Revolutionizing Psychiatric Diagnoses: Understanding the HiTOP Model (a DSM Alternative) with Dr. Robert Krueger

Dr. Robert Krueger returns to the show to join Dan in a conversation into psychiatric diagnoses. Dr. Krueger is a clinical psychologist and member of the DSM-5 Personality Disorders Workgroup.

In this episode, Dan and Dr. Krueger discuss the limitations of the DSM (Diagnostic and Statistical Manual of Mental Disorders) in accurately diagnosing and treating psychiatric disorders. They explore the complexities of mental health conditions, emphasizing that many individuals do not fit neatly into categorical diagnoses and dive into the Hierarchical Taxonomy of Psychopathology (HiTOP) model, a new framework for understanding psychopathology that is hierarchical and dimensional, allowing for a more nuanced approach to diagnosis and treatment.

Special Guest: Dr. Robert Krueger

Episode Links
HiTOP Model in an image

Original HiTOP Article

HiTOP Self-Report Measures

Sample HiTOP Clinical Assessment Profile

ARCS Institute

Official HiTOP Website

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Chapters

• 0:00 Introduction & Welcome
• 1:12 What’s Wrong with the DSM?
• 10:33 Complexity of Psychiatric Diagnoses
• 14:05 Comorbidities and Clinical Reality
• 17:56 Administrative vs Clinical Use of the DSM
• 21:30 Introducing the HiTOP Model
• 24:40 Founding and Growth of the HiTOP Consortium
• 32:40 Overview of the HiTOP Framework
• 35:20 HiTOP’s Hierarchical and Dimensional Structure
• 38:42 Clinical Applications and Personality Insights

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. If you find the show interesting, it'd be much appreciated. If you shared it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I can be more excited to welcome back one of the world's authorities on mental health diagnoses. While having this conversation, I was so inspired by how my guest and his colleagues developed grass roots and an scientifically-based movement for changing how we do diagnoses. In this conversation, you'll learn about the high-top model, which is what psychiatric diagnoses would look like if they were based on science. This episode starts with my guest responding to my question, "What's wrong with the DSM?" So without further ado, it is my pleasure to welcome my very special guest, Dr. Bob Krueger.[MUSIC] What's wrong with the DSM? Where to start?[LAUGHTER] So the DSM, I think many listeners will appreciate, consists of literally hundreds of fugitively categorical psychiatric diagnoses, right? And it stems from a kind of paradigm, or like a way of thinking about the world and the way of approaching psychiatric diagnosis that's embedded really in, you know, 19th century medicine. So if you think about like the origins of scientific medicine, and the way in which concepts in medicine were originally generated, they relied pretty heavily on clinical observations, right? So the star of many medical intuition about a diagnostic concept is the experience of physicians working with patients, noticing that certain patients share certain kinds of features, right? And that on the basis of those shared features, one might characterize the phenotype, but the clinical presentation of a certain kind of class of individuals. And then with that, kind of being laid out, right? Like we tend to encounter people for whom these things are present, right, in terms of clinical science and symptoms. That's when the scientific process comes into play, right? So you have a pretty good description of the clinical phenotype, like what people with a certain kind of set of characteristics look like in the clinic. Then, right, you can apply modern scientific methods to try to understand what the ideology, like the underlying cause, and the pathophysiology, like current physiological correlates, right, of that category might be. And, you know, for a lot of medicine, this kind of paradigm, right? This approach has worked reasonably well for a number of different things like infectious diseases. And probably the reason, right, that this approach, kind of works for a lot of things, is because the ideology and the pathophysiology, I don't want to call them simple, but are sort of straightforward. Like if there's a pathogen, right? It's going to interfere with certain key biological processes. Many pathogens can be seen under a microscope, as you can see that they're there, and they're not there for comparison, you know, for example, since some kind of study. And so the paradigm kind of works for a lot of things. And I think what we face now, broadly in medicine and definitely in, you know, psychiatry and clinical psychology, is kind of the residual. Like what's left after we've kind of figured out some of that more straightforward stuff. So like a lot of late life medical disorders are complicated in terms of their ideology. You know, many different genes are involved, many different environmental exposures are involved, and it's hard to characterize a singular, you know, a certain cause. And for these psychiatric kinds of things, that's almost certainly true, based on a pretty substantial literature, right? The psychiatric conditions are not simple in terms of their causes, in terms of their pathophysiology, you know, like what you could observe using scientific means for characterizing biological correlates. And they combine not just kind of, you know, it's called them for ease of, you know, communication, like biological, you know, distal, like faraway causes, like genomic variants. It also combines that with a bunch of experiences that people have in their lives. All this being mediated through the brain, which is the most complex organ, a considerable amount. So you have kind of this conflict between a paradigm that worked well, and that's traditional in medicine, where things get classified into these categories, and the reality of human variation, which is much more multifaceted, complex. And that's, I think, the basic fundamental issue, right? The DSM continues to be wedded to a kind of descriptive paradigm that originates, again, from 19th century medicine, whereas the science has shown us that that's not really a very good account of the way in which causes, you know, ultimate causes kind of lead to human suffering of a psychological measure. So then the question is like, well, what are you going to do? Right? And the issue with the DSM is it's kind of persisted with this approach, because it's traditional, it's well understood, it's embedded in all of our textbooks, it's embedded in residency training programs, it's embedded in psychology doctoral programs, like it's just part of the fabric of these disciplines. And so how are you going to proceed, right, given this emerging knowledge of how complex, you know, these ideology, like things are going to be? So that, I think, well, when I think about it, that's the fundamental issue, right? The DSM is wedded to an approach that worked well for a lot of things, and isn't working well for understandings like the after-conditions. So some new approach to describing clinical presentations, you know, might work better. And I love the example that you gave right at the beginning of that of the pathogen, which is immediately outside of anything I know anything about. But the idea of you have the pathogen or you don't have the pathogen, right? It's an on-off switch. Yeah. And so in that context, in a diagnostic context, it makes sense to have a category. Does she have it? Does she not have it? Right? But when it comes to psychiatric disorders, that it just doesn't work that way. And I think about, you know, during my training, and just sort of generally in the field, they're signed up kind of this, you know, people kind of laugh about the idea of a patient having a single disorder. Yeah. That doesn't really, you know, once you start, once you really understand the DSM, the diagnostic classifications, and have a really strong sense of it, you know, sort of once you've been doing it for a little while. And you start seeing a bunch of, you know, you start to have a certain number of patients where you start to have seen a bunch of different presentations of these symptoms, and that sort of thing. You start to realize, oh, nobody has just one thing. There's a bunch of stuff going on, which is a critique in our field when we come to treatment stuff, which we'll talk about a little bit later on. But because oftentimes our treatments are designed for a specific disorder, and with no, what we'd probably call comorbidities. But it just that I think for any clinician or even person in training who's a little while long, it becomes pretty clear relatively early on that these things are not just on-off switches that have nothing to do with one another. Yeah. No, and that's, it's, I appreciate you bringing it back to, you know, the clinical realities. Because that's where a lot of this started for me, right? So I'm a clinical psychologist by training. More involved in research than clinical work these days, but not zero involved in clinical. I'm just kind of busy with my academic job. But it all kind of started with that, right? It started with wanting to be a good diagnostician, you know, wanting to understand the concepts that are in the DNA, one of the good job in the clinic of characterizing presentations. And then just finding it frustrating to see the extent to which the basic sort of differential diagnosis approach didn't really work for a lot of presentations. Because the idea, right, is, okay, choose the best single categorical label. Sometimes that might be confusing because other things might be present, but your job is to try to figure out the best single label and find me like the presentations didn't fit well with that approach because there were always other nuances, right? And other complications. And in a categorical diagnostic system, as you you know, mentioned the only way to really handle that is to say there's a bunch of comorbid conditions. And that doesn't necessarily work well either because then like how do you pick a primary and how do you characterize the secondary and then the other thing I think that one finds in clinical practice is one uses things like the DSM and really the ICD comes, of course, fond to it, at least in the United States, right? Those are the codes that you use when you're dealing with a third-party pair, right? Because you got to put something into the record. That does, that's an administrative matter for a lot of clinicians, right? You got to do it and you're supposed to be familiar with that nozzology because that's how you're justifying your professional activities into clinic. But then in terms of case conceptualization, people go in a hundred other different directions, right? I don't think typical clinicians are super-webid to this person has panic disorder with the Grophobia. That's it. Like nothing else here is relevant. I have this manual on my shell for what to do and it's a kind of slavish manner you'd like go through the treatment manual. I just don't think most seasoned, sensitive, effective clinicians are doing that. And so that's another kind of disjunction that you discover in the clinic that okay, we have to kind of deal with these things for administrative purposes but for case conceptualization purposes and really for like effective psychotherapy, people are bringing in a host of other bits of information, approaches, skills, techniques, right? That are naturally connected with a much more nuanced way of thinking about the person and the presentation. Yeah, I think if you have any, you know, when you talk to full-time practitioners, it seems like the idea of this person has this one specific disorder and really solely attending to that disorder is going to help them live the life they want to live and that's going to be the sole focus of treatment. That's the outlier. Like, it's not that it never exists. Yeah, that's fair. But it's once a year or two. I mean, it's, you know, it's so uncommon that the idea of basing our way of thinking and working with clients on that is ridiculous. Limiting at the very least and out of sync with a lot of presentations. I mean, you're right. Sometimes you might encounter someone who really has a specific foe where or something like this. Right. And it's so rare. Or they come in with, and see oftentimes these cases are milder, right? Like a specific thing happened in their life now they're depressed and that's really kind of yet. And it was very like something happened. Right. And they've never really experienced serious episodes of depression. For and that can be kind of focal and you can kind of be effective thinking about this is fairly specific. But in my experience at least, in public others too, like that that's rarer and it's often a simple presentation of less severity. Right. Such like many people that we encounter have a much more shifting fluid complex life history and set of presentations. Right. So that is hard to conceptualize it as something happened. And now the person's functioning rather differently. And I can really hone in on some specific diagnostic construct to guide the intervention. So as in sort of a way forward a way that's guided by the science. And I mean, and frankly, by the practitioner experience as well. Yeah. You just started the you and your colleagues started the high top model. So what I'm curious about is how that gets started broadly. And also what some of those conversations with like we're like with your with your collaborators. Yeah. High top started around 2015, 2016 somewhere in there. A number of people have been kind of publishing on patterns of comorbidity among DSM disorders is kind of a so hold on trying to understand how you might evolve to a different kind of system. And in particular, there are two other people that I need to mention that's Roman Kotov and David Watson. If you look at the history of high top, it's fair to say that the three of us were kind of the founders. And really, Roman in a lot of ways is the engine behind a lot of this stuff. The person who who catalyzed all of this right and said, look different people are kind of publishing on similar ideas. They're sort of doing it within their own lab or work group. And coming up with similar and related kind of conceptualizations based on the data. So would it be viable to assemble or the consortium? Right? Like a group of people who are taking similar approaches with the goal of working on some of these limitations of DSM style approaches in a consortium. Right? Like working together, linking a lot of people together. And so, you know, to be honest, my initial reaction of that is it would be hard because of how academics works. Right? So there's a lot of hurting of cats. It's like the thing that happens in those circumstances. Collean once told me that, you know, approaches, right? Like the way you think about the world, they're kind of like, or models even, right? Like, or like toothbrushes, right? Everybody's got one they don't want to use somebody else's. Right? So the challenge there I think was like, could you get people enough on the same page to see the bigger picture and the advantages of working on this collaboratively, you know, versus working on it more sort of competitively or focusing on somewhat narrow differences among different approaches and conceptualizations to see like the advantages of big picture. And some of the advantages of pulling us all under a rubric, a title, a consortium, a concept. And it's really the Romans credit, really. Like I wanted to be involved rather than not involved, right? That was clear to me from the beginning. Because it's exciting and fun to think that such a thing might even be possible. I've got to get a lot of credit to Roman for like doing a lot of the hard work of pulling people together, giving them on the same page, right? He, he's glad. And I, you know, played a pretty substantial role in it, but he was the first author on the very first consortium publication. That's the 2017 you know, high-top paper that's often cited as the origin of the approach. And that's been very gratifying, I think, the word I want to use, right, to see that we could do this, right? That there was enough interest among a diversity of colleagues with a diversity of views in trying to get a kind of unified approach together that provides an empirically based alternative to the traditional DSM categorical classification from this kind of grassroots movement, right? So high-top's never been connected with or attached to a particular authoritative body, right? So, you know, the DSM is published by the American Psychiatric Association. So has the full weight and financial resources and everything that comes from that kind of connection. Another alternative we might talk about at some point is the R-doctor approach. That's an alternative to the DSM, the National and Tutorial Mental Health, as promoted. And I mentioned it in this context because it's another viable and I think in many ways successful alternative to the DSM, but it's connected with the NIMH. So it has these auspices under which it functions. High-top is a grassroots movement by contrast, right? It's academics and many clinicians getting together in a grassroots kind of way to kind of propose and alternative. So does that kind of, I think that addresses your question, I think where it's all common from, right? It came from that and then it grew from there, right? It turned into a pretty substantial consortium, it's hundreds of members now. Many different work groups that are very active on different elements of the kind of intellectual space in which, you know, psychological diagnosis is sitting, right? So, it's a genomics work group, a neuroscience work group, and clinical applications work group, and these kinds of things, right? So it's ground from a few people interested in trying to make it happen to many people wanting to be part of the party, basically, right? And engaged with the endeavor. Yeah, and I think you very much hit on what I was struck by because there's so much thoughtful infrastructure that you all have put around this. And as an outsider and looking at it all, I'm saying, how the hell did these people do this? Not that it's impossible, but that, like, just like you're saying, to an extent, the academic grant getting, like, it doesn't prioritize or sort of reward what you all did. I mean, it seems like, you know, it's rolling a boulder up a mountain. Then when you get to the top of the mountain and start to go down the other side, then, you know, there might be some benefit in the traditional ways you would think about because you do have this huge, or sort of this machine theoretically that you can use to build and, right, grants and papers into all these other collaborative, wonderful things. But just getting that going without being a part of a pre-existing, reasonably supported organization, I was just rather like, damn, wow, I would have been the skeptic. I would have been the person who sort of said, yeah, this is a great idea in theory. But the amount of hoops and hurdles and challenges is we're going to be working on this thing for years before there's any potential benefit and that, you know, but likely it's going to get cut off before we even get there. And I just, I just sort of a little bit like, man, that was impressive that they got this thing going and we're so successful. Well, I appreciate you saying that. You know, I think maybe part of the reason that was tractable or kind of happened that way is the people who were looking for an alternative. In research, right, the DSM is fundamentally frustrating and trying to work with because again, like many presentations don't fit very well. So it's hard, I think, to do research with constrained by the DSM paradigm. And, you know, there wasn't really what I want to call it. It's like a descriptive alternative, right? Like a real target. High top's not perfect or anything, but it does provide a target, right? Like, here's a, here's an alternative. It has a name. Right? There's these figures in our papers that come described with the alternative looks like based on the existing data that can be, you know, brought to bear on kind of like, what could be the outlines of a viable, empirically based alternative. So like, I think that might be part of why that worked the way it did is because there was a need. And the need is, it's, it's the other way as you're saying, like to fulfill a need like that is develop, you know, Kruger's model or whatever, right? And then, you know, like, science is always this dialectic, I think, right? I suspect that historians of science, philosophers of science, would back me up on this between competition and cooperation, right? There are times when a certain degree of healthy competition can be motivated for a field because you've got people working within a paradigm to solve certain kinds of problems, trying to be the first to the finish line. But there are other times. And I think many, many modern areas of science and againpory look like this because of the complexity of the problems that we're trying to tackle, where the collaborative approach, right? Really is the only one. Because it requires leveraging a lot of people and resources and data to come together. So another area that I work in is genetics and genomics. And there, that's very clear, right? Those those scientific problems are sufficiently complex and multifaceted that it's been much more successful to create consortium-like endeavors to make progress versus, you know, thinking that you're going to make some miraculous discovery, you know, working on your own late night in your lab. It's kind of your recon moment. It has a certain sort of remapsism about it, right? And might play well in the movies, but you know, like in reality, it's a lot, it's a lot of hard slogging and collecting a lot of data and working together in larger groups, right? To make your own progress. And that's I think part of why High Top Might might have worked the way it did. And then people came together is because it was a viable alternative and people saw the, you know, desirable aspects of trying to cooperate under the umbrella. Because there wasn't really like an alternative to the BS and that they had a name and a figure, right? And you know, the kind of stuff that's in all those high top competitions. So before we go much further, could you give us the overview of the High Top framework and just as a reminder to the listeners? So this is dealing with the problem of we've treated these things, these disorders as pretty much distinct categories. But the data, the reality doesn't line up with that. These things are much more complicated and much more co-vary. They relate much more. So give us the the broad overview of the High Top model. Sure. I can try to do that. And again, as we were discussing, right? There'll be some information to show notes, some URL's, right? But people can look at to kind of get some visual representation of what I'm going to try to convey using words. But basically there's two features that I could sort of highlight that make High Top distinctive from the DSM style approach. So again, the DSM style approach is to eliminate a variety of categorical concepts for use in describing patients. Where the idea is the concept applies or it doesn't, right? The diagnosis is reasonable to apply or not. And High Top is different from that in two key ways. There's the hierarchical aspect of it. Right? So that's sitting in the lane, right? The hierarchy with taxonomy of psychic college. High Top. And it's dimension. Right? So it doesn't impose categorical distinctions where those distinctions might not be distant nature. So going through those two things, right? High Top concepts are organized from very broad and general. Right? So they summarize a lot of information about people, the broader and more general concepts, to very, very specific. So I think we can talk about sort of three big spectrums of psychopathology. So I talk really invokes this notion of a spectrum, right? That's meant to get at the idea that some things have certain things in common and also certain things that are distinctive, right? That's the hierarchical aspect, right? Whereas at the higher levels of the hierarchy, characterizing features that different, you know, people have in common at a broad level, at the lower levels we're talking about very fine grain distinction of on different specific patient presentations. But anyway, maybe like close to the broadest level are these three big spectrums, right? Internalizing, which is problems with mood and anxiety, and basically the experience of negative emotions. Externalizing, right? Which is problems that people have when they act out, and they create problems for society at large or other people in their lives. And, you know, sort of kind of psychosis spectrum, which is, you know, difficulties with cognition essentially, right? With reality testing. And so at a broad level, all the stuff, right, that's described in something like the DSM kind of falls into those three big bins, right? Internalizing, externalizing, and psychotic problems. And the dimensional part is, a high top, you know, recognizes that there's a substantial scientific literature showing that these thresholds that are set in something like the DSM are hard to kill. So there's no compelling scientific basis for a lot of the thresholds that are in the DSM. Oftentimes their set is just more than half of the criteria, right? So a typical setup in the DSM is there's nine criteria, and you qualify up to five, and five is the threshold, because it's more than half of nine, not because there's any evidence for some kind of cost. Is that really the reason? Yeah, as far as I know, right? That's hilarious. I mean, you know, yeah, I can say that with pretty good confidence in the personality disorders area, because that's mostly where I contributed to the previous DSM. What we talked about in our previous conversation about the alternative model of personality disorders there, I'm pretty confident in saying that there was no real basis for those thresholds other than the surround half or slightly more than half of the criteria needed to be present. And that's not a compelling scientific basis for claiming that these things are categories. So anyway, getting back to high top, right? These things are considered dimensional, and that much better fits the data. Right? The people might have these features to different degrees, and their differences in degree and not so much in time, and also then when you think about case conceptualization, you're talking about a profile of qualities that a person has, not the presence or absence of a specific diagnosis. So just making it simple with these three broad spectrums, any given patient could be characterized by some mix of those or one being more primary. And that helps with all the complicated comorbidity, exclusionary rule stuff. It's always been awkward in the DSM setup. So to pick a really specific example that you often see clinically, many people present with psychotic types of problems. Some of them, many of them have various kinds of mood disturbances, but very in time varying ways with their psychotic coming in and out of psychotic episodes. Right? And is the mood antidating the psychosis? Is it entirely there? With the psychosis, does it have bipolar type features, by which I mean, of course, mania or elevated mood? Right? That all gets handled in the DSM by saying, well, these like, you know, 50 different categories that you can put people into based on arbitrary distinctions about course and timing and stuff like that. The alternative is to think about this in a kind of more profile, dimensional kind of way and say, well, a person could be having a level of psychoticism that's pretty dramatic and not much, you know, internalizing type disturbance. Another person might have a mix of those things. Some people will present without externalizing features, right? Which often have to do with substance use and anti-social behavior and things like this. Some people do present with that. So instead of like, okay, we need to figure out the right categorical label from among the hundreds that are sort of possible here based on relatively arbitrary rules about course. And then, you know, to make that course stuff make sense, you have to sort of trust the patient as a historian. That brings up challenges too. Only how easy to get from a person who's has some thought disorder type characteristics, the exact nature of the disturbance over the last 10 years. So that's hard. Clinically, right? Instead, the idea here is, okay, well, we'll come up with a dimensional profile. And we can use that to describe patients' presentation and to frame our intervention efforts. And then I'll just, you know, add another piece because people often ask about this because it's a logical thing to wonder about next. Well, then how do you decide how to intervene? Right? One of the traditional, punitive advantages categories is, oh, they have the diagnosis. Here's the book that describe treatment for the diagnosis. What are you talking about in terms of intervening on a profile or intervening on the dimension? And I think that's a matter, you know, we have a clinical translation work group, right? In high top, that's really kind of articulated this in ways that I think are very useful. But it's basically a matter of taking strategies and things that exist, right? In the existing psychotherapy and psychopharmacologic literatures, right? And applying them to what are some of the most acute things? What can we do about them? You know, pretty, you know, traditional kind of way. It's just, they're not tethered necessarily to arbitrary categories. They're tethered to the current presentation and what might be helpful. And I think there's evidence that that's what people do kind of anybody. Like, I don't, I haven't spent a lot of time in clinical settings where people kind of aren't thinking like this because it wouldn't make a lot of sense. But which I mean, I don't have a lot of experience with people being really wedded to the categories. It's more like, well, what is the person, you know, complaining about or suffering from right now? We have these interventions to help with that. And not a lot of concern with, well, you know, we can't do anything about their mood problems because mood is excluded if thought disorders presents or something like this, right? It's more like, well, we have these things, right? That can help with thought disorder type problems. We have these things that can help with mood type problems. Well, somehow, you know, meld these things together to come for the treatment plan. That makes sense. I think that's kind of how people function anyway as my point. It's just high top, maybe as closer to the way in which clinical case formulation works intuitively. It is kind of my, I guess, assertion here. So the idea is, so you know, and the way the DSM's organize now is you basically have a bunch of different, and you might know how many is about a dozen ish chapters, I don't know if you've even called chapters sections that are sort of divided by type of disorder or something like that. And so what high top is saying is that there are these three spectra that seem to work out pretty well in terms of organizing psychopathology. So this internalizing, externalizing, and psychosis, or I think what you all call it is thought disorder. But I think we can all see, think of that generally synonymously, generally, I'm sure we're missing some of the nuance there, right? So you have these three broad spectra that the psychopathology tends to organize itself within. And then you have then what falls underneath of that. Right, so that's a good point. That's the high co-organization. And again, this is easier to see visually and somewhat more challenging to describe this using words. But, you know, we can pick these specific spectrum and talk about how they fall out in terms of more fine-grained distinctions. So let's pick externalizing, as an example, right? There are two two things that kind of come within the realm of externalizing, roughly speaking. One is more like a disappearedatory tendency, right? So kind of like acting on the screw of the moment and kind of being driven by immediate rewards rather than thinking about future consequences. So a disappearedatory variant of externalizing. And the other variant is a more antagonistic variant of externalizing. So doing things that are hostile, hurting other people on purpose, you know, acting out in angry and obstinate ways, right? So within externalizing there, these two sort of subspectrums. One is more disinhibitorial and one is more antagonist group. Then you can go down further, right, in these things and get into very fine-grained personality concepts and symptom clusters, essentially, right? As you move down the hierarchy. So it's kind of a bandwidth fidelity situation, right? So by bandwidth, I mean the broader constructs. We have a lot of bandwidth. We have a lot of information with one variable. And fidelity is at lower levels of the hierarchy, where you need many more variables to convey the same information. So that's something that, you know, the clinician can think about, right? Is there some utility in a much broader label or is there some utility in very fine-grained things? And that's going to vary based on the presentation as to and end really for the scientific purposes too. That you're kind of suddenly thinking like, if you use this kind of high-doubt approach, you can figure out where something is located within the hierarchy. If you have a biological correlate you're interested in, for example, does it relate to a broad spectrum? Does it relate to a specific symptom cluster? Right? That becomes much less frustrating, that kind of signs, I believe. It becomes much less frustrating because you're casting these correlates within the hierarchy and not trying to figure out, you know, like based on arbitrary categories where it falls, because that literature often leads to the conclusion that there are similar correlates, you know, to diverse disorders. Not to mention all the interpretive stuff with like, what do we mean by that? How did people get into those disorder groups? How arbitrary was that? Wouldn't the investigators do about comorbidity? Stuff like this. It's easier again to see this visually, right? And I hope people will sort of turn those figures, but I'm trying here using words to talk about like very broad spectrums right, or part of the model at a high level, and much finer-grained concepts, right, or part of the model at a lower level. And the key scientific piece of this is that our organization fits the data, which I think is the most attractive thing from a scientific perspective about how high-top words. It's not somebody in their armchair, right, kind of trying to say like, I think it might work like this, right? Rather than there's a lot of data that speak to the organization of psychopathal watchful signs and symptoms as having this patterning, right, the number for interview. And so when I say, you know, roughly there's internalizing, externalizing, it's like, oh, so it's just a lot of data. It says, okay, that's how natural patterns of variation and psychopathology tend to fall out. Or when I'm saying within externalizing, there tend to be more disinhibitory and more antagonistic aspects. That's how that literature looks, right? You take the whole set of things that people have come up with for assessing externalizing problems and ask, kind of, how does that stuff go together in nature? Well, that's what you find, right? There are kind of more disinhibitory aspects and more antagonistic aspects. So what I'm describing here has a basis in reality, right? And actually a pretty substantial scientific literature that leads to, you know, the kind of high-top model, it's been described in all these papers that you... Well, I think that the example that you gave of disinhibition and antagonism is a great one because it, it immediately helps the person in the field. I'm sort of, to make sense of why is this person doing this? Or like what, what, like the important stuff, right? So is it that this person... Is this person in jail because they just sort of can't stop themselves from, you know, whatever their impulses are, right? They're just sort of going, right? They're just... They just can't stop myself, right? So that's sort of that disinhibition. They can't just, you know, they're going to versus the antagonistic person who's in jail, who's there because they, the most extreme example want to do harm to others or something like that. And those are, right, that's both those people, right? These are folks who are more likely to get in trouble in school and class, and then, you know, with the criminal justice system and all that sort of stuff. But those, those are really important differences. And it's very clinically meaningful in terms of what, what am I going to do to try to help this person? Yeah, I think that makes sense. Yeah, I think that, well, I mean, again, like that fits the data. And I think the way you're describing it is a useful way of characterizing, you know, why you want to understand the personality, essentially, right, of a person that you're dealing with. So that's another thing we haven't really talked about. It's supposedly part of the reason that high-topp, it looks the way it does, because personality really is kind of the infrastructure for second pathological presentation. That's a wrap on our conversation. As I noted at the top of the show, be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time...[Music]