Understanding Precision Psychiatry

Understanding Precision Psychiatry

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I can't seem to correctly understand what exactly is precision psychiatry? I can't find good sources on the internet about it, other than "The new field of 'precision psychiatry'" by Fernandes et al. (2017), maybe because this is a new field. Is this different from precision medicine? If so, how? How does it relate to the definition of the word precision (Precision refers to the closeness of two or more measurements to each other)?

Specifically, I can't understand how to apply precision psychiatry in order to diagnose or predict a mental disorder, for eg. PTSD. Do I have to decide and make a checklist of parameters of the subject by which I can decide if that person has that disease, and how will someone go on about diagnosing the disorder after that. Can you explain it with respect to an example like PTSD or some other disorder?

Fernandes, B. S., Williams, L. M., Steiner, J., Leboyer, M., Carvalho, A. F., & Berk, M. (2017). The new field of 'precision psychiatry'. BMC medicine, 15(1), 80.

According to the article you linked to, Precision Psychiatry (PP) is literally the application of Precision Medicine to psychiatry. Here "precision" is used to mean personalisation to each individual patient.

In your question, you don't seem intereseted in how treatment would differ between regular Psychiatry and PP, so I won't address it. As for how diagnosis differs, it seems to mostly just imply using way more data:

Arguably, the most logical way of obtaining hypothesis-free and data-driven approaches in the neurobiology of psychiatric disorders is making use of 'omics' techniques. Genomics, epigenomics, transcriptomics, proteomics, metabolomics, metagenomics and lipidomics are capable of independently providing valuable information about the neurobiology of these psychiatric conditions. Further, when combined with a multi-omics approach, in what is called panomics, and analysed using system biology computations, they might unveil the underlying biological pathways involved in psychiatric disorders.

Concidering the example of PTSD, one can imagine a patient entering a PP practicioner's office complaining of PTSD symptoms. Given these tests, the practitioner would be able to diagnose them with either PTSD type-A or PTSD type-B or maybe actually Depression type-C depending on what mechanistic deviations are seen. The authors describe this change as:

It can be conceptualised as a highly sophisticated and intricate classification system, where infinitesimal categories will, ideally, attain perfection in a detailed multidimensional classification.

This differs from the typical diagnosis of PTSD, which doesn't really have a biological component, aside from anecdotal lifestyle questions about quality of sleep, exercise and diet.

To respond to your question:

Do I have to decide and make a checklist of parameters of the subject by which I can decide if that person has that disease, and how will someone go on about diagnosing the disorder after that.

It's not really a person making an individual checklist from thin air, but more about a collection of different cases being used to highlight individual differences.

One example of PP would be the clustering of Depression symptoms to choose the best anti-depressant medication, as described in "Reevaluating the Efficacy and Predictability of Antidepressant Treatments: A Symptom Clustering Approach" by Chekroud et al.

Precision medicine (PM) is a medical model that proposes the customization of healthcare, with medical decisions, practices, or products being tailored to the individual patient.

Precision psychiatry is a sub-field of precision medicine - focusing specifically on individually tailored medical interventions for psychiatric disorders.

The practice of precision psychiatry does not necessarily suggest a different diagnosis for psychiatric disorders such as PTSD or a different diagnostic criteria or process. In fact, the diagnosis could very well remain the same.

Rather, precision medicine and psychiatry are concerned with customizing treatment. To this end, medical testing would need to be more extensive and more accurate / "precise". It is this additional testing, useful for tailoring treatment and monitoring its progress, that is the focus of precision psychiatry:

The major challenge that precision psychiatry faces is that psychiatry does not yet use measurement to track the equivalent of vitals and images of the organs of interest, namely the brain and alterations in peripheral measures such as blood.

A couple of good examples to consider are schizophrenia and depression.

Schizophrenia was traditionally divided into several symptom-based sub-types. This categorization was dropped recently, and early genetic research suggested quite different sub-types that might explain why the original sub-types did not work out. However, sub-types based on genetic profile clusters may also be untenable. Current research has revealed over 100 genetic loci contributing to schizophrenic symptoms, and suggesting the potential for custom treatments, as many medications have different targets. Here we have a single diagnosis of schizophrenia done in the traditional way, where additional genetic testing may guide individual treatment.

Depression - the core clinical symptom of major depressive disorder - has several potential treatment regimens, including a variety of medications, psychotherapies, brain stimulation, and alternative therapies such as light exposure and meditation, each of which appear moderately effective across the patient population. Recently however, some limited research has suggested that brain scans can help predict which therapy would be most effective for each individual. Here again, we have a standard diagnosis based on patient-reported symptoms, where the addition of brain scans may eventually guide individual treatment and monitoring.

In precision oncology for example (another sub-field of precision medicine), the classification of biomarkers and their corresponding treatments has sometimes led to differential diagnoses, and sometimes not. For example, breast cancer is known to have several different receptor biomarkers and corresponding treatments, but is not necessarily classified as different types of breast cancer because the biomarkers don't cluster - they are specific to the patient.

I can't understand how to apply precision psychiatry in order to diagnose or predict a mental disorder, for eg. PTSD.

No one can, because precision psychiatry is pie in the sky right now. From the paper mentioned:

Considering that no single biomarker will probably define any psychiatric disorder as defined by traditional diagnostic boundaries, it will be essential to pursue in parallel theory- and data-driven discovery approaches to delineate the multivariate and combinatorial profiles of biomarkers (across units of analysis) that account for the heterogeneity of mental illnesses as they manifest clinically.

And if we simply talk about individualized treatments, the older term personalized psychiatry covers it just as well. There has been some terminological debate in the NRC, hence the old new thing.

What Is Mental Health?

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood.

Over the course of your life, if you experience mental health problems, your thinking, mood, and behavior could be affected. Many factors contribute to mental health problems, including:

  • Biological factors, such as genes or brain chemistry
  • Life experiences, such as trauma or abuse
  • Family history of mental health problems

Mental health problems are common but help is available. People with mental health problems can get better and many recover completely.

What Is Mental Health?

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood.

Over the course of your life, if you experience mental health problems, your thinking, mood, and behavior could be affected. Many factors contribute to mental health problems, including:

  • Biological factors, such as genes or brain chemistry
  • Life experiences, such as trauma or abuse
  • Family history of mental health problems

Mental health problems are common but help is available. People with mental health problems can get better and many recover completely.

Positive Psychiatry and Mental Health

In today’s world, mental illness and distress are common and these account for a significant burden of disability within our community. At the same time, there is a growing interest in understanding and enhancing positive mental health and wellbeing particularly from developments in the fields of positive psychology and mental health promotion. Positive Psychiatry is a new term (Jeste et al 2016) that describes a dual approach to mental health, where we build strengths, supports and healthy lifestyles as well as treating illness and distress.

In this course, we will explore different aspects of good mental health as well as provide an overview of the major kinds of mental disorders, their causes, treatments and how to seek help and support. The course will feature a large number of Australian experts in psychiatry, psychology and mental health research, and we will also hear from “lived experience experts”, people who have lived with mental illness, and share their personal stories of recovery. We take an evidence-based approach to a range of strategies that anyone can use to enhance their own mental health and that of others, from exercise and relaxation techniques through to the role of love, relationships and 'good' types of work. We cover topics from creativity and yoga through to psychiatric medications and psychotherapies.

History of psychiatry

Specialty in psychiatry can be traced in Ancient India. The oldest texts on psychiatry include the ayurvedic text, Charaka Samhita. [1] [2] Some of the first hospitals for curing mental illness were established during the 3rd century BCE. [3]

During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin, [4] a view which existed throughout ancient Greece and Rome. [4] The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century, [5] although one may trace its germination to the late eighteenth century.

Some of the early manuals about mental disorders were created by the Greeks. [5] In the 4th century BCE, Hippocrates theorized that physiological abnormalities may be the root of mental disorders. [4] In 4th- to 5th-century BCE Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy. [6]

Religious leaders often turned to versions of exorcism to treat mental disorders, often utilizing methods that many consider to be cruel and/or barbaric. [4]

A number of hospitals known as bimaristans were built throughout Arab countries beginning around the early 9th century, with the first in Baghdad. [7] They sometimes contained wards for mentally ill patients, typically those who exhibited violence or suffered from debilitating chronic illness. [8]

Physicians who wrote on mental disorders and their treatment in the Medieval Islamic period included Muhammad ibn Zakariya al-Razi (Rhazes), the Arab physician Najab ud-din Muhammad [ citation needed ] , and Abu Ali al-Hussain ibn Abdallah ibn Sina, known in the West as Avicenna. [9] [10] [11]

Specialist hospitals were built in medieval Europe from the 13th century to treat mental disorders but were utilized only as custodial institutions and did not provide any type of treatment. [12]

Founded in the 13th century, Bethlem Royal Hospital in London was one of the oldest lunatic asylums. [12] In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. Already in 1632 it was recorded that Bethlem Royal Hospital, London had "below stairs a parlor, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in". [13] Inmates who were deemed dangerous or disturbing were chained, but Bethlem was an otherwise open building for its inhabitants to roam around its confines and possibly throughout the general neighborhood in which the hospital was situated. [14] In 1676, Bethlem expanded into newly built premises at Moorfields with a capacity for 100 inmates. [15] : 155 [16] : 27

In 1713 the Bethel Hospital Norwich was opened, the first purpose-built asylum in England, founded by Mary Chapman. [17]

In 1621, Oxford University mathematician, astrologer, and scholar Robert Burton published one of the earliest treatises on mental illness, The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it. In Three Maine Partitions with their several Sections, Members, and Subsections. Philosophically, Medicinally, Historically, Opened and Cut Up. Burton thought that there was "no greater cause of melancholy than idleness, no better cure than business." Unlike English philosopher of science Francis Bacon, Burton argued that knowledge of the mind, not natural science, is humankind's greatest need. [18]

In 1656, Louis XIV of France created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was applied. [19]

During the Enlightenment attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. In 1758 English physician William Battie wrote his Treatise on Madness on the management of mental disorder. It was a critique aimed particularly at the Bethlem Hospital, where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind. [20] [21] Exorcisms and other methods such as trephining weren't common

Thirty years later, then ruling monarch in England George III was known to be suffering from a mental disorder. [4] Following the King's remission in 1789, mental illness came to be seen as something which could be treated and cured. [4] The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke. [4]

In 1792 Pinel became the chief physician at the Bicêtre Hospital. In 1797, Jean-Baptiste Pussin first freed patients of their chains and banned physical punishment, although straitjackets could be used instead. [22] [23]

Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pussin and Pinel's approach was seen as remarkably successful and they later brought similar reforms to a mental hospital in Paris for female patients, La Salpetrière. Pinel's student and successor, Jean Esquirol (1772–1840), went on to help establish 10 new mental hospitals that operated on the same principles. There was an emphasis on the selection and supervision of attendants in order to establish a suitable setting to facilitate psychological work, and particularly on the employment of ex-patients as they were thought most likely to refrain from inhumane treatment while being able to stand up to pleading, menaces, or complaining. [24]

William Tuke led the development of a radical new type of institution in northern England, following the death of a fellow Quaker in a local asylum in 1790. [25] : 84–85 [26] : 30 [27] In 1796, with the help of fellow Quakers and others, he founded the York Retreat, where eventually about 30 patients lived as part of a small community in a quiet country house and engaged in a combination of rest, talk, and manual work. Rejecting medical theories and techniques, the efforts of the York Retreat centered around minimizing restraints and cultivating rationality and moral strength. The entire Tuke family became known as founders of moral treatment. [28]

William Tuke's grandson, Samuel Tuke, published an influential work in the early 19th century on the methods of the retreat Pinel's Treatise On Insanity had by then been published, and Samuel Tuke translated his term as "moral treatment". Tuke's Retreat became a model throughout the world for humane and moral treatment of patients suffering from mental disorders. [28] The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now The Institute of Living).

Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with — a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country. Hill's system was adapted, since Conolly was unable to supervise each attendant as closely as Hill had done. By September 1839, mechanical restraint was no longer required for any patient. [29] [30]

Scotland's Edinburgh medical school of the eighteenth century developed an interest in mental illness, with influential teachers including William Cullen (1710–1790) and Robert Whytt (1714–1766) emphasising the clinical importance of psychiatric disorders. In 1816, the phrenologist Johann Spurzheim (1776–1832) visited Edinburgh and lectured on his craniological and phrenological concepts the central concepts of the system were that the brain is the organ of the mind and that human behaviour can be usefully understood in neurological rather than philosophical or religious terms. Phrenologists also laid stress on the modularity of mind.

Some of the medical students, including William A. F. Browne (1805–1885), responded very positively to this materialist conception of the nervous system and, by implication, of mental disorder. George Combe (1788–1858), an Edinburgh solicitor, became an unrivaled exponent of phrenological thinking, and his brother, Andrew Combe (1797–1847), who was later appointed a physician to Queen Victoria, wrote a phrenological treatise entitled Observations on Mental Derangement (1831). They also founded the Edinburgh Phrenological Society in 1820.

The modern era of providing care for the mentally ill began in the early 19th century with a large state-led effort. Public mental asylums were established in Britain after the passing of the 1808 County Asylums Act. This empowered magistrates to build rate-supported asylums in every county to house the many 'pauper lunatics'. Nine counties first applied, and the first public asylum opened in 1812 in Nottinghamshire. Parliamentary Committees were established to investigate abuses at private madhouses like Bethlem Hospital - its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions the inmates lived in. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums.

The Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. The Act created the Lunacy Commission, headed by Lord Shaftesbury, to focus on lunacy legislation reform. [31] The Commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act [32] the compulsory construction of asylums in every county, with regular inspections on behalf of the Home Secretary. All asylums were required to have written regulations and to have a resident qualified physician. [33] A national body for asylum superintendents - the Medico-Psychological Association - was established in 1866 under the Presidency of William A. F. Browne, although the body appeared in an earlier form in 1841. [34]

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies, [35] and, in 1839, he opened the first school for the severely retarded. His method of treatment was based on the assumption that the mentally deficient did not suffer from disease. [36]

In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. [37]

At the turn of the century, England and France combined had only a few hundred individuals in asylums. [38] By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization was soon disappointed. [39] Psychiatrists were pressured by an ever-increasing patient population. [39] The average number of patients in asylums kept on growing. [39] Asylums were quickly becoming almost indistinguishable from custodial institutions, [40] and the reputation of psychiatry in the medical world had hit an extreme low. [41]

In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality. [42] The term psychiatry (Greek "ψυχιατρική", psychiatrikē) which comes from the Greek "ψυχή" (psychē: "soul or mind") and "ιατρός" (iatros: "healer") was coined by Johann Christian Reil in 1808. [43] [ unreliable source? ] [44] Jean-Étienne Dominique Esquirol, a student of Pinel, defined lypemania as an 'affective monomania' (excessive attention to a single thing). This was an early diagnosis of depression. [42] [45]

In 1870 Louis Mayer, a gynecologist in Germany, cured a woman's "melancholia" using a pessary: "It relieved her physical problems and many severe disorders of mood . application of a Mayer Ring improved her quite considerably." [46] According to The American Journal of Obstetrics and Diseases of Women and Children Mayer reportedly decried the "neglect of the investigation of the relations between mental and sexual diseases of women in German insane hospitals". [47]

The 20th century introduced a new psychiatry into the world. Different perspectives of looking at mental disorders began to be introduced. The career of Emil Kraepelin reflects the convergence of different disciplines in psychiatry. [48] Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry. [48] Following his appointment to a professorship of psychiatry and his work in a university psychiatric clinic, Kraepelin's interest in pure psychology began to fade and he introduced a plan for a more comprehensive psychiatry. [49] Kraepelin began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum. [50] The initial ideas behind biological psychiatry, stating that the different mental disorders were all biological in nature, evolved into a new concept of "nerves" and psychiatry became a rough approximation of neurology and neuropsychiatry. [51] However, Kraepelin was criticized for considering schizophrenia as a biological illness in the absence of any detectable histologic or anatomic abnormalities. [52] : 221 While Kraepelin tried to find organic causes of mental illness, he adopted many theses of positivist medicine, but he favoured the precision of nosological classification over the indefiniteness of etiological causation as his basic mode of psychiatric explanation. [53]

Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry. [54] The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. [54] Freud resisted subjecting his theories to scientific testing and verification, as did his followers. [55] As evidence-based investigations in cognitive psychology led to treatments like cognitive behavioral therapy, many of Freud's ideas appeared to be unsupported or contradicted by evidence. [55] By the 1970s, the psychoanalytic school of thought had become marginalized within the field. [54]

Biological psychiatry reemerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine thus identifying it as the first-known neurotransmitter. [56] Neuroimaging was first utilized as a tool for psychiatry in the 1980s. [57] The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, [58] as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. [59] Psychotherapy was still utilized, but as a treatment for psychosocial issues. [60] In the 1920s and 1930s, most asylum and academic psychiatrists in Europe believed that manic depressive disorder and schizophrenia were inherited, but in the decades after World War II, the conflation of genetics with Nazi racist ideology thoroughly discredited genetics. [61]

Now genetics are once again thought by some prominent researchers to play a large role in mental illness. [56] [62] The genetic and heritable proportion of the cause of five major psychiatric disorders found in family and twin studies is 81% for schizophrenia, 80% for autism spectrum disorder, 75% for bipolar disorder, 75% for attention deficit hyperactivity disorder, and 37% for major depressive disorder. [63] Geneticist Müller-Hill is quoted as saying "Genes are not destiny, they may give an individual a pre-disposition toward a disorder, for example, but that only means they are more likely than others to have it. It (mental illness) is not a certainty.” [64] [ unreliable medical source? ] Molecular biology opened the door for specific genes contributing to mental disorders to be identified. [56]

Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (1961), written by sociologist Erving Goffman, [65] [66] [ better source needed ] examined the social situation of mental patients in the hospital. [67] Based on his participant observation field work, the book developed the theory of the "total institution" and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor". The book suggested that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. Asylums was a key text in the development of deinstitutionalisation. [68] At the same time, academic psychiatrist and psychoanalyst Thomas Szasz began publishing articles and books that were highly critical of psychiatry and involuntary treatment, including his best-known work The Myth of Mental Illness in 1961.

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals. [69] Later, though, the Community Mental Health Centers focus shifted to providing psychotherapy for those suffering from acute but less serious mental disorders. [69] Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals. [69] Some of those suffering from mental disorders drifted into homelessness or ended up in prisons and jails. [69] [70] Studies found that 33% of the homeless population and 14% of inmates in prisons and jails were already diagnosed with a mental illness. [69] [71]

In 1973, psychologist David Rosenhan published the Rosenhan experiment, a study with results that led to questions about the validity of psychiatric diagnoses. [72] Critics such as Robert Spitzer placed doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement. [73]

Psychiatry, like most medical specialties, has a continuing, significant need for research into its diseases, classifications and treatments. [74] Psychiatry adopts biology's fundamental belief that disease and health are different elements of an individual's adaptation to an environment. [75] But psychiatry also recognizes that the environment of the human species is complex and includes physical, cultural, and interpersonal elements. [75] In addition to external factors, the human brain must contain and organize an individual's hopes, fears, desires, fantasies and feelings. [75] Psychiatry's difficult task is to bridge the understanding of these factors so that they can be studied both clinically and physiologically. [75]

Understanding Transference In Psychology

Understanding transference in psychology can be a difficult concept to grasp. In psychology, transference is described as a situation that occurs when an individual's emotions and expectations toward one person are unconsciously redirected toward another person.

Sigmund Freud first developed the concept of transference in his book Studies on Hysteria (1895). In his book, he described the intensity of the feelings that developed during his own experiences in therapy with patients. Freud explained patient to therapist transference occurring unconsciously where the patient transfers his or her emotions toward the therapist he or she is seeking treatment with.

Freud asserted that transference is often related to unresolved issues occurring in the client's past. Freud found that transference can be destructive or helpful during therapy depending on how the patient and therapist interact. The client often unconsciously continues the behavior even if it is pointed out to them.

Since Freud, there have been other ways of describing transference. In The Psychotherapy Relationship, author Gelso defines transference as "the client's experience of the therapist that is shaped by his or her psychological structures and past, and involves displacement onto the therapist, of feelings, attitudes, and behaviors belonging rightfully in earlier significant relationships."

Both definitions agree that transference involves experiences from an individual's past. As described above, transference most often occurs in therapy situations, but there are other types.

Types Of Transference

All transference is psychologically the same basic principle. However, in order to make it easier to talk about, experts have classified a number of subdivisions of transference based on how transference manifests in an individual&rsquos relationships with others.

Non-Familial Transference

This type of transference occurs when individuals treat others according to what they have idealized the person to be instead of who they are. This can happen with any individual who fulfills a role in the person's life.

Maternal Transference

This kind of transference occurs when an individual treats another person the same way they would treat their mother or a maternal figure.

If they have had a positive relationship with their mother, they may reach out to the individual for comfort and love. However, if the individual experienced a negative relationship with their mother, they may have deep feelings of rejection and lack of comfort and nurturing.

Paternal Transference

Paternal transference is much like maternal transference, except the individual looks at another person in a fatherly role.

The individual may expect more of an authority figure or someone who takes on a protective or powerful role. Negative paternal transference, as is the case with negative maternal transference, could bring about strong feelings of rejection, and feelings of being inadequate as a person, or could create an unhealthy reliance on this person who does not actually view themselves as a paternal figure to the individual.

Sibling Transference

Sibling transference is unlike maternal or paternal transference. In this case, it does not take on a leader-and-follower role. It occurs in more of a peer or colleague situation.

Patient-Therapist Transference

Transference also includes the patient's expectations about how they will behave and feel, and what their expectations are from the therapist.

The client's expectations may include love, disapproval, and an entire range of emotions. Clients might even subconsciously behave in a way that produces the reactions they are expecting from the therapist, a sort of self-fulfilling prophecy.

It is important to realize that transference is not an exact distortion or a repetition of the past. It is the client's interpretation of interactions with the present.

For instance, say a patient develops romantic feelings toward their therapist and the therapist does not return those feelings but reinforces the acceptable boundaries between client and therapist. The client may experience the same feelings of hurt, abandonment, or anger experienced in past relationships. If the patient never comes to understand what is happening, progress will not be made.

Whether the transference is positive or negative, it can be beneficial to therapy in different ways. Positive transference may lead the client to view the therapist as kind, caring and personally concerned about his or her well-being. Negative transference may cause the client to re-direct anger, sadness, and other negative feelings toward the therapist.

However, the therapist may be able can help the patient use these projected emotions to create an understanding of why the transference is occurring. Once the client has a greater understanding of the transference, they can begin dealing with the issues causing the transference and begin the healing process. Freud used transference as a tool crucial to understanding the patient's subconscious or repressed feelings.

Communicating Transference

There are several ways clients communicate the transference that is occurring toward their therapist. The first method is when the client communicates their feelings directly with the therapist. In this case, the client realizes what is occurring.

The second method of transference is symbolic. The client may communicate transference through their experiences or stories. The stories or experiences can resemble their perception of the relationship with the therapist. The client may or may not realize transference is occurring.

The third method of transference occurs through communication of dreams and fantasies experienced by the client. The patient may have dreams or fantasies about the therapist, where the therapist is present, or about the current relationship with the therapist. The patient may or may not realize transference is occurring.

The fourth method is enactment, where the client takes on a particular role with the therapist. For instance, a patient may take on the role of a child treating the therapist as though the therapist is their mother. The client may expect the therapist to fulfill all maternal needs that were not fulfilled as a child. In this case, the client usually does not realize transference is occurring.

Issues Regarding Transference

Several serious issues can occur during transference.

The patient's mental health and relationships are affected and can be helped or harmed by transference. The major concern is that the patient is not seeking to build a relationship with an actual person, but rather a projected image of one. The client is seeking a relationship with another individual whom they have projected feelings and emotions toward.

Dealing With Transference

Dealing with transference in therapy involves more than just talking about events and feelings in the patient's past or current experiences. It is also a lived experience. Change can only come about through the patient's re-experiencing and understand these processes.

Major techniques in dealing with transference involve intervention to work on interpreting occurrences and developing explanations for the transference. Interpretation helps the client understand the meaning of the transference that is occurring.

It is important to understand the definition of interpretation in therapy. In therapy, interpretation offers an alternative perspective to what is being perceived. The way the therapist interprets it is just as important as the content of the interpretation. Even if a correct interpretation is made but conveyed in the wrong way, it may not be therapeutic to the patient at all.

To deal with transference, the client must be made aware of what is occurring. The therapist needs to work to help the client identify occurrences causing the transference. The therapist may recommend techniques, such as the patient keeping a journal. This will help the patient identify triggering occurrences causing the transference. Through identifying such occurrences, reoccurrences of transference can be minimized.

A therapist might also educate a patient on the identification of situations in which transference may be taking place. This process usually requires repetition of events and interpretations of those events over an extended period. This leads to an understanding followed by a transformation as the patient's issues are worked through. That requires exploring and then resolving issues that the client has.

This might include current relationships, work, a family of origin, and the transference. In therapy, this process of applying what is learned in therapy to other situations is referred to as generalization.

Finding Help With BetterHelp

If you think that transference or other mental and emotional health disorders are negatively impacting your quality of life, it may be time to seek professional help. Online therapy with BetterHelp could be an option for you.

Online therapy has been found to be just as effective as in-person therapy in treating a large variety of mental health conditions such as depression, PTSD, anxiety, trauma, and relationship issues, among others. Additionally, 98% of BetterHelp users have made significant progress in their mental health journeys, 96% prefer it to in-person therapy, and 91% of users report that it&rsquos there exactly when they need it. This is compared to ratings of in-person therapy of 74%, 60%, and 63%, respectively.

Finding mental health resources like those that we have discussed in this article can be difficult to find in some areas, or are difficult to afford for some people. BetterHelp has the added benefits of being accessible anytime and anywhere &ndash you&rsquoll just need an internet or data connection to get started. Additionally, it&rsquos typically cheaper than in-person therapy since our therapists don&rsquot have to pay to rent out office space and clients don&rsquot have to commute to sessions! Sessions can be held via phone call, video chat, texting/instant messaging, live voice recording, or any combination thereof that works for you.

Continue reading to find some reviews of our board-certified therapists from people seeking help with similar issues.

&ldquoLauren has helped me out with my anxiety and stress around relationship issues. She&rsquos super easy to talk to and I enjoyed that she really keep the conversation going with great feedback.&rdquo

&ldquoI was in a really bad headspace before connecting with Amanda. She has been so helpful! I have started my journey into mindfulness with her and have gained a variety of CBT tools with her help. I am now better able to regulate my emotions of anxiety and stress, cope with my past traumas, and start to live my life with peace. I definitely feel like she helped me get back not only to my old self but help me start to grow into the best version of myself. She is there for you with tools if you need them or just to listen if you tell her that&rsquos what you need. In these times of chaos it&rsquos wonderful to feel like you have someone in your corner and on your side. If you suffer from anxiety, trauma, or self esteem issues I highly recommend her!&rdquo

Frequently Asked Questions (FAQs)

What Is An Example Of Transference?

We&rsquove already given some hypothetical examples of transference through this article, but a potentially more approachable example of transference from popular culture may be found in the comedy series Brooklyn Nine-Nine.

The ensemble comedy about a dysfunctional New York police team regularly looks for laughs from the relationship between the successful but unprofessional detective played by Andy Samberg and the stoic and formal captain played by Andre Braugher.

In a number of these interactions, Samberg&rsquos character refers to Braugher&rsquos character as &ldquoDad&rdquo and even comments on his view of his captain as a stand-in for his real father. In some episodes, these characters and other characters on the show actively acknowledge these incidences of transference.

What Is Psychological Transference?

Psychological transference is when an individual approaches interactions with preconceived notions of how the other person will behave based on interactions with another specific individual in their lives.

Most of us use transference to some degree at various points in our lives. However, transference can become a problem when it leads to inappropriate or unrealistic expectations of interactions that can make it difficult to form healthy relationships.

What Is Transference And Countertransference In Psychology?

Countertransference is when the person being transferred upon also transfers upon the other person.

That sounds messy. Let&rsquos look at it this way:

The classic situation that we&rsquove been discussing is when the patient or client sees their therapist or counselor as a father, teacher, or other authority figure. This is transference. When the therapist or counselor also sees the patient or client as a child, student, etc., that is countertransference.

Is Transference A Defense Mechanism?

Not necessarily. According to Freud, defense mechanisms are tools that a person subconsciously employs in order to avoid dealing with difficult issues.

As a tool that the mind uses &ndash often subconsciously &ndash as a way of taking shortcuts in new experiences, transference is not listed among the classic defense mechanisms commonly discussed by psychologists. However, transference can be used like a defense mechanism in some situations.

Suppose a student young student applies paternal transference onto a male teacher. This isn&rsquot necessarily a defense mechanism. However, if that same students acts up in class because they are upset with experiences at home, then they may be using transference as a defense mechanism that allows them to vent frustration with the father onto the teacher instead.

Is Transference Good In Therapy?

Freud, the father of modern psychotherapy and the first to identify transference, believed that transference could be either helpful or harmful in therapy.

Therapy is, at its heart, a relationship between the client and the therapist. Transference may or may not disrupt that relationship. It depends on the individuals and how the transference manifests in their interactions.

For example, many people who experience transference in therapy see the therapist or counselor as a parental figure. In this case, the relationship that the individual had with his or her parents can impact the relationship formed with the counselor. It may cause them to be more receptive to or more dismissive of the advice that they receive from their therapist or counselor.

How Do You Avoid Transference And Countertransference?

It may not be possible to avoid transference and countertransference entirely. However, being aware that they may be taking place allows you to prevent yourself from acting on transference or countertransference in the event that you do experience it.

How Common Is Transference In Therapy?

This is a difficult question to answer, and one that lacks concrete data.

Freud suggested that while transference may not always be problematic in all people, it may play a role in everyone&rsquos interactions - at least at first. So, theoretically, transference always plays some role in therapy. Perhaps the more apt question is how big a role that is and whether it is disruptive or not.

What Are Signs Of Countertransference?

Signs of countertransference are infinitely varied. As is the case with transference, countertransference varies based on the individual and the role that they expect the other person to play as well as their own relationship to that role.

Final Thoughts

Transference is like many other thought patterns &ndash it isn&rsquot inherently good or bad. However, it can have positive or negative consequences based on the situation, our awareness of it, and our ability to control it.

Additional Reading

Freud, S. ([1911] 1958) Psycho-analytic notes upon an autobiographical account of a case of paranoia (Dementia Paranoias), in J. Strachey (ed.) The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 12. London: Hogarth.

Freud, S. ([1912] 1958) The dynamics of transference, in J. Strachey (ed.) The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 12. London: Hogarth.

Freud, S. and Breuer, J. ([1895] 1955) Studies on hysteria, in J. Strachey (ed.) The Standard Edition of the Complete Psychological Works of Sigmund Freud,Vol. 2. London: Hogarth. (Grant & Crawley, 2002, p. 139)

The Role of Psychology in the Mental Health System

Mental illness affects one in five Canadians. This is a well-known statistic, but no matter how many times we say it, it still feels like a staggering number. With so many people potentially dealing with mental health issues, it takes a variety of clinicians and specialists to provide adequate treatment and care.

As a psychologist, I am but one of the options people can turn to for help.

How psychologists can help

Psychologists offer a wide range of assessments and treatment options to those struggling with mental health issues. Yes, we&rsquore there to improve an individuals` quality of life in times of crisis, but we are also there to prevent relapse and maintaining care. From a health system perspective, psychologists can address issues with readmission rates, and we try to keep them out of the proverbial revolving door of care. To do that, we rely on comprehensive psychological assessments that help identify and diagnose various mental health issues and illnesses. This helps guide appropriate treatment, and lessens issues that can cause a relapse.

Psychologists work in inter-professional teams in hospitals and other facilities to provide care. In addition to comprehensive psychological assessments, psychologists also provide evidenced-based psychotherapies such as Cognitive-Behavioural Therapy (CBT) to provide ways to help people face fears, deal with anxiety, or add structure to their day if they are working to address depression or manage negative and challenging thoughts.

Often, we may also see patients diagnosed with concurrent disorders &ndash these are the co-occurrence of mental health issues and substance use disorders. Part of our job is to also identify this and suggest further care as needed. It&rsquos important that we address not just the symptoms of the illness, but also any underlying or resulting concurrent issues.

Access to care

Yet, many who are diagnosed with mental illness don&rsquot always have an easy time of accessing treatment. The treatment individuals receive is often dependent on whether or not they have access to care without a cost.

In Ontario, many who are able to afford access to services pay for it privately, but those who can&rsquot are stuck on wait lists, or fall through the cracks and may not receive help at all.

In fact, there is no Canadian province that covers therapy delivered by psychologists. Some families may have some coverage through extended insurance provided by employers, but it may not be enough. Of course there is some OHIP covered care that is available in hospitals but in many cases there is a limit to how many clients can be seen and how many appropriate services are available. If these services were not available, there would be no access to care.

Outside of paying out of pocket, or joining a wait list, alternate treatment options are available. Access to Employee Assistance Programs (EAP) through employers or Family Physicians who can refer to Psychiatrists that are covered under OHIP may be an option as well. But in terms of other non accessible evidence based therapies provided by psychologists, there is much to be done to make these services more accessible to everyone.

These are just a few of the issues that many with lived experience have to face, on top of their psychological concerns and needs.

Where do we go from here?

As a country and a province, we have to do a better job to make necessary psychotherapy accessible to all who need it. One in five Canadians suffer from mental illness. Many of these people will require appropriate comprehensive psychological assessment and long-term therapy from a psychologist. This needs funding. And while we are getting better at spreading awareness of mental health and mental illness, awareness and advocacy isn&rsquot enough. It&rsquos my hope that the future provides a silver lining &ndash one where five out of five Canadians can seek the help they might need.

We have a ways to go, but by raising these important issues, we can be of more help to many Canadians suffering from mental illness.


The simulations described in this article can be reproduced by downloading the SPM software ( and running the MATLAB script DEM_demo_ontology.m. This demonstration uses the standard specification of dynamical systems used in the dynamic causal modeling of neurophysiological time series. For people who are interested in the technical or analytic aspects of model inversion, please see Friston et al. (2008) and Friston, Stephan, Li, and Daunizeau (2010) for a generalization of these schemes (see also Their application in a variety of neuroimaging, cognitive, and computational neuroscience domains can be surveyed within the demo by using the graphical user interface opened by typing “DEM.” This provides access to annotated MATLAB scripts that offer a pseudocode specification of variational model inversion. For people interested in practical procedures, the simplest way to start would be to reproduce the inversion of fMRI time series described in the SPM tutorial (chap. 38), available from

The Promise Of Basic Research

Basic research is the foundation for future advancements in addiction prevention and treatment. A sustained focus in this area will help researchers define the pathways from gene variation to molecular profile, neuron function, brain-circuit activity, and ultimately to disordered behavior, revealing new targets for prevention and treatment interventions.

While research in animal models has contributed to the development of medications for alcohol, opioid, and tobacco use disorders, it often fails to predict efficacy in clinical trials. This may reflect the reliance on abstinence as the primary endpoint in clinical trials for substance use disorder. The use of alternative outcomes may lead to greater correlation of findings. In parallel, researchers are incorporating more complex social environments into experiments testing medications in animal models that might increase their predictive validity.

The prevention and treatment of substance use disorders would also benefit from biomarkers to help classify individuals into biologically based categories that are reproducible and have predictive validity (178). Biomarkers for the detection of drug exposures in body fluids are valuable but can be used to corroborate only acute or relatively recent drug use. Thus, research is needed to develop and validate biomarkers that reflect chronic drug exposure and that predict disease trajectories and treatment responses. Advances in genetic, epigenetic, and brain imaging tools and technologies offer unprecedented opportunities for the development of such biomarkers.

The same neuroimaging tools that have expanded our understanding of the structural and functional deficits underlying addiction may one day be deployed to monitor, optimize, and personalize addiction treatment (175). An individual’s environment, experience, and biology combine to determine his or her risk for developing a substance use disorder, the trajectory the substance use disorder will take, and the interventions that will be most effective for treating it. Large, national investments in basic research, including the Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative (179), the Adolescent Brain Cognitive Development study (74), and the Precision Medicine Initiative (180), a prospective study that aims to genotype and phenotype one million Americans, are poised to bridge the gap between neuroscience, genetics, behavioral research, and personalized interventions for the prevention and treatment of substance use disorder.


Biomarkers are emerging as important tools in disorders where subjective self-report of an individual and/or clinical impression of a healthcare professional are not always reliable. Recent work by our group has identified blood gene expression biomarkers that track suicidality using powerful longitudinal within-subject designs, validated them in suicide completers, and tested them in independent cohorts demonstrating their ability to predict state (suicidal ideation) and to predict trait (future hospitalizations for suicidality) [5, 2, 6, 49]. Similar to suicidality, psychological stress is a subjective feeling, with objective roots. It may reflect past or current traumatic events, their adverse consequences, and compensatory mechanisms. Metabolic and hormonal changes may be an informative but incomplete window into the underlying biology [50].

We present work describing a powerful longitudinal within-subject design [4,5,6,7, 49, 51, 52] in individuals to discover blood gene expression changes between self-reported low stress and high stress states. The longitudinal within-subject design is relatively novel in the field and has shown power with very small Ns [4,5,6,7, 49, 51, 52], as also illustrated and discussed by Snyder and colleagues [53], as well as by Schork and colleagues [54, 55]. Human studies, particularly genetic ones that use a case–control design, are susceptible to the issue of being underpowered. We estimate, based on our previous body of work in genetics and gene expression, that gene expression studies, by integrating the effects of many SNPs and environment, are up to three orders of magnitude more powerful than genetic studies. We also estimate based on previous work that a within-subject design is up to three orders of magnitude more powerful than a case–control design. In toto, our approach may be up to 6 orders of magnitude more powerful than a genetic case-control design (GWAS), hence a cohort of ≈10 1 for within-subject discovery may be powered to the equivalent of a GWAS with ≈10 6 subjects. In fact, recent results described for a large GWAS of PTSD in veterans carried out by Stein, Gelernter and colleagues [56] implicate the genes CAMKV, KANSL1, possibly CRHR1, and TCF4 (as discussed in Duncan et al. 2018 [57]). Three of these genes (KANSL1, CRHR1, and TCF4) have functional evidence for tracking stress in our within-subject discovery (Step 1), passing our preset threshold (see Supplementary Information- Complete Data and Analyses), and being carried forward into prioritization (Step 2) and validation (Step 3). CRHR1 was also nominally significant after validation. This convergence of independent findings using independent approaches in independent populations is reassuring. We believe that, because: (1) we are using a within-subject design for discovery, analyzing gene expression, which is closer to the phenotype, (2) are using a CFG to prioritize findings, integrating our data with other lines of evidence in the field (from human and animal model studies), (3) are validating our biomarkers in a clinically severe population, and (4) are testing them for both state and trait predictive ability in independent cohorts, we are getting reasonably robust and reproducible results for the field to follow-up on. It has to be noted that our cohort sizes are comparable to our published gene expression studies in suicide, which had a similar design, and were successful in identifying biomarkers that were predictive [4,5,6,7] and independently discovered and/or validated by other investigators [52, 58,57,58,59,62].

Some of these candidate gene expression biomarkers are increased in expression in high stress states (being putative risk genes), and others are decreased in expression (being putative protective/resilience genes). We cannot readily differentiate with our observational studies which of them are a reflection of damage and which are compensatory mechanisms. However, given the fact that these biomarkers are discovered in Step 1 by tracking present/state changes in the perception of stress and not past/trait exposure, they are more likely a reflection of pathogenesis rather than adaptation.

Our systematic approach led to the identification of objective predictive biomarkers for stress, state, and trait. We present evidence for universal biomarkers for stress, as well as show evidence that personalization by gender and diagnosis enhances precision, going from AUCs >60% to AUCs >80%. Earlier studies in mice by us [28, 29] and by Yehuda and colleagues [44] had indicated as well profound sex differences in brain/blood gene expression patterns in stress. More than half of the top predictive markers we have identified overlap with markers previously identified by us in suicide, and the majority of markers have evidence in other psychiatric disorders, underlying the toxic impact of stress on mental health. These biomarkers may permit novel patient stratifications for treatments, such as the possible use of lithium in patients with changes in TL, FKBP5, OAS1, SNCA, and STX11, as well as the use of omega-3 fatty acids in patients with changes in TL, RTN4, SNCA, and B2M (Table S4). The biomarker gene expression signatures also open the door to drug repurposing approaches, including other nutraceuticals such as folate, already used in depression [63] and schizophrenia [64], both of which are disorders eminently susceptible to stress, and betulin, which also has other metabolic and cardiovascular health benefits [65]. Nutraceuticals are particularly amenable to use in preventive population-level approaches. In conclusion, our studies identified new biological underpinnings of psychological stress and provide important leads toward novel diagnostics and targeted therapeutics for devastating stress–related disorders, such as PTSD.

Identifying biological markers for improved precision medicine in psychiatry

Mental disorders represent an increasing personal and financial burden and yet treatment development has stagnated in recent decades. Current disease classifications do not reflect psychobiological mechanisms of psychopathology, nor the complex interplay of genetic and environmental factors, likely contributing to this stagnation. Ten years ago, the longitudinal IMAGEN study was designed to comprehensively incorporate neuroimaging, genetics, and environmental factors to investigate the neural basis of reinforcement-related behavior in normal adolescent development and psychopathology. In this article, we describe how insights into the psychobiological mechanisms of clinically relevant symptoms obtained by innovative integrative methodologies applied in IMAGEN have informed our current and future research aims. These aims include the identification of symptom groups that are based on shared psychobiological mechanisms and the development of markers that predict disease course and treatment response in clinical groups. These improvements in precision medicine will be achieved, in part, by employing novel methodological tools that refine the biological systems we target. We will also implement our approach in low- and medium-income countries to understand how distinct environmental, socioeconomic, and cultural conditions influence the development of psychopathology. Together, IMAGEN and related initiatives strive to reduce the burden of mental disorders by developing precision medicine approaches globally.

Watch the video: 28ο Πανελλήνιο Συνέδριο Ψυχιατρικής - Η δραματοθεραπεία στον καιρό της πανδημίας - Στ. Κρασανάκης (August 2022).