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Dr. Sharp: [00:00:00] Hey everyone. This is Dr. Jeremy Sharp, and this is The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment.

Hey, welcome back. Today’s episode is brought to you by The Testing psychologist Beginner Practice Mastermind. This is a group coaching experience just for testing psychologists who are about to launch or who have just launched their practices. If you are in that group, head over to thetestingpsychologist.com/beginner, to get all kinds of information about the group and figure out if you might be a good fit.

These groups have been really awesome in the past. It’s great to have community support as you’re going through this journey and it can be an excellent resource to feel confident as you build your practice. I would love to have you.

Today’s episode is a really interesting episode. I’m so grateful to have my [00:01:00] guest with me. My guest is Dr. Katherine Jonas. She’s a licensed clinical psychologist and Assistant Professor in the Department of Psychiatry & Behavioral Health at Stony Brook University. She completed her graduate degree at the University of Iowa, and her clinical residency at the Minneapolis VA. She joined the Hierarchical Taxonomy of Psychopathology consortium in 2017, and she contributes to the consortium’s development of self-report and interviewer-based measures of psychopathology, as well as the implementation of HiTOP assessments in clinical settings. She is also a big contributor to the consortium’s program of genomic research.

As you can tell from that intro, we are talking all about the hierarchical taxonomy of psychopathology or HiTOP as it is known. HiTOP is a different nosology for [00:02:00] classifying, describing, and assessing psychopathology.

So we talk a lot about HiTOP, where it came from, what it is, the many dimensions, and we spend a fair amount of time on measures and how you can actually implement these measures in your clinical practice at this point. So this is a fascinating interview and I just love this area of, I guess you would say, alternative ways of describing human thoughts, feelings, behaviors, and psychopathology. I think it’s great to be able to have different options for that as we move forward.

All right. Without further ado, here is my fascinating conversation with Dr. Katherine Jonas.

[00:03:03] Hey everyone. Welcome back to another episode of The Testing Psychologist podcast. Glad to have you back. I think this is going to be another episode released in the COVID-19 era. So hopefully, all of you are doing well and staying safe and healthy.

We’re going to be talking today all about HiTOP. If you don’t know that acronym, that is totally okay. We’ll fill you in. HiTOP, very briefly is, well, what is HiTOP?

I should probably introduce you before I ask you questions. My guest today, Katherine Jonas is going to talk with us all about HiTOP. So Katherine, welcome to the podcast first of all.

Dr. Katherine: Thank you. Glad to be here.

Dr. Sharp: Good. Thanks. I really appreciate it. I was getting ahead of myself, but there’s our [00:04:00] first question, I guess. What would you call HiTOP?

Dr. Katherine: What is HiTOP? HiTOP is a way of thinking about mental illness. That sounds very abstract, but I’m avoiding saying it’s another diagnostic system and a nosological system because I think that’s what we’re trying to avoid, but to think of a science-based way of thinking about your patients, assessing your patients, thinking about what their specific strengths and weaknesses are and what kind of treatments could be useful for them based on a large body of scientific literature. So that’s the real thrust of it is making decisions about what disorders are similar to one another based on real scientific literature and large bodies of evidence and data that have been accumulated over time.

Dr. Sharp: Nice. The language [00:05:00] gets interesting. What do you call it? It is tough, right?

Dr. Katherine: Right. I guess it’d be helpful to break down the acronym, HiTOP. HiTOP is that hierarchical taxonomy of psychopathology. The first word, hierarchical, just means that the system is designed to function at various levels of specificity and generality.

So you can probably think of some patients in your practice who seem to have a lot of different problems. They’ve got a lot of different symptoms from different areas of psychopathology maybe, substance use problems and depression and aggression; maybe some neurodevelopmental problems as well.

So, the diagnostic system, that’s maybe 5 or 6 diagnoses. The point of a hierarchical system is that we can say at a very general level, there’s a general factor of psychopathology. This person is high on that general [00:06:00] factor. But because it’s hierarchical, you also have these specific factors that make up that general factor of Internalizing, Externalizing, Antagonism, Detachment, Psychoticism. So you can break that down into more specific domains, or we call them spectra of psychopathology and you can break that down further into sub-spectrum all the way down into facets, where you’re getting into very specific things like blood injury illness phobias or something much more specific.

In the current diagnostic system, we have some really specific diagnoses, some diagnoses that are functioning at that very specific level like blood injury, injection specific phobia. And we also have some huge, almost umbrella diagnoses like borderline personality disorder or schizophrenia, I would argue, where two people with the same diagnoses can have very different symptoms. So, is meant to [00:07:00] address that. A hierarchal component of the model is meant to let you as a clinician describe your patient at the level of generality or specificity that best suits what you see in front of you.

And then taxonomy, this is a way of describing differences that we see in psychopathology, differences that you can say carve nature at its joint. That’s the purpose of the taxonomy. And of course, psychopathology, we’re primarily focusing on things that are currently instantiated in the DSM or ICD but also looking towards neurodevelopmental disorders and some other things

Dr. Sharp: I see. So I don’t want to set this whole thing up as an either-or black and white decision-making kind of thing against the DSM or against something like RDoC [00:08:00] but I do think that it may be helpful to do a little compare and contrast just to get some sense of how HiTOP is similar and different from each of those systems, let’s say.

Dr. Katherine: For sure. To start with, looking for the similarities among them, these are all systems trying to create common definitions that we can agree upon so that we can communicate better with one another. That’s the fundamental similarity between them. After that, things change. As that was the founding principle of the diagnostic manual was like, all right, let’s make sure that when we say I have a patient with schizophrenia that we’re all talking about the same kind of patient.

We’ve gotten pretty far away from that because now the DSM started as a way of [00:09:00] sort of almost a census document, a way of counting how many people in mental institutions fell under various categories. Now it serves so many functions for research for advocacy, for insurance billing, very important for clinicians. So it’s come to play a number of roles.

And one of the criticisms of that is that maybe it’s not as good at all of those things. Maybe something can function well for the purposes of one application and not for others. Similarly, with RDoC, the intention of RDoC is as much more scientific or basic science-driven; the idea is that all mental disorders are brain circuit disorders, as Thomas Insel said. The [00:10:00] idea of RDoC was to identify those brain circuits so that we could do a better job of identifying the causes and treatments for mental illness.

The only problem with RDoC was that it didn’t have… RDoC can’t tell you when your patient walks into your office, you can’t describe that person in the RDoC system.  It doesn’t have any level of analysis that plays to clinical phenotypes.

I think the impulse behind the RDoC is really good and really valuable, like, let’s take the most modern methods available to us as scientists and build a sort of, not a diagnostic system, but a descriptive system, a taxonomy based on science. And I think that’s really great. It just didn’t get to the level that is necessary to make this clinically useful document.

[00:11:00] Even researchers want to know, let’s say, what is this brain circuit? Let’s say, we’re going to say everything’s a brain circuit. If this brain circuit is out of balance, everybody wants to know, what’s the implication in real life. What does this mean for my patient? And what does it mean for their functioning? Their ability to live a fulfilled life? And that’s where RDoC ends, unfortunately.

So, some differences there. I should say more specific, probably most importantly is that DSM is a categorical symptom system. So you either have depression or you don’t. And the truth is there are some people who have 4 out of 5 symptoms and they don’t meet the criteria. And then there’s a person with five and they meet the criteria. And those people are very, very similar, but one of them has the diagnosis and the other doesn’t. And that has [00:12:00] implications for billing and treatment.

So, HiTOP is important. It’s a completely dimensional system so that everybody can be described in terms of these dimensions, whether they have a very severe illness or no symptoms at all, but theoretically, every person who walks in your door could be described in terms of HiTOP.

Dr. Sharp: Yeah. That’s something that really caught my eye when I started to read about it. I think as diagnosticians and all of us are doing testing and assessment, we run into so many cases. There’s so much discussion of well, what if we’re in the subclinical level but just by a one or two symptoms, or what do you call these kids who are kind of anxious and kind of depressed? It seems like the same thing, but we can’t figure out how to describe that. Yeah, it seems like the utility is pretty evident just on the surface. And [00:13:00] I’m just excited to dig in and see how that is coming into fruition.

Dr. Katherine: I think it could also really be useful for particularly severe cases and for advocating that this individual needs more. They need more than somebody who comes in with, let’s say, who just barely meets the criteria for some diagnosis. They have everything. They need a higher level of care. And the dimensional system, I think that’s where it really excels to is really finding a way to direct attention also to people who have a heavy burden of symptoms and who need more from our healthcare system.

Dr. Sharp: Yeah, absolutely. The problem of severity, I suppose, is a tough one to solve in the DSM. A lot of it is… I mean it tries to be objective, but honestly, it feels very subjective most of the time. And [00:14:00] being able to do ding into this is important somehow.

Dr. Katherine: Yeah. I think there was an effort. There was an effort made in the last revision to move towards some dimensional systems, and in some areas they did. For example, substance use disorders now are on a continuous spectrum. I believe now in schizophrenia, there are rating scales for various symptom domains. You can rate severity within them. Autism spectrum, another one. But I think also that that revision process made clear that it is a political document maybe, and not a scientific, or it’s a scientific document, and the literature that HiTOP is based on this has been accumulating since the late 90s.

A number of the individuals who are [00:15:00] deeply involved in HiTOP were also involved in the DSM–5 revision process and were asked to provide guidance as to how the manual should be revised to take into account this new body of evidence and came up with a proposal that was ultimately voted down by the leadership. So, in the wake of that, I think some people said, all right, there is evidence to make changes or scientific evidence that these symptoms are like you said, they differ in terms of severity and we should reflect that in our diagnostic system, but the political will wasn’t there to do that. Not in all cases. So, there you go. There’s HiTOP. People decided to start something new.

[00:16:00] Dr. Sharp: Okay. There we go. I definitely wanted to ask about the origin story and where this all came from. Anything else that you might add to that? Like how did this emerge? And honestly, maybe the bigger question for me just out of curiosity is, where do you even start when you try to build a new system like this?

Dr. Katherine: I would say just to broadly describe the science that is motivating this because a lot of it is based on essentially factor analytic methods. These are just statistical methods that quantify, let’s say, a person who reports a lot of insomnia is also more likely to report a lot of, let’s say fatigue and low mood, and say these three things are pretty highly correlated. And[00:17:00] we can quantify that bundle of symptoms together. Those three things are more correlated with one another than they are with, let’s say, a person’s probability that they’ll say I have a problem with drinking and I tend to be aggressive and get a lot of arguments and fights.

So just basically breaking down correlations among symptoms into what 10 things tend to co-occur together and creating these dimensions based on these symptoms that can tend to co-occur. They tend to be stable over time. They tend to rise and fall together. Just saying, let’s let this symptom-level data lead the way, right? So let’s not say, well these things must co-occur because they’re in the same diagnostic category. Let’s actually take a look at do they co-occur and go from there, from the ground up.

So that’s the [00:18:00] evidence-based that’s been building up since the 90s when this statistical method became really easy to implement on very large datasets like the national comorbidity surveys, which are thousands of people. So very many thousands of data points.

So, that’s, I would say, the scientific movement that is driving HiTOP. I will give credit… Well, a number of individuals, a number of leaders of the consortium have really taken on a large load driving it forward, but probably Roman Kotov has really spearheaded the effort. And a lot of People had, I think thought of maybe formalizing this body of research into some sort of coherent document, but as he tells it, he [00:19:00] was looking for a way to celebrate getting tenure, and somebody said, well, why don’t you take a road trip and go talk to some people you’ve always wanted to meet. And he thought, well, that sounds like a good idea. So he went on a road trip and visited Bob Krueger in Minnesota and his graduate school advisor, David Watson in Notre Dame.

And this was shortly after the DSM-5 revision had come out, I believe, and just on the shoulders of this disappointment in terms of what people hoped the revision would encompass and will that it ultimately did. And so, I guess Roman decided that the best way to celebrate getting tenure is to make mischief. And so that’s what he did.

So, Bo, David Watson, and Roman have could have been core founding members and really [00:20:00] initiated writing that first paper, which eventually, I think 70 people took a part in writing. And so the consortium’s grown around that nucleus, but I have to say, I don’t know that the consortium would be as large or as productive, actually, I’m 100% it wouldn’t be as large as productive without Roman because he’s a force of nature. And this is the energy required to corral 70 academics. Writing a paper together is something only he could do, I  think.

Dr. Sharp: Yeah, that sounds like my worst nightmare, to be honest. That is incredible. So tell me a little bit about where it’s gone from there. I know when we were preparing for the recording that there are a number of branches, I suppose, of this research. So tell me what that’s [00:21:00] looking like these days.

Dr. Katherine:  So as the consortium has grown, we’re really happy. A lot of people have joined with areas of expertise and in different fields. I think for people listening to this podcast, probably what’s most relevant is our workgroups that are aimed at outreach to clinicians making the tools created by the consortium, and also just making the science and the system accessible to clinicians.

We have a few workgroups surrounding those. One is the Utility Workgroup which focuses on, okay, well, if you’re going to use HiTOP instead of some other system, what is this going to mean for, let’s say, your research or your clinical practice? What benefits could you expect in terms of better predicting [00:22:00] treatment outcomes or better match king, you’re finding a more appropriate treatment for your patient.

There’s the Clinical Translation Workgroup which is really focused on building applications that make it easier for clinicians to use the system. I’m involved in developing web interfaces so that you can, let’s say, you have a new intake coming in, you can send them an email with a link to complete a HiTOP assessment, and it’s automatically scored and sent to the clinician’s email and provides a little chart for you that describes the patient in this HiTOP system.

And then the other one that’s probably applicable to your listeners would be the Measures Development Workgroup with developing new assessment methods specifically like a self-report [00:23:00] inventory, as well as a clinical interview that can be used, again to just quantify people in the major domains that the consortium has identified.

Dr. Sharp: Got you. Yeah, I think those are probably the most relevant areas for our audience. And I’m really looking forward to talking more about the measures themselves and just how we put this into practice, if possible. And I’m sorry. I know I’m cutting you off. I can’t hear you about that. But maybe that’s a big question even to start with, and maybe a naive question, which is, is this something that we can actually put into practice now, or is it aspirational? What’s the status there?

Dr. Katherine: Yeah, it certainly is, which is really exciting. We’ve rolled out this sort of, we’re calling it the [00:24:00] HiTOP self-report. So, we just got grant funding to develop the self-report and interviewer measure. And in the meantime, what we’ve done is we’ve accumulated a number of other-dimensional measures that measure the big spectra that I mentioned a while back. So internalizing, Externalizing, Antagonistic, Detachment, and Thought Disorder, these five big areas of psychopathology.

So we’ve found some measures that assess those things and we’ve set them up in a web interface that’s HIPAA compliant. We have essentially started this at Stony Brook at our outpatient psychiatry clinic, as well as we’re rolling it out to a number of other institutions right now. When a new intake comes to the [00:25:00] clinic, the front office staff sends them an email that invites them to complete the assessment. The email is a unique link that links them to their provider so that when the individual completes the assessment, it is scored and a report is sent to the provider’s email, which they can then upload to the medical record system. And it provides an overview of these dimensions. They’re somewhat tailored to the clinical population.

So in the Stony Brook clinic, we have a lot of internalizing and externalizing, such as depression, now a growing group of substance use providers. And so, we focus on assessments that get at those symptoms and less on, let’s say schizophrenia, psychosis, which aren’t so much seen at that outpatient clinic, but really it’s meant to be adaptable to your patient population. So[00:26:00] building in other measures for other clinics as needed for their populations.

And I believe there’s also a clinician network, a HiTOP clinician network, which is led by Camilo Ruggero. And I believe there is a website where you can go and basically sign up to be alerted to new findings from the consortium and new things that may be relevant to your practice.

Dr. Sharp: I see. We’ll definitely list those in the show notes. Any resources that we’re talking about here will go on the show notes. I think people will be pretty curious about that after listening.

Dr. Katherine: Great.

Dr. Sharp: I’m immediately interested in this web-based assessment system. That sounds very helpful and efficient.

[00:27:00] Dr. Katherine:  Our hope, obviously, I do research now, but I did my training in clinical psychology and that will help with a lot of emphasis on assessment. And what got me excited about this was the idea of having real empirical data on your patient before they even walk in the door so that you don’t have to spend your intake screening for symptoms that they don’t have. You can focus on the things that they do have and spend your time there.

I don’t have experience in terms of… I know I haven’t written reports based off of the output of these things, although I’ve used many of these measures in my own training. But my hope is also that this report would make it very much easier to write up a report just in having all of the scales scores. We’ve found norms for everything. [00:28:00] So having everybody percentiled according to a normative population allows you to just really, I would imagine save you some time writing things up.

Dr. Sharp: I see. How does something like this compare to, I mean, I think of other self-report measures like the PHQ-9 or GAD-7, things like that. How do those relate?

Dr. Katherine: That’s a great point. I think that right now until the actual HiTOP measure is rolled out, which will hopefully be in the next year, this is essentially the like that but broader. So it’s sort of an omnibus screener that you can manage from one portal that’s scored automatically. I think PHQ-9 is great. BDI is great. These dimensional measures of depression, a lot of people are [00:29:00] used to working with those. And that’s good…

If you’re wondering what it would be like to work with the HiTOP assessment, I think if you’ve worked with the BDI or something like that, that’s a good template to think about- a mental template in terms of using these. So you have scores; everything in our measure is T scored. So you get a score relative to the normative population percentile. And we’ve created some heuristics in terms of severity ranges. And that’ll be something that we’ll be doing a lot more research on in the coming year as part of this funded research project.

But currently yes, think of it like the BDI, but if you had something like the BDI, quick, well-normed, easy to use, pretty simple to interpret, but also for everything else, aside from depression too.  So, just one [00:30:00] stop shopping and cover everything.

Dr. Sharp: Sure. It sounds very useful. I think a lot of us could find a really nice way to implement that, like you said, if nothing else, to save time screening all these concerns that may not be relevant.

Dr. Katherine: Yeah.

Dr. Sharp: That’s fantastic. Just to be clear, you said that some of these are available now, but then there are other components that are coming within a year, hopefully?

Dr. Katherine: Yeah. So right now, what we’re working on… The battery that we’ve developed right now from existing measures that are, we call them HiTOP Concordance. I think that sounds a little bit formal. They’re HiTOP Concordance, sure. These are existing measures right now we have in our battery.

In the outpatient clinic, for example, we have the IDAS, which is the [00:31:00] inventory for depression and anxiety. It’s broadband internalizing symptoms, as well as some post-traumatic stress, and some specific phobia. We have for alcohol and drug use, the AUDIT, and the DUDIT basic screening. We have then for sort of stable trait pathology, we have the CAT-PD, which is a computer adaptive test for personality disorders. We’re actually not using the computer-adaptive version, but that is something that we would really like to move towards is using that computer-adaptive model to even further reduce the amount of time for the patient to complete this.

Dr. Sharp:  Can you say just a brief word about what computer adapted means or a computer-adaptive? 

Dr. Katherine: Yeah, of course. So, computer-adaptive tests are… You can imagine it as if [00:32:00] you had a really good, let’s say math teacher who rather than having you fill out a page of 90 addition math problems, very simple addition math problems, every time you got one right, they would write up a new test and come up with one that was more appropriate for your ability. So let’s say you already know calculus, they figure that out pretty fast and they start writing a harder test for you.

So just imagine that computer program that is picking questions to ask the patient that are going to be most appropriate for them based on the questions they’ve already answered. So, if somebody has very few symptoms of depression, you probably don’t need them to answer 10 questions about suicidal thoughts, plans, behaviors. Obviously, you need to screen for those things and you can build that [00:33:00] into the system, but you don’t need to have them answer all those items, or if they don’t have any psychotic symptoms, you don’t have to ask them about visual hallucinations and auditory hallucinations, and olfactory hallucinations, et cetera. You’re just, okay. We’ll drop that part of the test and we’ll focus on, let’s say your alcohol use problems. 

Dr. Sharp: I see. This sounds familiar. Is this item response theory in some form?

Dr. Katherine: Yeah.

Dr. Sharp: Okay. 

Dr. Katherine: All based on item response theory. Good old item response theory, but using the characteristics of the individual and the normed characteristics of the test to save time, essentially.

Dr. Sharp: Sure. I think a lot of us… I’ve heard rumblings of trying to make our cognitive assessments head more in that direction as well. I’m just counting the days until we reach that point, maybe […] 

[00:34:00] Dr. Katherine: Although essentially, that’s what the waste is now. In essence, you don’t start with the easiest question on many subtests. You start with the third hardest one because that’s where the most people. So, that’s the analog way of computer adaptive testing that’s similar to stopping rules- you stop after they fail two items. You don’t make them beat their head against the wall with the 11 item digit span. You say, okay, we’re done. And you save their time. 

Dr. Sharp: Cool. Well, thanks for taking that little detour with me here.

Dr. Katherine: Oh yeah.

Dr. Sharp: Sure. I don’t want to short sell the measures that are out there now. Are there others that we should be aware of?

Dr. Katherine:  Let’s see. We have the AUDIT, the DUDIT, the CAPE- which is the community assessment for psychotic experiences. This is a brief screener of both threshold and subthreshold psychotic symptoms, positive, [00:35:00] negative, and depressive. And we also have right now a Metro functioning. That’s, I think an important part of the HiTOP system that is maybe less… well, I’d say it’s not always part of other diagnostic systems.

In HiTOP functional impairment, just how well a person is getting on in their life, trying to assess that separately from psychopathology because it can get muddled if your diagnostic criteria are something that mixes up both the symptom and the impairment that it causes. And it’s important for various reasons to distinguish those two things so that you can get a sense of a person’s symptoms, what are their experiences, and also, how is all of that altogether affecting their life?

So, we have the WHODAS as part of the [00:36:00] assessment battery to assess for functional impairment, and also, I hope it’ll try to help people get better over time and treatment.

Dr. Sharp: Sure. Yeah, that’s the name of the game. The more we move forward, the easier that it gets to administer these, keep track of the results and maybe plot the results over time. I could see that being a great application for the system.

Dr. Katherine:  Yeah. I think that’s been one of the… some of the more successful assessments out in the world, they’re basically successful because they are easy to understand and easy to interpret. So we’ve placed a huge emphasis on making the results really easy to understand and interpret. What we’re working on now for our outpatient clinic is if [00:37:00] anybody’s familiar with data visualization software, we use Tablo so that you get a color-coded image bar chart of a person’s functioning across all these domains, group by domain. And we can also, as we implement longitudinal assessments, track change over time; which symptoms are getting better, which symptoms are getting worse. 

Dr. Sharp: That sounds fantastic.

Dr. Katherine: We’re excited about it.

Dr. Sharp: I know that you’re really trying to focus on, again, this application. You mentioned in our pre-recording chats that you’re working on treatment guidelines as well. Can you say anything about that?

Dr. Katherine: Yeah, these are a work in progress, so they’re currently underway. But certainly, the idea is that [00:38:00] taking, for example, schizophrenia, one of these really large diagnoses where people can have a variety of different symptoms within it. And some treatments are better for some of those symptoms than others.

For example, for 2 individuals with schizophrenia, one may have a lot of positive symptoms, a lot of hallucinations and delusions, another person may have no positive symptoms, but a lot of negative symptoms. They are unmotivated to leave their home. They aren’t interested in social interaction. Antipsychotic medications are really only useful for the positive symptoms and not for the negative symptoms. So the idea of HiTOP based treatment guidelines is that we can map the treatments that we have on to different levels of the hierarchy in different symptom domains to try and make treatment guidelines more specific than let’s say a diagnosis, especially if it’s a broad diagnosis.

But [00:39:00] also to capture trans diagnostic treatments, for example, exposure therapy which works for almost every anxiety disorder, right? So, you don’t need a manual on exposure therapy for specifics- exposure therapy for blood injury illness, exposure therapy for emetophobia, exposure therapy for dog phobia. We’ll have a treatment guideline for exposure therapy for anxiety disorders at this higher level of the hierarchy. So the whole idea is really parsimony- making things simple making it easy to understand both for clinicians and for patients too because it’s not great for the patient who gets the report and sees that they have five different diagnoses. It’s also terrifying and confusing. 

Dr. Sharp: I’m so glad you brought that up. I might put you on the spot a little bit just to ask this question which is that sort of like I [00:40:00] mentioned toward the beginning, I feel like there are so many diagnoses that are now separate in the DSM that seem very related. And I’m just wondering, of all the research that you’re aware of as you’re working with HiTOP, are there any that really jump out that might be helpful for us to know about maybe not even formally in practice, but just to know like anxiety and depression or I don’t even know, substance use and personality disorders or whatever. Are there any like that, that you’re noticing?

Dr. Katherine: Yeah. The example I always think of is generalized anxiety disorder and depression. If you take two groups of people, let’s say you can find two groups of people who have only one of those two diagnoses: they only have depression or they only have a generalized anxiety disorder. If you give them an assessment of [00:41:00] either of those diagnostic criteria, it is nearly impossible to tell those two groups apart on any kind of outcome that you might care about, let’s say their health or the status of their relationships and their job functioning. They’re very similar. Even their symptom profiles are very similar. I think the exception to that is people with generalized anxiety disorder report more muscle tension. So, obviously, there’s a very small difference there, but I don’t know if it’s clinically meaningful.

I think that’s an example of two diagnoses that have evolved. If you look at the number of diagnoses in the DSM over experienced revisions, it’s a very steep and precinct slope over time. I don’t know if you’ve taken that to its logical extreme. At some point, we’ll have more diagnoses than we have people. I think that’s a good example of maybe where they are diagnostic categories that are not useful to either patients or [00:42:00] clinicians. They’re not providing you any incremental knowledge above and beyond each other.

Dr. Sharp: That’s a good way to put it. Yeah, that’s exactly my experience.

So let’s see. I feel like we have done a nice broad overview of HiTOP and how it’s being implemented. What else should people know about the system and about the work that y’all are doing that would just help put this in context and know what we can expect and how we might be able to implement it in the future.

Dr. Katherine: Well, I guess I should say, I don’t want to give the hard science researchers in the group a short trip. There’s a Genetics Workgroup as well, and Neurobiological Foundations Workgroup. So, groups that are looking at, let’s say by analogy to what we were just discussing, [00:43:00] are the genetics of depression or is a genetic risk for depression any different from genetic risk for generalized anxiety? How different is it from genetic risk for anxiety? So, that kind of work is going on as well.

I think an important part of the consortium is that there is also a Revisions Workgroup. So if you have new evidence that actually GA is very different in some important way from depression, that can be put to the Revisions Workgroup to come up with an argument with multiple lines of evidence, and revisions can be made to the system. So, there’s a process in place, at least for making revisions to the model as evidence accrues.

For clinicians who are interested, Camilla Ruggero is the head of the Clinical Translation Workgroup. [00:44:00]I, Katherine Jonas is playing a big role in the rollout of the assessment. We’re really interested in hearing from providers, particularly if you’ve heard of this and you have questions, you have concerns because we want people to use this. We want it to be useful. And so, we do need feedback from providers about what are the needs of a clinical provider?

Obviously, we have clinicians in the group, but we want feedback from people who have the clinical practice about what their needs are. And if they’re using, let’s say HiTOP or HiTOP Concordance measures as part of their practice, what are the problems they’ve encountered? What can we be doing better? What would make this more useful and more accessible?

Dr. Sharp: That’s great. What’s the best way to provide that feedback?

Dr. Katherine: I’ll send you the Clinical Translation Workgroup [00:45:00] website. But also, if people should be interested, you can get involved. There’s that How to Get Involved section of the HiTOP website that includes Dr. Roman Kotov’s email address. So if you’re interested in getting involved, it is easy. It’s not a closed system. You don’t have to be elected by a number of people in robes. It’s really open to all.

There’s also a HiTOP conference. I don’t know if it’ll be happening this year, but there’s a HiTOP conference that happens. All the consortium participants are listed on the website. And so, people should feel free to be in touch with anybody listed there.

Dr. Sharp: That sounds great. And then again, I’ll link to all those resources in the show notes. I [00:46:00] wonder if I could close with a totally random question that you may not know the answer to. We’ll go out with a bang here. Do you have any idea how something like this would impact billing insurance and things like that? Has that come up at all?

Dr. Katherine: Yeah, certainly. I mean, because that’s for a clinician, right? You need to be able to bill for your services. So, I think that’s the million-dollar question is that at what point can we move to make this billable system? Right now, a lot of people can bill using DSM or ICD. So it’s really a question of getting in touch with insurance companies. And in part, it’s a little bit of a chicken and egg in that you need enough clinicians using this- enough demand for this that it is worth it for the insurer [00:47:00] to develop a system for accommodating billing based on the HiTOP system. But yeah, that’s definitely something that we want to want to see happen in the future and are working towards.

Dr. Sharp: Great. That’s always the question. How do we get paid for this? I think that’s the thing. I really don’t envy your position. It’s like David versus Goliath kind of thing where we have these established means of doing things and then you come along and it sounds great. It sounds better in many regards. And it’s just dislodging what’s already in place. It can be challenging. 

Dr. Katherine: Yeah. And I think that that is where the burden is on us to make this as useful to clinicians as possible so that the benefits outweigh the [00:48:00] costs and that it’s worth it for people to do it.  And hopefully, in time, that means also that some of these bureaucratic impediments can be dealt with because there’s enough demand for it. But really, we need to be useful to clinicians if we want this to be widely used and disseminated. And we really value the opinions of clinicians who have given us feedback because they’re the front line.

Dr. Sharp: Right. That’s great. I think that’s a good reframing and maybe a nice note to close on.

Dr. Katherine: To be clear, I think the way I see it is that, this is learning from the reality of clinicians, the clinicians who say, well, DSM doesn’t match the patients that I see. It’s not how I think of my patients. And we’ve heard that from many clinicians as well. Why do I need… [00:49:00] This system is exactly what I was doing anyway. So I’m like, “Great. Let us help you do what you’ve been doing already. That’s all we want.” So, that’s our goal is to take the experience of people.

A lot of the scientists who have contributed to the system, they’re clinical scientists, they’re people who run clinical labs working with real patients, real humans. And so their experiences are similar to yours but sometimes these diagnostic criteria don’t fit. And you have people who have four symptoms instead of five. How you can make sure they get treatment? So, it is from the ground up. It’s from the clinical frontlines up.

Dr. Sharp: I like that. I’m excited. I’m going to keep following the work that y’all are doing. And I hope others will do the same. I’m just really grateful that you were willing to come on and take time out of [00:50:00] your busy quarantine to hang out with me for an hour.

Dr. Katherine: Oh yeah, that’s great. I minimize some of the social distance. That’s great.

Dr. Sharp: Right. Whatever I can do. Well, thanks again, Katherine. This was fantastic.

Dr. Katherine: Thank you.

Dr. Sharp: Hey, y’all. Thanks again for listening to this episode with Dr. Katherine Jonas. I am just fascinated with this whole area of describing human behavior. Nosology, I suppose, is the right term. It was such a privilege to be able to talk with her about another means of doing that. I love seeing the emergence of these alternative methods of nosology. And I hope that you took a lot away from this episode. There are a few links in the show notes if you’d like to learn more about HiTOP and explore a bit further.

Like I said, at the beginning [00:51:00] of the podcast, if you’re a beginning testing practice owner, there is a group coaching experience just for you. The Testing Psychologist Beginner Practice Mastermind will be launching soon after much delay. Thank you, COVID-19. But we’re going to get off the ground soon and I would love to have you fill those last couple of spots in the group. So, if that’s interesting to you, check it out at thetestingpsychologist.com/beginner to grab more information and schedule a pre-group consultant call to see if it’s a good fit.

All right. Take care, y’all. Stay healthy. Until next time.

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