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March 2016

Why We Need a Transdiagnostic Staging Approach to Emerging Psychopathology, Early Diagnosis, and Treatment

Author Affiliations
  • 1Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, Australia
  • 2Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
JAMA Psychiatry. 2016;73(3):191-192. doi:10.1001/jamapsychiatry.2015.2868

One of the urgent challenges for psychiatry is to create a simpler, more useful approach to diagnosis.1 Our traditional diagnostic systems are categorical and siloed, consisting of polythetic operational definitions of clinical phenotypes. The boundaries between syndromes and phenotypes are not clear and comorbidity is the rule rather than the exception. We know that dimensionality underlies most of these phenotypes and that distress, impairment, and need for care is not limited to the full threshold versions of these phenotypes. This means that a transdiagnostic approach is going to be necessary. The dynamics of early psychopathology are complex and emerging microphenotypes ebb, flow, and evolve in many patterns, which do not follow rigid train tracks to discrete macrophenotypes such as schizophrenia or bipolar disorder. The reification of these macrophenotypes has led to a spurious certainty about the indications, specificity and timing of drug therapies, with risks of premature and overtreatment, undertreatment, and mismatched treatment. Emerging psychopathology is a mixture of anxiety, affective dysregulation, aberrant salience, motivational changes, and other features that dynamically influence one another over time, creating a range of clinical patterns.2,3 Despite this complexity and dimensionality, treatment decisions are binary, and clinicians need useful categories for guiding these decisions. This is why clinical staging has emerged as a potentially useful model.4