Holly Frances Levin-Aspenson

Diagnostic heterogeneity is a longstanding challenge for the classification of mental illness because people who receive the same diagnosis can differ markedly in their symptom presentations as well as in the mechanisms underlying those symptoms. High heterogeneity undermines both the clinical utility of diagnostic labels and what we can learn from research that treats disorders as coherent constructs. In this study, we examined heterogeneity across six internalizing disorders (specific phobia, social anxiety disorder, agoraphobia, generalized anxiety disorder [GAD], major depressive disorder [MDD], and posttraumatic stress disorder [PTSD]) using three complementary approaches to quantifying heterogeneity: 1) descriptive heterogeneity (how many symptom profiles can theoretically satisfy the diagnostic criteria, and how many are observed in practice), 2) person-focused heterogeneity (whether diagnostic labels capture people with similar symptom presentations), and 3) construct-focused heterogeneity (whether diagnostic labels group symptoms with similar patterns of association with external validators). Analyses drew on subsamples from a large convenience sample with elevated psychopathology, predominantly from Australia and the USA (n = 14,762, mean [SD] age = 38.0 [18.0]; 55% women). Results showed that specific phobia was consistently the least heterogeneous; social anxiety disorder, agoraphobia, and GAD had mixed results; and MDD and PTSD were highly heterogeneous across all metrics. Notably, empirically derived phenotypes nested within each disorder substantively reduced heterogeneity relative to the DSM diagnoses. The study provides both a systematic multi-method approach to characterising different types of diagnostic heterogeneity, and a practical path toward more precise and informative constructs that can be implemented by rescoring existing data.

A range of tools have been developed for assessing hypomania/mania risk and/or personality and temperament styles related to hypomania. These measures have utility in many ways, but they generally focus on yielding composite scores without providing multidimensional assessment of personality tendencies related to hypomania. A focus on broader composites potentially obscures assessment of heterogeneous aspects of personality that may show unique associations with hypomania history and other clinical variables, and we address this gap by conducting the initial development and validation of the Hypomanic Tendency Scales (HTS). We present data supporting the HTS’s utility as an efficient, 18-item measure including subscales of Elation, Agitation, Expansive Thinking, and Positive Urgency. Our measure development efforts include evaluation of internal structure, test-retest reliability, and multimethod validity associations across four samples and three studies, and we also discuss ways for enhancing assessment with the HTS in follow-up validation research.

The purpose of this paper is to define and describe impairment from the perspective of theHierarchical Taxonomy of Psychopathology (HiTOP). This work is intended to establish afoundation for the development of a system for assessing impairment to complement HiTOPmeasures of psychopathology. We define impairment as the direct or indirect impact ofpsychopathology that is not itself part of psychopathology, involving (a) difficulty achievingimportant and reasonable personal goals and/or (b) direct or indirect interference with the goalsof others. We articulate seven specific assessment features of a HiTOP-optimal impairmentmeasurement approach and, having found no existing measures with all seven features in areview of the literature, sketch a prototype approach using a case example and outline a planfor generating a suite of tools for assessing impairment from a HiTOP perspective.

Considerable research in recent decades has focused on developing measures assessing transdiagnostic dimensions, including measures that target dimensional symptoms rather than traditional diagnostic categories. Furthermore, a sizeable literature has focused on assessing social-cognitive vulnerabilities (e.g., experiential avoidance) thought to be linked to an array of symptoms and functioning difficulties, and a range of measures of transdiagnostic, social-cognitive vulnerabilities have been developed. However, few of them include item content directly assessing conflict resolution difficulties and ineffective interpersonal relational strategies, which also are linked to a range of psychopathology and are targeted in cognitive-behavioral and third-wave treatments. We address this gap in the transdiagnostic assessment literature by presenting initial validation data for a measure of ineffective interpersonal strategies across three studies and four samples of participants (N = 301 adults; N = 808 adults self-identifying a mental health diagnosis; N = 368 undergraduate students; N = 226 community adults). Analyses based on these samples spanned evaluation of participant perspectives on item face validity, quantitative examinations of internal structure, test-retest stability, and evaluating validity associations with a range of self-report and interview measures. Results collectively support the initial validation of an efficient interpersonal measure, the Transdiagnostic Ineffective Relational Strategies Scale (TIRSS), which can be incorporated into a range of study formats due to its brevity. We discuss future validation steps to build from this work, as well as ideas for sharpening interpersonal and transdiagnostic assessment research more broadly.

We assessed mania/hypomania and a range of other symptoms, substance use, and personality dimensions across interview and self-report methods toward advancing understanding of mania/hypomania’s multimethod assessment. Our study, informed by transdiagnostic, dimensional models examined these issues in a clinically-oriented sample ( N = 245; mean age = 32, SD =12; 59% currently accessing psychotherapy and/or medication), and as a secondary aim, we evaluated the structure of lifetime interview ratings of hypomania symptoms. We found evidence for a single-factor structure of interview-rated hypomania, and interview-rated hypomania associated strongly with psychosis and related variables, consistent with recent classification-focused research. Self-rated mania/hypomania-relevant measures shared these associations to some degree, but there were also key differences in associations across measures and methods (e.g., self-rated euphoria showed distinctive positive associations with extraversion). We draw on these results to provide ideas for modeling mania/hypomania symptom heterogeneity more thoroughly in future studies and for sharpening multimethod clinical assessment.

This commentary focuses on describing how global, general assessments of personality and psychopathology provide complementary information to social-cognitive measures (e.g., rejection sensitivity, behavioral inhibition/activation) in clinical assessment. We completely agree with perspectives that additional within-person research is needed to inform evidence-based treatment planning, and we applaud related efforts focused on understanding personality structure and associations using intensive longitudinal methods. However, we believe that additional within-person research is also needed for social-cognitive measures, in addition to personality measures based on trait models, as most psychometric research on these measures has been cross-sectional and/or at the between-person level. We also hope that research can continue to advance understanding of the significant overlap across personality and social-cognitive models and measures. In addition to highlighting important areas of overlap, we also describe how general assessments of personality and related constructs can provide helpful information, in initial treatment planning phases, especially for screening; strengthening diagnostic formulations; and collaboratively establishing general profiles of client strengths, functioning, and areas of need in a structured manner.

We assessed mania/hypomania and a range of other symptom, substance use, and personality dimensions across interview and self-report methods towards advancing understanding of mania/hypomania’s multimethod assessment. Our study informed by transdiagnostic, dimensional models examined these issues in a clinically-oriented sample (N = 245; mean age = 32, SD =12; 59% currently accessing psychotherapy and/or medication), and as a secondary aim, we evaluated the structure of lifetime interview ratings of hypomania symptoms. We found evidence for a single-factor structure of interview-rated hypomania, and interview-rated hypomania associated strongly with psychosis and related variables, consistent with recent classification-focused research. Self-rated mania/hypomania-relevant measures shared these associations to some degree, but there were also key differences in associations across measures and methods (e.g., self-rated euphoria showed distinctive positive associations with extraversion). We draw on these results to provide ideas for modeling mania/hypomania symptom heterogeneity more thoroughly in future studies and for sharpening multimethod clinical assessment.