Clinicians’ Concepts of �Mental Disorders

Woo-kyoung Ahn /oo-gyung än/

Yale University

Outline •  Part 1: What are clinicians’ beliefs about

causal bases of mental disorders and how do they affect their beliefs about treatment of mental disorders?

•  Part 2: Evaluation of a promising new proposal for personality disorders (Five-Factor Model) in terms of cognitive theories on categorization

Biological System

Psychological System Environmental System

Genetic predisposition

Anxiety, stress Tobacco smoke, cold air

ASTHMA

Part 1: Clinicians’ beliefs about �causal bases of mental disorders�

Engel’s Biopsychosocial model of Disease

Biological System

Psychological System Environmental System

Hormonal Imbalance

Stress Bad Economy

DEPRESSION

Part 1: Clinicians’ beliefs about �causal bases of mental disorders�

Mental Disorders

Yet, people may have difficulty thinking about the interactions, because

Tendency to separate Biological and Psychological Domains

•  Different mechanisms – Children believe bodily symptoms (coughing) are

contagious, but behavioral abnormalities (obsessively washing hands) are not (Keil, 1992).

•  Separate, non-interacting domains – Children have difficulty believing that psychological

events (feeling nervous) can cause physical health outcomes (a tummy ache) (Notaro, Gelman, & Zimmerman, 2001).

–  (Lynch & Medin, 2006) undergraduates and nurses rarely mentioned interactions between mental and physical causes.

•  Bloom (2004), “we are dualists who have two ways of looking at the world: in terms of bodies and in terms of souls”

(Proctor, 2008, PhD Dissertation)�Materialism, Mild Dualism, Extreme Dualism

•  “Some aspect of the mind can act on its own without the brain being involved. Some mental events (some thoughts, feelings, and decisions) are dependent on the physical activity of the brain, but not all of them. In other words, when you think about dogs, feel happy, or decide to buy gum, there could be some change in the activity in your brain, but there doesn't have to be. There can be a change in your mind without any change in the physical activity of your brain.”

•  Endorsed by 27% of Yale undergrads

Proctor (2008, PhD dissertation)

•  “… Bill was diagnosed with depression and was treated with psychotherapy / medication … and now Bill no longer has depression.”

•  To what degree did the psychotherapy / medication affect Bill’s mind / brain?

0

1

2

3

4

5

6

Rat

ings

Affecting Mind Affecting Brain

If materialists…

Proctor (2008, PhD dissertation)

•  “… Bill was diagnosed with depression and was treated with psychotherapy / medication … and now Bill no longer has depression.”

•  To what degree did the psychotherapy / medication affect Bill’s mind / brain?

0

1

2

3

4

5

6

7

Rat

ings

Affecting Mind Affecting Brain

Are clinicians dualists? 89 mental health clinicians (psychiatrists, psychologists, SW)

Biological System

Psychological System Environmental System

“any genetic or psychophysiological factors”

“any behaviors, thoughts, emotions, or identity-related factors”

“current or past environmental factors”

445 DSM-IV disorders

(Ahn, Proctor, & Flanagan, 2009) Experiment 1

Extreme Materialism� Psychology = Biology

Treating psychological terms as mere metaphors to biological processes (e.g., Andreasen, 1984)

Psychiatrists?

Biological

Psychological

Biomedical Model •  All mental disorders have

biological bases, but there may be psychological phenomena that cannot be easily captured by biological constructs, and the contributions of such psychological components may vary depending on disorders.

Biological

Psychological

Psychological Model

•  “At the other end of the spectrum are those psychotherapists and social workers who believe that abnormal behavior can be wholly explained in social and psychological terms”

Biological

Psychological

Integrated View

•  “psychiatric disorders are…complex multi-level phenomena…and their full understanding will require the rigorous integration of multiple disciplines and perspectives”

Biological

Psychological

Dualism

Dualism

Disorders of Mind

Disorders of Brain

Inverse relationship;�Bio-Psych Single Continuum

Biological

Psychological

Experiment 1: Results �(average clinicians)

1

2

3

4

5

1 2 3 4 5

Biological

Psychological

rBP = – 0.92

Same pattern within individuals Same pattern with first block only

5.0

1.5

4.5

2.0

Environmental

4.0

2.5

5.03.54.5

3.0

Psychological

4.03.0

3.5

3.5

Biological

4.0

2.5 3.0

4.5

2.52.0

5.0

2.01.5 1.5

rBP = – 0.92 rBE= – 0.86 rPE= + 0.84

Disorder Names Biological Psychological Environmental

Mental Retardation 4.5 1.2 1.6

Schizophrenia 4.3 2.1 1.8

Bipolar I Disorder 4.3 2.3 1.9

Bipolar II Disorder 4.0 2.3 1.9

Schizoaffective Disorder 3.9 2.5 1.9

ADHD 3.7 2.4 2.5

Cyclothymic Disorder 3.7 2.6 2.2

Major Depressive Disorder 3.5 3.0 2.6

Obsessive-Compulsive Disorder 3.5 2.9 2.3

Substance Dependence 3.4 3.0 3.1

Schizotypal Personality Disorder 3.2 2.9 2.3

Dysthymic Disorder 3.2 3.2 2.8

Panic Disorder With Agoraphobia 3.2 3.4 2.8

Substance Abuse 3.1 3.3 3.2

Generalized Anxiety Disorder 3.0 3.4 2.8

Schizoid Personality Disorder 3.0 3.0 2.3

Obsessive-Compulsive Personality Disorder 2.9 3.3 2.5

Conduct Disorder 2.9 3.1 3.1

Paranoid Personality Disorder 2.9 3.4 2.6

Oppositional Defiant Disorder 2.8 3.2 3.2

Antisocial Personality Disorder 2.6 3.7 3.1

Borderline Personality Disorder 2.6 3.8 3.0

Anorexia Nervosa 2.6 3.8 3.1

Posttraumatic Stress Disorder 2.5 3.6 3.9

Social Phobia 2.5 3.7 3.1

Bulimia Nervosa 2.5 3.8 3.0

Histrionic Personality Disorder 2.3 3.8 2.9

Dependent Personality Disorder 2.2 3.8 2.9

Narcissistic Personality Disorder 2.2 4.0 2.8

Adjustment Disorders 1.9 4.0 3.8

Bereavement 1.6 4.0 3.8

Same pattern of relations for familiar disorders.

Same pattern of relations broken down by professional background.

Experiment 2: What is going on? (N=63 clinicians)

9 familiar mental disorders (MDD, bulimia, schizophrenia, … )

List as many causes Biological Psychological Environmental Bulimia

Depression Genetic predisposition Stress personality

3 5 2 1

5 1 5 5

4 1 3 3

Schizophrenia

Brain trauma Stress

Replication: rbio-psych = -.74. rbio-env = -.66, rpsych-env = .55

•  Why do we keep on finding this pattern of correlations?

•  What are the specific causes that they listed?

Experiment 3: �Implications of Causal Beliefs

•  Causal knowledge is for control; planning actions. –  Skin rashes caused by shell fish Avoid shell fish.

•  Do clinicians’ causal beliefs affect treatment choices? Psychotherapy

Medication

Experiment 3 �(N = 44 clinicians from Exp 2)

Case #

Mental Disorder

Caused by To what extent do you think PSYCHOTHERAPY could improve, control, or manage this person's disorder?

1 Bulimia Nervosa

Social pressure

2 Schizophrenia

Genetic factors

3 Mental Retardation

physiology

Experiment 3 �(N = 44 clinicians from Exp 2)

Case #

Mental Disorder

Caused by

To what extent do you think MEDICATION could improve, control, or manage this person's disorder?

1 BulimiaNervosa

Social pressure

2 Schizophrenia

Genetic factors

3 Mental Retardation

physiology

Medication Therapy Bio Basis of Causes 0.829 -0.687 Psycho Basis of Causes -0.763 0.653 Enviro Basis of Causes -0.878 0.527

All interaction effect p’s < .001

Inverse relationship;�Bio-Psych Single Continuum

Pychotherapy

Medication

Is this good or bad? •  Possibly bad because

–  Research indicates that for many disorders, a combination of therapy and medication is the most effective cure.

–  If clinicians are influenced too much by their causal beliefs in selecting treatment plans (e.g., psychotherapy only for bulimia), they may miss benefits of alternative treatment plans.

•  Future Directions –  How strong is this bias? What other inductive inferences

are affected by this bias?

Given: •  Biologically/

Psychologically caused Mental Disorder X

Infer: •  Effectiveness of

psychotherapy/ medication

Infer: •  Whether Mental

Disorder X is Biologically/Psychologically caused

Given: •  Effectiveness of

psychotherapy/ medication on Mental Disorder X

New discovery of effectiveness of

medication in treating a mental disorder

Stronger beliefs in biological bases of that mental disorder

Questions on Part I?

Part II: �Personality Disorders

•  Ten in the DSM-IV –  Paranoid –  Schizoid –  Schizotypal –  Antisocial –  Borderline

–  Histrionic –  Narcissistic –  Avoidant –  Dependent –  Obsessive-compulsive

Problems with DSM-IV Personality Disorders

•  There are too few. –  The 10 personality disorders in the DSM-IV cover only

about 50% of personality problems. •  Relationship / attachment problems •  Depressive personality disorders •  Passive-agressiveness

•  There are too many. Some DSM personality disorders have extremely high co-morbidity rates.

Problems with DSM-IV PD’s

•  The cut-offs are arbitrary and discrete. •  Borderline personality disorder (5 out of 9)

–  1. frantic efforts to avoid abandonment. –  2. a pattern of unstable and intense interpersonal relationships –  3. identity disturbance –  4. impulsivity –  5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior –  6. affective instability due to a marked reactivity of mood –  7. chronic feelings of emptiness –  8. inappropriate, intense anger or difficulty controlling anger –  9. transient, stress-related paranoid ideation or severe dissociative symptoms

•  Those who meet 4 out of 9 criteria for borderline does not get the diagnosis.

Dimensional Proposals for the DSM-V (Arriving in 2011?)

•  Dimensionalizing existing personality disorders – One more or less has Borderline Personality

Disorder

Dimensional Proposals for the DSM-V

•  Dimensionalizing existing personality disorders – One more or less has Antisocial Personality

Disorder •  Remove categories altogether,

dimensionalize along fundamental dimensions

Five-Factor Model Proposal

•  Eliminate all personality disorder categories •  Describe each patient in terms of 5 factors

– Extraversion – Agreeableness – Conscientiousness – Emotional stability (neuroticism) – Openness

Why FFM?�: Construct Validity

•  verified across many different cultures (Allik, 2005; McCrae & Allik, 2002).

•  biologically based (e.g., Bouchard & Loehlin, 2001; Yamagata et

al., 2006), •  stable across time (Costa, Herbst, McCrae, & Siegler, 2000),

•  related to life outcomes (Basic Behavioral Science Task Force, 1996; Judge, Higgins, Thoresen, and Barrick, 1999).

Why FFM?�: Overcome many problems with DSM-IV�

•  The DSM-IV 10 personality disorders are not exhaustive. – Anybody can be scored on FFM; FFM can

cover a broader range of personality. •  DSM-IV criteria are discrete and arbitrary.

– FFM is continuous, no arbitrary boundaries.

Clinicians can reliably use FFM. (Samuel & Widiger, 2004)

•  Practicing clinical psychologists •  Think about the most typical patient with

[narcissistic] personality disorders. Rate that patient on the 30 facets.

Mean Ratings on Narscissistic PD (Samuel & Widiger, 2004)

Fairly high Inter-rater Reliability : 0.64~0.78

Clinicians probably can use FFM with good reliability.

Potential Problems with FFM •  FFM uses trait descriptors only.

–  A person is low on agreeableness, high on excitement-seeking…

•  But previous theories in categorization found that meaning of features (e.g., agreeable) can be quite ambiguous.

“Open” eyes hand

door mind

“has wings”

“large”

•  Introvert

FFM profiles may not capture subtle but clinically important signs.

Angry

DSM FFM

Samuel & Widiger (2004)

Paranoid PD High Anger Borderline PD Antisocial PD Narcissistic PD

MANY ONE

DSM FFM Paranoid PD High Anger Borderline PD Antisocial PD Narcissistic PD

MANY ONE

?

Back-translation

If clinicians were provided only with the FFM profiles, �they may not be able to recognize the DSM disorders.

Rottman, Ahn, Sanislow, & Kim (2009)

•  DSM condition – Patient cases presented using the DSM

symptoms •  FFM condition

– Patient cases presented using FFM traits

DSM condition� for Narcissistic PD

FFM version (Samuel & Widiger, 2004)

Rottman, Ahn, Sanislow, & Kim (2009)

•  DSM condition – Patient cases presented using the DSM

symptoms •  FFM condition

– Patient cases presented using FFM traits

Make DSM-IV diagoses.

Practicing clinicians showed difficulty recognizing DSM disorders from the FFM profiles alone. This can’t be due to lack of knowledge about the DSM-IV disorders. �It suggests that FFM profiles may not be specific enough.

% C

orre

ct

Results from DSM Diagnosis Task

# of

Inco

rrect

Dia

gnos

es

(N= 187)

Comments on the FFM materials •  "I don't think there is an axis 2 diagnosis.”  "this graph does not

seem to have any diagnosis jump out at you.”  •  "Not enough information.” "Without a description of how these

personality traits are impacting the person's functioning it's nearly impossible to give a diagnosis.” "There is not nearly enough information to render a viable diagnosis.”

•  "CEO of a Fortune 500 company!” •  "normal adolescent?"  --- for Borderline •  Republican, member of president’s cabinet -- for Narcissistic

Clinicians’ ratings on clinical utilities of DSM and FFM �

Clinical Utility of

1.  Treatment

2.  Prognosis

3.  Comm (Prof)

4.  Comm (Patients)

5.  Describing (Important)

6.  Describing (Global)

2.0 2.5 3.0 3.5 4.0

6

5

4

3

2

1

Utility Ratings (95% Confidence Intervals)

DSM FFM

Experts �(Rottman, Kim, Ahn, & Sanislow, in preparation, 2009)

•  Would training / familiarity with personality disorders or FFM help?

•  Experts in Personality Disorders

Experts: Personality Disorder researchers�

•  authors on at least 3 peer-reviewed papers on “Personality Disorder”

•  at least one article during 2006 - 2008 •  consider personality disorders to be among

their primary research interests and have been conducting research on personality disorders for at least four years

•  N = 73

Results from DSM Diagnosis Task (N=73)�

Clinical Utility of

1.  Treatment

2.  Prognosis

3.  Comm (Prof)

4.  Comm (Patients)

5.  Describing (Important)

6.  Describing (Global)

•  If FFM profiles are not specific enough, clinicians may also feel that the FFM system is not clinically useful.

2.0 2.5 3.0 3.5 4.0

6

5

4

3

2

1

Utility Ratings (95% Confidence Intervals)

DSM FFM

Results from DSM Diagnosis Task (Equally familiar with DSM and FFM; N=24, a median of 20 papers on personality disorders )�

Clinical Utility of

1.  Treatment

2.  Prognosis

3.  Comm (Prof)

4.  Comm (Patients)

5.  Describing (Important)

6.  Describing (Global)

•  FFM experts’ ratings on clinical utilities

0 1 2 3 4

6

5

4

3

2

1

DSM FFM

Person-oriented (DSM) •  Different set of features for each person •  Easy to come up with coherent, causal stories

–  1. frantic efforts to avoid abandonment. –  2. a pattern of unstable and intense interpersonal relationships –  3. identity disturbance –  4. impulsivity –  5. recurrent suicidal behavior, gestures, or threats, or self-mutilating

behavior –  6. affective instability due to a marked reactivity of mood –  7. chronic feelings of emptiness –  8. inappropriate, intense anger or difficulty controlling anger –  9. transient, stress-related paranoid ideation or severe dissociative

symptoms •  Easy to come up with treatment plans,

prognoses, etc.

Variable-oriented (FFM)�Same variables across multiple people

Person 1 Person 2 Person 3 Person 4 Person 5 Person 6 Variable 1 4 2 Variable 2 3 3 Variable 3 1 5 Variable 4 5 7 Variable 5 6 1 Variable 6 3 4 …

Different meanings of variables depending on configurations Too many possible combinations of values Difficult to come up with causal theories

Conclusion for Part 2

•  Using standardized variables for describing mental disorder patients can be useful.

•  Thorough •  Exhaustive

•  But standardized variables may not convey subtle but clinically important meanings. – Clinicians (and even experts) could not

recognize well-known pathological patterns. – Difficult to come up with causal theories