The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been criticized for several reasons. One major issue is that the DSM medicalizes psychological problems, treating them as though they function exactly like medical illnesses. Diagnosis requires meeting a specific number of criteria, which can oversimplify the complexity of psychopathologies. For instance, a person experiencing four symptoms of Major Depressive Disorder (MDD) would not qualify for the diagnosis, even if those symptoms cause significant impairment. This “all-or-nothing” approach leaves no room for individuals in the gray area between wellness and disorder, which can lead to underdiagnosis or missed opportunities for treatment coverage. Furthermore, this rigid categorization contributes to the high rates of comorbidities, as overlapping symptoms are often classified as distinct disorders. Another notable concern with the DSM is the lack of reliability and the heterogeneity within diagnoses, where two individuals with the same diagnosis may present with vastly different symptoms. HiTOP (Hierarchical Taxonomy of Psychopathology) is an empirically based alternative model for the DSM. HiTOP is a dimensional approach to classify psychopathologies as opposed to a categorical approach like the DSM. A dimensional approach focuses on the severity of each trait within the spectrum (Figure 1). HiTOP recognizes that patients who do not meet the criteria for a disorder may still require treatment. It is based on three core principles that help integrate this model into clinical practice: dimensions with ranges of cutoff scores, hierarchical nature of illness, and impairment rated separately. The former principle refers to describing psychopathology in terms of degrees of severity, with each dimensional level of HiTOP having a range of scores. The hierarchical nature of illness refers to the idea that to assess psychopathology using the HiTOP model, the first step is, to begin with the higher-order spectra (internalizing, thought disorder, antagonistic externalizing, etc.) and then move down to more specific symptoms/traits. The latter principle refers to HiTOP’s attempt to separate symptoms from actual impairment. This is to rule out “false positives” and it is based on symptom ranges found in empirical studies.   HiTOP also considers that comorbidities are likely manifestations of a common underlying factor as opposed to two different disorders. For instance, a clinician would identify the patient’s symptom dimensions (e.g., high stress, moderate fear, low compulsivity) and then tailor interventions for the dominant dimensions, potentially addressing the overlapping symptoms more efficiently. This approach allows for more personalized treatment and an opportunity to target overlapping symptoms. One of my favorite aspects of this model is that it is a continuous framework that constantly evolves as research advances in the field. For instance, against contrary belief, HiTOP is not limited to dimensional classifications. If there is enough evidence to demonstrate a natural boundary for certain conditions, it will be integrated into the model. This adaptability ensures that HiTOP remains relevant as new research emerges. However, the DSM was created for a reason and continues to serve an important role in the field. One of the main reasons it was created was to establish a standardization of psychiatric disorders, providing a common language for mental health professionals to describe different symptom clusters. This standardization facilitates communication between clinicians, researchers, and the public. Additionally, clinicians use the DSM to get reimbursement from Insurance companies and document care and treatment plans, which rely on specific DSM diagnoses. Additionally, for some patients, receiving a diagnosis can bring a lot of relief. Having a name for their struggle validates their experience because a diagnosis means that their disorder has been researched, it has established treatments, and it makes it easier for them to find other people with the same disorder. The DSM was created under the consensus of several experts in the mental health field who agreed on how to categorize different psychiatric disorders, and this standardized framework has shaped the field for decades. In contrast, HiTOP may face some challenges in the implementation process. For example, how would insurance companies use a dimensional model like HiTOP to provide reimbursement? Another challenge is a potential resistance to change. Given that the DSM has been used for decades, it is expected that clinicians will be hesitant to change their diagnosis approach. Further, it is important to note that HiTOP has not yet demonstrated superior clinical outcomes than the DSM. However, this is understandable, given that HiTOP is still in its early stages of development. Finally, the HiTOP model may lead to a lack of standardization in communication. Unlike the DSM, which has specific labels, HiTOP describes symptoms along dimensional score cutoffs. This approach could make it harder for clinicians to communicate with each other and with their patients, as the language becomes less intuitive. What are your thoughts on this? Figure 1 : The current HiTOP model. From: https://www.hitop-system.org/ If you are interested in learning more about HiTOP, visit the official website here , and for additional information, click here If you are interested in how HiTOP was developed click here If you are interested in how to integrate HiTOP into your clinical practice, click here References: Hierarchical Taxonomy of Psychopathology Consortium. (n.d.). Home.  HiTOP System. https://www.hitop-system.org/ University of North Texas. (n.d.). Hierarchical taxonomy of psychopathology (HiTOP).  https://hitop.unt.edu/

As someone deeply fascinated by the etiology of psychiatric disorders, I find it challenging to admit that there is a single cause for each psychiatric disorder. There are disorders, however, that have more predominant causes such as genetics and the development of schizophrenia. It is more accurate to recognize that multiple factors can contribute to the development of a psychiatric disorder. For instance, one individual might experience depression due to persistent rumination habits, while the other might suffer from depression due to abnormally low levels of Brain-Derived Neurotrophic Factor, or BDNF, in the hippocampus 1 . Understanding the etiology of a mental disorder is crucial for guiding effective treatment. However, beyond identifying specific causes, it is essential to ensure that every patient receives fundamental care to address their condition. This includes promoting practices that have been shown to enhance overall well-being, such as maintaining good levels of vitamin D, exercising, and engaging in social activities when possible. There is substantial evidence supporting the positive effects of practices such as diet, exercise, sleep, and socialization on overall wellbeing 2,3,4,5 . Before prescribing any kind of medicine or therapy to a patient, clinicians should ensure their patients are meeting a baseline of wellness. The antidepressant itself is rarely enough to treat depression, especially since there is no “miracle” drug on the market. We can go as far as to say that even various therapies should establish this baseline, not just pharmacology. While it seems like common sense that healthy practices- such as a balanced diet, regular exercise, and social engagement- are effective, the reality is that many of us, myself included, struggle to consistently implement them. To help clarify let’s continue using unipolar depression as an example here. One of the challenges in treating depression is patient compliance. So, you might ask yourself, is it easier to ask someone to take a pill or to change their entire lifestyle and habits? Perhaps the pill. However, we should consider the long-term financial and health benefits of promoting a healthier lifestyle as a first step in treatment. By encouraging an overall healthy routine and diet, we can potentially help people save a lot of money on medicine or intensive therapy. If the approach is successful, it might help prevent relapse rates and the lack of long-term benefits from medications. Since the practice of establishing a baseline of well-being is not very common, we lack data on how many patients would achieve remission solely through lifestyle changes. However, it is safe to assume that everyone, not just patients, would benefit from adopting healthier habits. So why not make sure that those who are struggling physiologically meet that baseline? Another concern that comes to mind is that when suggesting significant lifestyle changes, can discourage some patients from pursuing treatment altogether.  Many individuals will come to psychiatrists and psychologists to obtain medication as a quick fix for their symptoms. Considering this, the approach suggested in their article will likely lead to lower patient compliance rates. However, it is important to not generalize; some patients are willing to try several different treatment methods before giving up. For those who seem more reluctant to lifestyle changes, it is crucial to address and explore their reluctance. Additionally, you might be asking yourself, aren’t there available therapies such as behavioral activation therapy and motivational interviewing practices that teach how to attain all these healthy habits I have described above? You would be correct. However, while these therapies focus on specific aspects of behavior change- like encouraging fun activities and healthy relationships and increasing motivation- they are often used as separate components of treatment rather than being integrated into a holistic treatment plan. Not all patients are assessed on their lifestyle habits (diet, sleep, social activities); it usually depends on the clinician’s approach, treatment setting, and the specific concerns the patient presents with. I propose a more integrated approach that combines some of these therapeutic elements to establish a wellness baseline for every patient. This approach assures that the clinician addresses the patient’s wellbeing based on physical and psychological factors, rather than just psychological. We need to focus on creating and sustaining healthy habits. This involves tailoring plans to individual needs, considering physical limitations and scheduling constraints that the individual might have. The challenge lies in finding motivation and maintaining consistency and discipline over time. What are your thoughts on this?   For a detailed and self-teaching guide on how to do Behavioral Activation Therapy click here.   REFERENCES: 1-       Ferreira Fratelli C, Willatan Siqueira J, Rodrigues Gontijo B, de Lima Santos M, de Souza Silva CM, Rodrigues da Silva IC. BDNF Genetic Variant and Its Genotypic Fluctuation in Major Depressive Disorder. Behav Neurol. 2021 Nov 1;2021:7117613. doi: 10.1155/2021/7117613. PMID: 34760029; PMCID: PMC8575598. 2-       Grajek M, Krupa-Kotara K, Białek-Dratwa A, Sobczyk K, Grot M, Kowalski O, Staśkiewicz W. Nutrition and mental health: A review of current knowledge about the impact of diet on mental health. Front Nutr. 2022 Aug 22;9:943998. doi: 10.3389/fnut.2022.943998. PMID: 36071944; PMCID: PMC9441951. 3-       Scott AJ, Webb TL, Martyn-St James M, Rowse G, Weich S. Improving sleep quality leads to better mental health: A meta-analysis of randomised controlled trials. Sleep Med Rev. 2021 Dec;60:101556. doi: 10.1016/j.smrv.2021.101556. Epub 2021 Sep 23. PMID: 34607184; PMCID: PMC8651630. 4-       Mahindru A, Patil P, Agrawal V. Role of Physical Activity on Mental Health and Well-Being: A Review. Cureus. 2023 Jan 7;15(1):e33475. doi: 10.7759/cureus.33475. PMID: 36756008; PMCID: PMC9902068. 5-       Briguglio M, Vitale JA, Galentino R, Banfi G, Zanaboni Dina C, Bona A, Panzica G, Porta M, Dell'Osso B, Glick ID. Healthy Eating, Physical Activity, and Sleep Hygiene (HEPAS) as the Winning Triad for Sustaining Physical and Mental Health in Patients at Risk for or with Neuropsychiatric Disorders: Considerations for Clinical Practice. Neuropsychiatr Dis Treat. 2020 Jan 8;16:55-70. doi: 10.2147/NDT.S229206. PMID: 32021199; PMCID: PMC6955623.

Antidepressants are one of the most widely prescribed types of medication in the United States, with about 11% of the population currently taking some kind of antidepressant (1). Additionally, it is very common for patients to go through multiple antidepressants before they find the right one. This can take several months and effort from the patient to continue treatment. It can be extremely expensive and discouraging to go through multiple antidepressants that are not helping the patient and that may be worsening their symptoms. When it comes to Major Depressive Disorder, only about 30% of patients achieve full remission with antidepressants. Many factors contribute to the mismatching of antidepressants with patients. One of the factors, which is the most important one for this article is the variability of patient responses to antidepressants. In this article, I wanted to address this issue by providing a possible solution. This Solution involves doing genetic testing for the P450 enzymes, also known as CYP enzymes. The P450 Test is a pharmacogenetic test that looks specifically at the cytochrome (CYP) P450 enzymes, which can be found throughout the body but are more commonly found in the liver. The test requires DNA from the individual being tested, which can be acquired either through a buccal swab or blood draw. The DNA sample is then analyzed to identify specific alleles in the genes found in CYP enzymes, such as CYP2D6, CYP2C19, CYP1A2, and CYP3A4. CYP enzymes are responsible for breaking down foreign substances found in our body, such as medications and drugs so these substances can be excreted properly. The information provided by this kind of test is the category of metabolizer type that best fits the individual. There are four main categories created by gene variations: Poor, intermediate, extensive, and ultrarapid metabolizer, from slower to fastest enzyme activity respectively. This information can be useful because the metabolizer level helps clinicians determine which antidepressants would be most beneficial for the patient and which would be best to avoid. For example, individuals with a poor metabolizer profile for CYP2D6 may experience increased side effects with drugs such as fluoxetine or paroxetine. For more examples and suggestions on what to prescribe, visit the CPIC Guidelines provided in the references (2). By understanding what type of metabolizer the patient has, it becomes easier to match them with the correct type of antidepressant. However, a few issues come to mind when developing this approach, including insurance coverage, the time required for the pharmacogenetic test to give results, and practicability. I am unsure how long it would take for the test results to return from the lab. Additionally, while this method could improve the matching rate of patients to antidepressants, it may not be the most effective approach. Nonetheless, it is a viable option to consider. I encourage psychologists and psychiatrists to consider this an ethical issue. Prescribing the “go-to” antidepressant to a patient without assessing the patient’s unique biological profile can be harmful for them. It can be argued that current clinicians are doing a “trial-and-error” approach every time they prescribe a medication without knowing the patient’s biological profile. Of course, the approach suggested in this article does not lead to a 100% match rate, but it would be a step closer to more efficacious treatment options. What’s your opinion on this issue? References: 1-      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8633963/#:~:text=Antidepressants%20are%20one%20of%20the,several%20billion%20dollars%20%5B1%5D. 2-       https://cpicpgx.org/guidelines/cpic-guideline-for-ssri-and-snri-antidepressants/

Currently, the traditional way of assessing and diagnosing patients is through a categorical approach called the Diagnostic and Statistical Manual of Mental Disorders (DSM). There are many issues involving this approach, mostly because of its lack of validity. It creates distinct mental disorder categories, oversimplifying the complexities of human disorders. In some cases, two people who have the same disorder can present completely different symptom clusters, commonly known as a problem of heterogeneity in psychiatric disorders. Comorbidity is another common issue adding to the layer of complexity in clinical presentation in psychiatric disorders. With many more issues, such as stigma and labeling, the lack of multidimensionality representation, the emergence of other approaches became necessary in the field. Dimensional approaches, instead of categorical ones became preferred. Particularly, the Hierarchical Taxonomy of Psychopathology (HiTOP) and the Research Domain Criteria (RDoC) are worth mentioning and are approaches that have been getting some traction in recent years. HiTOP is a system that mental health providers can use to organize and assess psychopathologies better, considering the complexity of psychopathologies and their presentation. This system groups related symptoms together, which is extremely relevant for the high incidence of comorbidity in psychopathologies. Below is an example of how eleven different DSM-5 classes of psychopathologies can be incorporated into the HiTOP. This also helps “diagnose” people who don’t neatly fit into a criterion for a mental disorder, since applying discrete categories to mental disorders does not account for the complexity of human symptomalogy presentation. RDoC, is an approach to used for researching mental disorders that focuses on understanding the basic dimensions (domains) of functioning across different levels of analysis, such as genes, brain circuits, cells, behaviors, and self-reports. RDoC takes a holistic approach to understanding human functioning and mental health conditions. It encourages the integration of multiple levels of analysis to provide a more comprehensive understanding of the emergence and manifestation of mental illnesses. While this model isn’t utilized for psychiatric disorder assessment and diagnosis, it offers an improved approach to such processes. SPECT brain scans do not show distinctive patterns for each mental disorder, in other words, it does not prove the existence of distinctive DSM-based criteria for mental disorders. SPECT aligns more accurately with dimensional approaches. Rather than relying on symptom clusters provided by the patients, SPECT could aid in the creation of neurobiological profiles that can be associated with their symptoms, alongside the usage of frameworks such as HiTOP and RDoC. Further, personalized medicine should be the goal, as everyone manifests disorders differently and responds to treatments differently. Treating patients with the same type of medicine/therapy is bound to fail as it does not take their neurobiology and individual differences into account. SPECT is not meant to diagnose patients, but simply aid in guiding clinicians to the right path towards diagnosing and treating their patients. It is important to note that such dimensional approaches are still not covered by insurance companies, which brings me to one of the goals of this blog. By comparing, at least superficially, the DSM with more modern frameworks I aim to persuade the reader to join me in advocating for broader insurance coverage of alternative methods beyond the DSM. I dare say that this advocacy is particularly pertinent to the principle of nonmaleficence, one of the five moral principles of the Code of Conduct every psychologist is obligated to serve (more on this later, stay tuned).

Dr. Amen outlines common SPECT imaging patterns that are clinically relevant after analyzing thousands of brain SPECT scans. According to his article, “Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based Underutilized Tool”, 2021, there are 6 clinically useful general patterns that can be observed in patients. Let’s go over each one of them: 1-    Overall Decreased Perfusion, or “Scalloping”: This pattern is most commonly observed in individuals who have been exposed to toxins, certain illnesses (such as Lyme disease, meningitis anemia, ect), or other insults to the brain. This is common among individuals who struggle with substance abuse, who are taking certain medications, who are exposed to toxins in their environment, and even exposure to general anesthesia. The figure below shows an example of a patient who had been misdiagnosed with two mixed personality disorders. The pattern shown in his brain is from his constant exposure to toxins at his job. Image from: Amen DG, Trujillo M, Newberg A, Willeumier K, Tarzwell R, Wu JC, Chaitin B. Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool. Open Neuroimag J. 2011;5:40-8. doi: 10.2174/1874440001105010040. Epub 2011 Jul 28. PMID: 21863144; PMCID: PMC3149839. 2-    Traumatic Brain Injury (TBI) Pattern: many people might forget that they suffered a brain injury and might fail to report it to their physician. TBI can cause several different psychiatric symptoms as well as changes in cognition, and mood. Depending on the type of brain injury someone has, SPECT can help identify if a trauma is present. Dr Amen listed common findings in trauma on SPECT as “focal decreased near sight of injury and/or opposite side (contra coup), asymmetrical hypoperfusion in the prefrontal, temporal, parietal or occipital lobes; flattening of the prefrontal pole, decreased anterior temporal poles, and decreased contralateral cerebellar perfusion”. The following image shows the brain of a patient with severe impulsivity and depression, who had denied he suffered a brain injury 10 times. In his scan, there was evidence of “hypoperfusion, consistent with trauma in the left frontal-temporal lobe region”. When he was asked again, he remembered a motorcycle accident he had been in. (Image from: Amen DG, Trujillo M, Newberg A, Willeumier K, Tarzwell R, Wu JC, Chaitin B. Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool. Open Neuroimag J. 2011;5:40-8. doi: 10.2174/1874440001105010040. Epub 2011 Jul 28. PMID: 21863144; PMCID: PMC3149839.) 3-    Cognitive Decline Patterns: SPECT is normally used to assess cognitive decline in dementia disorders and to distinguish between the different types of dementia. The brain scan pattern associated with Alzheimer's Disease (AD) for example, is a decrease in the posterior cingulate gyrus, parietal and medial temporal lobes; Frontal Lobe Dementia includes frontal and temporal love deficits; Vascular Dementia includes decreased activity in multiple areas. For more details on other dementia and cognitive decline, please visit “https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149839/” 4-    Negative Emotionality and Hyperfrontality: can be seen in psychiatric disorders that have “cognitive inflexibility or getting stuck on negative thoughts or behaviors […], patients who struggle with being rigid, inflexible and oppositional […]”, which can include disorders such as OCD, Autism Spectrum Disorder, PTSD, and other mood and anxiety disorders. Identifying this brain activation pattern is particularly important for identifying individuals who can benefit from serotonergic medication for depression (1-5) and OCD (6,7), to predicting a good response to sleep deprivation (8,9), and repetitive transcranial magnetic stimulation (10) for depression. These are just some of the examples that brain SPECT can help by providing more specific routes of diagnosis and even treatment. Below are examples of active scans showing hyperfrontality compared to a healthy scan. As seen in the healthy scan, the more active regions in the brain are in the cerebellum. Image showing hyperfrontality from: Amen DG, Trujillo M, Newberg A, Willeumier K, Tarzwell R, Wu JC, Chaitin B. Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool. Open Neuroimag J. 2011;5:40-8. doi: 10.2174/1874440001105010040. Epub 2011 Jul 28. PMID: 21863144; PMCID: PMC3149839. 5-    Behavioral Problems and Hypofrontality: Hypofrontality or the lack of activation of the prefrontal cortex is associated with “a negative response to serotonergic medication in depression and clozapine in schizophrenia as well as with predicting relapse in alcoholics, improved response to acetylcholine- esterase inhibitors for memory and behavior in AD, predicting poor response to ketamine in fibromyalgia patients and improved response to stimulants in patients with ADHD symptoms during a concentration challenge” (Amen, 2011). The list goes on. It is important to note the variability of psychopathologies that hypofrontality is associated with. Nevertheless, it can be used to focus on specific symptoms and narrow down on specific diagnoses. 6-  Mood Instability, Memory Problems, and Temporal Lobe Abnormalities: Temporal lobe abnormalities in brain scans can be common among people with memory problems, mood instability, aggressive behavior, and language. Temporal Lobe Epilepsy (TLE) is a common that is associated with depressed/euphoric mood, anxiety, anergia, fear, atypical pain, irritability, and insomnia. Without a brain scan, such symptom clusters could lead to a personality disorder diagnosis and bipolar disorder. Epilepsy can be detected by EEG, however, EEG can also miss certain abnormalities that can be detected by SPECT. EEG can be used in combination with SPECT to identify TLE more accurately. SPECT can be useful in identifying other abnormalities that are not necessarily related to epilepsy disorders. Dr Amen recommends the use of anticonvulsants as a first-line treatment for people with mood instability or anger/aggression problems and who have either high or low perfusion in the temporal lobes. This is one example of how SPECT could lead to more accurate treatments for patients. For more information and details visit these two articles by Dr. Amen that go into more depth about each brain scan pattern: 1-    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8702964/ 2-    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149839/ References: 1. Brockmann H, Zobel A, Joe A, et al. The value of HMPAO SPECT in predicting treatment response to citalopram in patients with major depression. Psychiatr Res. 2009;173:107–12. [PubMed] [Google Scholar] 2. Hoehn-Saric R, Schlaepfer TE, Greenberg BD, McLeod DR, Pearlson GD, Wong SH. Cerebral blood flow in obsessive-compulsive patients with major depression: effect of treatment with sertraline or desipramine on treatment responders and non-responders. 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SPECT stands for single-photon emission computed tomography. It is an imaging technique that shows blood flow in tissues and organs. This test uses a radioactive substance (around 0.68 radiation exposure, compared to 0.90 rem from a head CT scan) that is injected into the bloodstream to show how well blood is flowing in that area. The old president of the Society of Nuclear Medicine, Michael Devous, Ph.D., wrote, “SPECT […] procedures have no more risk than MRI-based procedures[…]. Indeed, there are no data demonstrating harm to humans by radiation exposure at diagnostic imaging levels”. The radioactive trance produces gamma rays that are picked up by a gamma camera. The SPECT scan produces 3D images of the area being examined. SPECT was developed more than 50 years ago. Brain scans using SPECT are normally used to look at Alzheimer’s Disease, seizures, strokes, head trauma, chemical exposure, Lyme disease, brain inflammation, and drug toxicity. (Image from https://www.braingymmer.com/en/blog/SPECT_imaging/ ) A “surface view” shows areas with low activity in the brain. A healthy surface view scan should show a “full” brain with symmetrical activity. An “active view” shows active areas. In a healthy brain scan, the most active area of the brain is the cerebellum (Amen 2021). (Both images are from the Amen Clinics Website: https://www.amenclinics.com/approach/why-spect/) References: Amen DG, Easton M. A New Way Forward: How Brain SPECT Imaging Can Improve Outcomes and Transform Mental Health Care Into Brain Health Care. Front Psychiatry. 2021 Dec 10;12:715315. doi: 10.3389/fpsyt.2021.715315. PMID: 34955905; PMCID: PMC8702964.