With all the controversy surrounding DSM-V including the NIMH’s promise to stop funding research based on its categories, it might be a useful time to start reconsidering how we think of psychopathology. Along those lines, I spell out here why I think that clinicians should start thinking in terms of Negative Affect Syndrome (NAS) rather than trying to be incredibly specific about the nature of the depression or anxiety profile of their clients. NAS is a conception I find myself using more and more, and it is based on both my unified framework and owes much to the work done in the past decade by Dr. David Barlow, who is one of the outstanding clinical researchers of our time (see here for a recent APS talk by Barlow).
What do I mean by NAS? NAS is a state of psychological difficulty suffering characterized by the preponderance of negative moods and emotions that impair adaptive functioning and well-being. If this sounds very broad, it is. Indeed, it exists in stark contrast to the ever more refined categories that the DSM-V attempts to promote. The problem with the DSM-V framework was that it was not built effectively on a basic model of human mental systems, and without that the taxonomy that followed has been quite confused.
NAS starts with a foundational observation regarding how the nervous system in general and brain in particular were designed. The brain is the organ of behavior, which means that it was fashioned by evolution as the control center that computes actions. It ultimately computes actions based on two broad dimensions, costs and benefits. Costs diminish the interests of the animal; benefits enhance them. Higher animals (i.e., birds and mammals) moved away from guiding behavior based on fairly rigid fixed action patterns, and instead have systems for learning what is beneficial and costly via experience. Nature accomplished this by ingraining the brain with two broad bio-behavioral systems, one that orients the animal to signal benefit and reinforce approach behaviors in which benefits follow, and the other to signal costs and reinforce avoidance behaviors in which costs follow. Shifting to the level of human experience, your positive affect system is your approach system. It tells you what you intuitively value as good and beneficial (and responds when you acquire them). Your negative affect system tells you what you intuitively see as costly (and responds with pain, fear, anger, or despair when you anticipate or experience those costs).
Although there are, of course, many disputes about specifics (see, for example, Gray’s more complicated version), this broad two domain model is consistent with the views of behaviorists, psychodynamic and personality theorists, evolutionists, and neuroscientists. Indeed, many scientists would agree with this basic distinction and proceed to add another fundamental distinction, that of active or passive. Together the two dimensions give rise to the following 2 x 2 grid of core states, known as the circumplex model of affect.
While I hope you can see how this grid might be connected to NAS (it relates to those who predominantly on the left side of the spectrum), let me add one other piece to the picture. Human personality can be usefully divided into two broad domains of temperament and character. Temperament refers to the broad, general ways in which people tend to respond to the environment and the Big 5 model has been successful at carving out a useful model of the key traits that undergird specific behaviors. Character refers to the learned, situation specific adaptations as well as the self-concept and identity of the individual. The separation of these two aspects of personality is useful in understanding both the origin and development of NAS, as well as what is going on in the treatment of NAS.
In regards to the origin of NAS, probably the most well-known basic trait that exists in virtually all models and studies of trait concepts is Neuroticism. What is trait neuroticism? (see here) It is the reactivity of the negative affect system. Some people are predisposed to have heightened feelings of emotional threat, pain, despair, etc. in the face of stressors (i.e., those people are high in trait neuroticism), whereas others are much less likely to have such low thresholds for such feelings. Either extreme high or low neuroticism can be greatly problematic. For example, I treated a psychopath once who had stolen a car and was racing away from the police. He crashed the car, hit his head the steering wheel, splitting his forehead open with a large piece of skin flapping down over his eye and an extraordinary amount of blood. He recalled looking in the mirror and thinking “I look so cool” as the police surrounded his car. His complete lack of negative feeling states caused him to ignore pain and risk with great functional impairment to all involved.
The concept of character allows us to think how specific patterns develop in individuals. The strong negative emotional reactions that high neurotic individuals are predisposed to have orient them toward the identification of threat and avoidance behaviors. Avoidance behaviors, by removing the person from the anticipated threat, can be strengthened through negative reinforcement (i.e., once the person decides to stay home after anticipating being embarrassed at a party, then the threat is gone and the fear will be generally strengthened when a similar situation arises in the future). In addition to specific behavior patterns, individuals will develop elaborate narratives about threats in the world, their own value and competencies, and what they anticipate will happen to them. This domain is the focus of traditional cognitive therapy. The manner in which people make sense out of their emotions can create complex personality dynamics, because negative emotions themselves can become the source of pain to be avoided. Psychodynamic theorists talk of affect phobias and defense mechanisms whereas modern behaviorists talk of experiential avoidance—and recent work in integration allows us to see they mean similar things (see, e.g., Wachtel's integrative cyclical psychodynamics).
Negative Affect Syndrome then emerges when individuals are unable to achieve an effective ratio of costs and benefits (i.e., they feel they can’t get their needs met) and they suffer as a consequence. Unfortunately, the suffering tends to generate the anticipation of future suffering as well as patterns of avoidance that, paradoxically, tend to result in them getting less and less of their needs met. On this view, depressive and anxious conditions are closely related. They are conceptually differentiated by the fact that depression arises more when there is a felt sense of failure and irreversible damage that occurred in the past, whereas the anxious mood is a more active and future oriented, but they both focus the individual on costs, losses and threats, and become dysfunctional when that focus leads to maladaptive cycles.
David Barlow’s work helps delineate the common elements of anxiety and depression, and he does so in a way that leads to what I think is a central advance for CBT treatments. He articulates what he calls a “unified model” for treating emotional disorders (i.e., negative affect syndrome) which centers on three crucial treatment principles.
1. Identify triggers for negative affect and the responses and train the individual to respond in the opposite manner. Thus, if a stimuli triggers anxiety, train them in relaxation. If a situation triggers depressive shutdown, train them in behavioral activation.
2. Address avoidance via exposure; the way new learning emerges is via contact with the feared stimuli that produces a more adaptive and habituated response. Thus, if an individual is afraid of a bridge, they need to experience being on a bridge in a way that fosters mastery rather than panic. This is true of internal stimuli as well, which bridges much behavioral and psychodynamic work. (See here on a treatment intervention I developed based on this principle).
3. Identify beliefs that over-exaggerate future threat. Barlow beliefs that traditional cognitive interventions are much better focused on the way the individual anticipates threat.
Although his work is a bit short on the relational aspects of the humanistic and dynamic theorists, I am a big fan of Barlow because his work not only is based on much research, but is grounded in broad concepts that are clinically relevant and have clear, principled –based application (rather than manual-recipe driven application that can easily be misapplied in complicated situations). I have found that it is very useful to think about clients I treat and supervise as suffering from Negative Affect Syndrome and being guided by Barlow’s treatment principles.