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Hey everyone, welcome back. Today we’re talking about dimensional diagnosis and dimensional conceptualization. I’ve had a number of guests over the years. I’m thinking of Dr. Jenni Pacheco from RDoC, Dr. Katherine Jonas from HiTOP, the guys from the SPECTRA, and any number of folks who have talked about dimensional models of mental health. And today I [00:01:00] have another esteemed guest and expert who has literally written the book on dimensional models and makes a pretty compelling argument for why we might want to switch to a dimensional model of mental health.
So, my guest, Dr. Ben Lahey is a clinical child psychologist, who is the Irving B Harris professor of epidemiology, psychiatry, and behavioral neuroscience at the University of Chicago. His research has focused on the identification of dimensions of psychological problems across the lifespan but mostly in children using longitudinal studies of population-based samples.
We’re going to speak a lot about his new book. It’s called Dimensions of Psychological Problems: Replacing Diagnostic Categories with a More Science-Based and Less Stigmatizing Alternative. You can find the link to the book in the show notes, of course.
The material from [00:02:00] our interview today is largely drawn from the book simply because it is so rich, and really dives deep on the why’s and how’s of a dementia model.
So just a few things we talk about are: why now could possibly be a tipping point in moving from a categorical model to a dimensional model. We talk about why Ben calls the dimensional model a “positive revolution” in our world. We talk about the influence of genes and the environment on psychological problems. We also get into some of the downsides of a dimensional model among many other things. Again, this is just a jam-packed interview with really rich content from a true expert in this area.
Without further ado, let’s jump to my conversation with Dr. Ben [00:03:00] Lahey.
Ben, welcome to the podcast.
Dr. Ben: Thank you very much for inviting me. It’s a pleasure.
Dr. Sharp: Pleasure is all mine. I’m honored to be talking with you. I know you’ve had a long career and have done many things over the years but I am particularly excited to be talking with you about your recent work and your recent upcoming book on the dimensional diagnosis. So, I’m just glad to have some of your time. I really appreciate it.
I want to start with the typical first question for our podcast here. And that question is always why is this work important to you? Why [00:04:00] do this out of everything?
Dr. Ben: Well, I’ve spent a good bit of my career trying to find the optimal ways to describe the psychological problems of children originally. And as my longitudinal samples grew into adults, we can’t understand the causes of X unless we can define X. So we are trying to… when I say we, the hundreds of psychologists and psychiatrists are doing the same thing …we’re trying to carve nature at its joints in the most optimal way to understand the origins of psychological problems and to help find the best ways to prevent and treat them.[00:05:00] Specifically in writing this book, I made the decision to add my voice to hundreds of other people in the field, to call for a positive revolution that is in one sense something is happening here and now but it’s been brewing for over 50 years and is only now reaching a tipping point.
Some of the most important papers and books on this top topic were written by Albert Bandura and Tom Achenbach and Harry Stack Sullivan over 50 years ago.
This revolution, it’s urging all of us to reconsider how we view psychological problems and in a very pointed way to leave behind [00:06:00] the binary diagnostic categories of mental disorders and DSM-5 and the international classification of diseases.
Dr. Sharp: Sure. So you mentioned so much during that brief piece there. Let us pull it apart and let’s dive right in. You used the term positive revolution in your references history. I wonder if we might just set some context here as we get going. Can you talk through a little bit of the history around the diagnosis and how we have approached this over the years and how this dimensional view really got started?
Dr. Ben: Well, classically, diagnosis is an outcome of the revolution that happened in the 1800s [00:07:00] and earlier in which individuals who were troubled with very serious problems, such as general paresis were thought to have for the first time had a medical problem. Devin and others discovered that the germ that causes syphilis, if untreated, and it was always untreated at that point, goes on to destroy brain cells and create what was then the most common diagnosis referred to institutions for dealing with individuals with serious problems which was, as I say, general paresis.
That, very understandably, set into motion the belief that [00:08:00] every psychological problem will ultimately be discovered to be the result of some kind of infection or medical problem that led to renaming institutions to asylums and mental hospitals and physicians were put in charge for the first time. The physicians who were in charge got together and created an organization that they call the American Psychiatric Association. And from then on, psychiatrists, psychologists, and other mental health practitioners viewed psychological problems as a result of mental illness.
When no more germs were discovered but a few more were discovered, then most individuals [00:09:00] struggled to maintain that categorical diagnosis by turning the medical model into an analogy. So then they were trying to diagnose an abnormal mind rather than find an underlying abnormality of the brain. We’re still stuck there with binary categories.
Now, the revolution is in part to get away from the stigmatizing view that we are normal until we have another problem. And then we’re still normal. And then we have another problem and we’re still normal. And then all of a sudden, we reached the diagnostic threshold and fall into the abyss of mental illness. Trying to get away from that terribly [00:10:00] stigmatizing view not just because we’re humanists but because that’s what science is saying.
It’s very clear from many years of research now that everything that we call a mental disorder is dimensional, not categorical, that there is a linear relationship between the number and severity of psychological problems. So, by psychological problem, I’m using a non-stigmatizing synonym for symptoms because that’s all in medical model thinking. So as the number and severity of, say, depression problems increases, there’s a simple linear increase in the amount of distress and impairment in our life functioning.
By drawing an artificial [00:11:00] line between normal and abnormal, we create stigma and we also make our measurement far less reliable and valid because there are many subthreshold cases if you use diagnostic language where the individual might be terribly impaired with just false symptoms of depression, and if a clinician were to follow the rules exactly, they would say, “No, you’re perfectly fine. Go home” even though they’re telling you that they’re actively suicidal with just the false symptoms. I’m exaggerating, but by putting everything into binary Benz, we reduced our liability and the validity of measurement.
So the [00:12:00] revolution has another aspect that flows from that, that although psychological problems are very distressing often, very problematic for people who are going through those problems often, they’re actually, I think better thought of as perfectly ordinary variations in behavior in two ways: They arise through the same psychological and biological processes as adaptive behavior. They’re just aspects of our behavior. They’re individual differences in our behavior that are sometimes impairing and distressing.
The other way in which I think we need to recognize that psychological problems are ordinary is that [00:13:00] longitudinal studies have been taking place over the last 15 years and are finally to the point where they can look back show that psychological problems are far more commonplace than anyone ever expected even if you use DSM diagnostic criteria which ignores people with impairing sub-threshold problems.
Moffitt and Caspi and other studies show that over 80% of us at some time in our life meet the criteria for at least one DSM mental disorder. And if you then think about the sub-threshold problems, it’s basically all of us. What’s very unusual is for somebody to cruise through life [00:14:00] without any aspects of their behavior creating distress and interfering with their lives.
Dr. Sharp: Right. Well, there’s a lot of good information in there. Where do we even start to dig in? So you use the phrase tipping point a while back. I’m curious what leads you in that direction? Like why now? Why are we at this tipping point for a push toward more dimensional classification compared to say 10 years ago, 5 years ago, 20 years ago, what is it that’s leading you to use that term?
Dr. Ben: That’s a really interesting question. I thought long and hard before writing this book because I know that it’s [00:15:00] going to add another target tattooed to my chest for slings and arrows that not everybody’s going to be happy with what I’m saying. And I was convinced that this view is correct. But being a bit of a coward like most people, I wanted to not send this out in the wilderness and become another Thomas Szasz who is perhaps the most misquoted person in psychiatry and psychology. Everybody knows what Thomas Szasz said, but nobody’s actually read Thomas Szasz, almost nobody. He didn’t actually say there’s no such thing as mental health problems. He just was opposed to the medical model.
But I didn’t want to be just an odd character [00:16:00] urging us to change our view of something in a way that other people have tried and failed in. So, part of it was the social psychology of the moment that an increasing number of very credible individuals in the field, in articles, in journals have been calling for this revolution. And includes people like Bob Krueger and Leanna Clark who are not people to be ignored. They have a crowd phenomenon that encourages all to speak out and raise our hand and say, yeah, this really is an important revolution that needs to take place, and I’m going to stand in the front lines with [00:17:00] you.
But there are two other things that are important. So those people that I just mentioned, Bob Krueger and Leanna Clark, and a number of others, Tom Whitaker, very bravely were part of the DSM–5 workgroup on personality disorders and tried to get DSM–5 changed just in the personality disorder section to a dimensional approach and they failed or they succeeded only partially. They got a backhanded compliment and a little bit was put into the DSM–5 that’s dimensional. And I think that angered a lot of us that these folks who were very sensible, very databases in their approach [00:18:00] we’re not allowed by the establishment to change how we thought. So not only are there a lot of us speaking up now, we’re a little bit angry. And I just avoided some synonyms for angry there.
But I am a scientist. I have worked in the trenches of research throughout my career and I wouldn’t be jumping into this battle line, even with people that I deeply respect if there weren’t so much new data. So this is very much a database revolution. Albert Bandura and others did not have access to the data that we have now: to the many studies that have formally [00:19:00] tested the dimensions of psychopathology or psychological problems, to the longitudinal studies that look at people over time and so on.
So we’re beginning to see things that really help us think about psychological problems I haven’t mentioned yet. One is, when we look dimensionally at psychological problems, we see that they’re highly correlated more so than you see when you look at odds ratios between different diagnoses or to what extent they overlap. And those correlations reveal a number of really fascinating things.
So by correlation, I mean, [00:20:00] let’s say we’re doing a large longitudinal study and at time one, the first time we assess everybody we correlate these counts of problems, counts of depression problems, counts of separation anxiety problems, attention problems. We correlate them and we get a pattern of cross-sectional correlations. So keep that in mind as I start to talk. So the first implication of those very high correlations is when you correlate, say, inattention problems with say depression problems and you find that there’s a strong correlation, what that means is, if you have a high number of inattention problems you also have a high number of depression problems.
If you think about that for just a moment more, what that means is our psychological problems don’t come in [00:21:00] independent silos. People tend to have lots of problems from lots of dimensions at the same time. And the extent to which these cross-sectional correlations are high. You’re going to have more of a mish-mash of these problems. So even though DSM says, look for children that have six symptoms of inattention, and six symptoms of hyperactivity-impulsivity, you’re not going to find many, if any, who only have that, who only display those problems.
And there’s a tendency once you’ve made a diagnosis to ignore everything else, to use the analogy of the procrustean bed, the Robert Baron Procrustes brought [00:22:00] travelers into his home and had them sleep in his special metal bed but he wanted them to all fit the bed. So he stretched parts of their body that didn’t quite fit on one side and he chopped off parts of the body but that didn’t fit on the other side to make everybody fit the procrustean bed perfectly.
Well, we have a tendency to do that with diagnoses, say, “Yes, this child has ADHD” and chomp off the depression symptoms and the oppositional behaviors and so on unless they also meet diagnostic criteria for something else.
So one implication is don’t expect people to come to you for help that just has problems of one sort. That mishmash combination is what we’re going to [00:23:00] expect to find. And if you stop and think about your practice for even just a second, I think most of you would agree.
The other thing that’s that we found out that is amazing and revealing is that over time, there is continuity. So people who have psychological problems one year tend to have psychological problems in the next year and the year after that. But there are two kinds of continuity. Some of it is continuity and that the same dimension of problems is high over time. So they might have high levels of inattention every year. But there’s also a great deal of heterotopic continuity in the sense that every psychological problem that correlates its baseline [00:24:00] cross-sectionally, predicts future problems of other kinds at that same level.
So that’s to say, let me just slip into a diagnostic language to make it simple, people who meet the criteria for depression, adults, in the three years later are at increased risk for every other diagnosis that was measured. Every other one. The extent to which they predict other diagnoses is consistent with the cross-sectional correlation. So at baseline, people often have generalized anxiety disorder and depression symptoms at the same time. So depression predicts future generalized anxiety disorder much better [00:25:00] than it predicts, for example, any social personality disorder. But it predicts everything.
And if you look at the relationship between the cross-sectional correlation and the prognostic correlation it’s 0.9. So psychopathology is not only highly correlated, which makes the boundaries between the bins very fuzzy. It is fuzzy over time so that we see lots of change but the change is predictable by how correlated the problems are. In chemistry, if carbon over time changed into calcium, you’d be really surprised. Something would be wrong with the science. But in the science of [00:26:00] psychological problems, we need to expect lots of change.
I have done a lot of practice but I used to see charts come in for children in which they’d been seen by other people say four times before and got four different diagnoses. And I thought it’s a good thing they came to me because I’ll give the accurate diagnosis. And what may very well be the case is that those children presented with different problems every time. I’ve been talking for a long time. Let me turn it back to you for your questions.
Dr. Sharp: Oh no, this is all good stuff. I think you’re describing an experience that a lot of us have had either, I think we’ve seen both sides of the coin where we are seeing a kid for a comprehensive [00:27:00] evaluation and end up with a laundry list of diagnoses because they just seem to meet the criteria for any number of things, it’s depression and anxiety and panic and maybe some ADHD and some ODD. We could theoretically list all those diagnoses just because they have so many symptoms but we’ve also had that experience of seeing those kids who have the laundry list and then thinking, oh, I’m going to get it right this time. I’m going to clarify this for the parents and for the kids.
Dr. Ben: Let’s take the data that I’ve just described and go back to the DSM. So the DSM wants us to believe, and of course, I don’t mean to be flippant, the founder or the people who write these diagnostic categories, they believe that there are distinct [00:28:00] unchanging categories of mental disorders. And that’s not what the data say. The dimensionality of psychological problems makes us question the binary Yes/No categories, but it’s also very important in terms of stigma.
In a dimensional approach, there’s no hard line between normal and abnormal. There’s no hard line between normal and ill to be sure. So that a person doesn’t need to think, I might be mentally ill to go and seek help, to go and ask if there’s something that can be done to make my life happier and more functional. They simply, in a dimensional [00:29:00] approach, if we can get these ideas out, which is one of the goals of the book, they simply have to say there are things about my behavior that just aren’t working. I want to go see if I can get some help.
Just like if you’re a tennis player and you are now serving the ball consistently into the net and you just can’t get it right, you don’t have to call up your tennis pro and say, I’ve fallen into the abyss of mental illness and I need your help. You just say, hey, something about my game isn’t working. Can you look at it? Talk to me about things that I can do to make it more functional for me. And so that that game can be the game of life. We can go in and seek help in a way that doesn’t require [00:30:00] admitting that we’re no longer like every other human being. We’ve become qualitatively different from them.
Dr. Sharp: Yeah, I’m glad that you brought that up. That was a question that was running through my mind as we were talking. This question of how then do we determine who needs treatment or not if we’re without these maybe the false security, I guess, of a binary diagnostic system to tell us when someone reaches the threshold for treatment. How do we think about that? How does someone know? How do we know as practitioners?
Dr. Ben: Yeah, that’s a very good question. I addressed it in the book. I know it’s going to be one of the fights coming up if this revolution comes about. And by that, I mean, if enough of us stand up and say, [00:31:00] DSM-6 either has to be a fully dimensional system or we’re going to leave it behind and we’re going to develop an alternative dimensional system. One of the fights that are going to happen is the insurance companies and maybe the APA- the American Psychiatric Association, are going to say, you can’t do that. It’s going to open the flood gates. Everybody’s going to want to come in and get services with their psychological problems.
So, there are two responses. First of all, we won’t know until we do try. It’s an empirical question. Secondly, it may not result in any increase at all because right now practitioners, and I don’t mean this in a negative way, for the benefit of the people that come [00:32:00] in seeking help, rarely turn people away. They find ways of giving diagnoses that will lead to reimbursement so that individuals can receive services. So there may be no more people receiving services but I hope there will be actually.
I hope that by reducing stigma, far more people will come in and say, I need help. I’m miserable and I’m not doing my job well and I’m missing work a lot. I lost it the other day and my wife wound up in the emergency room. Those people I hope under conditions of reduced stigma will come in for help [00:33:00] earlier and more often so that we are in the wonderful situation of having to fund more mental health services. I just lapsed into the old view and said mental health, but more services for psychological problems.
I’m perfectly happy for my insurance rates to go up a little, my taxes to go up a little to fund more services just because evidence-based practice is good for human beings. I think there are ways of making evidence-based interventions more cost-effective to bring the cost down a bit but if that individual and then the millions like him or her are able to get help for their depression and go back to [00:34:00] work consistently and be more productive, that will reduce the economic burden of psychological problems which is fast. So I think it would be a very good investment.
Now, please follow up on that if you wish because it’s important. But I want to not fail to mention a theoretical point that is near and dear to my heart before we finish.
Dr. Sharp: Yeah. By all means. You can go for it and I’ll hold my question here until you wrap up.
Dr. Ben: Okay. So one of the things that come to mind when you see that every dimension is correlated is that as Tom Achenbach saw in the 1960s, very brilliantly and ahead of the rest of us, you can create a second-order [00:35:00] factor of Internalizing and Externalizing problems. And now we know that you can have a third one of thought disorder kinds of problems.
And Tom noticed and honestly reported the internalizing and externalizing are correlated. So these second-order dimensions are themselves correlated at 0.5. It’s a big correlation. That’s not accounting for measurement error. And that has been bothering me since I was a graduate student. And notice how I’m pointing out that I was in graduate school when Tom Achenbach came up with this. I am not the oldest living psychologist in the field but I will admit that Tom Achenbach is far younger and healthier looking than I am.
So [00:36:00] Tom noticed that it bothered me because theoretically, I thought internalizing and externalizing should be negatively correlated. You either act in or you act out and you can’t do both. And it took years and years until I thought, wait a minute, maybe that’s telling us something. So we started looking at the correlations among dimensions of psychopathology not as something that we need to ignore because it didn’t fit our thinking but we started thinking about these correlations as the figures rather than the ground. As something that tells important information. I won’t go into the details, but you can then use the correlation among the internalizing and externalizing factors although we don’t literally do it that way, to define what I [00:37:00] called the general factor of psychopathology and what Avshalom Caspi and Terry Moffitt called the P factor.
So at the highest level, there’s a factor that accounts for variation in every psychological problem. And then below that, there are these second-order dimensions that independently explain further the correlations among internalizing externalizing and thought disorder. And with my colleagues in 2017, we published a paper in the Psychological Bulletin called a Causal Taxonomy of Psychopathology, I was still using the term psychopathology four years ago, which we said these correlations mean, and now there’s evidence to support this, that many of the ideological factors [00:38:00] for psychological problems are entirely diffused, entirely nonspecific.
And we now know that most of those are genetic predispositions which is to say that most of our genetic predisposition to psychological problems increases the risk for something but not any particular dimension of psychological problems. It’s other things that determine which kind we experienced. Some of those are specific genetic influences, but mostly its experiences. And it’s mostly the kind of experiences that each individual and their family has independently.
So one sibling is in a car accident or one sibling makes a deep friendship with a girl [00:39:00] who later committed suicide or these other experiences that the evidence from twin studies and even molecular genetic studies now suggest shape what particular problems we experience. And that is why they change over time, our hypothesis says, because over time, these experiences that are specific to each person change for us. I now get into college and I fall in with the group of individuals that are studious and are happy and play sports after they study. And that makes me less depressed and so on.
So this is why I think we’re coming to a new understanding. Robert Pohlman calls this a generalist [00:40:00] genes specialist environments hypothesis when he was doing his work on reading that genetic predisposition is not specific, which is why if a parent has a particular diagnosis, their children are at increased risk for any diagnosis, not just their particular one. So there’s this very non-specific predisposition that then is shaped by our experiences into the particular problems that we are having at that time.
Dr. Sharp: That’s so fascinating. So then this might be a leap. Point me in the right direction if I’m off base. TAre you saying, or does the research say rather that we can’t really say, “depression is heritable” or [00:41:00] OCD is genetically transmitted or even things like thought disorder or autism spectrum disorder, things like that. I mean, are you saying that we’ve been saying it wrong over the years?
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Dr. Sharp: Or are there some other problems that are more heavily linked to?
Dr. Ben: So let me restate what you’re saying in the way that I think the data are saying. I am not in any way challenging the heritability of any diagnostic category or dimension which we know to be substantial for everything. Very high for schizophrenia, autism spectrum, modest for anxiety, but everything is heritable. What I am saying is that most of what [00:43:00] makes depression, for example, heritable, is shared with every other dimension of psychological problems.
There are very few genetic variants that are specific to each particular dimension. They tend to be generalists but there are some. And I’m not saying they’re unimportant. And there’s much more to be discovered but there’s a paper in the press that has come from a big group called the Psychiatric Genomics Consortium that looked on their data on tens of thousands of individuals, and they found consistent with the model that I’m talking about that only about 20% of the genetic variance, and they’re looking at snips single-nucleotide [00:44:00] polymorphic variants, only about 20% are specific to one disorder. The other 80% are shared with other psychological problems.
So genetics is very important. But genetics is not mostly specific to any particular problem. What is specific to problems is more the experiences that individuals have, which gives us as psychologists and psychiatrists the targets for changing people with psychological interventions. Those experiences that each individual has include the experiences that therapists create for individuals using evidence to figure out what is the most [00:45:00] important experience this individual with Agoraphobia can have to change that particular set of psychological problems. And you hopefully go back to your training and see that guided exposure is what is needed here. That there’s the strongest evidence. And so you arrange for that experience. And can in many cases change the problems that the individual has. You can’t change the genetic predisposition, but you can certainly attack the environmental end of it.
Dr. Sharp: I see. Yeah, thanks for talking through that. This research is just fascinating to me. I do wonder how you conceptualize maybe some of the neurodevelopmental disorders, like learning disorders, certainly autism, maybe even ADHD. How [00:46:00] did those fit in a dimensional model? And is that any different than some of these things we’ve already discussed like anxiety, depression, etc?
Dr. Ben: I’m trying to decide where to start. First of all, I don’t like the DSM-5 broad category of neurodevelopmental disorder because everything is a neurodevelopmental disorder, and singling out some doesn’t make sense to me. Putting ADHD in the same broad category with the autism spectrum does that make sense to me. All the data suggests it should be with other externalizing problems, although it’s somewhat unique from them as well.
So the other issue is, does the dimensional approach work [00:47:00] for serious problems like autism spectrum or schizophrenia? There’s a lot of research none of which I’ve been involved in, this is from many other researchers who are looking at these uncommon problems in a dimensional way and making it very clear that they are also dimensional, but dimensional with distributions so that if you did a study of 10,000 people, you’d find many thousands of individual with a count of zero of those kinds of problems but you do then find people with one or two or three and so on.
And there’s a linear association between the number of those serious problems and how much they impact an individual’s lives. [00:48:00] My guess is although the autism spectrum isn’t defined in DSM in a way that you can easily count problems, it’s vaguer than I think it needs to be, my guess is that the big increase in the number of individuals that are considered to be on the autism spectrum is reflecting the recognition that people that are lower on this distribution of problems are often impaired as well. And so that the idea of the spectrum is to recognize their need for services just like the much more extreme problems that were perceived as ” autism services in the past.”
Dr. Sharp: [00:49:00] I see. Gosh, there are so many directions that we could take this. So I’m going to try to ask this question. It may not come out in a coherent manner. So bear with me and set me on the right path, if not. But I guess what I’m thinking about then is, as we conceptualize things in a dimensional way, does that preserve the… I’m trying to find a different word for psychopathology but I can’t. So I guess what I’m getting at is, how do we not turn everything into basically just a trait that everyone has to some degree and thereby wash out the significance? [00:50:00] So now’s where I asked. Does that question make any sense at all?
Dr. Ben: Oh yeah, it makes perfect sense. I’m really glad you asked it. So I mean this in the nicest possible way. Because we’re all trained to think in binary ways, we’re all trained to think that most people are normal but some people really need help because they’re abnormal. I have not said my message in a way yet that has penetrated. I’m trying to be really nice and find a way of saying, you’re missing the point.[00:51:00] Dr. Sharp: There we go.
Dr. Ben: We are trying, I am, and I think most of the people in this group, and I mean mentioned a large group called HiTOP- the Hierarchical Taxonomy of Psychopathology group that I’m a member of. They share a lot of my views, although they still use the term psychopathology.
So all of us are trying to get people that think in terms of dimensions are saying everything is a trait. Everything is a dimension. There is no defensible point on that dimension where you can categorize it and say, it’s a disorder. It’s psychopathology. There’s just no defensible way of doing that.
As the severity of problems [00:52:00] goes up on every dimension, so does the amount of impairment and distress. And in my view, with the help of the psychologist or psychiatrist counselor, social worker, each individual who has these problems needs to decide, I’m at a point where it’s worse for me to just continue living with these problems than to seek help. So if I seek help, even if I’m not buying into the stigma, which is hard to do, hard to avoid, I’m going to have to say, well, at least I’m somebody that needs help. And even that’s a little stigmatizing. They might prescribe me a medication that’s going to give me an adverse reaction, or I’m at least maybe going to be paying out-of-pocket costs.[00:53:00] There are some costs in seeking help, but every individual should be free. I think to say my level of inattention is to the point where I think I’m a pretty smart, capable person that I’m just not succeeding in my job. And I’m going to get hurt and I’m going to hurt my other employees if I don’t get some help.
Now, you can’t go to the DSM and look it up and say, “Oh, no, you only got five inattention problems, you don’t need help.” It’s a continuum. You have to just use common sense. I’m hoping that you’ll get away from thinking some people are disordered, some people aren’t. Again, I’m saying this in the nicest way. Ironically, we’re all nuts. Individual [00:54:00] differences in our behavior broadly define emotions, thinking, beliefs, perceptions, individual differences characterize the human race. And sometimes during our lives, our individual differences in almost all of us are going to cause us distress and impairment. And there’s a whole group of people all of whom I hope follow the tendency of evidence-based practice, who can help us reduce those problems: stop feeling the distress, and function better in life. And none of that involves a disorder.
Dr. Sharp: Thank you. So let me ask another question that might stir the pot a little bit. How do we conceptualize or reconcile maybe individuals [00:55:00] who perceive themselves to have some impairment in an area, whatever that might be, let’s just call it ADHD, you said inattention, and yet I think we all run into these cases in our practices. Someone comes in and they say, “I’m really struggling. I can’t pay attention. I keep losing things. I don’t know what I’m doing.” But that’s not measurable. So others in their lives don’t see these concerns, maybe our objective test data doesn’t necessarily reflect those concerns. So I’m wrestling with how much do we trust or rely on an individual’s self-report of impairment, especially if it’s toward the lower end of the [00:56:00] dimension. Do you see what I’m getting at here?
Dr. Ben: Yeah, I do. You may be asking the approach that I’m advocating in the book to accomplish more than I’m setting out to do. I’m not upset with that. I’m just saying, you’re talking about a problem that can’t be solved necessarily by going from a dimensional point of view. We can solve a lot of problems, but you’re always going to have people coming in for help, or you’re just not sure what’s going on and not sure whether to take them seriously when you can’t get corroboration especially if it’s something where they’re hoping you’re going to [00:57:00] recommend either that the child be qualified for special education services that you’re not sure is needed or that you might recommend to a physician that they get Ritalin because they want an A-plus average instead of an A-minus average. Those are real issues that I don’t think are any easier in a dimensional versus a categorical approach.
But one thing I will say that I hope practitioners will do, and we maybe need more instruments to do this well, is not having someone come in and complain about ADHD problems and try and decide if they have ADHD like [00:58:00] I used to do years and years ago, but to then ask them about the ODD disorder, major depression, et cetera, ask them about everything. So at the end of that you might decide, well, I’m not so sure about ADHD, but this person clearly has a high level of depression problems including difficulty paying attention which is a symptom of depression as well in the medical model approach.
So I’m asking people to be comprehensive in evaluating. Putting it all together, look at each person’s particular mishmash of problems and then do the validations of their reports as best as you can.
Dr. Sharp: I like that. As [00:59:00] we start to wrap up this discussion, it went by really fast. There are two other things I want to touch on. You mentioned toward the beginning, this idea that it’d be great to band together and say, DSM-6, if you are not going to go dimensional, then we’re doing something different. What path do you see toward doing something different? What would that even look like to get away from the DSM if it sticks with this categorical model?
Dr. Ben: All right. One thing that occurred to me is that I should write a book…
Dr. Sharp: Look at that.
Dr. Ben: …to try and explain in the best way that I can, and so dimensions of psychological problems which is coming out this month from Oxford [01:00:00] University Press the month in which this podcast is released. It is my attempt to persuade as many people as possible that this is something that needs to be done so that the pressure on the DSM and ICD establishment becomes acute.
Now, there are a lot of steps in that. The insurance companies are going to fight back. The people listening to this podcast are going to say, “Yeah, this is all fine, but I have to in the report that I write up, I have to put diagnoses in.”
What I’m advocating here is not let that requirement dissuade you from describing the psychological problems of the child or the adult [01:01:00] in dimensional terms and then say, this could be viewed in DSM terms as leading to the diagnosis of.. and even trying, if you can, in certain situations leave that part out. After you’ve described somebody fully and recommended what needs to be done, unless there’s a legal requirement for a diagnosis for a school or some other program, I hope I’ve convinced you to not feel the necessity to put them in.
As more and more people become convinced that this is an approach that is good for human beings and that you can adopt it in your practice and feel even better about it, there’ll be more pressure. But [01:02:00] it’s also going to require more papers, more books written by people that will be read by the founders of DSM. I am a friend of Darrel Regier who led the DSM-5 workgroup. I will send him a copy and I will hope to hear from him. I don’t want to distress him, but whoever’s going to be in charge of DSM-6 will certainly get a copy. And it’s this process to their credit, the American Psychiatric Association to their credit, always opens it up to public comment. And many of us will comment and I hope many of the listeners here will comment.
Dr. Sharp: Well, [01:03:00] I know that there’s a lot of energy around this. I think I mentioned even on the podcasts, we’ve had folks from RDoC and HiTOP and the guys that co-developed the SPECTRA, which is a dimensional assessment of personality and psychological problems. So there’s a lot of energy around it. And I think a lot of us in the field would say, this makes a lot of sense, and this is more aligned with research and what we know. And I mean, it all seems like things are pointing in that direction. It feels at the same time like a huge undertaking to shift this diagnostic model that we have grown up at, largely because it’s so rooted in healthcare. I mean, that’s a behemoth of an entity to take on. So I’m just glad that there are a lot of [01:04:00] folks out there doing good work and trying to push this and bring it to the forefront.
Dr. Ben: Well, I think it’s happening. Two days ago, I presented to a committee set up by the National Academy of Sciences Engineering and Medicine on how to best describe in their terms psychopathology. Tom Insel presented on HotDoc another dimensional approach. And I believe they’re going to make a recommendation that dimension approaches be explored further and funded more. I’m hoping. That’s the way the conversation seemed to be going. But even if they don’t, there are a lot of us who believe in this who are [01:05:00] excited by the data that are allowing us to move from opinion to well-informed views and that we think we see insight a change that’s going to get this monkey off the back of people who have psychological problems who have to endure the stigma which makes their problems even worse and may dissuade them from seeking services.
So I think there’s a way to be more scientifically valid and to fight the stigma that’s right there on the horizon. So join the army, help get DSM to think in the right way. And I just want to make sure everybody understands that this is not an anti-psychiatry [01:06:00] diatribe. This is, if anything, a diatribe against the book that they sell, that the American Psychiatric Association sells. Many psychiatrists are in favor of this book, and some of them are nice enough to write nice blurbs on the back of my book cover endorsing the view. So I hope everyone will read it and will get in contact with me with questions and pushback. If you feel like joining us, please do.
Dr. Sharp: That’s fantastic. I love that. Yeah, we’ll link to the book in the show notes, obviously, so people can check it out and get it if they’d like to do that. But I think that’s a nice note to close on. Here we have it, folks. Join the revolution. Join the dimensional revolution and help us provide better care with less [01:07:00] stigma.
So thanks, Ben. I really appreciate it. This is a fascinating and informative conversation and I really enjoyed it.
Dr. Ben: Thank you, Jeremy. It’s been my pleasure.
Dr. Sharp: All right. Thanks so much for listening. All the resources that we mentioned are listed in the show notes, including Ben’s book, like I said at the beginning. Definitely check that out if you have an interest in this topic. I think it’s a good one.
If you have not subscribed to the podcast, now is a great time to do that. I always love to build the audience. And if you’re a practice owner, either at the beginning phase or the advanced stage, who’s looking to take your practice to the next level and just have some accountability and some guidance in doing so, I would love for you to check out the Beginner Practice or Advanced Practice Mastermind group. You can get more information at thetestingpsychologist.com/advanced or thetestingpsychologist.com/beginner, depending on where you’re [01:08:00] at. And we can schedule a pre-group call to see if it would be a good fit.
Okay, y’all, that’s it for today. I will be back with you next time.
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