The Hierarchical Taxonomy of Psychopathology (HiTOP) Is Not an Improvement Over the DSM.

In their response to our article (both in this issue), DeYoung and colleagues did not sufficiently address three fundamental flaws with the Hierarchical Taxonomy of Psychopathology (HiTOP). First, HiTOP was created using a simple-structure factor-analytic approach, which does not adequately represent the dimensional space of the symptoms of psychopathology. Consequently, HiTOP is not the empirical structure of psychopathology. Second, factor analysis and dimensional ratings do not fix the problems inherent to descriptive (folk) classification; self-reported symptoms are still the basis on which clinical judgments about people are made. Finally, HiTOP is not ready to use in real-world clinical settings. There is currently no empirical evidence demonstrating that clinicians who use HiTOP have better clinical outcomes than those who use the Diagnostic and Statistical Manual of Mental Disorders (DSM). In sum, HiTOP is a factor-analytic variation of the DSM that does not get the field closer to a more valid and useful taxonomy.

Folk Classification and Factor Rotations: Whales, Sharks, and the Problems With the Hierarchical Taxonomy of Psychopathology (HiTOP).

The Hierarchical Taxonomy of Psychopathology (HiTOP) uses factor analysis to group people with similar self-reported symptoms (i.e., like-goes-with-like). It is hailed as a significant improvement over other diagnostic taxonomies. However, the purported advantages and fundamental assumptions of HiTOP have received little, if any scientific scrutiny. We critically evaluated five fundamental claims about HiTOP. We conclude that HiTOP does not demonstrate a high degree of verisimilitude and has the potential to hinder progress on understanding the etiology of psychopathology. It does not lend itself to theory-building or taxonomic evolution, and it cannot account for multifinality, equifinality, or developmental and etiological processes. In its current form, HiTOP is not ready to use in clinical settings and may result in algorithmic bias against underrepresented groups. We recommend a bifurcation strategy moving forward in which the DSM is used in clinical settings while researchers focus on developing a falsifiable theory-based classification system.

Why Does Therapy Work? An Idiographic Approach to Explore Mechanisms of Change Over the Course of Psychotherapy Using Digital Assessments.

BACKGROUND AND OBJECTIVES: While psychotherapy treatments are largely effective, the processes and mechanisms underlying such positive changes remain somewhat unknown. Focusing on a single participant from a treatment outcome study that used a modular-based cognitive behavior therapy protocol, this article aims to answer this question by identifying changes in specific symptomatology over the course of the treatment. Using quantitative data derived from digital health methodology, we analyzed whether a given therapeutic intervention was related to downstream effects in predicted symptom domains, to assess the accuracy of our interventions. METHODS: This case study employed an observational N-of-1 study design. The participant (n = 1) was a female in the age range of 25-35 years. Using digital health data from ambulatory assessment surveys completed prior to and during therapy, separate linear regression analyses were conducted to assess if hypothesized treatment targets reduced after a given module, or intervention. RESULTS: Support was found for some of the hypothesized quantitative changes (e.g., decreases in avoidance after exposures module), yet not for others (e.g., decreases in rumination following the mindfulness module). CONCLUSION: We present data and results from our analyses to offer an example of a novel design that may allow for a greater understanding of the nature of symptom changes with increased granularity throughout the course of a psychological treatment from the use of digital health tools.

Interpersonal Problems Predict Differential Response to Cognitive Versus Behavioral Treatment in a Randomized Controlled Trial.

OBJECTIVE: We examined dimensional interpersonal problems as moderators of cognitive behavioral therapy (CBT) versus its components (cognitive therapy [CT] and behavioral therapy [BT]). We predicted that people with generalized anxiety disorder (GAD) whose interpersonal problems reflected more dominance and intrusiveness would respond best to a relaxation-based BT compared to CT or CBT, based on studies showing that people with personality features associated with a need for autonomy respond best to treatments that are more experiential, concrete, and self-directed compared to therapies involving abstract analysis of one's problems (e.g., containing CT). METHOD: This was a secondary analysis of Borkovec, Newman, Pincus, and Lytle (2002). Forty-seven participants with principal diagnoses of GAD were assigned randomly to combined CBT (n = 16), CT (n = 15), or BT (n = 16). RESULTS: As predicted, compared to participants with less intrusiveness, those with dimensionally more intrusiveness responded with greater GAD symptom reduction to BT than to CBT at posttreatment and greater change to BT than to CT or CBT across all follow-up points. Similarly, those with more dominance responded better to BT compared to CT and CBT at all follow-up points. Additionally, being overly nurturant at baseline was associated with GAD symptoms at baseline, post, and all follow-up time-points regardless of therapy condition. CONCLUSIONS: Generally anxious individuals with domineering and intrusive problems associated with higher need for control may respond better to experiential behavioral interventions than to cognitive interventions, which may be perceived as a direct challenge of their perceptions.

A quantitative method for the analysis of nomothetic relationships between idiographic structures: dynamic patterns create attractor states for sustained posttreatment change.

OBJECTIVE: The present article aimed to demonstrate that the establishment of dynamic patterns during the course of psychotherapy can create attractor states for continued adaptive change following the conclusion of treatment. METHOD: This study is a secondary analysis of T. D. Borkovec and E. Costello (1993). Of the 55 participants in the original study, 33 were retained for the present analysis due to the homogeneity of psychotherapy outcome among these participants. Of these 33, the majority were White (88%) and female (70%), and the average age was 35.44 years (SD = 14.46). Participants participated in 12 weeks of either cognitive behavioral therapy or applied relaxation. Daily diary entries from the treatment period were subjected to time series analyses in order to determine the degree of order versus disorder present within individual dynamic systems. These idiographic data were then aggregated for nomothetic analysis of treatment outcome via linear mixed effect models. RESULTS: Spectral power due to daily to intradaily oscillations in thrice-daily diary data significantly moderated reliable change over posttreatment follow-up such that lesser power predicted increases in reliable change over the 1-year follow-up period. Additionally, residual variance for dynamic factor models significantly moderated the slope for change over the follow-up period, such that lesser variance--and thus greater order in dynamic systems--predicted increases in reliable change. CONCLUSIONS: The degree of order in dynamic systems established during therapy acted as an adaptive attractor state, promoting continued positive gains 1 year after the conclusion of therapy. The present study represents an important innovation in the study of dynamic systems in psychotherapy.

AN OPEN TRIAL OF INTEGRATIVE THERAPY FOR GENERALIZED ANXIETY DISORDER.

Cognitive- behavioral therapy (CBT), although effective, has the lowest average effect size for generalized anxiety disorder (GAD), when compared to effect sizes of CBT for other anxiety disorders. Additional basic and applied research suggests that although interpersonal processes and emotional avoidance may be maintaining GAD symptomatology, CBT has not sufficiently addressed interpersonal issues or emotion avoidance. This study aimed to test the feasibility and preliminary efficacy of an integrative psychotherapy, combining CBT with techniques to address interpersonal problems and emotional avoidance. Eighteen participants received 14 sessions of CBT plus interpersonal emotional processing therapy and three participants (for training and feasibility purposes) received 14 sessions of CBT plus supportive listening. Results showed that the integrative therapy significantly decreased GAD symptomatology, with maintenance of gains up to 1 year following treatment. In addition, comparisons with extant literature suggested that the effect size for this new GAD treatment was higher than the average effect size of CBT for GAD. Results also showed clinically significant change in GAD symptomatology and interpersonal problems with continued gains during the 1-year follow-up. Implications of these results are discussed.