 – On Robert’s background

Robert was trained as a clinical psychologist, obtaining a PhD in clinical psychology. His interest in diagnosis and categorisation goes back to early experiences struggling to apply the standard diagnoses to his clients.

2:55 – On the problems associated with the DSM diagnostic procedure

Under the DSM, diagnoses are made when someone meets a certain threshold of diagnostic criteria from a list of diagnostic criteria. Under this system there can be considerable heterogeneity within categories (people with different symptoms receiving the same diagnosis). Similarly, people tend to meet the criteria for more than just a single diagnoses. This is known as the co-morbidity problem, and limits the usefulness of a diagnosis for planning appropriate treatments.

5:05 – How did we end up with the DSM given how readily the associated problems are observed, and given the transdiagnostic approach of early psychotherapists?

DSM-3, published in 1980, was a significant turning point. Earlier editions of the DSM had only descriptive paragraphs instead of well delineated criteria sets (which was also problematic). It is only by doing research with such criteria sets that their problems clearly emerge.

8:20 – On the pendulum swinging back the other way now.

Robert identifies the main reasons why people in the research community are supportive of a move  to a more empirical diagnostic system as due to the disappointing search for biomarkers of psychiatric conditions. For clinicians, it is the lack of informativeness of a diagnosis for planning appropriate treatments.

11:50 – An outline of the HiTOP (Hierarchical Taxonomy Of Psychopathology) approach to diagnosis and categorisation.

HiTOP is an effort to follow the evidence of how the symptoms associated with psychiatric conditions are organised. The resulting view is one where people’s experience is seen to fall along different dimensions, rather than in clearly different categories. The dimensions are considered to be organised hierarchies from signs and symptoms at the lowest level to a general psychopathology factor at the highest level.

17:20 – On why traditional categorical diagnoses appear in the HiTOP?

The presence of traditional categorical diagnoses in HiTOP, such as Major Depressive Disorder and Bipolar Disorder, partially reflects that fact that most research has been done along the line of such categories. However they are also intended to help with the transition from the current approach to an empirical approach.

In time, the use of such diagnoses may fall away if such a change was supported by the evidence.

22:25 – On the similarities and differences of Research Domain Criteria (RDoC)

The RDoC project is an initiative being developed by US National Institute of Mental Health. It was initiated in response to the same dissatisfactions with the DSM criteria that motivated HiTOP. However, in comparison with HiTOP, RDoC is more focused on biological mechanisms and makes less concessions to ensure continuity and an easy transition from the current approach.

RDoC and HiTOP should be seen less as competing approaches, and more as complementary approaches that will dialogue and converge on a consensus conception of psychopathology.

26:40 – On other approaches to deriving an empirically derived nosology, apart from HiTOP and RDoC.

There are a variety of approaches currently being explored with the hope of deriving an empirically derived nosology. Network approaches focus on the relationship between different symptoms. A key difference between network approaches and HiTOP is that network approaches don’t give much focus to higher levels of the hierarchy proposed by HiTOP.

28:55 – Will the shift to an empirically derived nosology be a big change for clinicians?

In some ways, especially around record-keeping and insurance, the move to a HiTOP-type system may require significant changed. But in terms of how they think about and approach treatment, clinicians may already operate in a way that is consistent with a HiTOP-type system. For example, they may often forego a formal diagnostic assessment as they consider it to have little clinical utility. Instead, they may think about their client’s difficulties in broader terms than DSM-5 labels, something like the HiTOP spectra (internalising, externalising and thought disorders).

33:20 – Thinking about an example involving multiple diagnoses, from a HiTOP perspective.

The example involved a case where a person presents with symptoms of anxiety, depression and substance-use disorder. There is little difference in the way one would approach treatment (again, testament to the fact that most clinicians don’t use DSM-5 diagnoses to guide treatment).  However, a notable opportunity that comes from thinking in a HiTOP-consistent way, is to identify processes that are relevant to a number of diagnostic categories.

37:15 – Does the move toward an empirically derived nosology have any implications for debates around the over-pathologising of normal human experience?

For one thing, efforts to derive an empirically derived nosology have highlighted that there is no bright line between psychopathology and normal variation. This spectrum-based thinking, instead of categorical thinking, highlights that it is convention that dictates when to intervene, rather than a simple case a disease is present and therefore an intervention is warranted/necessary.

41:00 – What advice does he have for students?

Pursue your passion. This might seem cliche, but for Robert, doing something meaningful and interesting makes it easier to persist through the difficult times.

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Announcements

There is currently an opportunity to volunteer as a research assistant with the Black Dog Institute. They are particularly after volunteers who can visit Walcha and/or Glen Innes (travel costs reimbursed), though opportunities exist in other areas of New South Wales too. The positions will support The Future Proofing Study, which is the largest mental health prevention study ever undertaken in Australia. I spoke with the Chief Investigator of The Future Proofing Study in Episode 10 (https://www.mindstewpodcast.com/e010/). Details of the position can be found here.

What I’m Reading

Currently Reading:

The New Mind-body Science of Depression by Vladimir Maletic and Charles Raison

To Read:

Act Made Simple: An Easy-to-read Primer on Acceptance and Commitment Therapy by Russ Harris

Being No One by Thomas Metzinger

Finished Reading (a general snapshot and selection that might be of broad interest):

The Emotional Foundations of Personality: A Neurobiological and Evolutionary Approach by Kenneth Davis and Jaak Panksepp

  • This book makes a strong case that the structure of personality should be conceived of as reflecting the primary emotional systems of SEEKING, CARE, PLAY, RAGE, PANIC/sadness and FEAR, rather than the linguistic-factor-analytically derived Big 5. A thought-provoking and broadly relevant exploration of how emotion shapes personality and psychopathology. 

Carhart-Harris, R. L., & Friston, K. J. (2019). REBUS and the Anarchic Brain: Toward a Unified Model of the Brain Action of Psychedelics. Pharmacological Reviews, 71(3), 316–344.

    • An important predictive coding account of how psychedelics work. Obviously preliminary, but sketches out useful concepts that are likely to shape future neuroscience research on psychedelics.

Clayton, M. S., Yeung, N., & Cohen Kadosh, R. (2015). The roles of cortical oscillations in sustained attention. Trends in Cognitive Sciences, 19(4), 188–195.

    • A really useful summary of the cortical oscillations observed in studies of sustained attention, and hypotheses of the roles of the observed oscillations. Worthwhile for anyone interested in cognitive control and EEG.

Note: As an Amazon Associate I earn from qualifying purchases. If you purchase a book through the links on this site, I earn a small slice without you paying any more than if you purchased directly. This hasn’t actually earned me a cent yet, and probably never will, but if it did, it would be a preferable way to offset the costs of the podcast compared to advertising.

E11. Rebecca Brewer – Interoception

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Today we speak with Dr. Rebecca Brewer, Senior Lecturer in Psychology at Royal Holloway, University of London. Rebecca studies social and emotional abilities across a range of clinical and typical populations, and how interoception (the perception of the internal states of one’s body) is related to these emotional and social abilities.

Interoception is a topic that I’ve been finding fascinating lately. Interoception is important to many processes fundamental to what makes us who we are, from homeostasis to subjective experience itself, from decision making to psychopathology.

In this conversation, we focus particularly on the relation of interoception to psychopathology, an area where Rebecca has done interesting work and proposed big ideas.

Show Notes

1:20 – What is interoception and why study it?

4:25 – On the relevance of interoception to psychopathology.

6:25 – On interoception abnormalities as the p-factor.

9:45 – Does the relationship of interoception abnormalities to psychopathology appear causal?

13:00 – On treatments targeting interoceptive ability.

21:45 – On what Rebecca hopes the next wave of interoception research

26:00 – On the importance of interpretation of interoceptive signals

28:30 – On whether interoception is an area of interest for positive psychology

30:30 – On the focus of upcoming research for Rebecca’s group

39:40 – What Rebecca wishes she new when she was a student.

1:20 – What is interoception and why study it?

Interoception is the perception of signal arising from within the body. Sometimes the definition is widened to include stimuli that share similar neural pathways, such as slow sensuous touch.

Rebecca’s early research focused on ASD and alexythymia (difficulty understanding your own emotions), which led her to interoception.

4:25 – On the relevance of interoception to psychopathology.

Many different clinical populations struggle to understand their own emotions. Additionally, it seems linked to other disorders unrelated to emotional recognition, such as eating disorders and substance use disorders.

6:25 – On interoception abnormalities as the p-factor.

The p-factor is idea that there is a single factor that might underlie susceptibility to psychopathology in general, analogous to the g-factor in intelligence. Rebecca did work with Geoff Bird and Jennifer Murphy suggesting that the p-factor might relate to interoception. They suggested this as interoceptive abnormalities have been seen across a very wide range of psychopathologies (including depression, anxiety, OCD, schizophrenia, eating disorders, substance use disorders).

9:45 – Does the relationship of interoception abnormalities to psychopathology appear causal?

It’s unclear at this point. In some cases interoception abnormalities can lead to psychopathology, but the relationship is likely bidirectional.

13:00 – On treatments targeting interoceptive ability.

There are different aspects to interoceptive ability. Hugo Critchley and Sarah Garfinkel proposed the following aspects:

  • Accuracy/sensitivity: your objective ability perceive a particular internal signal. eg. Accuracy in counting heartbeats.
  • Sensibility: how much do you report noticing and focusing on your internal states.
  • Metacognitive awareness: Your accuracy of your perception of your interoceptive accuracy/sensitivity.

There are treatments that train both sensibility (focusing more on internal signals) and accuracy. Sensibility can be targeted through mindfulness-based interventions. Accuracy can be targeted by providing external feedback at the same time a an internal signal, most commonly heartbeart.

It is not yet clear whether training heartbeat perception translates to improved perception of other interoceptive signals, and the other psychological processes that involve interoception, such as understanding emotions, empathy, processing risk and reward.

21:45 – On what Rebecca hopes the next wave of interoception research

On of the main things is to develop better tests of interoception. And, of course, larger studies looking at whether altering interoceptive ability changes cognitive functioning and psychopathological symptomatology.

26:00 – On the importance of interpretation of interoceptive signals

Alongside the objective accuracy one’s ability to perceive interoceptive signals, the interpretation of perceived signals is important. Interoceptive signals can be over-interpreted, as in the case of someone with anxiety who might think that they are having a heart attack when it is really just a slight increase in their heart rate, or under-interpreted, as in the case of those with alexythymia who tend to report heart attacks too late.

28:30 – On whether interoception is an area of interest for positive psychology

There have been some studies on non-clinical populations, looking at for example the relation between interoceptive ability and decision making. However, the majority of the work is clinically focused.

30:30 – On the focus of upcoming research for Rebecca’s group

One thing that Rebecca’s group will be looking at the link between interoception and social perception. For example, does your ability to perceive whether you are tired correlate with your ability to perceive if someone else is tired. This work could inform interpersonal interactions in medical and care-based professions, and any work where empathy is important.

39:40 – What Rebecca wishes she new when she was a student.

Rebecca wishes she new how much freedom and flexibility academia provides, both in terms of collaborators and research areas. Also, that not every piece of work needs to entail a groundbreaking idea. And that she had a better understanding of the publication process.

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Episode References

Other key researchers working on interoception include Sarah Garfinkle, Hugo Critchley, Anil Seth, Sahib Khalsa, Karen Quigley and Manos Tsikiris.

E10. Aliza Werner-Seidler – Preventative Mental Health Care

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Today we speak with Dr. Aliza Werner-Seidler, a Clinical Psychologist and Senior Research Fellow at the Black Dog Institute, affiliated with the University of New South Wales. Aliza works on the prevention and treatment of depression and anxiety disorders, particularly via school-based and digitally delivered, evidence-based programs. She is currently the Chief Investigator of the largest preventative program of anxiety and depression run in Australia, a randomised controlled trial involving 20,000 young people across 400 schools.

Prevention is an emerging and understudied area of mental health, but one with the potential to save huge amounts of suffering and make a significant contribution to the alleviation of the economic burden of mental health disorders facing the modern world.

In this conversation, Aliza provides outlines the work that she is leading at the Black Dog Institute and gives an overview of the field of preventative and early intervention approaches to mental health care.

Show Notes

0:55 – On the history of preventative and early intervention programs, and the reasons increasing interest in them

2:45 – Do preventative and early intervention programs actually reduce the incidence of mental health issues or reduce their severity?

5:05 – What do we know about matching people with different sorts of preventative and early intervention programs?

6:50 – Challenges that preventative programs face, beyond being a young field

7:45 – On what a typical universal prevention program looks like.

11:35 – On the relation between mental health promotion and mental disorder prevention.

13:35 – What is happening at the moment in terms of pilot programs?

18:10 – What content is typical of a universal program aimed at preventing depression and anxiety?

21:00 – What is the attitude of schools toward preventative programs?

26:05 – On the goals of the Future Proofing study Aliza is currently leading

27:45 – How do we prevent less common mental health challenges, such as psychotic disorders.

32:15 – What do the economics of preventative mental health programs look like?

39:10 – What must be considered around “critical windows”?

43:25 – Early life trauma and preventative programs

44:50 – How to learn more about the field of prevention

47:45 – Opportunities to get involved in the field, and the work at the Black Dog Institute.

50:10 – On disorders which preventative approaches don’t seem to be effective for.

0:55 – On the history of preventative and early intervention programs, and the reasons increasing interest in them

The increasing interest in preventative and early intervention programs was catalysed by a statement from a taskforce of the Institute of Medicine in 1994 on disease prevention. Additionally, interest has been fuelled by growing recognition that the high rates of common mental disorders, such as depression and anxiety, must be addressed with not only treatment but preventative efforts.

2:45 – Do preventative and early intervention programs actually reduce the incidence of mental health issues or reduce their severity?

In short, both. But it is worth differentiating between different sorts of programs.

  • Universal prevention programs are delivered to an unselected group (eg. an entire school or workforce). Universal programs have been shown to reduce the incidence of mental health problems.
  • Selective intervention programs are delivered to people on the basis of the presence of some risk factor.
  • Indicated prevention programs are delivered to people who display symptoms of a disorder but don’t yet meet clinical criteria.
  • Early intervention, which has some overlap with indicated prevention programs, but is also used to refer to programs that have experienced their first episode of a mental health disorder.

In school, universal programs, can be expected to reduce the incidence of depression by ~20% in the 2 years after the program. How this translates to later outcomes is unknown.

5:05 – What do we know about matching people with different sorts of preventative and early intervention programs?

As the field is still quite young, most meta-analyses lump all preventative and early intervention programs in together without differentiating between them. One factor to consider when comparing programs is that the very low symptom levels displayed by the recipients of universal prevention programs (ie. healthy populations) result in a floor effect, and hence indicated prevention programs typically appear more effective.

6:50 – Challenges that preventative programs face, beyond being a young field

A key challenge is motivating people to engage in preventative exercises if they don’t have any symptoms or risk factors. This is particularly challenging given the audience is children and adolescents and a challenge the field is yet to solve.

7:45 – On what a typical universal prevention program looks like.

Typically universal prevention programs will resemble a CBT course that has been adapted from being part of a treatment program. The skills taught are the same as a treatment course, and often the scenarios used in the program are the same. There are other non-CBT prevention programs, such as interpersonal psychotherapy programs, mindfulness programs, yoga and exercise programs, but CBT programs have been studies the most and (therefore?) have the most evidence to support them. Overwhelmingly, these programs are delivered to children in school. Due to cost considerations, digital programs are being increasingly explored, however engagement is even more of a challenge with digital programs.

11:35 – On the relation between mental health promotion and mental disorder prevention.

Mental health promotion often aims to increase help-seeking behaviours and increase people’s knowledge about mental health problems. Preventative programs tend to be more skills-based. So the two are distinct, but with significant overlap.

13:35 – What is happening at the moment in terms of pilot programs?

At the moment, the program designers are focused on building engagement by learning from the gaming community and increasingly involving young people. There is also room for improvement with selling these programs in to schools: stigma and a preference for a positive-focus continue to be challenges. Consequently, Aliza is; (a) targeting the angle of poor sleep, as a risk factor and an angle to increase engagement, and (b) seeking to understand how psychological skills can be incorporated into PDHPE classes.

18:10 – What content is typical of a universal program aimed at preventing depression and anxiety?

Most programs are based on a modified CBT approach. They contain psycho-education, relaxation techniques, thought challenging and restructuring, behavioural activation and for anxiety, some sort of exposure therapy. Aliza would ideally like to see modules on interpersonal relationships, sleep, well-being promoting practices (such as exercise and time outdoors) and also something on less-common psychotic disorders.

21:00 – What is the attitude of schools toward preventative programs?

The state government’s education department and other peak bodies are very much on board with preventative programs. And although individual schools are varied in their enthusiasm for preventative programs, there is enough support that the largest digital mental health prevention trial ever attempted is underway. 

26:05 – On the goals of the Future Proofing study Aliza is currently leading

The Future Proofing study is looking at how to scale up and implement digital preventative programs. In part this involves looking for patterns in how engagement and outcomes vary, with a focus at school-level differences and how to increase student engagement.

27:45 – How do we prevent less common mental health challenges, such as psychotic disorders.

Screening is a key approach to helping prevent less common mental health challenges, and Aliza sees a place for universal screening. Alternatively, it might be considered that less common disorders are better suited to an early intervention approach rather than a preventative approach. This second position, is supported by the difficulty in predicting who will suffer a mental health disorder even if we can screen for risk factors. In other instances, we can sensibly target high risk groups, such as those with particular personality traits or adults who have recently been diagnosed with cancer or other serious illnesses associated with risk of depression and anxiety. Ultimately, it depends…

32:15 – What do the economics of preventative mental health programs look like?

Prevention programs, and especially digitally-delivered prevention programs, are likely to have very favourable economics, especially once lost productivity, the recurrent nature of common mental health disorders and other social outcomes are considered. This is evidenced by, for example, the work of Pim Cuijpers in the Netherlands But at this stage, a lack of long-term follow up studies in Australia, limits what we can say with precision and confidence. Hence, vision is required at a policy level.

39:10 – What must be considered around “critical windows”?

This is still being teased apart, but the jump in mental health difficulties seen among 16-17 year olds, compared to 11-15 year olds, suggest a critical window during adolescence. There is also demand from schools for programs for younger children.

43:25 – Early life trauma and preventative programs

Preventative programs aren’t intended to treat the effects of early life trauma. Preventative programs could be an adjunct to but not a replacement for other therapy for trauma.

44:50 – How to learn more about the field of prevention

Some papers shared by Aliza:

47:45 – Opportunities to get involved in the field, and the work at the Black Dog Institute.

The Future Proofing Study will be supported by a team of volunteer research assistants who will support school visits. The next wave of volunteer research assistants will be recruited our next year. If this is something you are interested in, please keep an eye on the Black Dog website closer to the end of the year. Also, the Black Dog Institute, in association with the University of New South Wales, offers a number of PhD scholarships.

50:10 – On disorders which preventative approaches don’t seem to be effective for.

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Episode References

The 1994 report from the Institute of Medicine’s Committee on Prevention of Mental Disorders

Blackdog’s preventative, digitally-delivered Future Proofing Study, involving 20,000 high school students.

A seminal meta-analysis on the prevention of depression by Pim Cuijpers’ group at the Vrije Universiteit Amsterdam (The Netherlands).

World Health Organization pages on the prevention of Mental Health disorders and Suicide.

Aliza’s profile at the Black Dog Institute.

E5. Maria Kangas – Anxiety and depression

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Today we speak with Dr. Maria Kangas, Associate Professor of Macquarie University’s Centre for Emotional Health.

Maria is a registered psychologist with dual endorsements from the Psychology Board of Australia in Clinical and Counselling Psychology. Maria is also Director of the Clinical Psychology program at Macquarie University. Her research has focussed on coping strategies and emotional regulation relating to stress/PTSD, anxiety and mood disturbances in trauma and medical (e.g., cancer) populations, across the lifespan.

*Please accept my apologies for the recording quality. There are a number of moments where a faulty internet connection has undermined our VOIP program and resulted in a recording that was clipped in a few places.

Episode References

Dr. Kangas’ Macquarie University home page which uses a tool called Fingerprint to present a great visual representation of Maria’s research areas

Centre for Emotional Health

The HiTOP consortium, taking an empirically-driven approach to re-classifying  psychopathologies.

Emotional regulation