Integrating HiTOP and clinical staging: A developmental framework for multidimensional psychiatric assessment

Abstract Precise assessment and classification of psychopathology are essential components of precision psychiatry. The transdiagnostic clinical staging model holds tremendous promise to advance classification of psychopathology across the lifespan, but it is currently limited in its ability to model complex within-stage symptom profiles (e.g., mixtures of clinical and subclinical symptoms) both during the development of illness (Stages 0-1) and after illness onset (Stages 2-4). The Hierarchical Taxonomy of Psychopathology (HiTOP) provides an operationalized dimensional structure spanning all relevant psychopathology symptoms. Based on a narrative review and synthesis of relevant developmental psychopathology research, this paper theoretically integrates HiTOP and clinical staging to combine the strengths of both approaches. Clinical staging currently conceptualizes symptoms as a unidimensional transdiagnostic domain proceeding from less severe/specific/chronic to more severe/specific/chronic. HiTOP’s classification system can be integrated into the clinical staging framework as a multidimensional symptom domain. This would allow researchers and clinicians to track longitudinal change in psychopathology symptom structures across development, account for clinical complexity, and more accurately forecast risk for Stage 2 psychopathology in early developmental stages (Stages 0-1). Reviewing evidence for patterns of symptom progression that are both consistent and inconsistent with the predominant current clinical staging model, we identify an initial set of five possible developmental tracks (e.g., crystallization from general to specific symptoms, sequential development of different kinds of symptoms, spread from an initial seed symptom dimension). We then highlight opportunities and challenges inherent in this HiTOP-informed clinical staging model, and discuss future implications for research and treatment.