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.

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