The Hierarchical Taxonomy of Psychopathology (HiTOP) is a revolutionary new strategy to approach mental health diagnoses and all of the complex problems involved in them. Since the first Diagnostic and Statistical Manual (DSM) was introduced, mental health diagnoses have been plagued by inconsistency and subjectivity. The first DSM identified homosexuality as a mental illness, and masturbation itself was identified as a hallmark of mental health problems.
In 1973, homosexuality was removed from the DSM after activists and gay psychiatrists forced the APA to recognize they were diagnosing based on social stigma and sexual morals, not science. Multiple Personality Disorder became a hot, popular, and sensational diagnosis in the 80's, and it was heavily involved in the scandal of the Satanic Ritual Abuse and Recovered Memory movement. MPD was predominantly diagnosed by therapists who believed in it, and differential diagnosis from personality disorders and other issues was controversial. Ultimately the MPD diagnosis was changed to Dissociative Identity Disorder, and has quietly been de-emphasized since, with increased recognition that therapist influence and issues of personality disorder can be deeply involved in this presentation.
But, even in DSM-5, political issues, financial conflicts, and personalities continue to influence diagnostic formulations. During DSM-5 development, there was brief consideration of classifying the disorder Vaginismus as an anxiety disorder. But, the stigma associated with diagnosing or treating sexual issues interfered, and Vaginismus remained relegated to the “sexual ghetto” of diagnoses, robbing many women of better treatment and consideration of their needs.
In a recent study, it was found that clinicians, researchers and law enforcement people who believe that Internet/Gaming Use Disorder is real tend to be individuals who are older, have less personal experience with video games, and hold more negative views of young people. What does that mean? It creates the strong potential that this diagnostic framework, like sex addiction, could be inappropriately used to diagnose and treat based on social judgment, morality, and generational differences. The personal charisma and commitment of these individuals to this diagnostic formulation, influenced by the above characteristics, could lead us to treat this as a real disorder, without careful consideration of the complexity of the science and social issues.
HiTOP instead invites us to begin considering mental health issues along a spectrum. Instead of trying to shoehorn a person into fitting a certain diagnostic category, through psychiatric gerrymandering, we instead assess a variety of different areas. A similar strategy exists in the DSM-5, in the alternative diagnostic approach to personality disorders, where clinicians can assess areas such as affect, detachment, antagonism, disinhibition and psychoticism, recognizing that many people with personality disorders don’t neatly fit into rigid categories.
The HiTOP model requires us to base diagnoses and mental health approach on scientific evidence, not opinion or anecdote. So, if there’s no scientific evidence that a certain condition is clearly distinguishable, is abnormal, is persistent, and is separate from normal range of behaviors, then it can’t be diagnosed under HiTOP. No matter how many people online think it’s real, and no matter how much money some shady therapists make by selling unsupported treatments for it. Co-occurring disorders or problems are grouped under a single taxonomical approach, rather than saying that a person has these multiple disorders – instead, we can describe how these various mental health issues occur along a continuum, in this individual.
Shortly after DSM-5 came out, the National Institutes of Mental Health released the RDoC, or Research Domain Criteria. This is a slightly related concept, also assessing along a spectrum, but is primarily focused on neurophysiological and biological issues in the brain. As there is still not a single mental health disorder which can be diagnosed based on neural physiology, based on the science, the RDoC remains speculative and forward looking in the actual practice of mental health treatment. Instead, the HiTOP model gives clear, scientifically-driven attention to the specific mental health needs of an individual.
HiTOP includes six spectra:
The HiTOP model allows for greater assessment and classification of varying levels of functional impairment than does traditional diagnoses. It also starts to move us away from reductionist, distracting diagnostic frameworks, that divert attention to a certain high profile issues or behavior (like Internet use, sex, etc), rather than assessing and addressing the behavior within the larger context. So, under HiTOP, an individual currently (mis) labelled as a sex addict might end up classified as primarily internalizing (if their sexual problems emerge from anxiety or depression or social impairments); or as disinhibited externalizing (if their behaviors reflect impulsiveness, entitlement, selfishness and disregard for others); as antagonistic externalizing (eg., their behavior reflects emotional instability, or need for attention); or even as an aspect of Detachment, if their sexual behaviors (such as high use of porn to exclusion of relationships) reflect difficulties with intimacy and social engagement. Or, an individual might simply fall on different places across all these spectra. But, this strategy would now force clinicians to avoid "one-size fits all" treatment approaches, and require more sophisticated theories, to address heterogeneous presentations.
The HiTOP model has great potential for application in treatment of children with mental health issues, where symptoms often look different than they do in adults. For instance, in adolescent males, depression often looks more like anger, and can lead to misdiagnosis. But under a spectrum-based approach, we can recognize that children’s symptoms and struggles may be fluid, evolving, context-dependent and individualistic.
There’s great work ahead of us. How to integrate the HiTOP model into current mental health practice and the business of mental health is complex. During the DSM-5 development, health insurance companies had an unfortunate level of influence, over what they would pay for or not, which influenced diagnostic decisions. How will HiTOP affect reimbursement? Currently, there are many diagnoses such as personality disorders, which many insurance plans don’t treat as covered diagnoses or treatments. Frankly, I think that’s reprehensible and discriminatory. Under a HiTOP model of diagnosis, insurance companies would have great difficulty saying for instance, “We’ll pay for services for people with high levels of thought disorder but not high levels of antagonistic externalizing.”
For sexual disorders, currently languishing in the “sexual ghetto,” HiTOP offers great opportunity, to begin better integration of sexual issues into an overall concept of a person, relating their sexuality to their affect, relationships, context, personality and life. Instead of trying to treat sexual issues as though they are siloed problems, HiTOP allows us to treat sexuality as just one aspect of a whole person, and starts moving us away from the limitations of the medical model.
HiTOP is introduced by giants in the psychological and psychiatric field. This is the future. Maybe not tomorrow. But within a few years, I believe we will see this introduced to the practice of mental health. Our patients will benefit, and so will our field.