HiTOP as a Replacement for the DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been criticized for several reasons. One major issue is that the DSM medicalizes psychological problems, treating them as though they function exactly like medical illnesses. Diagnosis requires meeting a specific number of criteria, which can oversimplify the complexity of psychopathologies. For instance, a person experiencing four symptoms of Major Depressive Disorder (MDD) would not qualify for the diagnosis, even if those symptoms cause significant impairment. This “all-or-nothing” approach leaves no room for individuals in the gray area between wellness and disorder, which can lead to underdiagnosis or missed opportunities for treatment coverage. Furthermore, this rigid categorization contributes to the high rates of comorbidities, as overlapping symptoms are often classified as distinct disorders. Another notable concern with the DSM is the lack of reliability and the heterogeneity within diagnoses, where two individuals with the same diagnosis may present with vastly different symptoms.

HiTOP (Hierarchical Taxonomy of Psychopathology) is an empirically based alternative model for the DSM. HiTOP is a dimensional approach to classify psychopathologies as opposed to a categorical approach like the DSM. A dimensional approach focuses on the severity of each trait within the spectrum (Figure 1). HiTOP recognizes that patients who do not meet the criteria for a disorder may still require treatment. It is based on three core principles that help integrate this model into clinical practice: dimensions with ranges of cutoff scores, hierarchical nature of illness, and impairment rated separately. The former principle refers to describing psychopathology in terms of degrees of severity, with each dimensional level of HiTOP having a range of scores. The hierarchical nature of illness refers to the idea that to assess psychopathology using the HiTOP model, the first step is, to begin with the higher-order spectra (internalizing, thought disorder, antagonistic externalizing, etc.) and then move down to more specific symptoms/traits. The latter principle refers to HiTOP’s attempt to separate symptoms from actual impairment. This is to rule out “false positives” and it is based on symptom ranges found in empirical studies.  

HiTOP also considers that comorbidities are likely manifestations of a common underlying factor as opposed to two different disorders. For instance, a clinician would identify the patient’s symptom dimensions (e.g., high stress, moderate fear, low compulsivity) and then tailor interventions for the dominant dimensions, potentially addressing the overlapping symptoms more efficiently. This approach allows for more personalized treatment and an opportunity to target overlapping symptoms.

One of my favorite aspects of this model is that it is a continuous framework that constantly evolves as research advances in the field. For instance, against contrary belief, HiTOP is not limited to dimensional classifications. If there is enough evidence to demonstrate a natural boundary for certain conditions, it will be integrated into the model. This adaptability ensures that HiTOP remains relevant as new research emerges.

However, the DSM was created for a reason and continues to serve an important role in the field. One of the main reasons it was created was to establish a standardization of psychiatric disorders, providing a common language for mental health professionals to describe different symptom clusters. This standardization facilitates communication between clinicians, researchers, and the public. Additionally, clinicians use the DSM to get reimbursement from Insurance companies and document care and treatment plans, which rely on specific DSM diagnoses. Additionally, for some patients, receiving a diagnosis can bring a lot of relief. Having a name for their struggle validates their experience because a diagnosis means that their disorder has been researched, it has established treatments, and it makes it easier for them to find other people with the same disorder. The DSM was created under the consensus of several experts in the mental health field who agreed on how to categorize different psychiatric disorders, and this standardized framework has shaped the field for decades.

In contrast, HiTOP may face some challenges in the implementation process. For example, how would insurance companies use a dimensional model like HiTOP to provide reimbursement? Another challenge is a potential resistance to change. Given that the DSM has been used for decades, it is expected that clinicians will be hesitant to change their diagnosis approach. Further, it is important to note that HiTOP has not yet demonstrated superior clinical outcomes than the DSM. However, this is understandable, given that HiTOP is still in its early stages of development. Finally, the HiTOP model may lead to a lack of standardization in communication. Unlike the DSM, which has specific labels, HiTOP describes symptoms along dimensional score cutoffs. This approach could make it harder for clinicians to communicate with each other and with their patients, as the language becomes less intuitive.

What are your thoughts on this?

Figure 1: The current HiTOP model. From: https://www.hitop-system.org/

• If you are interested in learning more about HiTOP, visit the official website here, and for additional information, click here

• If you are interested in how HiTOP was developed click here

• If you are interested in how to integrate HiTOP into your clinical practice, click here

References:

Hierarchical Taxonomy of Psychopathology Consortium. (n.d.). Home. HiTOP System. https://www.hitop-system.org/

University of North Texas. (n.d.). Hierarchical taxonomy of psychopathology (HiTOP). https://hitop.unt.edu/