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Clinicians’ Concepts of �Mental Disorders
Woo-kyoung Ahn /oo-gyung än/
Yale University
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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
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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
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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
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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.
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• Bloom (2004), “we are dualists who have two ways of looking at the world: in terms of bodies and in terms of souls”
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(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
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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…
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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
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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
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Extreme Materialism� Psychology = Biology
Treating psychological terms as mere metaphors to biological processes (e.g., Andreasen, 1984)
Psychiatrists?
Biological
Psychological
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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
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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
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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
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Dualism
Dualism
Disorders of Mind
Disorders of Brain
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Inverse relationship;�Bio-Psych Single Continuum
Biological
Psychological
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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
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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
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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.
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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
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Replication: rbio-psych = -.74. rbio-env = -.66, rpsych-env = .55
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• Why do we keep on finding this pattern of correlations?
• What are the specific causes that they listed?
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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
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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
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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
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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
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All interaction effect p’s < .001
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Inverse relationship;�Bio-Psych Single Continuum
Pychotherapy
Medication
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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?
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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
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New discovery of effectiveness of
medication in treating a mental disorder
Stronger beliefs in biological bases of that mental disorder
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Questions on Part I?
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Part II: �Personality Disorders
• Ten in the DSM-IV – Paranoid – Schizoid – Schizotypal – Antisocial – Borderline
– Histrionic – Narcissistic – Avoidant – Dependent – Obsessive-compulsive
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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.
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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.
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Dimensional Proposals for the DSM-V (Arriving in 2011?)
• Dimensionalizing existing personality disorders – One more or less has Borderline Personality
Disorder
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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
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Five-Factor Model Proposal
• Eliminate all personality disorder categories • Describe each patient in terms of 5 factors
– Extraversion – Agreeableness – Conscientiousness – Emotional stability (neuroticism) – Openness
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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).
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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.
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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.
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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.
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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.
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“Open” eyes hand
door mind
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“has wings”
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“large”
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• Introvert
FFM profiles may not capture subtle but clinically important signs.
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Angry
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DSM FFM
Samuel & Widiger (2004)
Paranoid PD High Anger Borderline PD Antisocial PD Narcissistic PD
MANY ONE
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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.
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Rottman, Ahn, Sanislow, & Kim (2009)
• DSM condition – Patient cases presented using the DSM
symptoms • FFM condition
– Patient cases presented using FFM traits
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DSM condition� for Narcissistic PD
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FFM version (Samuel & Widiger, 2004)
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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.
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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)
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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
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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
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Experts �(Rottman, Kim, Ahn, & Sanislow, in preparation, 2009)
• Would training / familiarity with personality disorders or FFM help?
• Experts in Personality Disorders
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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
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Results from DSM Diagnosis Task (N=73)�
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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
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Results from DSM Diagnosis Task (Equally familiar with DSM and FFM; N=24, a median of 20 papers on personality disorders )�
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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
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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.
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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
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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