If you talk to any clinical psychologists or mental health professional, they will tell you the many flaws of the current diagnostic model like the Diagnostic and Statistical Manual of Mental Disorders Edition 5 (DSM-5 to you and me). This model proposes that mental conditions exist in a case where you either have it or you don’t. Clinical psychology has known for ages that this isn’t how mental health conditions work as they exist on a continuum so a new model is needed. Thankfully there is a lot of hope for a new psychology model called the Hierarchical Taxonomy of Psychopathology (HiTOP) and that’s the focus of this fascinating clinical psychology podcast episode.
This episode has been sponsored by Formulation In Psychotherapy. Available from all major eBook retailers and you can order the paperback and hardback copies from Amazon, your local bookstore and local library, if you request it.
What Is The HiTOP Approach?
I’m not going into to go too much into depth about the problems with the existing “All-Or-Nothing” model of diagnosis that always misses out too much important information and it misses the important something-in-between action. Because I’ve mentioned it before on the podcast, in books and it’s very well documented.
Therefore, over the past 20 years, there has been a call within psychology to replace the old DSM system, and this call has been gaining strength and momentum ever since. Resulting in these efforts causing and coalescing into what’s known as the “Quantitative Classification Movement”. This is a group of scientists with the goal to get rid of the traditional reliance on a priori (non-tested) assumptions about mental health conditions, like the idea that they’re categorical when they aren’t, and replace the system with a new dimensional model based on the findings about the actual organisation of psychopathology.
For example, the system will provide a more useful guide for patients, clinicians and researchers as well as enabling psychologists to study and treat characteristics that are common to a range of conditions.
In addition, the HiTOP approach uses statistical procedures, like factor analyses, to identify constellations of co-occurring signs, maladaptive traits and symptoms. Then the approach organises them into a hierarchy based on patterns of association.
Resulting in this model, certain mental health constructs, like externalising behaviours, are measured and regarded on a continuum (or sliding scale if you will) in the exact same way how medical doctors think of blood pressure or viral loads. Leading to the different levels of the construct being empirically associated with different common outcomes and treatment being assigned based on these risks.
Personally, I think this approach so far sounds very promising like Formulation In Psychotherapy, it is about moving mental health into the future and advancing it. Moving away from outdated models that don’t work as effectively as they did due to new research casting doubt them. As well as it is important to keep moving forward because as I mentioned in my Clinical Psychology Reflection book, the unofficial mandate of clinical psychologists is to absolutely help people improve their lives and decrease their psychological distress.
And if this HiTOP approach is something that can help us to do, then we must consider it and advancing the field of mental health forward.
Research On The HiTOP Approach:
It turns out that the HiTOP approach is actually the result of research into the new dimensional approach of mental health. With HiTOP itself looking to empirically identify psychopathology structures in a person by, according to the Renaissance School of Medicine at Stony Brook University:
“combining individual signs and symptoms into homogeneous components or traits, assembling them into empirically-derived syndromes, and finally grouping them into psychopathology spectra"
In much easier terms to understand this, the HiTOP approach seeks to match a person’s difficulties and their behaviours with fundamental dimensions of maladaptive behaviours. For example, matching a person’s depressed mood and negative cognitive style with some dimensions giving you depression. That is the easiest way to explain it at the moment.
What Are Spectras In HiTOP?
In the HiTOP approach, you have 6 different spectras so far and each one includes both the psychopathology symptoms and maladaptive traits which are parallel to each other on different time scales. As well as each of these traits capture relatively stable and typical (chronic) personality tendencies, all whilst symptoms tend to reflect the current acute picture of a person’s mental health.
With these six spectras being:
· A Thought Disorder Dimension
This dimension ranges from normal reality testing to maladaptive traits of psychoticism to hallucinations and delusions as well as encompasses symptoms and traits commonly seen in bipolar and psychotic disorders.
· “Internalising” Dimension
The second spectra focuses and accounts for the comorbidity (having two or more conditions at the same time) that can be found in conditions. Like anxiety, depression, PTSD and eating disorders, as well as OCD and sexual dysfunctions.
· Detachment Dimension
Rather similar to personality traits to some extent, this dimension ranges from introversion to maladaptive detachment, to blunted affect and a-violation. As well as the easiest way to think about this dimension is it covers symptoms that are commonly seen in avoidant personalities, so if you cast your mind back to learning about Bowlby and avoidance attachment types. This is what this dimension focuses on more or less.
· Antagonistic Externalising
Then on the flip side this dimension doesn’t focus on avoidant personalities but instead accounts for the comorbid symptoms in other personality conditions. Like those seen in borderline personality disorder and paranoid personalities. Something that I must cover on the podcast at some point.
· Somatoform Dimension
The penultimate dimension focuses on psychosomatic symptoms with it focusing on conversion disorders and other representations of psychological symptoms in physiological ways. For instance in conversion disorder people have symptoms that are common with neurological disorders but there is no physiological explanation for the symptoms. Or another example is people who cannot walk despite there not being a medical reason why not.
However, this dimension is only has been added into the HiTOP approach provisionally as the current evidence for the dimension is ambiguous about whether or not this dimension is actually unique from the internalising dimension.
· Disinhibited Externalising
The final dimension of the approach accounts for comorbidities amongst conditions like conduct disorder, antisocial behaviour, substance abuse and Attention-Deficit-Hyperactivity disorder.
Bringing It More Together
So in an effort to bring everything more together because believe me, I know this is a lot of information and knowledge to take in. but research is continuing in the model with the focus being refining our understanding of the dimensions. As well as evidence like Kotov et al. (2020) suggests that those 6 spectras might be able to be combined into a super-spectra. For example, “emotional dysfunctions” combine the characteristics of internalising and somatoform spectra.
And I must add that would really help to solve the ambiguous problems with those two dimensions.
In addition, the “psychosis” super-spectra might be able to combine the thought disorder and detachment spectras.
However, what is most important for us psychology students and professionals learning about this for the first time (well I am anyway) is that above all these complex words like spectras could sit a general psychopathology dimension containing features common to all mental conditions.
Again we don’t have that sort of overarching understanding with the current DSM model. We aren’t able to look at all mental conditions and see if there are any links between them because in the DSM model everything is organised in concrete categorical with minimal overlap allowed.
As well as you might have thought about it when I was explaining the 6 dimensions but there is ongoing research onto refining the different dimensions themselves because in their current state they do cover a lot of ground that could make it difficult to narrow down different conditions potentially.
That’s why they’re examining the sub-factors of each dimension.
Such as for the internalising dimension, it has been found to have two very distinct subgroups. The distress factor that is evident in PTSD, generalised anxiety disorder and depression. As well as the fear factor that is present in OCD and panic disorders.
Bringing It All Together And Conclusion:
So I know in this podcast episode I have introduced you to a lot of brand new information and I won’t lie, it did get complex at times. But now we all have the information, let’s bring it all
together.
The HiTOP model is a very new model that has thankfully generated a very needed date about the concerns different people have about its practical and theoretical limitations. Doe example, one critic points out the HiTOP model provides very little specific guidance on how HiTOP will help create a classification system for mental conditions that are based on causes and mechanisms.
However, the entire point of this new approach is that it still might be very early days for it in the long term. Yet the research on the model has been promising, like Waszczuk et al. (2021) and the different HiTOP dimensions seem to account for different psychopathological impairments better than the DSM diagnoses.
Additionally, these dimensions have been shown to predict future onset of conditions and symptom timing better than either current or past DSM diagnoses.
Also Ruggero et al. (2019) showed that because of the DSM’s problems, community clinicians often don’t select treatments according to the DSM diagnosis. Since they’re already focusing on symptoms and the person’s signs and experiences.
Overall, clinicians are already aligning their thinking with the HiTOP approach rather than traditional diagnoses. So why not make this approach official?
Personally, that is something I don’t understand. Because under the current system we just give clients a label based on an unempirical category, but if the HiTOP approach is successful.
Then we will instead give our clients results from scientific tests from good solid psychopathology and personality dimensions to generate a psychological profile.
These profiles will replace these labels and the cut-off scores will replace categories. As well as these clients’ profile scores (along with their scores on the different dimensions) will correspond scientifically to certain genetic vulnerabilities, functional impairments, neurobiological factors, environmental risk factors and psychological abnormalities.
Then it is all this data that will be used to guide treatment instead of some categorical thing that the research doesn’t support.
So to wrap up this rather longer than expected podcast episode, as clinical psychology students and professionals, it isn’t a secret how not ideal the DSM system is and that it needs to change. And in an effort to advance mental health and meet the unofficial clinical psychology mandate, it is absolutely imperative that we advance the system we use to diagnose mental health conditions.
And hopefully, just hopefully the HiTOP approach might be the way to go.
I really hope you have enjoyed today’s forensic and clinical psychology podcast episode.
If you want to learn more, please check out:
Formulation In Psychotherapy. Available from all major eBook retailers and you can order the paperback and hardback copies from Amazon, your local bookstore and local library, if you request it.
Have a great day!
Clinical Psychology References:
Kotov, R., Jonas, K. G., Carpenter, W. T., Dretsch, M. N., Eaton, N. R., Forbes, M. K., ... & HiTOP Utility Workgroup. (2020). Validity and utility of hierarchical taxonomy of psychopathology (HiTOP): I. Psychosis superspectrum. World Psychiatry, 19(2), 151-172.
Waszczuk, M. A., Hopwood, C. J., Luft, B. J., Morey, L. C., Perlman, G., Ruggero, C. J., ... & Kotov, R. (2021). The Prognostic Utility of Personality Traits Versus Past Psychiatric Diagnoses: Predicting Future Mental Health and Functioning. Clinical Psychological Science, 21677026211056596.
Ruggero, C. J., Kotov, R., Hopwood, C. J., First, M., Clark, L. A., Skodol, A. E., ... & Zimmermann, J. (2019). Integrating the Hierarchical Taxonomy of Psychopathology (HiTOP) into clinical practice. Journal of consulting and clinical psychology, 87(12), 1069.
https://renaissance.stonybrookmedicine.edu/HITOP/AboutHiTOP
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