Researchers at the University of Kansas led a large-scale study of undergraduate students to better understand how psychological conditions such as depression, anxiety, post-traumatic stress disorder, and eating disorders are related.
The study, published in the Journal of Psychopathology and Clinical Science, relied on the Hierarchical Classification of Psychopathology (HiTOP), a new alternative to the traditional guide for diagnosing and treating patients, the Diagnostic and Statistical Manual of Mental Disorders (DSM).
This finding suggests that the use of symptom dimensions by HiTOP may better support more accurate and individualized mental health care.
The way we diagnose people with mental health problems is problematic. The current system is categorical, so you either have a mental health condition or you don’t. This can be extremely problematic for a variety of reasons, and is especially true for eating disorders. ”
Kelsey Forbush, first author, KU Professor of Clinical Child Psychology
Forbush also pointed to concerns about the DSM, currently recommended by the American Psychological Association, including the tendency for disorders to be highly diverse.
“There are many ways to meet the criteria for a category,” Forbush said. “I think there are 126 different people who meet the criteria for anorexia nervosa. So in many cases, a yes or no label alone doesn’t tell a clinician or therapist what’s really going on with that person. It’s also possible that people with anorexia nervosa and bulimia nervosa share exactly the same symptoms, except for their weight.”
Forbush said two patients could have completely different diagnostic labels but have nearly identical symptoms. Under the DSM, two people with little overlap in symptoms can sometimes be assigned the same label, she added.
“We think some of these issues will also create diagnostic migration issues over time,” Forbush said. “For example, in a study we conducted a few years ago, we found that none of the people diagnosed with anorexia nervosa at baseline had the same diagnosis a year later, but all of them had an eating disorder.”
Forbush said that under the DSM diagnostic system, small changes in symptom presentation can lead to different diagnoses. Because of these issues, HiTOP is attracting attention.
“People want systems that are more clinically helpful and convey more information about prognosis,” she said. “This is another problem with the current diagnostic system. When I receive the label, I don’t know: Is this person a high-risk person or a low-risk person? It’s not very informative in that respect.”
Alternatively, HiTOP uses a dimensional system rather than diagnostic categories. More specific subdimensions, such as fear, distress, and eating disorders, are grouped under broader dimensions.
“These are dimensions, not categories,” Forbush says. “One way I think about it is that when you measure your blood pressure or your weight, it’s a range of numbers. And you can say, ‘Oh, this is high blood pressure,’ or ‘This is the weight that the CDC would say is obese,’ right?”
Forbush and his colleagues are using HiTOP to develop a hierarchy of symptoms and relationships between them to better understand what people are experiencing.
“In our past research, we found that this dimensional system is much more predictive of things like whether someone has recovered, their mental disorder, and how severe their mental health condition is, even after a year,” Forbush said. “On the other hand, the current system, the DSM, was less predictive, even when looking at many diseases together.”
This study used data from a nationally representative sample of veterans collected at KU. All participants were military veterans who had separated from their department of service within the past 6 months.
The researchers analyzed how symptoms clustered and identified internalizing as a broad, higher-order dimension that reflects a tendency toward inward distress. This hierarchical internalization structure supports HiTOP for DSM-style diagnostic categories.
“I think the core of internalization is a heightened tendency toward negative emotions,” Forbush says. “Very high levels of neuroticism. They’re more likely to feel sad, depressed, and anxious; they’re just wired that way. Even negative temperaments. Some babies are born with more negative temperaments than others. That doesn’t mean they’ll develop the disorder. That doesn’t mean it is, but it’s more likely. So the key is to treat that core negative emotion, and the hope is that if it’s treated properly, people won’t develop further disorders in that area.”
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Reference magazines:
Forbush, K.T. Others. (2026). Modeling internalizing symptoms in U.S. veterans using the Hierarchical Taxonomy of Psychopathology (HiTOP) framework: Gender invariance and longitudinal stability. Journal of Psychopathology and Clinical Sciences. DOI: 10.1037/abn0001118. https://psycnet.apa.org/doiLanding?doi=10.1037%2Fabn0001118
