HiTOP, an efficient alternative model of psychopathology?
Considering the ubiquity and practical omnipresence of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (1) in North American psychiatric practice and research, it may come as a surprise to some that the validity of many (if not most) of the diagnoses described are consistently questioned; in fact, up to 40% of diagnoses failed to reach justifiable reliability in the DSM-5 field trials(2)(3). Moreover, many clinicians do not refer to the DSM in practice (4).
While in a clinical sense it is important for many patients to know they have a psychiatric disorder or not, there is no evidence to support the existence of mental disorders as discrete categorical entities; in fact most evidence points to a dimensional or continuous nature of psychopathology (5).
In response, Roman Kotov and colleagues proposed a new model called “Hierarchical Taxonomy of Psychopathology” (HiTOP)(5). This alternative model of psychopathology conceptualizes mental disorders as dimensional and hierarchically organized. This new approach, which is driven by statistical modelling rather than clinical impression, suggests that mental disorders could be described at various levels, beginning from a transdiagnostic factor for psychopathology (“p” factor (6)) down to individual signs, symptoms, and personality traits. It is also considered a living model, which is continuously updated with the most recent scientific evidence(5)(7).
While still quite novel, and changing, the HiTOP model may be a revolutionary alternative to clinicians and researchers alike, with the possibility to be a complementary factor to clinical manuals such as the DSM-5 and ICD, opening the door to innovative ways of conceptualizing and testing hypotheses about mental illness.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). American Psychiatric Pub; 2013. 1520 p.
2. Chmielewski M, Clark LA, Bagby RM, Watson D. Method Matters: Understanding Diagnostic Reliability in DSM-IV and DSM-5. J Abnorm Psychol. 2015 Aug;124(3):764–9.
3. Regier DA, Narrow WE, Clarke DE, Kraemer HC, Kuramoto SJ, Kuhl EA, et al. DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses. AJP. 2013 Jan 1;170(1):59–70.
4. Ruggero CJ, Kotov R, Hopwood CJ, First M, Clark LA, Skodol AE, et al. Integrating the Hierarchical Taxonomy of Psychopathology (HiTOP) into Clinical Practice. J Consult Clin Psychol. 2019 Dec;87(12):1069–84.
5. Kotov R, Krueger RF, Watson D, Achenbach TM, Althoff RR, Bagby RM, et al. The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. J Abnorm Psychol. 2017 May;126(4):454–77.
6. Caspi A, Houts RM, Belsky DW, Goldman-Mellor SJ, Harrington H, Israel S, et al. The p Factor: One General Psychopathology Factor in the Structure of Psychiatric Disorders? Clin Psychol Sci. 2014 Mar;2(2):119–37. 7. Kotov R, Krueger RF, Watson D, Cicero DC, Conway CC, DeYoung CG, et al. The Hierarchical Taxonomy of Psychopathology (HiTOP): A Quantitative Nosology Based on Consensus of Evidence. Annual Review of Clinical Psychology. 2021;17(1):null.