The Art of Clinical Science

Gabriel Dichter, PhD, earned a Hettleman Prize for his work imaging and elucidating brain regions involved in various aspects of autism, depression, and other neurological conditions.

When Gabriel Dichter was a teenage tennis instructor, younger kids would confide in him, telling him their troubles and concerns. It seemed he was a good listener with a knack for asking the right questions. His parents joked that he should consider becoming a therapist. That didn’t seem so funny to him.

A few years later, during a college psychology course at Haverford College in Philadelphia, he learned that psychologists could become scientists. They could do research. They could ask questions and form research projects about intangible things, such as feelings and emotions. They could uncover new knowledge on conditions such as autism and depression. And perhaps this research, he realized, could help a lot of people.

This past year, Dichter, now an associate professor of psychiatry in the UNC School of Medicine, published a pair of novel imaging studies that broaden our understanding of both autism and depression while illuminating better diagnostic criteria and the effectiveness of a non-invasive treatment for these conditions, which affect millions of people.

For his efforts, as well as his teaching and leadership of the UNC Clinical Affective Neuroscience Lab, Dichter earned one of this year’s Phillip and Ruth Hettleman Prizes for Artistic and Scholarly Achievement by Young Faculty at UNC.

We sat down with Gabriel Dichter, PhD, for a Five Questions feature to discuss his road to clinical research, his work, and his hope as a scientist in the fields of neuroscience and psychology.

Why did you choose to focus on research, as opposed to more clinical work?

I’ve always found clinical research fascinating and energizing. As a graduate student in clinical psychology at Vanderbilt my graduate advisor, Dr. Andrew Tomarken, told me that you need two things to be a researcher: a constancy of effort and a need to know. These mantras fit my personality – the scientific process is rarely an “aha” moment. It’s usually an iterative process between reading the literature, conducting a study, then going back to the literature, and then running the next study. This process is really more a marathon than a sprint, and I loved the fact that good science truly has no definitive endpoint but will inevitably produce a new set of questions to answer.

How and why did you come to UNC? Has it been a good place to be a researcher in this field?

I met my wife in graduate school at Vanderbilt, where she was getting a clinical psychology degree, and we were applying to clinical internships at the same time. We did a “couples match” for internship placement so we would wind up in the same city. I actually studied affective disorders rather than autism in graduate school, but my wife was doing autism research training with Dr. Wendy Stone. Since autism was a more specialized area of research, I told my wife that we could do our internships in any city that would be a good fit for her interests. She matched at UNC, which is such a hotbed of autism clinical services and research, and I wound up at the Durham VA.

Later, I heard about a postdoctoral opportunity at UNC through a training grant at the Carolina Institute for Developmental Disabilities. This was an opportunity to learn about neuroimaging in the context of autism research. I didn’t have a strong background in autism research but wanted to receive training in it. That was in 2004 and I’ve been at UNC ever since.

UNC is an exceptional place to do research. I had the poor timing of trying to develop a research lab when NIH funding was at historic lows, but the collegiality of my colleagues across the UNC School of Medicine and the department of psychology [in the College of Arts and Sciences] has provided wonderful opportunities for collaborative research. I’ve also found a home at the Carolina Institute for Developmental Disabilities, which provides research cores to support my research, opportunities to see patients clinically, and a fabulous environment to train graduate students, postdocs, and junior faculty.

You are the director of the Clinical Affective Neuroscience Lab. What is it and what are its goals?

Since starting my lab, I have been very clear with my students that we need to think beyond a particular psychiatric condition. I have always been interested in the neural underpinnings of affect and reward, and how impairments in brain systems that support these processes can result in mental illness. I received some career advice early on to focus only on one disorder or I would be too spread out. I’m glad that I didn’t heed this advice, and I have managed to maintain parallel programs of autism research and depression research, while also publishing articles in the areas of schizophrenia and obsessive compulsive disorder.

But all of our work focuses on constructs that cut across disorders, processes that are involved in cognitive control, reward, and affect regulation. These things are impaired in several disorders, and so we can apply similar paradigms across studies in clinically meaningful ways.

This is an approach that my basic science colleagues understand well – if you bore down and study a circuit or a gene or a molecular process, you can learn about the etiology of a range of psychiatric and neurodevelopmental disorders. But clinical scientists like myself haven’t traditionally been trained this way. I tell my students that they are going to have to initially become an expert in one disorder, but if they limit themselves to the research literature on just one condition they’ll be missing a big piece of the picture. I firmly believe that psychiatry will make more progress if we focus on common constructs that cut across disorders.

I should add that the National Institute of Mental Health has started to adopt this approach, as well. This kind of research has provided insights that would not have been possible otherwise.

What should people take away from your most recent studies, one in depression and a second in autism?

On the surface, depression and autism are very different disorders. One is characterized by intense sadness that may not emerge until late adolescence or adulthood, and the other is characterized by social difficulties that are present from infancy. But by using brain imaging, we detected a common mechanistic impairment in brain reward circuitry.

Impaired reward circuits may result in feelings of anhedonia – loss of pleasure – in patients with depression or it can result in social disinterest in a child with autism. But the underlying brain impairment in one disorder might have a lot in common with the impairment in the other disorder. This can have important implications. First, it can partially explain the very high rates of depression in autism. Second, it may suggest similar pharmacotherapies or brain stimulation treatments for the two disorders.

Clearly, depression and autism are different, but looking at common pathophysiologies can lead to insights about possible treatment approaches that may benefit people who have these disorders.

What are your ultimate hopes as a researcher when it comes to helping people with depression, autism, and other psychological and neurodevelopmental conditions?

I’m very concerned that academia produces researchers that are good at publishing papers but whose work does little to change the lives of individuals with psychiatric illness and neurodevelopmental disorders in meaningful ways. I think psychiatric research is at a tipping point, where we’re starting to see momentum in terms of developing novel psychiatric treatments that are the result of neurobiology research, and I would like to be a part of that movement.

When we design new studies, a critical question we should ask is whether results could impact how we think about clinical care, either in the long-term or the short-term. If not, it’s probably not an important question to address. We should train new clinical scientists to gauge the success of their programs of research on the basis of the potential to relieve suffering.

For me, this is where continuing to do some clinical work comes in. I rely on my patients to show me how much work is left to be done and to remind me of the distance between the lab and clinical practice.

Dichter is also an adjunct associate professor of psychology in the UNC College of Arts and Sciences.