Mechanism of vantage sensitivity
Our selective review of recent empirical evidence for vantage sensitivity may suggest the involvement of different molecular, neurological, physiological, and psychological mechanisms. However, it is more likely that these different mechanisms all jointly orchestrate aspects of a higher-order mechanism of sensitivity. In other words, these various factors may reflect the same core sensitivity mechanism at different levels of analysis—a hypothesis which remains to be tested. As discussed in more detail elsewhere [
34,
43,
73], there are several higher-order processes that involve the various detected individual sensitivity markers and may represent important candidate mechanisms underlying vantage sensitivity (or environmental sensitivity more generally): attentional processes, reward sensitivity, social sensitivity and stress responsivity [see
43]. These are each central nervous system processes, providing substantiation of the centrality of the nervous system in environmental sensitivity [
40,
74]. According to this general hypothesis of “Neurosensitivity
”, both genetic and environmental factors contribute to heightened sensitivity of the central nervous system which manifests itself both physiologically and psychologically [
34,
41,
73,
75]. In summary, environmental sensitivity—defined as the ability to perceive and process information about the environment [
41,
69]—may be driven primarily by a more sensitive central nervous system on which experiences register more easily and more deeply. Integral to this core mechanism of sensitivity is the quantifiable neurobiological trait of sensory processing sensitivity, held to influence the depth and degree by which sensory stimuli are processed, which we propose as a key candidate for the measurement of vantage sensitivity [
40,
76].
Measurement of vantage sensitivity
While all the reviewed genetic, physiological, and psychological traits appear to reflect sensitivity to positive features of the environment, they do not represent a direct measure of the proposed underlying higher-order sensitivity. Hence, they should be considered sensitivity markers—some more proximal than others—and as such may not be ideal or practical for the measurement of sensitivity. However, sensitivity to both negative and positive environmental influences can be measured reliably with the highly sensitive person (HSP) scale in adults [
76] and the highly sensitive child (HSC) scale in children [
69]. These are validated psychometric self-report questionnaires originally designed to capture sensory processing sensitivity, manifested in higher awareness of subtleties in the environment, heightened processing of sensory input, and the tendency to be more easily overwhelmed by emotionally and sensory stimulating environments, to name just a few of the items. First evidence of vantage sensitivity in relation to sensitivity measured with the HSC scale has been reported in a study examining individual differences in response to a school-based resilience-promoting program aimed at reducing depressive symptoms in adolescents [
77]. The intervention proved effective in reducing depression symptoms up to the 6-month follow-up assessment (but was no longer significant at 12 months) [
78]. When investigating whether HSC moderated treatment effects, it was found that children scoring low on the HSC scale failed to show any improvement at all (i.e., displaying vantage resistance) while those scoring high in sensitivity showed substantial reductions in depression symptoms all the way through to the 12-month follow-up assessment [
77]. In other words, as hypothesized the HSC scale predicted individual differences in vantage sensitivity related to treatment response. These findings have recently been replicated in a large randomized control trial (
N = 2024) testing the efficacy of a school-based anti-bullying intervention [
79]. Although the intervention significantly decreased victimization and bullying across the whole sample, examination of moderation effects revealed that intervention effects were driven by children characterized by high sensitivity. Children scoring low on HSC, on the other hand, did not benefit from the intervention.
Implications
There is now cogent evidence that environmental sensitivity factors explain individual differences in response to both adverse and supportive experiences [
43,
44,
80]. In the context of psychotherapy, the converging evidence that people respond to a greater or lesser degree to enhancing, supportive experiences as a function of endogenous factors, hypothesized to be associated with higher-order sensitivity mechanisms, has important implications for clinical practice. Most importantly, differences in response to psychological treatment should not only be expected but already considered when making decisions about the provision of treatment. Given that sensitivity can be measured as a phenotype, there is a significant potential for the application of existing sensitivity measures such as the HSP [
76] and HSC [
69] scales as well as for the development of further screening tools for the detection of individuals more or less likely to respond to psychological intervention as a function of inherent sensitivity. The measurement of sensitivity before treatment contributes to a personalized medicine approach [
81], allowing the clinician to select the treatment that is most likely to help the patient based on her/his individual degree of sensitivity. To enable such a personalized treatment approach, continued investigation and cataloging of sensitivity markers is crucial to achieve an objective, testable profile of vantage sensitivity and vantage resistance that can be incorporated into diagnostic and clinical practices. However, as environmental sensitivity is likely an outcome of many molecular and neurobiological mechanisms, it may be most promising to focus on measurable higher-order traits rather than the various underlying properties. Several studies using the HSC scale, for example, demonstrate that it may be possible to predict individuals least and most likely to respond to therapeutic intervention without collection of genetic and physiological data [
77,
79].
The currently limited ability to accurately predict what effects a psychotherapeutic intervention is likely to have, and for whom, remains a significant challenge. One central factor that contributes to this challenge may be of predominately methodological nature: the focus on main effects when evaluating the efficacy of treatment often means that the consideration of individual differences is neglected. Group means provide no information on how much individuals differ in response to treatment. As a consequence, aggregating treatment outcomes can lead to considerable overestimation (in the case of vantage resistant individuals) and underestimation (in the case of vantage sensitive individual) of the effectiveness of interventions [
14,
82]. Failure to investigate degrees of individual difference in response to treatment, and specifically to identify systematic heterogeneity in response to treatment, may explain, at least in part, the stark contrast in the successful development of drugs to treat physical illness and disease compared to the limited progress made in the treatment of psychiatric disorders [
13].
The practical benefits of focusing interventions better are clear, and pertain not just to financial costs and provision of service on a more effective basis, but also to the consideration of patients for whom current therapeutic interventions do not work. While individuals most sensitive and responsive to environmental influence may require shorter or lower intensity programs of intervention, vantage-resistant individuals may require interventions of greater duration, intensity, simultaneous application of two or more treatment types—or it may be found that for some people for whom vantage resistance is very pronounced, it is not just a question of intensity and duration of therapeutic intervention(s), but a redefinition of therapeutic strategy. Importantly, being less sensitive to one type of treatment may not necessarily mean lacking sensitivity to all treatments. Future research will have to investigate whether treatment-specific vantage sensitivity factors exist and whether those that are resistant to intervention due to low sensitivity may require more intensive intervention approaches or rather alternative types of treatment (e.g., medication).
Implications of vantage sensitivity go beyond therapeutic intervention. Applications in educational and social care plans are also conceivable. For example, many children and young people in institutional care go through multiple failed residential placements, with the level and type of residential care ‘stepped up’ each time a placement breaks down. Measures to better assess the different levels of care that children require, at the point where children enter care, may have an enormous impact on the lives and developmental trajectories of many children.
There are two reasons children and young people may be a critical focus, should vantage sensitivity be incorporated into diagnostic and clinical practices. First, vantage sensitivity factors may build over time, according to positive exposures. That is, there is some evidence that biomarkers related to increased vantage sensitivity also predict their own increased expression during early developmental periods [
83], in contexts of positive exposures, suggesting that individual propensity for vantage sensitivity may spiral upwards over time, subject to conditions. This leads to a second important question: whether vantage sensitivity itself can be directly influenced through intervention. While it is not possible to change genetic structure, it may be possible to increase responsivity to positive exposures, or anatomically affect biological substrates (i.e., brain structure and function), through interventions that specifically target higher-order characteristics of vantage sensitivity.
Future directions
The notion of vantage sensitivity is still relatively new, and much remains to be investigated. Presiding questions include whether vantage sensitivity describes positive response to all kinds of positive experiences and exposures, or whether it is domain specific, with individuals differing in what types of positive exposures they are sensitive to. Whether vantage sensitivity can itself be influenced, and if so, during which the developmental periods have important social and psychological implications. More research on vantage sensitivity is required in relation to psychotherapy to replicate findings, to identify alternative therapeutic approaches for individuals that appear to show vantage resistance to standard treatment, and to develop a more fine-grained assessment of vantage sensitivity factors in the context of psychological therapy. Significant further investigation of specific endogenous factors and mechanistic pathways that predict differential response to interventions is also required. In particular, identifying endophenotypes and examining candidate genetic and neurophysiological markers of higher-order sensitivity traits as well as whether and how these various sensitivity markers are associated with self-reported sensitivity assessed with questionnaires. Furthermore, future research should also investigate whether there are specific vantage sensitivity factors that do not also increase vulnerability to the negative effects of adverse experiences.
It is eminently possible that the measurement of environmental sensitivity may not only contribute to the development of screening tools for tailored psychotherapeutic and other intervention programs, but also be the critical element therein. Measurement of environmental sensitivity is feasible with the HSP and HSC scales, and can be readily introduced into current research and clinical settings. Notwithstanding, while sensory processing sensitivity may capture important characteristics of environmental sensitivity in a robust way, more specific measures of environmental sensitivity are required, and HSP and HSC scales can be refined with more research to better predict treatment response.