Researcher Caroline Balling discusses how doctors perceived an emerging diagnostic model when compared to the gold standard of mental health diagnosis

Written by ZACHARY HAYES

The process of mental health diagnosis as we know it today is so familiar, it’s hard to imagine any other way: you go to a doctor, you tell them what you’re experiencing, and based off that, they pick the best fit from one of the hundreds of diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders, or DSM, the psychiatric gold standard. But this system has its fair share of flaws, and in recent years, researchers have begun developing alternative diagnostic models to address the limitations of the DSM. The question is, will doctors be open to the change?

One researcher, Caroline Balling, a graduate student and doctoral candidate studying at Purdue University’s clinical science program, decided to investigate this crucial question herself. In her study, published in December 2021 as her master’s thesis, Balling looked into how clinicians perceived an emerging diagnostic model, known as the Hierarchical Taxonomy of Psychopathology, or HiTOP, when compared to the DSM. The study, which asked 143 clinicians to rate how useful these two models were in diagnosing one of three case studies, was the first of its kind to gauge how open clinicians might be to adopting the HiTOP as an alternative system.

Unlike the DSM, which categorizes mental illnesses as discrete medical entities diagnosed based on a checklist of symptoms, the HiTOP model views all mental illness — from bipolar to OCD — as existing on a continuous spectrum that ranges from “normal,” healthy functioning to severe impairment. Under this system, patients would receive a report of scores across the spectrum rather than a single diagnosis, a concept that is foreign to both patients and clinicians alike. But the study revealed some surprising openness to the system among the sampled doctors.

When asked to compare the HiTOP and the DSM on seven measures of clinical utility, clinicians ranked the HiTOP model higher on six of them, including overall clinical utility, utility for formulating effective intervention, communicating clinical information to the client, comprehensively describing client illness, describing global functioning and ease of applying the system to the individual. With the final measure — ease of communicating with other mental health providers — there was no preference, meaning that the DSM was not favored in any of the tested measures, a glaring indictment of the model that forms the basis of our mental healthcare system.

“I thought best case scenario, it would be a dead-even split,” says Balling. “Researchers really seem to hate the DSM, clinicians really seem to hate them DSM, but we really have no idea how they’d respond to something as complicated as a HiTOP hierarchy. I was kind of expecting clinicians to be like, ‘what the heck is this?’”

The DSM, published by the American Psychiatric Association, or APA, has come under fire in recent years, with increasing evidence pointing to issues with low reliability and validity of diagnoses, high rates of comorbidity — being diagnosed with more than one disorder at a time — and arbitrary lines between sick and healthy individuals, amongst others, issues that models like HiTOP hope to address. Even so, the DSM is the standard by which clinicians, insurance companies, policymakers, the criminal justice system and a host of other stakeholders discuss and understand mental illness.

“I compare it to how the incumbent president is always at an advantage,” says Balling. “People hate change. It's hard, and it's scary and threatening, and we're going to be protective of the status quo.”

With this in mind, Balling included a free-response section at the end of the study to solicit feedback from clinicians about the study and the HiTOP model. Despite the DSM’s widespread influence, she found that many clinicians were hardly even using it as part of the diagnostic process.

“In the free response box, we saw the vast majority of clinicians saying the DSM is for insurance purposes,” she says. “In order to get paid, I have to diagnose something. The clinicians in the study often did have a DSM and it is baked into their education. You take classes in psychology, diagnosis, that sort of thing. But in terms of using it to actively diagnose clients, it's pretty rare.”

This openness to another diagnostic system could lead to the adoption of these kinds of alternative models down the road, but with the study largely sampling psychologists, Balling acknowledges that the lack of input from the field of psychiatry needs to be considered.

“Amongst psychiatrists, I would not predict this outcome,” she says. “Psychiatrists tend to really stand by the DSM in a way that psychologists or masters-level clinicians don't. A part of that is the APA. It's developed by psychiatrists. And it's a big cash cow for psychiatry.”

Still, Balling believes that the study provides a glimpse into the future when it comes to the potential for another diagnostic system to emerge.

“I think it is a finger on a distant pulse,” she says. “Paradigm shifts take decades and decades, and one thing that gives me some comfort is that a lot of other disciplines, like astronomy and mathematics, they go back 1000s of years. By comparison, psychology and clinical psychology is very much in its infancy. So maybe when people were figuring out the basics of how, like, the world doesn't hurl itself into the sun, maybe it felt like really helpless and confusing, and now we look back and we're like, ‘well, duh.’ So maybe we just haven’t found the Rosetta Stone yet.”