Prioritization of Psychopathological Symptoms and Clinical Characterization in Psychiatric Diagnoses: A Narrative Review

Importance: Psychiatry mainly deals with conditions that are mediated by brain function but are not directly attributable to specific brain abnormalities. Given the lack of concrete biological markers, such as laboratory tests or imaging results, the development of diagnostic systems is difficult. Observations: This narrative review evaluated 9 diagnostic approaches. The validity of the DSM and the International Classification of Disorders (ICD) is limited. The Research Domain Criteria is a research framework, not a diagnostic system. The clinical utility of the quantitatively derived, dimensional Hierarchical Taxonomy of Psychopathology is questionable. The Psychodynamic Diagnostic Manual Version 2 follows psychoanalytic theory and focuses on personality. Unlike the personality assessments in ICD-11 or DSM-5's alternative model, based on pathological extremes of the big 5 traits (extraversion, agreeableness, openness, conscientiousness, and neuroticism), it lacks foundation in empirical evidence. Network analytic approaches are intriguing, but their complexity makes them difficult to implement. Staging would be easier if individually predictive biological markers were available. The problem with all these new approaches is that they abstract patient experiences into higher-order constructs, potentially obscuring individual symptoms so much that they no longer reflect patients' actual problems. Conclusions and Relevance: ICD and DSM diagnoses can be questioned, but the reality of psychopathological symptoms, such as hallucinations, depression, anxiety, compulsions, and the suffering stemming from them, cannot. Therefore, it may be advisable to primarily describe patients according to the psychopathological symptoms they present, and any resulting personal syndromes, embedded in a framework of contextual clinical characterization including personality assessment and staging. The DSM and ICD are necessary for reimbursement, but they should be simplified and merged. A primarily psychopathological symptoms-based, clinical characterization approach would be multidimensional and clinically useful, because it would lead to problem-oriented treatment and support transdiagnostic research. It should be based on a universally used instrument to assess psychopathology and structured clinical characterization.