What we’ve said about Diagnostic hierarchy

“I want to emphasize it doesn't mean that you assume the one at the top of the hierarchy is there. It's that if you have evidence for both, you must treat the one on top of the hierarchy before the lower one, if you have evidence for both”

“the hierarchy, even if it's simplified and not perfect, makes sure that you don't diagnose conditions that are secondary to another condition, that you're not diagnosing ADHD before treating mood symptoms, which are leading to difficulty with concentrating. You're not diagnosing a personality disorder before treating mood symptoms that could be exacerbating personality aspects”

“we ought to rate each diagnosis on its empirical validity. How valid is And we develop a sort of hierarchy where the more robustly validated disorders are prioritized in diagnosis, and you sort of move down the hierarchy if the patient doesn't meet the criteria for the more Robustly Validated Disorders”

“Starting with DSM-3 and especially DSM-3R, which I think is published in 1988, it removes actually a lot of the hierarchy from DSM. So it becomes possible, for instance, to diagnose generalized anxiety disorder and major depressive disorder in the same patient. Now we can diagnose autism and ADHD in the same patient”

“Patient comes into primary care doctor. And they go, I have a cough. They don't get told they have a cough disorder. We have to figure out what's going on underneath”

“the most immediate recommendation is to try to take a step back, think a little bit harder about what might be driving all of these symptoms. That doesn't necessarily mean it's just one illness”

“i think the top is organic disorders um so we're talking about any sort of medical conditions biological conditions um depending on the disorder you're going to be looking for i think brain problems thyroid problems cortisol all that good stuff”

“True OCD, I would file that between the schizophrenia bipolar level and the level that you had below that, which was what? Depression? Depression, yeah. And sometimes OCD is severe and biological enough to really be on the same level as the psychosis and bipolar section”

“many child psychiatrists rightfully put adhd much higher in their diagnostic hierarchy because the fact is before the age of 17 all the other conditions that we just mentioned are way more rare okay”

“what's most valid? Well, certainly the organic diseases like Alzheimer's disease. But beyond the organic conditions in psychiatry, I think we have to begin with schizophrenia. With manic depressive illness, which is not necessarily equivalent to bipolar disorder”

“Within the personality disorders category, I think there are two personality disorders that are pretty robustly validated, and that's borderline personality disorder and antisocial personality disorder”

“a tool that we call the PRISM psychopathology refracted into seven modalities, that there's sort of like seven major modalities of psychopathology. Psychopathology, mood, personality, thought disorder, et cetera. And that maybe within each of those major modalities, there would be a hierarchy as well”

“can either of you think of a major psychiatric syndrome that doesn't involve problems with concentration and attention? So for me, ADHD is really falls very low. It's a very narrow syndrome that falls very low on the hierarchy. Basically, you have to rule everything else out”

“the ability to think in terms of a hierarchy and then also think in terms of a differential diagnosis where I don't think of my job as knowing for certain what the diagnosis is. But knowing, having a prediction and a percentage that I think it fits and then an order”

“I believe that you have to weigh each possible diagnosis and find which ones are supported. There's no hierarchy. There's a hierarchy if there's obviously sufficient symptoms of certain conditions, right? Mania, hypomania, acute psychosis, OCD, that would impair your ability to elicit or observe the diagnostic features of another condition”

“Would you ever say, I don't like to jump to bipolar disorder? I don't like to jump to schizophrenia. I don't like to jump to major depression. No one says that. You go off the clinical evidence”

“I think we're just tempted to believe this idea that If there is a diagnosis in the DSM and the patient meets the criteria for the diagnosis, we give the diagnosis. I think it's actually a very harmful way of thinking that's really philosophically and scientifically flawed”

“We have a rampant comorbidity problem, and that's the other issue that we talk about in the paper. And this sort of idea would help resolve a lot of what we believe is really spurious or false comorbidity in psychiatry”

“they go, you know, I have a patient, they have bipolar. MDD, ADHD, GAD, Lupus. Yeah. And now they can't focus and I don't know what medication I should go start. They don't really have a frame of reference for how to even think through the problem”

“Do you guys know what the diagnostic hierarchy is? And every single time, at least 80% have never heard of it. And this is residents. This is psychiatry residents at reputable residencies”

“If there's something fundamentally more medical, biological that will not respond to a talk therapy alone, ignoring that you're not going to get much progress”

“the challenge of the more complex it is, probably the more accurate it is, but also the less adherent people will be. And it's so complex that the average clinician can't even understand it. It's not going to get used”

“I would prefer for every clinician to have such a broad knowledge Of all humanity in psychopathology, that we would be individually aware of how biased our own practices, that we are seeing specifically this slice of humanity rather than the other”