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The standard of diagnosis in the United States is and has long been the Diagnostic and Statistical Manual of Mental Disorders (DSM), disseminated by the American Psychiatric Association (APA; APA, 2013). The DSM has been translated into 24 languages and is referred to by researchers, clinicians from multiple orientations, policy-makers, criminal courts, and third-party reimbursement entities (APA Publishing, 2017; Kawa & Giordano, 2012). It is the reference for the diagnosis and categorization of mental disorders of all types in the United States and increasingly in Europe and Asia (Kawa & Giordano, 2012). A classification system such as the DSM accomplishes many goals. It is fundamental to the study and treatment of psychopathology by providing a common language for researchers, clinicians, educators, and students to communicate with each other. It has become a central tool for the dissemination of research, conceptualization of psychiatric cases, and education of future psychologists. Further, it permeates beyond the boundaries of the psychological discipline alone and allows for interdisciplinary discourse, cooperation from insurance companies, and a foundation for understanding amongst the general public. The influence and impact of the DSM is undisputable. Concerningly, the DSM has been criticized through evidence suggesting it lacks appropriate validity, reliability, and clinical utility (Kotov et al., 2017; Widiger & Simonsen 2005; Widiger et al., 2018). One might review the DSM-5 field trials as evidence of the unacceptability of this diagnostic system; two of the most commonly occurring DSM diagnoses, generalized anxiety disorder and major depressive disorder, garnered poor kappa coefficients between 0.20 and 0.25 (Regier et al., 2013). Many criticisms of the DSM are rooted in the manual’s assumption that mental disorders and associated symptoms are discrete categorical phenomena, such that they can be definitively identified as present or absent. This dichotomous format implies the existence of meaningful cut-offs for these constructs, but this has not been demonstrated empirically. On the contrary, evidence has repeatedly indicated that psychopathology exists on dimensions that include adaptive and normative functioning (Achenbach, 2015; Carragher et. al, 2015; Eaton et al., 2011; Kotov et al., 2017; ). The consequences of the DSM approach to diagnosis are numerous. To start, polythetically defining psychological disorders produces significant heterogeneity within diagnostic groups. This leads to the loss of valuable clinical information, such as by eliminating details about the onset and chronicity of the individual’s symptoms, what symptoms the client is experiencing, and the severity of those indicators (Carragher et. al, 2015). As an example, consider that a client can meet DSM-5 criteria for borderline personality disorder (BPD) by endorsing five or more diagnostic criteria out of a possible nine. Two clients might share only one of the nine BPD criteria and still be lumped under the same diagnostic label of BPD, despite exhibiting clearly distinct clinical presentations. An additional consequence of the DSM system is that comorbidity is exceedingly common in clinical and community samples (Conway et al., 2019; Kotov et. al, 2017; Ruggero et al., 2019). This excessive co-occurrence of diagnoses further challenges the notion that the categorical diagnoses are discrete entities. Importantly, it also complicates and obscures empirical and clinical work, and empirically, this can lead to comorbidity exclusion criteria that render clinical study samples largely ungeneralizable (Zimmerman et al., 2019). Finally, the majority of patients are categorized with ambiguous “unspecified” or “not otherwise specified” diagnoses because they do not meet the often-arbitrary diagnostic thresholds of the more specific disorders (Achenbach, 2015; Carragher et. al, 2015; Kotov et al., 2017). Of course, these unspecified diagnoses have minimal utility in research or clinical practice. This abundance of unspecified diagnoses also calls into question the validity of the cutoffs that the DSM applies to its symptoms and syndromes. Taken together, this body of research has led some in the field to conclude that the DSM and its categorical diagnostic system are inadequate. The Hierarchical Taxonomy of Psychopathology (HiTOP) has been offered as a solution to these criticisms (Kotov et al., 2017; Widiger et al., 2005; Widiger et al., 2018). HiTOP was introduced in 2017 as a system for dimensionally classifying all variants of psychopathology, including Axis I and Axis II disorders (Kotov et al., 2017). Broadly, this model conceptualized the structure of psychopathology as a hierarchy; at the bottom of the hierarchy are psychiatric signs and symptoms and at the top are increasingly broad dimensions, such as internalizing and externalizing factors (Caspi et al., 2014; Kotov et al., 2017; Lahey et al., 2012). The highest and broadest level of the hierarchy is the superspectrum of general psychopathology (or p factor). At the next level down are the spectra such as internalizing and externalizing, followed by subfactors such as fear and distress, and then the level of syndromes and disorders. At the bottom of the hierarchy are psychiatric signs, symptoms, components, and traits, such as worry, checking behaviors, or anhedonia. The debut publication of HiTOP in 2017 challenged many long-accepted, -researched, and -implemented ideologies in the fields of psychiatry and clinical psychology regarding the classification of psychopathology. Although this publication was a first encounter with dimensional theory for many professionals, the publication was built on a sturdy, long-standing foundation of research into the dimensional nature of psychopathology across the lifespan (Achenbach, 1966; Achenbach, 2015; Carragher et al., 2015; Krueger & Eaton, 2015). Indeed, the developmental psychopathology approach already operates with an understanding that psychopathology is predominately dimensional in nature (e.g. Rutter, 2013; Rutter & Uher, 2012). But the recommendation to replace the DSM and its categorical diagnostic system has been met with criticism and doubt by others in the field. One scholar likens the movement away from the DSM to “throwing the baby out with bath water” (Zimmerman, in press) and others state that “the HiTOP consortium is writing checks it can’t cash” (Haeffel et al., in press). A common sentiment in these critiques is a lack of evidence that the HiTOP dimensions are clinically useful or that clinicians can appropriately apply them. Critics have also hypothesized resistance from clinicians to adopt such a system. Past research has evidenced that clinicians find dimensional models of personality pathology acceptable and often preferred to a categorical conceptualization (e.g. Hansen et al., 2019; Glover et al., 2012; Morey et al., 2014). For example, studies have found that clinicians consider dimensional personality traits to be more useful than categorical DSM diagnoses for clinical decision-making, treatment planning, comprehensively covering client difficulties, communication with the client, and generating global personality descriptions (Samuel & Widiger, 2006; Samuel & Widiger, 2011). Data pertaining to clinician perception of and satisfaction with HiTOP-friendly measures such as the ASEBA, MMPI, and PAI is lacking. Importantly, there is no data regarding clinician perception of the HiTOP model beyond personality pathology. Thus, of the questions that remain about the clinical application of HiTOP, assessing the clinician perception of this diagnostic approach is one area of sorely needed data. And in moments of differing opinion amongst researchers, perhaps it is most appropriate to turn to those most closely involved in patient care. The voices of clinicians are welcome and needed in this ongoing push towards HiTOP and dimensionalization, and we particularly need to assess the clinician perception of the utility, accessibility, and helpfulness of the full HiTOP model. The goal of the present study is to assess clinician perception of the utility and comprehensiveness of the HiTOP system for the conceptualization of diagnostically complex clinical cases. Clinicians will rate one of three clinical vignettes according to the top three HiTOP levels: superspectra (i.e. the p factor), spectra (somatoform, internalizing, thought disorder, etc.), and subfactors (e.g. eating pathology, substance abuse, mania). At present, there is limited distinction between the diagnoses of the DSM and the syndrome/disorder level of HiTOP, so this fourth level of HiTOP will be excluded. The fifth level of HiTOP, symptom components and maladaptive traits (e.g. anxiousness, checking behaviors, avolition), will also be excluded. This is in part because this level includes over eighty constructs, and that is too many items to reasonably ask clinicians to rate on a brief survey with minimal compensation. Additionally, signs, symptoms, and components will already be presented in the vignettes to convey clinical information, so to have the clinicians rate these would be redundant. In addition to rating the client on the three levels of HiTOP, clinicians will also rate the client according to DSM-5 diagnoses. Following diagnostic ratings, the clinicians will complete surveys assessing their subjective satisfaction with and overall perception of the HiTOP and DSM systems, as well as how the dimensional approach compares to their typical diagnostic categorization and their experience with the DSM-5.
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HiTOP
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Clinician Perception of the Utility of the Hierarchical Taxonomy of Psychopathology (HiTOP) System
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2021
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2021-06-07
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Clinician Perception of the Utility of the Hierarchical Taxonomy of Psychopathology (HiTOP) System
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Douglas B. Samuel
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Douglas B. Samuel
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Donald Lynam
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Caroline Balling
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Caroline Balling
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Susan Carol South
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Susan Carol South
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