J Psychopathol Clin Sci
Symptom-based model bests DSM on recovery prediction
Clinical takeaway: Tracking symptom severity across dimensions may give a clearer sense of prognosis than relying on diagnostic labels alone, especially when symptoms overlap or shift over time.
Mental health care still relies largely on DSM categories, yet many patients have overlapping symptoms that don’t fit cleanly into a single disorder. This study asked whether the Hierarchical Taxonomy of Psychopathology (HiTOP), which measures symptoms along continuous dimensions, could better explain how conditions cluster and change over time.
The study analyzed symptom patterns in a nationally representative sample of veterans who had separated from their service branch within the previous six months. HiTOP more accurately predicted clinically meaningful outcomes than DSM diagnoses, including recovery, overall impairment, and symptom severity at 1 year. In contrast, categorical diagnoses provided little prognostic insight, even when multiple disorders were considered together.
The difference is in how each system organizes illness. DSM assigns patients to discrete categories, while HiTOP places symptoms along dimensions. For example, anxiety, depression, post-traumatic stress disorder, and eating disorders fall under a broader “internalizing” domain, reflecting a shared tendency toward negative emotionality. More specific dimensions such as fear, distress, and disordered eating capture how symptoms vary within that broader pattern.
This structure helps explain inconsistencies clinicians see in practice. “There are numerous ways a person could meet criteria for a category,” said Kelsie Forbush, PhD, professor of clinical child psychology at the University of Kansas. “I believe there are 126 different ways a person could meet criteria for anorexia nervosa.” As a result, patients with the same diagnosis may share few symptoms, while those with different diagnoses can look nearly identical clinically.
Small symptom changes can also shift a patient from one diagnosis to another without meaningfully changing the underlying condition. In prior work, patients initially diagnosed with anorexia nervosa often had a different eating disorder diagnosis one year later, despite ongoing illness. “When I get the label, I don’t know: Is this somebody who is at high risk or low risk? It’s just not very informative in that way,” she said.
These findings add to growing evidence that dimensional models like HiTOP may better reflect real-world mental health presentations, matching how clinicians use ranges rather than binary cutoffs to assess severity in other areas of medicine. Framing symptoms this way could improve risk stratification, help anticipate who is more likely to recover or worsen, and support more individualized follow-up across traditional diagnostic boundaries.
The researchers are now working to refine these hierarchies and link them to underlying drivers, such as persistent negative emotionality, with the goal of targeting earlier intervention and potentially reducing progression across multiple disorders.
Source: Forbush KT. J Psychopathol Clin Sci. 2026 May 5. Modeling internalizing symptoms in United States veterans using the Hierarchical Taxonomy of Psychopathology (HiTOP) framework: Gender invariance and longitudinal stability.