Showing posts with label clinical models. Show all posts
Showing posts with label clinical models. Show all posts

Thursday, October 02, 2014

The Implications of the National Institute of Mental Health Research Domain Criteria for Researchers and Clinicians

http://www.div12.org/wp-content/uploads/2014/05/RDoC.jpg

The Research Domain Criteria (RDoC) signaled a major and controversial shift in the National Institutes of Mental Health (NIMH) research model and funding policy. It was designed to carry out "Strategy 1.4" of the NIMH Strategic Plan: "Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behaviour and neurobiological measures." The singular aim of RDoC was to implement precision/personalized medicine (where the individual patient receives the right treatment, at the right time, at the right intensity, for as long as needed) in psychiatric clinical practice, equivalent to other branches of medicine. To accomplish this goal, all future research would have to both identify a molecular, genetic, or biological target and suggest possible (psychopharmacological) interventions.
 
This is probably one of the worst moves in the ongoing effort of psychiatry to become a science that I have ever seen. At the very best, this model can identify biological markers indicating the presence of potential for disease. BUT it tells us nothing about etiology and is completely divorced from the entirely human and relational sources of most psychological distress.

The implications of the National Institute of Mental Health Research Domain Criteria for researchers and clinicians

Citation:
S. D. Østergaard, M. Fava, A. J. Rothschild, K. M. Deligiannidis. (2014, Sep 9). The Implications of the National Institute of Mental Health Research Domain Criteria for Researchers and Clinicians. Acta Psychiatrica Scandinavica; DOI: 10.1111/acps.12331
Enhanced Article (HTML) Get PDF (310K)

The Research Domain Criteria (RDoC) project launched by the US National Institute of Mental Health (NIMH) in early 2009 [1] is a source of ongoing international discussion. For instance, the entire debate section of the February edition of World Psychiatry (the official journal of the World Psychiatric Association) was dedicated to a discussion of RDoC [2-7], emphasizing that the project is not only of interest to the research community in the USA, but to many other countries as well. But what is RDoC—and why is it causing such an intense debate among academic psychiatrists across the globe? The aim of this editorial was to answer these questions and to provide an overview of the background and likely consequences of RDoC, particularly for researchers and clinicians based outside the USA.

What is RDoC and why was it developed?


RDoC represents a major shift in the NIMH research strategy and funding policy. It was designed to carry out ‘Strategy 1.4’ of the NIMH Strategic Plan: ‘Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behaviour and neurobiological measures’ [8]. The overarching aim of RDoC was to implement precision/personalized medicine (where the individual patient receives the right treatment, at the right time, at the right intensity, for as long as needed) in psychiatric clinical practice [9], equivalent to other branches of medicine [10-14].
The main driving force behind Strategy 1.4 of the NIMH Strategic Plan, and thus behind the conception of RDoC, was the lack of biological validity of mental disorders as currently defined by the two major diagnostic classifications [15], namely the Diagnostic and Statistical Manual of Mental Disorders (DSM) [16] and the International Classification of Disease (ICD) [17]. Despite decades of research, the pathophysiological mechanisms underlying the DSM/ICD mental disorders remain largely unknown [15]. This is probably, at least partly, a consequence of the significant heterogeneity contained within a diagnostic category [18-21]. Accordingly, no biological markers for illness or treatment stratification have been implemented in clinical practice due to insufficient sensitivity, specificity, and predictive validity [15]. Thus, with the ICD/DSM diagnoses being likely obstacles in the process toward precision medicine, the NIMH found it necessary to create a new platform for psychiatric research, which diverts from the traditional categorical DSM/ICD classifications of mental disorders (schizophrenia, bipolar disorder, major depressive disorder, anxiety, autism spectrum disorder, attention deficit hyperactivity disorder, substance use disorder, etc.).
RDoC urges scientists to study ‘fundamental biobehavioural dimensions that cut across current heterogeneous disorder categories’ [22], that is, to move away from the predominant use of DSM/ICD diagnoses as the sole basis for inclusion criteria in research studies. RDoC is initially intended to guide classification of patients for research studies and not as a clinical tool. It focuses on understanding dimensions of function (and dysfunction) from genes to circuits to clinical behaviour, rather than trying to understand the neurobiological underpinnings of a specific disorder. The belief is that this approach will more rapidly facilitate the elucidation of pathophysiology across psychiatric disorders and ultimately provide urgently needed insight to a more valid classification system and novel therapeutics, which can be utilized in the clinic.

How was RDoC defined?


An internal NIMH steering group advised by external experts met in 2009 to create the initial RDoC framework for conducting research on psychopathology. Based on the initial meetings, the group chose five major domains of functioning to represent central aspects of motivation, cognition, and social behaviour. Subsequent consensus workshops (which are ongoing), including both NIMH scientists and outside experts, developed the constituent elements for each of the five domains. The workshop participants deliberated over which constructs to include within each domain and how they were to be defined. The proceedings of these RDoC workshops are publically available at http://www.nimh.nih.gov/research-priorities/rdoc/index.shtml.
Thus, at the micro level, RDoC is best viewed as a matrix defined by five overarching ‘domains’: Negative valence systems, Positive valence systems, Cognitive systems, Systems for social processes, and Arousal/modulatory systems. Under each domain, a number of specifying dimensional ‘constructs’ and ‘subconstructs’ are listed. These constructs/subconstructs can be studied at different levels as indicated by the eight ‘units of analysis’: genes, molecules, cells, circuits, physiology, behaviour, self-reports, and paradigms. The domains, constructs/subconstructs, and units of analysis form the quite extensive matrix shown in Fig. 1, and the initial aim of the RDoC project was essentially to populate this matrix with results from research studies. The hope is that these results will eventually inform the diagnostic processes and choice of treatment in psychiatric clinical practice, thereby introducing precision medicine to psychiatry.

Figure 1. The National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) matrix. This version is slightly modified (the name of some constructs/subconstructs has been abbreviated) from the original version at: http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml. The matrix consists of the five domains: Negative valence systems, Positive valence systems, Cognitive systems, Systems for social processes, and Arousal/modulatory systems. Under each domain, a number of specifying dimensional ‘constructs’ and ‘subconstructs’ are listed. These constructs/subconstructs can be studied at different levels as indicated by the eight ‘units of analysis’: genes, molecules, cells, circuits, physiology, behaviour, self-reports, and paradigms. *The working memory construct has a different format. See: http://www.nimh.nih.gov/research-priorities/rdoc/working-memory-workshop.pdf for full information.

What does a ‘prototypical’ RDoC study look like?


Research studies based on the RDoC framework will investigate one or more dimensional constructs which cut across multiple disorders as traditionally defined. Thus, studies may include study participants from varying diagnostic groups as appropriate to the research question. For example, historically a study aimed at examining activation of a neural circuit in a particular anxiety disorder would conduct a neuroimaging study in subjects who met criteria for that particular anxiety disorder and compare findings to healthy control subjects. The findings may be specific to that particular anxiety disorder, or as we increasingly understand, more commonly are found across disorders. A study using RDoC principles may instead examine the neurocircuitry underpinning acute threat, or fear, in both healthy controls and subjects presenting with anxiety, regardless of specific anxiety diagnosis, comorbid psychiatric diagnoses or symptom severity. Physiological measures and psychometrics, for example, could then be employed to test hypotheses about activation of specific brain areas in the fear circuit.
An important aim of emerging treatment studies funded by NIMH under the RDoC project will be to demonstrate ‘target engagement’, that is, to determine whether a novel treatment engages a hypothesized target and if by engagement of that target, the behaviour/psychopathology under study is modulated. Thus, treatment studies will contribute to our understanding of the pathophysiology of the disorder as well as identify optimal dosing and duration for the intervention. Targets for pharmacological agents can include molecular and circuit-level mechanisms or cognitive systems for psychological interventions, among others [23].

How has RDoC been received by the research community?


RDoC now constitutes one of the main criteria by which applications for NIMH funding are evaluated [24] and applies to all levels of psychiatric research from preclinical/biological studies, clinical trials (pharmacotherapy, neuromodulation, and psychotherapy), to mental health service intervention/implementation projects [8]. This major change in funding policy has caused quite a stir in the scientific community. In a recent commentary, NIMH Director, Dr. Thomas Insel stated that ‘RDoC is already freeing investigators from the rigid boundaries of symptom-based categories’ [9]. Not all researchers agree that RDoC is a liberation, quite the contrary, as they argue that RDoC is overtly reductionistic [3] and detached from clinical reality [4]. Paradigm shifts will inevitably be subjected to criticism and the NIMH is aware of the fact that the current RDoC matrix may not necessarily reflect the natural neurobiological dissections. Therefore, they welcome criticism and suggestions for changes/additions/deletions [8]. Quite a few suggestions for such modifications have already been proposed by the research community [25, 26].

What are the likely consequences of RDoC for researchers outside the USA?


As in virtually all other branches of medicine, the USA assumes a leading position in psychiatric research. Therefore, in a recent commentary on RDoC, a highly relevant question was posed by a non-US based researcher: ‘Will major mental health funders in other countries follow NIMH down the RDoC road?’ [7]. It seems that this has already happened to some extent. For instance, the 2014–2015 ‘Personalising Health and Care’ call under the Horizon 2020 European Commission Framework Programme for Research and Innovation [27], which has a budget of 306 000 000 Euro, shares important features with the RDoC project. The following quote from the Horizon 2020 ‘Understanding common mechanisms of diseases and their relevance in co-morbidities’ subcall could easily have been a quote from the description of RDoC: ‘The development of new treatments is greatly facilitated by an improved understanding of the pathophysiology of diseases. There is therefore a need to address the current knowledge gaps in disease aetiology in order to support innovation in the development of evidence-based treatments. … Proposals should focus on the integration of pre-clinical and clinical studies for the identification of mechanisms common to several diseases’ [27].

Will RDoC change future clinical practice and diagnostic classifications?


Early findings from RDoC-informed research may initially be challenging to apply clinically as research conducted under RDoC is agnostic to the current disorder classification systems. The NIMH RDoC project seeks to spur advances in genomics, pathophysiology, and behavioural science so that eventually those advances will inform clinical diagnosis and treatment. Ultimately, if the findings from a range of RDoC studies consistently demonstrate that the variance in psychopathology and biology across current diagnoses, for instance major depressive disorder and anxiety disorders, is better accounted for by constructs under the ‘negative valence systems’ domain (acute threat, potential threat, sustained threat, loss, frustrative non-reward), the organizations behind the DSM and ICD may decide to incorporate these constructs/dimensions in their future classifications. This will have substantial consequences for clinical practice, but such development will take time.

Will RDoC affect the type of publications in Acta Psychiatrica Scandinavica?


In 2013, more than 10% of the manuscripts submitted to Acta Psychiatrica Scandinavica came from researchers affiliated with institutions in the USA (numbers provided by the editorial office). The studies conducted by these researchers, and thus, the resulting manuscripts are likely to change significantly in the near future as funded RDoC studies are published. Therefore, even if the RDoC-like funding strategy may not be adopted by countries outside the USA (although it appears that it will) the readers of Acta Psychiatrica Scandinavica, and other non-US based journals, will still benefit from having a basic knowledge of the rationale behind RDoC and the general framework of the matrix. Hopefully this report has provided such knowledge and will be a source of inspiration for further reading.

Conclusion


The NIMH RDoC project represents a major shift in research strategy and funding policy with the overall aim to implement precision medicine in clinical psychiatric practice. Despite being a US-based initiative, RDoC will have implications for the entire field. We therefore encourage all psychiatric researchers and clinicians to follow the progress of RDoC.

Declaration of interests

Søren D. Østergaard (last 3 years): No conflicts of interest.
Maurizio Fava (Lifetime): Research Support: Abbot Laboratories; Alkermes, Inc.; American Cyanamid; Aspect Medical Systems; AstraZeneca; BioResearch; BrainCells Inc.; Bristol-Myers Squibb; CeNeRx BioPharma; Cephalon; Clintara, LLC; Covance; Covidien; Eli Lilly and Company; EnVivo Pharmaceuticals, Inc.; Euthymics Bioscience, Inc.; Forest Pharmaceuticals, Inc.; Ganeden Biotech, Inc.; GlaxoSmithKline; Harvard Clinical Research Institute; Hoffman-LaRoche; Icon Clinical Research; i3 Innovus/Ingenix; Janssen R&D, LLC; Jed Foundation; Johnson & Johnson Pharmaceutical Research & Development; Lichtwer Pharma GmbH; Lorex Pharmaceuticals; MedAvante; National Alliance for Research on Schizophrenia & Depression (NARSAD); National Center for Complementary and Alternative Medicine (NCCAM); National Institute of Drug Abuse (NIDA); National Institute of Mental Health (NIMH); Neuralstem, Inc.; Novartis AG; Organon Pharmaceuticals; PamLab, LLC.; Pfizer Inc.; Pharmacia-Upjohn; Pharmaceutical Research Associates., Inc.; Pharmavite® LLC;PharmoRx Therapeutics; Photothera; Reckitt-Benckiser; Roche Pharmaceuticals; RCT Logic, LLC (formerly Clinical Trials Solutions, LLC); Sanofi-Aventis US LLC; Shire; Solvay Pharmaceuticals, Inc.; Synthelabo; Wyeth-Ayerst Laboratories. Advisory/Consulting: Abbott Laboratories; Affectis Pharmaceuticals AG; Alkermes, Inc.; Amarin Pharma Inc.; Aspect Medical Systems; AstraZeneca; Auspex Pharmaceuticals; Bayer AG; Best Practice Project Management, Inc.; BioMarin Pharmaceuticals, Inc.; Biovail Corporation; BrainCells Inc; Bristol-Myers Squibb; CeNeRx BioPharma; Cephalon, Inc.; Cerecor; CNS Response, Inc.; Compellis Pharmaceuticals; Cypress Pharmaceutical, Inc.; DiagnoSearch Life Sciences (P) Ltd.; Dinippon Sumitomo Pharma Co. Inc.; Dov Pharmaceuticals, Inc.; Edgemont Pharmaceuticals, Inc.; Eisai Inc.; Eli Lilly and Company; EnVivo Pharmaceuticals, Inc.; ePharmaSolutions; EPIX Pharmaceuticals, Inc.; Euthymics Bioscience, Inc.; Fabre-Kramer Pharmaceuticals, Inc.; Forest Pharmaceuticals, Inc.; GenOmind, LLC; GlaxoSmithKline; Grunenthal GmbH; i3 Innovus/Ingenis; Janssen Pharmaceutica; Jazz Pharmaceuticals, Inc.; Johnson & Johnson Pharmaceutical Research & Development, LLC; Knoll Pharmaceuticals Corp.; Labopharm Inc.; Lorex Pharmaceuticals; Lundbeck Inc.; MedAvante, Inc.; Merck & Co., Inc.; MSI Methylation Sciences, Inc.; Naurex, Inc.; Neuralstem, Inc.; Neuronetics, Inc.; NextWave Pharmaceuticals; Novartis AG;Nutrition 21; Orexigen Therapeutics, Inc.; Organon Pharmaceuticals; Otsuka Pharmaceuticals; Pamlab, LLC.; Pfizer Inc.; PharmaStar; Pharmavite® LLC.; PharmoRx Therapeutics; Precision Human Biolaboratory; Prexa Pharmaceuticals, Inc.; Puretech Ventures; PsychoGenics; Psylin Neurosciences, Inc.;RCT Logic, LLC (formerly Clinical Trials Solutions, LLC); Rexahn Pharmaceuticals, Inc.; Ridge Diagnostics, Inc.; Roche; Sanofi-Aventis US LLC.; Sepracor Inc.; Servier Laboratories; Schering-Plough Corporation; Solvay Pharmaceuticals, Inc.; Somaxon Pharmaceuticals, Inc.; Somerset Pharmaceuticals, Inc.; Sunovion Pharmaceuticals; Supernus Pharmaceuticals, Inc.; Synthelabo; Takeda Pharmaceutical Company Limited; Tal Medical, Inc.; Tetragenex Pharmaceuticals, Inc.; TransForm Pharmaceuticals, Inc.; Transcept Pharmaceuticals, Inc.; Vanda Pharmaceuticals, Inc. Speaking/Publishing: Adamed, Co; Advanced Meeting Partners; American Psychiatric Association; American Society of Clinical Psychopharmacology; AstraZeneca; Belvoir Media Group; Boehringer Ingelheim GmbH; Bristol-Myers Squibb; Cephalon, Inc.; CME Institute/Physicians Postgraduate Press, Inc.; Eli Lilly and Company; Forest Pharmaceuticals, Inc.; GlaxoSmithKline; Imedex, LLC; MGH Psychiatry Academy/Primedia; MGH Psychiatry Academy/Reed Elsevier; Novartis AG; Organon Pharmaceuticals; Pfizer Inc.; PharmaStar; United BioSource,Corp.; Wyeth-Ayerst Laboratories. Equity Holdings: Compellis; PsyBrain, Inc. Royalty/patent, other income: Patent for Sequential Parallel Comparison Design (SPCD), which are licensed by MGH to RCT Logic, LLC; and patent application for a combination of Ketamine plus Scopolamine in Major Depressive Disorder (MDD). Copyright for the MGH Cognitive & Physical Functioning Questionnaire (CPFQ), Sexual Functioning Inventory (SFI), Antidepressant Treatment Response Questionnaire (ATRQ), Discontinuation-Emergent Signs & Symptoms (DESS), and SAFER; Lippincott, Williams & Wilkins; Wolkers Kluwer; World Scientific Publishing Co. Pte.Ltd.
Anthony J. Rothschild (last 3 years): Dr. Rothschild receives grant or research support from Alkermes, AssureRx, Cyberonics, the National Institute of Mental Health, and St Jude Medical, and is a consultant to Allergan, Eli Lilly and Company, GlaxoSmithKline, Noven Pharmaceuticals, and Pfizer Inc. Dr. Rothschild has received royalties for the Rothschild Scale for Antidepressant Tachyphylaxis (RSAT)®; Clinical Manual for the Diagnosis and Treatment of Psychotic Depression, American Psychiatric Press, 2009; The Evidence-Based Guide to Antipsychotic Medications, American Psychiatric Press, 2010; and The Evidence-Based Guide to Antidepressant Medications, American Psychiatric Press, 2012.
Kristina M. Deligiannidis (last 3 years): Research/grant support: National Institutes of Health (NIH); Worcester Foundation for Biomedical Research; Forest Research Institute; University of Massachusetts Medical School; Assumption College; Michigan Institute for Clinical and Health Research. Royalty/patent: National Institute of Health (NIH) Employee Invention (with royalties). Travel/award funding: American College of Neuropsychopharmacology (ACNP); Society of Biological Psychiatry; Research Career Development Institute (CDI); National Network of Depression Centers (NNDC), Elsevier; American Society of Clinical Psychopharmacology (ASCP). Honoraria: Elsevier; Wiley; Oxford University Press; ObGyn.net.

References

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2. Maj M. Keeping an open attitude towards the RDoC project. World Psychiatry 2014;13:1–3.

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7. Phillips MR. Will RDoC hasten the decline of America's global leadership role in mental health? World Psychiatry 2014;13:40–41.

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8. National Institute of Mental Health. NIMH Research Domain Criteria (RDoC) matrix 2011. http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml [accessed 1 July 2014]. 
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23. Insel TR, Gogtay N. National Institute of Mental Health Clinical Trials: New Opportunities. New Expectations. JAMA Psychiatry 2014;71:745–746.

24. Cuthbert BN. The RDoC framework: facilitating transition from ICD/DSM to dimensional approaches that integrate neuroscience and psychopathology. World Psychiatry 2014;13:28–35.

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25. Ostergaard SD, Bech P, Trivedi MH, Wisniewski SR, Rush AJ, Fava M. Brief, unidimensional melancholia rating scales are highly sensitive to the effect of citalopram and may have biological validity: Implications for the Research Domain Criteria (RDoC). J Affect Disord 2014;163:18–24.

26. Badcock JC, Hugdahl K. A synthesis of evidence on inhibitory control and auditory hallucinations based on the Research Domain Criteria (RDoC) framework. Front Hum Neurosci 2014;8:180.

27. European Commission. The Horizon 2020 European Commission Framework Programme for Research and Innovation 2014: http://ec.europa.eu/research/participants/portal/desktop/en/opportunities/h2020/topics/2275-phc-03-2015.html [accessed 1 July 2014].
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Saturday, September 21, 2013

Bringing Embodied Cognition to the Clinical Domain (Giovanni Ottoboni)


In this new paper from Frontiers in Psychology: Cognition, Giovanni Ottoboni advocates for an interdisciplinary approach that would combine embodied cognition with clinical psychotherapy. While his argument is solid and useful, he fails to acknowledge the wide body of literature and approaches already working in that realm.

Peter Levine's Somatic Experiencing (Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences, 1997; and In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness, 2010, among others) and Pat Ogden's Sensorimotor Psychotherapy (Trauma and the Body: A Sensorimotor Approach to Psychotherapy, 2006) are two of the best known and clinically supported models.

Going back even further, there was Wilhelm Reich and his body-centered psychoanalytic approach (Character Analysis, 1933), out of which Alexander Lowen developed his own particular model, called Bioenergetics (Bioenergetics: The Revolutionary Therapy That Uses the Language of the Body to Heal the Problems of the Mind).

Anyway, there is more history to this idea than presented here, but this is still an interesting article.

Grounding clinical and cognitive scientists in an interdisciplinary discussion

Giovanni Ottoboni [1,2]
1. Department of Psychology, University of Bologna, Bologna, Italy
2. Centro di Psicologia e Psicoterapia Funzionale Integrata, Trieste, Italy
In most clinical approaches the body receives little attention. In cognitive science, in contrast, the embodied and grounded perspective, which emphasizes the importance of the body, has been intensively explored over the last decade. The present article aims to engage theorists of embodied cognition and clinical experts in a discussion encouraging them to consider the insights that may arise from each other’s approaches. In a review of the cognitive and clinical literature substantial overlap is revealed between cognitive and clinical domains.

Full Citation: 
Ottoboni G. (2013, Sep 19). Grounding clinical and cognitive scientists in an interdisciplinary discussion. Frontiers in Psychology: Cognition, 4:630. doi: 10.3389/fpsyg.2013.00630
The interpretations academics and professionals offer for psychological disorders are not unanimous. Traditional therapeutic approaches explain that psychological disorders arise from irrational beliefs and illogical thought patterns or from unresolved emotional conflicts (e.g., Zeig, 1997; Sutker and Adams, 2001). Within these perspectives, an even wider range of treatments is offered. Some treatment options are targeted at changing learned behaviors, others are aimed at reshaping old attachment styles, others work on memories arising from relations occurring within the original family system, and others involve medical psychosomatic concepts. Few approaches to clinical treatment, however, are able to provide a comprehensive and integrated theoretical account of all human expressions (Palmer and Woolfe, 2000).

Alongside such views, the connection between the body (and bodily states), cognition and emotion is theoretically accepted (Van Oudenhove and Cuypers, 2010). According to some therapeutic approaches (Totton, 2003), and even in some early works in psychodynamic theory – later studied in depth by other psychoanalysts such as Perrin (2010) – the body plays an important causal role in the development of mental disorders. From a more body-oriented perspective it is argued that the body is included in all processes involved in self-awareness (Segal et al., 2002). Röhricht and colleagues (Röhricht and Priebe, 2006; Röhricht et al., 2013) provide congruent evidence. For example, the authors specifically report on the positive effects of the bodily therapy in two separate groups of schizophrenic and depressed patients. They showed that the negative, depressive symptoms decreased more than in controls. The authors also report that bodily techniques are effective for treatment of mental disorders among patients who do not respond to traditional talking therapies, e.g., somatoform disorders/medically unexplained syndromes, post-traumatic stress disorder (PTSD), anorexia nervosa, and chronic schizophrenia (Röhricht and Priebe, 2006; Röhricht, 2009). Also for medical practice, a number of clinical studies support that bodily therapies have positive impacts in pathological conditions (Moyer et al., 2004; Tsao, 2007).

One of the approaches that is presently attracting the attention of researchers and professionals by claiming a full integration between the bodily and the psychological aspects is the Mindfulness approach. Mindfulness is described as “a process of regulating [clients’] attention in order to bring a quality of non-elaborative awareness to current experience and a quality of relating to one’s experience within an orientation of curiosity, experiential openness, and acceptance” (Bishop et al., 2004, p. 234). In recent years, a number of studies have investigated the both the psychological and the physical modulations that can be achieved when people reach certain states of mindful awareness (Grossman et al., 2004; Michalak et al., 2010). Mindfulness techniques have been used to enhance self-observation from inner and outer perspectives. The mindfulness approach represents a third-wave for many clinical and non-clinical treatments because it prepares people to respond functionally and consciously to their environment (e.g., Boyle, 2011).

In recent years, the connection between what is expressed and conveyed by the body and cognitive, functional and emotional expressions has received renewed interest from a wide range of neuroscientists. Damasio (2005) approached the mind-body link directly by proposing that somatic markers are intimately related to thinking and decision-making. In a similar manner, other scholars have suggested the existence of a gut–brain/brain–gut axes (Mayer, 2011). Gut microbes appear able to transmit information directly to the central nervous system (CNS), communicating many of the changes that occur in the gut. Through this communication pathway, the CNS can identify the presence of pathogens in the gut lumen and activate appropriate response mechanisms. It seems that the level of intestinal microbiota and inflammation markers have a role, as for example, in the depression states (Bested et al., 2013; Rawdin et al., 2013).

From a cognitive perspective, the body–mind coupling has been at the center of scientific discussion in neuroscience for many years. In the middle of the last century, Yarbus (1967) described the importance of the muscular eye movement for vision and visual attention. Similarly, Liberman et al. (1967) proposed that language comprehension is inseparable from language production. More recently, a group of neurons was discovered in the monkey premotor cortex (di Pellegrino et al., 1992). The neurons able to produce electrophysiological spikes that have a similar pattern regardless of whether the monkey is executing an action or observing the same action but performed by the experimenter (i.e., grasping some monkey food). The double-firing property has led to this group of neurons to be termed Mirror Neurons (Gallese et al., 1996). When evidence of a similar system was reported in humans (Mukamel et al., 2010), the connection between body and mind entered centrally in the domain of psychology. The mirror neuron network serves as an automatic and involuntary system that is strengthened by links, such as motor expertise, between the action observer and the action performer (Castiello et al., 2009). Dysfunctions within this reverberating network are also considered to be a basis of empathic deficits associated with autistic spectrum disorder (Williams, 2008). In last years, the human mirror neuron system network has been found to respond to various stimuli, including action words (D’Ausilio et al., 2009) and pain-related stimuli. Avenanti et al. (2005) reported higher levels of activation in the brain area that principally controls hand movements when participants watched a video clip of a needle piercing a person’s hand than when participants watched a neutral video in a control condition. However, in some cases, the mirror neuron network has been used to explain even the mechanisms of empathic and emotional resonance that come into play in therapeutic settings (Berrol, 2006; Gallese et al., 2007; Schermer, 2010), as well as cultural, social, and psychodynamic interactions (Vanderwert et al., 2012).

With the growing evidence for the influence of the body in the control of cognitive processes, a new perspective (e.g., Varela et al., 1991; Borghi and Pecher, 2012), known as Embodied Cognition (EC) has developed. Recently, theorists have argued that mind-body influences are related to bodily states as well as to the physical and bodily experiences people have (Fischer, 2012). Along this vein, Barsalou (2008) suggested that the use of the concept of grounding is preferable to embodiment because the former includes concepts relating to simulation that are able to occur even when the action actor and the action observer do not share the same action motor control. This would be the case if a patient suffering apraxic were to engage in conversation about a pen. The patient would be able to name and describe the pen and provide relevant information about it, such as where it can usually be found, but would not be able to perform actions with the pen, such as write with the pen. In this way, aside from the boundaries of the body, the concept of grounding relies more on the effectiveness with which physical experiences interact with cognitive processes (e.g., Symes et al., 2008; Eder and Hommel, 2013).

Aside from the growing scientific and clinical evidence supporting the grounded body–mind interconnection, what appears missing from both fields is a proper translational process that integrates the scientific and clinical domains. Regarding clinical psychology, the opinions of academics and professionals differ greatly: there are cases in which grounding the therapeutic process in bodily terms using movements, posture, and physiological indexes is neglected or it is used only metaphorically (Sensky et al., 2007). There are examples of professionals who commit to theater, yoga, and dance the bodily healing aspect. Such a process of devolution is necessary when it is not possible to theoretically integrate such aspects into the existing theory (Palmer and Woolfe, 2000). On the other hand, there are health care professionals who are accustomed to working only with the physicality of the body and who find themselves unprepared for dealing with emotional and psychological aspects that arise during treatment.

One relatively new clinical approach that integrates bodily and psychological aspects is the Neo-Functionalism (NF) approach (Rispoli, 2008; Ottoboni and Iacono, 2013). The NF approach was developed from the body-centered perspectives. The involvement of the body within the therapeutic setting has generated two kinds of advantages: it provides the clients with the opportunity to communicate their psychological states directly without limits and it provides the therapist with the opportunity to get deeply in touch with the clients’ emotions and expressions. According to this view, indeed, the body conveys and communicates the individual’s psychological states as it receives feedback from outcomes of physical actions. Body movements and facial expressions, as well as the contextual information have been indicated as influencing psychological states and activities, such as memory, predisposition, and decision-making (Strack et al., 1988; Hatfield et al., 1992; Craig, 2002; Dijkstra et al., 2007) and pain perception (Avenanti et al., 2005).

In the process of clinical evaluation and treatment, NF considers all life experiences people have had according to the experiences’ grounded and embodied aspects. The core concept of the NF approach relies on a discrete group of life instances whose experiences affect cognitive functioning and expressions (Rispoli, 2008; Ottoboni and Iacono, 2013). They are claimed to be universal and are called Basic Experiences of the Self (BEsS) to denote the strict connection between two concepts, the Self and grounded experiences. Indeed, the connection between behaviors (independently of their sane or deviant forms), the neurological background (intact or damaged), the social context (read social experiences) and the development of the Self has recently arisen a number of interesting debates within the scientific community (see, for example, Blanke and Metzinger, 2009; Brugger et al., 2013; Reed and McIntosh, 2013).

The way individuals experience each Basic Experience of the Self (BES) produces cognitive, emotional, physiological, and postural-related outcomes. Each time the same BES is experienced the individual stores a memory of the outcomes of the experience, matches them with past experiences and uses them to create expectations for the future (see Logan, 2002; see also Mancia, 2006 for a psychodynamic perspective). If the BES is experienced positively, memories are formed and are made available later for dealing with novel situations. In contrast, if the response to the BES is maladaptive, it may generate a sense of inability to deal with novel situations (Rispoli, 2008; Ottoboni and Iacono, 2013). Each BES may be experienced several times during the lifespan. The averaged mode in which each BES is experienced determines the manner in which memories of the BES are stored. The account that only the repeated outcomes of the same BES can modulate the behavior highlights that such a grounding process of memory development is not a point-to-point process; it required time either to form the maladaptive responses or to develop positive responses. Hence, if a large number of BEsS are experienced negatively, the individual’s responses to environmental demands will be poor because of a low level of resilience (Rothschild, 2000); indeed, the higher the functioning, the more adaptive the responses.

The NF interpretation of the word functioning is the same that grounding theory provides: each bodily expression (i.e., function) comprehends cognitive, emotional, postural, and physiological features (see also Hatfield et al., 1992). In line with this view, a depressed demeanor expresses a number of cognitive, physiological, and emotional features as well as bodily postures that must all be taken into account during therapeutic treatment (e.g., Michalak et al., 2009). By considering human expression as complex in nature, the NF therapist is able to find the most appropriate manner for interacting with the client. If one manner of expression is inappropriate, another manner may be pursued, and, as suggested by Röhricht (2009) in referring to body-centered techniques, unexpected results can be achieved. Let us consider, for example, a person suffering ruminations. The patient may be very careful and skilled at identifying appropriate verbal responses to the therapist’s requests. In such cases the therapeutic process could be made difficult. A way to achieve treatment results in such cases would be for the therapist to use the physical channel. The therapist must thus work on the client’s body (Ottoboni and Iacono, 2013) with calm and wide hand-on massages. Indeed, the focus of this therapeutic technique would be to calm the patient’s thoughts and let the therapeutic process to begin.

The healing outcomes are achieved by helping the client to re-experience the BEsS that were not positively experienced in the past. The process is intensive because, by using a grounding approach, the therapists tend to re-create the same physical and emotional conditions the patient experienced when the trauma begun. Mental thoughts, verbal expressions and body-related experiences are used in a combined fashion. The clients could, for example, be asked to lie down on the ground as they did in childhood, to wander in the room and express their feeling during the walk, or to vocalize with pre-verbal utterances the psychophysical sensations that therapeutic hand-on messages have made emerge. To repeat, these techniques are mainly used to make the patients emotionally regress to the specific moment of their past, because, in this way, the client may discharge the old memories and form new ones from the experience just-lived (Rispoli, 2008; Ottoboni and Iacono, 2013).

The change in the patient that the NF therapist aims to achieve concerns the attempt to reconstruct the harmonious organization of the Self as it was in the womb. Even if such a concept could be criticized for not accounting for the gestational period, the fetus could potentially experience problems and disease, premonitory of future functioning. I personally consider that the harmonious state indicates a general and natural state toward which everybody is inclined to experience. Using a Mindfulness concept, it could be claimed that such a harmonious state is the state of acceptance of internal and external changes (Grossman et al., 2004). This state involves a calm and relaxed state of mind.
 

Conclusion


A growing number of studies have shown that human cognition, emotions, and behaviors have embodied features, or as Barsalou (2008) has preferred to describe, grounded features.

However, this knowledge still remains in the research domain and is rarely applied in clinical practice. An attempt to translate grounded evidence in clinical practice has been introduced in a recent paper. Bedford (2012) theorizes that the visual component of perception can cure a number of medical symptoms by affecting the immune system. Vision, however, is controlled and modulated (Rizzolatti et al., 1994) by the motor system, as in the case of visual awareness studies demonstrating that the motor plan moderates perceptions of plan-congruent objects (Symes et al., 2008), or the reaching of a target in absence of visual awareness (Binsted et al., 2007). Interestingly, the visual information concerning the body is integrated and combined in several areas in the brain with information coming from the other senses too (see Blanke, 2012 for a review). As soon as the visually based information, mainly defining a map-like representation of body (e.g., Tessari et al., 2010), are integrated with kinesthetic and vestibular information, a body-based sense of self takes place (Blanke and Metzinger, 2009).

In sum, it appears that the approaches that effectively integrate cognitive and motor aspects of human behavior are few in number. One such approach is the NF approach (Rispoli, 2008; Ottoboni and Iacono, 2013). By working simultaneously on imagery-related techniques, verbal and bodily techniques (such as hand-on massages or body movements), the NF approach accounts for all aspects of human expression from a grounded perspective. During treatment, past experiences, which generate actual psychological states, are recalled and experienced again physically within a clinical setting.

However, the grounded assumptions, as well as the grounded techniques, must be tested thoroughly. As this review demonstrates, embodied cognition and grounded clinical approaches are still far from integrated with each other. Research exploring the effects of grounded therapeutic approaches should be a priority for scientists interested in understanding human behavior and its therapeutic treatments.

Scientific evidence suggests that embodied cognition could be very useful for achieving such an aim. Equally, studies dealing with embodied cognition could take advantage of what is known in clinical settings.

Conflict of Interest Statement

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
 
Acknowledgments

The author would like to thank Valerie Womble, Jonathan Rolison, and Anna Borghi for the critical discussion during the various stages of this manuscript. The author would also like to acknowledge the EU FP7 project ROSSI (No. 216125) for the initial economic support provided for personal assistance to the author.

References are available at the Frontiers site.

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