Psychiatry has always tried to bring order to human suffering. First came Freud’s neuroses, then Kraepelin’s manic-depressive insanity and dementia praecox, then DSM and ICD — our attempt to classify the mind the way medicine classifies heart disease or pneumonia.
But over time, cracks began to appear.

Today, clinicians across the world — and especially in busy outpatient clinics in India — face a dilemma:

• A patient walks in with depression… but also anxiety… and obsessive thoughts.

• Another with ADHD traits… but also anger, mood swings, rejection sensitivity, and identity confusion.

• A third with psychosis… but also panic, trauma, and addiction.

Do we give three diagnoses? Five? Or call it “mixed features”?
And more importantly — are these even separate disorders, or one underlying spectrum?

This is the crisis that led to a new way of thinking:
The Hierarchical Taxonomy of Psychopathology (HiTOP).

🚨 What’s going wrong with DSM & ICD?

DSM and ICD gave psychiatry a shared language. But they also created serious problems.

1. Diagnostic Overlap (Comorbidity Explosion)

Studies show that 60–70% of people with depression also meet criteria for anxiety.
OCD overlaps with depression.
Borderline personality + ADHD + PTSD + substance use? Common.
Are these truly separate disorders — or just different faces of the same brain vulnerability?

2. Artificial Cut-Offs → “You have 5 symptoms, so you’re ill. You have 4, so you’re normal.”

Major Depressive Disorder requires 5 out of 9 symptoms.
If someone has 4 severe symptoms, they get no diagnosis, no treatment. This is absurd in real life.

3. Same Diagnosis, Vastly Different People

Two people with “Depression”:

• One cries all day, can’t move.

• Another is functional, but empty and fatigued.
  Both get the same ICD code — but their brains, biology and treatment responses are not identical.

4. No Place for Severity or Personality Traits

DSM asks “Yes or No?”
But real mental health asks, “How much? To what extent?”
There’s no space for temperament, spectrum, individuality, or neurobiological gradients.

5. Neuroscience Doesn’t Match DSM Categories

Brain scans, genetics, neurotransmitter studies — none respect DSM boundaries.
For example:

• The same gene (COMT, DRD4, 5-HTTLPR) is linked to ADHD, bipolar disorder, and schizophrenia.

• The same brain circuits (anterior cingulate, prefrontal cortex) are involved in OCD, depression, and anxiety.

So what is the solution? → Enter HiTOP

HiTOP (Hierarchical Taxonomy of Psychopathology) says:

“Mental illness is not a set of boxes. It’s a spectrum, a gradient — from mild to severe, from normal to extreme — and different disorders often share the same roots.”

Rather than asking, “Does this person have depression?”, HiTOP asks:
“How high or low do they score on:

• Negative emotions (sadness, guilt, hopelessness)

• Anxiety and fear

• Obsessions and compulsions

• Impulsivity, aggression

• Detachment, social withdrawal

• Psychotic experiences**

Symptoms → form patterns → patterns cluster into syndromes → syndromes form spectra.

A Quick Glimpse of the HiTOP Spectra

This is what we’ll explore deeply in the next articles.

🌱 Why This Matters for You (Clinician, Student, or Patient)

• It explains why diagnoses overlap so much

• It helps you diagnose people, not labels

• It makes space for severity, biology, personality, trauma, and culture

• It opens doors to better therapy planning and research

DSM gave us structure. HiTOP gives us clarity, fluidity, and humility.

👨‍⚕️ Author

Dr. Srinivas Rajkumar T
MD (AIIMS, New Delhi), DNB, MBA
Consultant Psychiatrist — Mind & Memory Clinic
Apollo Clinic, Opp. Phoenix MarketCity, Velachery, Chennai
📞 +91-8595155808 | 🌐 www.srinivasaiims.com