nature reviews psychology https://doi.org/10.

1038/s44159-023-00218-4

Review article Check for updates

A review of approaches and

models in psychopathology
conceptualization research
Nicholas R. Eaton 1
, Laura F. Bringmann 2, Timon Elmer 2, Eiko I. Fried 3, Miriam K. Forbes 4,
Ashley L. Greene 5
, Robert F. Krueger 6, Roman Kotov7, Patrick D. McGorry8,9, Cristina Mei8,9 & Monika A. Waszczuk 10

Abstract Sections

Mental disorder classification provides a definitional framework that Introduction

underlies applied clinical and research efforts to understand, assess, Transdiagnostic dimensional
predict, prevent and ameliorate the burden of psychopathology. approaches

Many classification frameworks exist, perhaps most notable being Network psychometric
approaches
the ‘authoritative’ systems of the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders and the 11th revision of the Clinical staging approaches

International Classification of Diseases. However, numerous limitations Time and development

of official classification systems have been identified, fostering the Translation to clinical practice
development of empirically derived, statistical and psychometric
alternative classification approaches, which attempt to overcome
those limitations. In this Review, we describe three such advances:
transdiagnostic dimensional approaches (such as the Hierarchical
Taxonomy of Psychopathology; HiTOP), network approaches and
clinical staging approaches. We discuss their strengths, limitations,
divergence, overlap, and scientific and clinical utility, with a focus
on the potential synthesis and integration of disparate approaches
towards better classification of mental disorders.

1
Department of Psychology, Stony Brook University, Stony Brook, NY, USA. 2Faculty of Behavioral and Social
Sciences, University of Groningen, Groningen, The Netherlands. 3Department of Clinical Psychology, Leiden
University, Leiden, The Netherlands. 4School of Psychological Sciences, Macquarie University, Sydney, New South
Wales, Australia. 5VISN 2 Mental Illness Research, Education, and Clinical Center, James J. Peters VA Medical Center,
New York, NY, USA. 6Department of Psychology, University of Minnesota, Minneapolis, MN, USA. 7Department of
Psychiatry, Stony Brook University, Stony Brook, NY, USA. 8Orygen, Parkville, Victoria, Australia. 9Center for Youth
Mental Health, The University of Melbourne, Parkville, Victoria, Australia. 10Department of Psychology, Rosalind
Franklin University of Medicine and Science, North Chicago, IL, USA. e-mail: [email protected]

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Introduction approaches can be applied to study within-person changes over time

Mental disorder classification provides a definitional framework that in both the short term and across the lifespan, and we discuss their
underlies applied clinical and research efforts to understand, assess, potential clinical applications. We conclude with future directions for
predict, prevent and ameliorate the burden of psychopathology. the classification of mental disorders at the intersection of the three
A wide variety of such classification frameworks has emerged, dif- approaches.
fering in notable ways. Each takes a unique position on how mental
disorders should be diagnosed, classified and assessed and on how Transdiagnostic dimensional approaches
psychopathology itself is structured. Transdiagnostic dimensional approaches apply continuous (versus
‘Official’ classification systems (nosologies), such as the fifth categorical or dichotomous) dimensions to psychopathology data,
edition of the Diagnostic and Statistical Manual of Mental Disorders which represent unbroken spectra (also referred to as factors) that
(DSM-5)1 and the 11th revision of the International Classification of range from very low to very high levels (and all levels in between).
Diseases (ICD-11)2 are composed almost exclusively of very large sets Further, these spectra are transdiagnostic: these dimensions are not
of dichotomous (present/absent) diagnoses, each of which is itself simply continuous reflections of official dichotomous diagnoses but
composed of a set of diagnostic criteria. These are known as polythetic instead cut across the diagnostic boundaries separating disorders23,24.
criterion sets: if a given person exhibits a pre-defined number of these In doing so, these dimensions are interpreted as reflecting core
criteria, and experiences related distress or impairment, that person ‘building blocks’ of variation that characterize multiple disorders.
is assigned that particular diagnosis. Because the DSM-5 and ICD-11 Thus, a single transdiagnostic dimension, such as ‘internalizing’,
define disorders as independent of one another, one would expect can include psychiatric phenomena from different diagnoses of the
their frequency of comorbidity due to chance to reflect the preva- same type (in this case, major depressive disorder and dysthymic
lence rates of the disorders. For example, based on reported national disorder, both of which are mood disorders) as well as from differ-
prevalence rates of major depression (13.3%) and generalized anxiety ent groupings of disorders (in this case, mood disorders and anxiety
disorder (2.7%) in the USA,13.3% of individuals with generalized anxiety disorders)24.
should also have major depression due to chance alone3. However, the Transdiagnostic dimensions overcome many of the problems
observed rate of major depression in this population is closer to 53%3. with official nosologies. First, their dimensionality (versus a present/
Thus, a fundamental problem with these nosologies is that they do absent dichotomy) captures the structure of real-world data, where
not account for the high rates of comorbidity (co-occurrence) among samples of individuals report levels of psychopathology that generally
putatively distinct mental disorders. range widely — above and below DSM-5 diagnostic thresholds — and
The distinctions between categorical diagnoses are further have no clear points of discontinuity across severity levels25. Further
obscured by symptom overlap4. Moreover, because arbitrary thresh- empirical support for dimensionality comes from taxometric research
olds are used to demarcate the presence or absence of mental disorders that finds little evidence for discrete groups within a spectrum26, and
(such as requiring the presence of at least five of nine diagnostic criteria genetic evidence suggests that liability to mental illness is continuously
to receive a diagnosis), two people with the same diagnosis might distributed27.
have only a single symptom in common. A further consequence of this Second, although diagnostic comorbidity is viewed as a prob-
‘checklist’ approach is that one diagnosis often collapses hundreds or lem in traditional classification frameworks, transdiagnostic dimen-
thousands of potential symptom presentations into a single ‘present’ sional models explicitly embrace comorbidity by modelling these
versus ‘absent’ category5–7, which is inconsistent with the continuous relationships among mental health variables. These models explicitly
and dynamic nature of observed signs and symptoms that individu- allow for greater-than-chance correlations among different forms of
als experience in daily life8. In other words, the dominant models of psychopathology and for overlap among them.
mental disorder classification (such as discrete DSM-5 diagnoses) do Third, dimensionality overcomes the need for largely arbitrary
not fit the data9. Consequently, comparing people ‘with’ and ‘without’ a diagnostic criterion thresholds. As an example, using the official
diagnosis — for example, to identify risk factors or treatment effects — is nosologies’ threshold of at least five of nine criteria being present
often not a meaningful endeavour. Related to both symptom overlap to support the diagnosis of a given mental disorder, individuals with
and arbitrary thresholds, there is substantial unreliability in tradi- similar levels of psychopathology (such as a person meeting four cri-
tional diagnoses—there is low inter-rater reliability and instability in teria and another meeting five criteria) would be described as being
individual diagnoses over time6,10,11. totally different (in this case, diagnosis absent and diagnosis present,
Together with the misalignment between traditional diagnoses respectively), whereas individuals with notably different levels of
and key mechanisms in neuroscience, molecular genetics, biologi- psychopathology (such as a person meeting five criteria and another
cal psychiatry and clinical psychology12,13, the limitations of official meeting nine criteria) would be described as exactly the same (both
nosologies hinder progress in, for example, identifying biomarkers of receiving a diagnosis). Thus, thresholds obscure important similarities
mental illness and improving treatment outcomes14–16. Psychopathol- and differences within diagnoses and across individuals by group-
ogy classification is therefore facing a demonstrable paradigm shift in ing individuals into one of two diagnostic groups (diagnosis present
an attempt to overcome these limitations17–22. versus diagnosis absent). Because transdiagnostic dimensions have
In this Review, we summarize progress in psychopathology classi­ no thresholds, the similarity (or dissimilarity) between two individu-
fication to date emerging from three leading alternative approaches: als is fully characterized by their levels (or scores) on the underlying
transdiagnostic dimensional approaches, network approaches and dimension(s). This dimensional view of psychopathology addresses the
clinical staging approaches. Each approach takes a different route to — well known failure of traditional nosologies to recognize subthreshold
and makes different theoretical assumptions about — the structure of manifestations of psychopathology, which are associated with high
mental disorder. First, we review the foundations, key research find- rates of suicidal behaviour, health service utilization, public assistance
ings and limitations of each approach. Next, we consider how the three costs, and impairment and disability28,29.

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Key classification findings neuroticism (versus emotional stability), extraversion, agreeable-

Transdiagnostic dimensionsional approaches generally fall into two ness, conscientiousness and openness37,38. Multiple subdimensions
groups: those that arose specifically to organize personality disorder (facets) were identified as nested within each dimension, producing
variation, and those that arose to organize psychopathology more a hierarchical organization of personality traits with increasing levels
broadly. This grouping stems from early work on the part of personality of generality, ranging from narrow habits (for example, ‘frequency of
disorder researchers to move toward dimensional models to overcome tooth brushing’) at the base and broad predispositions (for example,
problems with official personality disorder diagnoses. Informed by ‘conscientiousness’) at the apex. This Five-Factor Model, and the very
this earlier work, psychopathologists began applying similar meth- similar Big Five (see Fig. 1a), are the best established frameworks of
odologies to broader types and numbers of disorders, sometimes still dispositional traits.
including personality disorders in their analyses. These models are Dimensional research on the structure of personality pathology
remarkably congruent despite their unique origins. Further, they build has been largely based on personality disorder symptoms included in
upon, and converge with, findings from research on the structure of the DSM-5. These studies consistently revealed five domains of mala-
normal-range personality variation, and they outperform models from daptive personality: negative affectivity (versus emotional stability),
official nosologies with regard to superior model fit to observed data detachment (versus extraversion), antagonism (versus agreeable-
and structural validity30–34. ness), disinhibition (versus conscientiousness) and psychoticism39. The
Fundamental dimensions of general personality were examined first four pathological domains map closely onto their normal-range
to organize all of the stable personality-related attributes that can Five-Factor Model counterparts40,41. The link between psychoticism and
describe people. They were shaped by comprehensive analyses of openness is unsettled42. As in the Five-Factor Model, the higher-order
adjectives abstracted from dictionaries35 and separately by hypotheti- domains of personality pathology subsume a set of narrow traits
cally derived lists of items36. Such research programmes independently (for example, ‘risk taking’). This hierarchical organization was included
identified five dimensions of personality, often referred to as domains: in the DSM-5 Alternative Model for Personality Disorders1,43 (Fig. 1b), and

a Simplified Five-Factor Model structural model

Domains: Neuroticism Extraversion Openness Agreeableness Conscientiousness
Assertiveness

Competence
Vulnerability

Dutifulness
Depression

Aesthetics

Modesty
Altruism
Warmth
Anxiety

Activity

Values

Order
Ideas

Trust

Facets:

b Simplified Alternative Model for Personality Disorders structural model

Domains: Negative affectivity Detachment Psychoticism Antagonism Disinhibition
Suspiciousness

Irresponsibility
dysregulation

Deceitfulness
Anxiousness

Depressivity

Callousness
Eccentricity

Grandiosity
Withdrawal

Impulsivity
Anhedonia

Perceptual

Risk taking
thoughts
Hostility

Unusual

Facets:

c Simplified HiTOP structural model

Superspectra: p-Factor

Externalizing

Antagonistic Disinhibited
Spectra: Internalizing Detachment Thought disorder
externalizing externalizing

Fig. 1 | Links between factors in dimensional models. a, Simplified Five- of Personality Disorders psychoticism domain and the HiTOP thought disorder
Factor Model structural model. b, Simplified DSM-5 Alternative Model for spectrum are unresolved. For simplicity, not all facets of each domain of
Personality Disorders structural model. c, Simplified Hierarchical Taxonomy the Five-Factor Model and Alternative Model for Personality Disorders are
of Psychopathology (HiTOP) structural model. Domain and spectrum boxes depicted. Only the highest-order portion of the full HiTOP model is depicted
are shaded by colour to show their corresponding domains and spectra (see Supplementary Fig. 1 for the full model), and the somatoform spectrum is
across the three models. The unfilled box around the five-factor model not included on account of ongoing questions about its optimal placement in
openness domain indicates that its associations with the Alternative Model the model.

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of covariation into a hierarchy, with the six core spectra described

Box 1 above at the centre. Individual symptoms, signs and traits cohere
into higher-level syndromes, then broader subfactors, then the spec-
tra and ultimately super-spectra. Current super-spectra include an
Relationships among externalizing dimension as well as a general factor of psychopathology
(the p-factor) — an overarching dimension that encompasses features
transdiagnostic dimensions common to all forms of psychopathology. Thus, the p-factor is con-

and other approaches ceptually similar to the broad g-factor, which is conceptualized as
general intelligence and represents the relationships among multiple
subtests of intelligence (such as subtests measuring the abilities to
A common question is how transdiagnostic dimensional approaches, answer factual questions, define word meanings and assemble blocks
such as HiTOP, relate to approaches such as the National Institute to reproduce a given pattern)27,49–53. The HiTOP dimensions also bear
of Mental Health’s Research Domain Criteria (RDoC), the National strong conceptual and structural similarities to other independently
Institute on Alcohol Abuse and Alcoholism’s Addictions Neuro­ developed models of psychopathology, such as the Achenbach System
clinical Assessment, and the National Institute on Drug Abuse’s of Empirically Based Assessment54 and the PSY-5 (ref. 55) (Box 1).
Phenotyping Assessment Battery. Although HiTOP takes an Extensive evidence indicates that the general dimensions of the
atheoretical stance on aetiology, these latter approaches were Five-Factor Model, Alternative Model for Personality Disorders and
specifically designed to organize research around biobehav­ HiTOP are closely aligned (see Fig. 1). In particular, there is direct cor-
ioural dimensions, with the intention that these biobehavioural respondence between the Alternative Model for Personality Disorders
dimensions might be closer to potentially aetiologic biological domains and the HiTOP spectra56. Compared to well established HiTOP
substrates such as brain circuits and genes. HiTOP’s focus on spectra such as internalizing and externalizing, relatively less informa-
phenotypes (that is, signs and symptoms of mental disorder), and tion is available about the HiTOP somatoform spectrum, which does not
these systems’ focus on putative biological bases of behaviour include traits explicitly, but nevertheless shows clear links to negative
might seem incommensurate. However, the different dimensions affectivity57. Normal-range personality domains also show expected
included in each of these four approaches have been linked to one links to HiTOP spectra57–61. Overall, a large body of evidence supports a
another, and represent similar constructs to some extent. These consistent structure that unifies these models, with additional unique
relationships usually do not reflect one-to-one relationships (such as variance accounted for by openness and somatoform constructs in the
one single HiTOP domain linking to one single RDoC domain) but Five-Factor Model and HiTOP frameworks, respectively. The models
rather multiple areas of overlap (such as one HiTOP domain linking differ primarily in what aspects of this structure they emphasize: the
to two RDoC domains). For instance, the HiTOP internalizing spec­ Five-Factor Model focuses on the normal range, the Alternative Model
trum shows positive associations with RDoC’s negative valence for Personality Disorders focuses on the maladaptive range, and HiTOP
domain and both negative and positive associations with different includes transient symptoms as well as maladaptive personality traits.
constructs subsumed under RDoC’s arousal and regulatory domain. The utility of transdiagnostic dimensions can be assessed by
Such associations have allowed the development of a crosswalk head-to-head comparisons to traditional diagnoses. Transdiagnostic
between the HiTOP, RDoC, Addictions Neuroclinical Assessment dimensions account for longitudinal links between disorders25 and
and Phenotyping Assessment Battery constructs, and using the sequential unfolding of psychopathology over time62 much better
these systems togther produces a coherent description of than do traditional diagnoses. Numerous studies have demonstrated
psychopathology244. superior prediction by dimensions for a wide variety of important
variables30. For example, dimensions outperform diagnoses in predict-
ing impairment63,64, suicidality25,65,66, and even mortality over 20 years67.
The breadth of these sorts of comparison is reviewed elsewhere45,63. Inves-
this model has been formally instantiated in the Personality Inventory tigation of additional outcomes, such as treatment-related course and
for the DSM-5 (ref. 44) and similar assessment instruments. outcome as well as relationship functioning, is needed to fully adjudicate
In a separate line of inquiry, analyses of common mental disorders the predictive utility of transdiagnostic dimensional approaches68.
and their symptoms consistently revealed six major dimensions: inter-
nalizing, detachment, thought disorder, antagonistic externalizing, Factor meanings and causality
disinhibited externalizing and somatoform30,45. These dimensions have Although the hierarchical approach provides some clear benefits,
been observed across hundreds of phenotypic studies and provide a there is debate on how to interpret transdiagnostic dimensions. One
useful framework for investigating risk factors, biomarkers, prognosis issue is the substantive interpretation of factors. For instance, there
and patterns of treatment response common among psychopathol- are many interpretations of the p-factor, including as a representation
ogy features within a spectrum45–47. Over a hundred narrow symptom of general liability for psychopathology or of overall psychopatho­
components (for example, ‘insomnia’) have been observed within logy severity27,51,53. Another possibility is that the p-factor is a general
these spectra48. consequence of psychopathology (for example, impairment or dis-
The Hierarchical Taxonomy of Psychopathology30 (HiTOP; Fig. 1c, tress) rather than its cause. Moreover, notable criticism has been levied
Supplementary Fig. 1) was developed by a consortium of quantita- against interpretation of what the statistical p-factor actually repre-
tive nosologists to synthesize the parallel literatures on the dimen- sents, owing to its conceptual instability as demonstrated by the varied
sional structures of maladaptive personality and traditional mental meanings ascribed to the general factor across studies69, samples70,
disorder diagnoses into a single overarching hierarchical model. The subsets of variables71, and factor analytic methods (such as exploratory
HiTOP framework organizes dimensions based on empirical patterns factor analysis versus confirmatory factor analysis).

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This issue of interpretation extends to other transdiagnostic such as ecology or meteorology, which have developed statistical
dimensions. Dedicated research is needed to test whether the dimen­sions tools for forecasting system transitions to different states (such as
represent risk for specific domains of psychopathology (that is, a pre- a healthy to a turbid lake or sunny weather to tropical storm). These
disposition towards experiencing the indicators of the dimension27,51), tools have been applied to forecast transitions into mental disorders
or a descriptive summary of the severity of presenting symptoms in that such as depression, and there is some preliminary evidence that both
domain45,52. For example, the internalizing dimension might capture variable-specific and system-level early warning signals might forecast
a propensity towards negative affect that causes experiences such as transitions from healthy to disordered states82–86. Much remains to be
depressed mood, worry and panic; or it might only describe these expe- done, and some work raises questions as to the value of early warning
riences. Both possibilities are useful for assessment and diagnosis, but systems as a personalized prediction method87,88.
they have different implications for application in practice. However, it Second, network approaches have shown promise in bridging
is important to remember that, statistically, latent variables estimated the gap between theoretical and statistical models via formal theo-
to model the structure of psychopathology simply summarize the pat- ries. To build a formal network theory, researchers first embed all
terns of comorbidity or covariation among the indicators in the model. of the evidence about the target system that they want to capture
Theory building and testing are required to move beyond the assump- into a coherent theoretical structure (for example, the components
tions and limitations of relying on latent variables and to understand of panic disorder, and the exact network relations among compo-
better the substantive nature of the dimensions. nents of panic disorder), and then translate these relations into
mathematical terms (usually difference equations) that specify the
Network psychometric approaches theory formally89,90. Such formal theories facilitate theory formation
Transdiagnostic dimensional approaches summarize psychopathol- by — among other factors — sidestepping ambiguities of language by
ogy at the between-subjects level, and each domain is conceptual- requiring mathematical notation (all variables and relations among
ized as dimensional at the population level26. Network approaches variables must be spelled out exactly) and allowing researchers to
to psychopathology offer an alternative point of view, where mental generate data from a given theory to investigate what theory-implied
health and disorder are seen as complex, dynamic biopsychosocial data would actually look like (which is not possible for verbal theories).
systems. The core idea is that problems, such as psychopathology The generated data can then be compared to observed data of the
symptoms, influence each other, and mental disorders emerge from phenomenon under investigation, leading to iterative theory building
the relations among these problems17,72–74. Further, mental disorders and testing89,91. For example, a formal theory for panic disorder73 found
are conceptualized as within-person systems that unfold over time. that the generated data were consistent with many known phenomena
From this perspective, mental health conditions can be thought of as about panic attacks (such as key phenomenological characteristics,
systems that have categorically distinct healthy and disordered states,
similar to other complex systems in science. For instance, lakes can
have clean (fresh and blue) or turbid (green and full of algae) states.
Transitions between such states might be abrupt for some individuals
(or lakes) but gradual for others, which is not consistent with a purely
Box 2
dimensional model17,75,76.
Network approaches have become more prominent owing to the Real-world statistical
development and translation of statistical network models into psy-
chology over the past decade and the availability of accessible tutorial implementation of dimensional
papers (Box 2). The network approach is particularly useful for estimat-
ing and visualizing interrelations of variables (such as symptoms) at and network approaches
the group level (Fig. 2a) or at the individual level (Fig. 2b).
Compared to official nosologies of mental disorders, research Transdiagnostic dimensional approaches and network approaches
on network approaches has thus far not aimed to identify or define to understanding mental disorders are grounded in particular
clear-cut categories; rather, it emphasizes that comorbidity is a natural statistical methodologies and models. Factor analytic methods
result of causal associations among problems, irrespective of diagnos- that are used in transdiagnostic dimensional approaches are
tic boundaries77. Viewed from a network perspective, existing catego- widely available in common software packages, including
ries such as major depressive disorder or schizophrenia are (more or SPSS, SAS, Stata, Mplus and R. Psychometric network models
less) useful simplifications of complex underlying processes, and high are usually estimated in R, where various R packages (such as
observed rates of comorbidity among categories reflect causal rela- qgraph, bootnet, gimme) have been developed. The application
tions among psychopathology symptoms. Network theorists have not of both methodologies requires a familiarity with their statistical
yet provided an empirically derived alternative framework to replace underpinnings as well as their implementation in software.
the DSM, but several steps forward have been suggested. One of them Fortunately, numerous resources are available for researchers
is to estimate psychopathology systems at the idiographic level and use interested in using these tools, many of which include syntax.
data-driven, bottom-up approaches to investigate to what degree these Several books provide straightforward conceptual and applied
processes can be clustered in meaningful ways across individuals78–81. factor analytic coverage245,246. We recommend approachable
tutorials on transdiagnostic dimensional247 and network
Key classification findings models112,119,248–252. There is also a wealth of instructional material on
Three key findings and ongoing research efforts from network network models on YouTube, produced by many of the approach’s
approaches are worth noting. First, the perspective of mental disor- key developers (see Sacha Epskamp’s YouTube channel).
der as a dynamical system aligns with many other scientific disciplines,

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a Group-level network b Person-specific networks

FA FA FA

CA CA CA
CO CO CO
FS FS FS

EL EL EL

FI FI FI

Person 1 Person 2

Fig. 2 | Group-level and person-specific network models. a, A directed network represent items from the Inventory for Depressive Symptomatology: EL,
fit to simulated data from 25 individuals, consisting of six depression symptom energy level; FS, feeling sad; FI, feeling irritable; CO, concentration; FA, falling
variables from the Inventory for Depressive Symptomatology243. b, Networks asleep; and CA, changes in appetite. Blue edges represent positive associations.
using time-series data from two different individuals from the sample of 25. The thickness and saturation of arrows indicate the strength of conditional
Nodes are depicted as circles and edges as arrows connecting nodes. Nodes dependence associations among nodes.

panic disorder onset and efficacy of established treatments), but it where temporal associations can be investigated. Although temporal
also identified gaps that future iterations of the theory need to tackle associations (such as where symptom X precedes symptom Y, control-
(such as the fact that there are people with panic attacks who never ling for symptom Z) do not necessarily indicate causal relations107, they
develop panic disorder). facilitate understanding of the antecedents, concomitants and conse-
Third, many tools of social network analysis have been used to quences of psychopathology by showing which symptoms temporally
investigate the predictive utility of network approaches73,92,93. For precede others108.
example, network characteristics such as node centrality (structural Similar to transdiagnostic dimensional approaches, there are
importance) and density (the overall degree to which all nodes are important debates on what inferences can be drawn from statis-
connected in a network) have been associated with depression94 tical network models — that is, how best to interpret their model
and psychosis95. Density has been related to psychopathology in output92,93,109,110. As such, it is an open question how the emerging field
cross-sectional data96, dynamic networks94,95, and dynamic networks of network approaches can contribute to psychopathology classi­
that change over time within a person84,85. However, some studies did fication research, and there are some important challenges that must
not replicate these results97,98. Similarly, studies have tested whether be addressed. First, it remains unclear how useful common network
symptom centrality predicts the onset of psychopathology or treat- models (such as the Gaussian Graphical Model) are for bringing data
ment dropout in cross-sectional or longitudinal networks, with mixed to bear on (often causal) network theories, given that models impose
results99–103. Overall, the question of whether centrality measures are assumptions on data (such as linear relations) that are inconsistent
useful predictive tools requires further study93,104,105. For example, with underlying theoretical accounts. Network theories often pre-
centrality measures such as betweenness centrality were not intended suppose feedback loops, systems with multiple states, abrupt phase
to be used for networks with negative relations, and they have been transitions and asymmetric relations among nodes, and some of these
shown to be conceptually questionable when applied to psychological phenomena can arise out of only non-linear relations91,111. Second, it
networks93. Betweenness centrality was made for distance measures is easy to over-interpret network graphs because they rarely provide
and meant for network structures in which there is a flow process in information about the accuracy of parameter estimates112. Bootstrap-
the network (for instance, gossip in a friendship network). However, ping routines can help to guide appropriate inferences (for example,
psychological networks are not based on distance, and it is an open whether one edge is significantly stronger than another, or one node
question whether statistical relations of psychological networks should significantly more central than another). Finally, there is disagreement
really be conceptualized as flow, given that they differ substantially about the empirical replicability of network models, which relates to
from social networks. network inference because it is not clear which model features are
suited to assess replicability109,110,112–118. Importantly, accurate param-
Causal and network inference eter estimation is necessary for statistical models such as network
An important assumption of network theory is the causal influence of models to replicate, but some parameter estimates in the extant
symptoms and other variables on each other. However, cross-sectional literature are likely to be inaccurate because they tend to be based on
networks (the most published form of psychological networks73) do samples smaller than recommended112,119. Much work remains to be
not lend themselves to causal inference91,106. Network models have done on the accuracy and replicability of network models, particularly
therefore been increasingly applied to intensive longitudinal data, in time-series data120.

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Clinical staging approaches personality disorders, or alcohol- and substance-use disorders). The
Drawing on staging systems successfully utilized in medicine, the clini- distinction between Stages 1a and 1b is supported by their contrasting
cal staging of mental disorders proposes a blended categorical and treatment needs and outcomes (for instance, simpler and less inten-
dimensional approach to classification that aims to strengthen diagnos- sive treatments for Stage 1a versus Stage 1b)128, risk of progression to
tic precision and utility. The clinical staging approach identifies where Stage 2 (ref. 123), and neurobiological profiles (for example, greater
an individual is situated along the continuum of illness, which is divided sleep dysfunction and more systemic changes within the limbic system
into stages, and facilitates the selection of preventive or pre-emptive for Stage 1b)129–132. Similarly, early research suggests that the cut-off
treatment and the prediction of prognosis. In psychiatry, these stages between Stages 1b and 2 can be validated from a neurobiological or
have been defined as asymptomatic but at-risk (Stage 0), help-seeking biomarker perspective122,133. Compared to attenuated syndromes,
with distress (Stage 1a), attenuated syndromes (Stage 1b), full-threshold individuals with full-threshold disorders show differential patterns
disorder (Stage 2), recurrence or persistence (Stage 3), and treatment of impairment on measures of neuropsychological function134,135,
resistance (Stage 4)21,121 (Fig. 3). Clinical staging can be applied to any brain imaging134,136–138, and sleep–wake behaviours and circadian
disorder that tends to or might progress21. The boundaries between rhythms130,139.
stages might be defined by therapeutic needs and biomarkers121,122. The transition from earlier to later stages of illness corresponds
The use of a hybrid dimensional–categorical approach captures the to a stepwise increase in severity, symptom specificity and functional
dynamic, longitudinal and dimensional aspects of psychopathology, impairment123,125. Longitudinal data indicate that threshold caseness
which are not accounted for in traditional static and cross-sectional (Stage 2) is reached by approximately 13–18% of young people with
models, while recognizing that clinical decision-making is routinely attenuated syndromes (Stage 1b); approximately half of these transi-
grounded in categories. Clinical staging represents a matrix of stage and tions occur within 12 months of baseline123,126. Transition from Stage 1a
syndromal formation and evolution, which is essentially transdiagnos- (non-specific symptoms) to Stage 2 is less common (3%)123,126. The staging
tic. There is a key distinction between a stage-based model of care and model recognizes that the emergence, progression and persistence
stepped care. The latter responds belatedly to a relapse or worsening of mental illness is heightened by a range of risk factors, including
of a condition, whereas staged care — like cancer treatment — aims to prenatal environment, childhood trauma, and alcohol or substance
pre-empt onset, progression and relapse. misuse140. Multistate models, which can characterize how an individual
occupies one state (of multiple possible states) at a given time, have
Key classification findings been used to examine variables at baseline that are associated with tran-
In clinical cohorts of young people attending low-entry-threshold sition from Stages 1b to 2 and Stages 1a to 1b123. Modifiable predictors
youth mental health services, most individuals at initial presentation of progression to any Stage 2 disorder (such as a major anxiety, mood
are classified at Stages 1a (30–60%) and 1b (31–61%), with few present- or psychotic disorder) include not being in education, employment or
ing at Stages 2 (4–9%) and 3 or 4 (3–5%)123–125, who often require more training, negative symptoms, psychotic-like experiences and circadian
specialized and intensive care. Inter-rater reliability of clinical stage disturbance123,141.
allocation has been shown to be acceptable (κ = 0.71)126. Individuals Approximately a third of individuals assigned to Stage 1a transition
assigned to Stage 1 generally have mild impairment or non-specific to Stage 1b123. This progression is associated with lower social function-
symptoms, while those with attenuated syndromes (Stage 1b) present ing, not being in education, employment or training, manic-like expe-
with increased symptom severity and functional impairment123,126,127. riences, psychotic-like experiences and self-harm123. These additional
Individuals at Stage 1b might meet the criteria for particular DSM-5 criteria capture the concept of ‘extension’, which defines progression
or ICD diagnoses such as anxiety or depression; however, in compari- across stages. Progression to Stages 3 and 4 is estimated to occur in a
son to Stage 2, symptoms have not reached the threshold required to third of those assigned to Stage 2 (mood and psychotic disorders)126
prompt a change in the type or intensity of treatment (for example, the and largely reflects recurrence or persistence of illness121,142. Individu-
commencement of antipsychotic medication or mood stabilizers)126. als assigned to Stage 3 have experienced Stage 2 syndromes with per-
At Stage 2, individuals present with stable, intense and sustained fea- sistence or incomplete remission at 12 months after mental health
tures of major disorders (for example, psychotic, mood or borderline service entry or recurrence of illness following 3 months of complete

Microphenotypes Fig. 3 | A depiction of clinical staging approaches. Symptom

Inc

Macrophenotypes severity, specificity and disability begins at the vertex at the upper
rea

right and proceeds in increasing stages (represented by sphere

sing

Stage 0 Asymptomatic size) outwards toward the left and bottom. Spheres and colours
sym

represent phenotypes. Stage 2 denotes the boundary between

Stage 1a Distress disorder
pto

non-specific symptoms/attenuated syndromes and full-threshold

Stage 1b Distress disorder and
m

Substance disorders. Clinical staging can be applied to any disorder that

sev

misuse sub-threshold specificity

tends to or may progress21, including those not represented in the
erit

Stage 2 First treated episode figure (for example, anxiety and eating disorders). Adapted with
y, s
pec

Stage 3 Recurrence or permission from ref. 133, Annual Reviews.

Personality
persistence
ifici

disorder
ty a

Stage 4 Treatment resistance

nd

Depressive
disa

disorder
Bipolar Psychotic
bilit

disorder disorder/
y

schizophrenia

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Glossary heterotypic nature of psychopathology144,145,147–149. Transdiagnostic

clinical staging is consistent with the fact that the early stages of major
adult-type mental disorders (such as psychosis, bipolar disorder,
Assessment reliability constructs that the test is intended depression and borderline personality disorder) are not sufficiently
The extent to which observed scores to measure, and justifiably supports dissimilar to support a disorder-specific approach150,151. Early clini-
on a test are precise and error-free and inferences drawn about the observed cal stages of these disorders are characterized by non-specific and
the degree to which observed scores test scores’ relations with other overlapping symptoms (microphenotypes) that might potentially
represent true scores of the construct variables. evolve and intensify, and follow various pathways to develop into
being assessed. relatively stable, although typically comorbid, syndromes (macro-
Macrophenotype phenotypes)152. Classic syndromes can be understood as relatively
Betweenness centrality Late stage of syndrome development late macrophenotypes, which are recognizable during later stages
Assesses the relative number of shortest that consists of stable, intense and of illness (Fig. 3).
paths between any two nodes in the sustained, or severe syndromes This reality of illness progression is well captured by network
network passing through a specific node (for example, psychosis, mania, analysis, in which symptom networks are more densely connected
(for example, if A and B are connected to depression, anxiety, alcohol- and with increasing severity or persistence73,96. It is also compatible with
C but not to each other, the node C lies substance-use disorders, and borderline dimensional approaches in which psychopathology is organized from
on the shortest path between A and B). personality disorder). broad to narrow dimensions. However, clinical staging adds a categori-
cal overlay, which may increase clinical utility. Clinical decision-making
Confirmatory factor analysis Microphenotype is closely intertwined with categories, which clinicians rely on for
A largely theory-driven latent variable Early stage of syndrome development treatment planning (for example, to treat or not to treat)153, and these
modelling approach in which the that consists of overlapping and sorts of approaches seem to necessitate that dimensional approaches
researcher decides the number of fluctuating symptoms. have identified cut-points to guide clinical care, with these thresh-
latent variables as well as which olds reflecting the risks and benefits of available treatments154. Such
items or scales load, and do not load, Model fit cut-points create categories, enabling dimensional approaches to be
on each factor. How well a statistical model is clinically relevant in psychiatry (and across general medicine)155. The
congruent with observed data, such categories imposed by clinical staging also provide a heuristic research
Exploratory factor analysis as discrepancy between values in strategy to clarify neurobiological markers by stage of illness and to
A largely atheoretical latent variable an observed correlation matrix and develop stage-specific interventions122. A more agnostic approach
modelling approach that generally those in a model-implied (estimated) to traditional diagnoses, which have limited construct validity156, and
estimates the number of latent factors correlation matrix. the dynamic and fluid nature of onset and progression provide the
underlying the observed items or scales, opportunity for dimensional and network methods to help guide and
in which each item or scale is permitted Structural validity populate staging models.
to load on all estimated latent factors. The degree to which observed
scores (such as those from a measure) Time and development
Inference validity adequately reflect the underlying Transdiagnostic dimensional approaches and network approaches
The extent to which observed scores dimensionality of the construct or have been largely based on cross-sectional data. Although there is
on a test reflect the construct or constructs being assessed. certainly value in cross-sectional approaches, longitudinal approaches
provide promising pathways towards understanding and classifying
psychopathology, because they enable the study of within-person
recovery126,142. Stage 4 includes individuals with unremitting illness who change. Thus far, however, most existing approaches mainly focus
have received relevant services for at least 2 years. on between-person differences instead of within-person change over
The clinical staging approach is currently being used to broaden cri- time157–160. By contrast, clinical staging approaches have taken a more
teria for identifying individuals at ultrahigh risk of developing psycho- explicit longitudinal approach, and have been used to monitor and
sis to encompass a range of syndromes rather than solely psychosis143. predict transitions between disorder stages73.
Preliminary findings suggest that various at-risk mental states (bipolar, As theorists, clinicians and statisticians have pointed out, studying
depression, psychosis and borderline personality disorder; that is, within-person change in addition to between-person differences can
Stage 1b), show substantial overlap and progress to a full-threshold reveal further insights into the nature of psychopathology161–163. The
disorder in both homotypic and heterotypic ways, supporting the study of such longitudinal within-person processes has two key advan-
theoretical basis of transdiagnostic staging144. tages. First, they might provide insights about how symptoms cluster
over time, and therefore how comorbidity develops, potentially inform-
Relation to dimensional and network approaches ing diagnostic and psychotherapeutic processes158,159,164,165. Second, the
The clinical staging model is grounded in epidemiological evi- study of within-person processes can characterize how individuals dif-
dence in terms of how mental disorders emerge and progress; that fer from their own average instead of from the between-person average,
is, non-specific symptoms and a need for care exist prior to meet- which might help clinicians to identify dynamic psychological patterns
ing conventional artificial syndromal thresholds143, and trajecto- in their patients78,157,160,166. Thus, some researchers argue that changes in
ries often defy traditional diagnostic boundaries with high rates within-person symptom dynamics can inform why individuals at risk
of comorbidity145. Clinical staging for mental disorders might be for psychopathology transition into pathological states74. Investigating
transdiagnostic140,146 in accordance with frequently shifting trajec- these dynamics over time might therefore reveal crucial insights into
tories across diagnostic boundaries, reflecting the pluripotent and the prevention and treatment of mental disorders.

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Within-person psychopathology psychopathological symptoms across the lifespan. Descriptively, pre-

In experience sampling method (ESM) studies, participants are asked dispositions towards general psychopathology are already present
to respond to short surveys repeatedly within their daily lives. Thus, in early childhood187–190 and there is substantial interest in studying
ESMs are a strong tool with which to study the dynamics of individuals’ maladaptive dispositions in adolescence as well191–193. Mirroring this
emotions, cognitions and behaviours in a natural environment, and observation, broad dimensions such as internalizing and external-
this methodology has been applied to the study of real-life experiences izing tend to be used more in childhood-related research and prac-
underlying psychopathology and mental disorders167,168. For example, tice, whereas there is a focus on more differentiated domains in older
ESMs have been used to study how one emotion predicts itself and how adolescents and adults50,190,194.
this relates to constructs such as depression169–171. Relatively limited research has empirically examined the extent to
So far, studies that focus on within-person processes have mostly which dimensions of psychopathology have developmental continuity.
examined the dynamics of ESM items in relation to psychopathology The largest body of work to this end is captured by the Achenbach System
with regards to affective172–176, social177,178 and cognitive179–181 domains of Empirically Based Assessment. In this framework, there is substantial
of an individual’s life. consistency in the nature of the domains of psychopathology that are
Regarding affect, individuals whose dynamic network of emotion identified from childhood through to late middle age (ages 6–59 years).
items took longer to return to baseline values after an external shock For example, the internalizing, externalizing and thought problems
or negative event (simulated statistically) had more negative trajec- dimensions comprise similar symptoms and syndromes over time195.
tories of depression symptomatology176. In addition, within-person The internalizing and externalizing domains are also identified in chil-
processes of affect instability and affect reactivity to interpersonal dren as young as 1.5 to 5 years, but not always in older adults (ages 60+)195.
perceptions have been found to be related to borderline personality Notably, the Achenbach System of Empirically Based Assessment inven-
disorder182,183. However, the extent to which these dynamic indices (such tories were derived cross-sectionally within each age group, rather
as the instability in affect level over the course of the study) predict than based on individuals’ development over time. Beyond work
general psychopathology measures beyond the mean (mean level of using these inventories, there is some evidence for substantial devel-
negative affect over the course of the study) remains inconclusive184. opmental continuity of transdiagnostic dimensions within individuals
Regarding the social domain, temporal dynamics of social inter- as they age145,190,196–199 and these are useful for understanding successful
actions rather than the number of interactions is predictive of change ageing200. Studies in child, adolescent and adult samples also suggest
in depressive symptoms, such as solitude inertia (prolonged states that more differentiated dimensions, such as distress versus fear, and
of being alone)177. Moreover, individuals with borderline personality oppositional/antisocial behaviour versus substance use, might emerge
disorder who displayed more fluctuations in mood also expressed more from broader dimensions (such as internalizing) over time, but more
dominance in social interactions185. longitudinal research is needed to corroborate these findings201.
Finally, in the cognitive domain, an ongoing study is investigat-
ing how cognitive function is longitudinally associated with various Translation to clinical practice
transdiagnostic symptoms. This study aims to identify clusters of Evidence-based approaches and models of psychopathology are poised
biological markers, cognitive dysfunctions and symptoms that predict to transform how case conceptualizations and diagnostic assessments
psychopathology181. are performed. This revolution, in turn, has the potential to affect
In general, deficits in these domains (affective, social and cognitive) mental health treatment profoundly.
have been associated with psychosocial dysfunction in a variety of
disorders74,186. These findings all suggest that temporal dynamics, Transdiagnostic dimensional approaches
studied for example with ESM, are important for understanding how Transdiagnostic dimensional approaches propose to forfeit categorical
psychopathology manifests and develops within a person. diagnoses, and instead to delineate patients’ problems dimensionally
In transdiagnostic classification systems, the temporal ordering at varying levels of specificity, from general propensities to individual
of structures or symptoms have been under-investigated, and HiTOP symptom manifestations202,203. Accordingly, the assessment proceeds
does not currently include constructs that reflect individual differences systematically, focusing first on the broad dimensions to identify major
in within-person processes because few studies have investigated rela- problem areas, then examining specific features and behavioural mani-
tions between these constructs and psychopathology dimensions45. festations within corresponding lower-order dimensions. Clinicians
Nevertheless, time remains of critical theoretical importance in dimen- can visualize a summary of patients’ problems on a profile spanning
sional transdiagnostic approaches. For instance, in the HiTOP model severity dimensions and specificity levels to comprehensively guide
the distinction between symptoms and traits is thought to reflect the individualized treatment planning and outcome tracking. For exam-
degree of functioning within short time frames (such as the past week) ple, a clinician might observe that a patient has elevated scores on the
versus general functioning (such as over multiple years)45,79. In this internalizing spectrum, driven mainly by high scores on anhedonia,
framework, symptoms vary around a relatively stable trait level of fatigue and sleep problems. The clinician can consider treatment tar-
functioning45. Increased focus on how psychopathology evolves within gets at a higher level, where approaches such as an antidepressant or
a person over time — and the degree to which people differ in these cognitive–behavioural therapy can improve multiple internalizing
trajectories — will be beneficial for capturing within-person processes symptoms simultaneously204, and at lower levels, when a problem
in classification approaches. requires a specialized intervention (for example, hypnotic drugs for
insomnia). Furthermore, strengths evident in the patient’s profile might
Classification over the lifespan inform treatment planning. For example, a low score on the antagonistic
Whereas more and more research using the network approach is externalizing spectrum might indicate that the patient could develop
studying short-term changes in symptom dynamics (such as over a a good therapeutic alliance with the provider and therefore respond
few weeks and months), other transdiagnostic research has examined well to psychotherapy.

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Dimensional transdiagnostic approaches have the potential to currently ongoing224. Larger samples, randomized controlled trials, and
inform efforts to assess and treat psychopathology. With regard studies on the reliability and validity of person-specific networks are
to assessment, previous research has indicated that these models still needed to clarify the utility of psychological symptom networks for
improve assessment reliability and inference validity relative to tra- psychotherapy120,229.
ditional diagnoses203. The psychometric properties of reliability and The advances to clinical practice proposed by network approaches
validity are necessary for results of psychological assessment to be are focused on the specific patient presentation, regardless of diag-
meaningful and interpretable, and to support clinical application (such nostic status. Within network approaches, there is a strong emphasis
as identifying the problems a patient is experiencing and selecting on the mechanisms underpinning etiology, maintenance and the
an appropriate intervention)205–207. Clinical case conceptualization psychotherapy process218,230. Idiographic (person-specific) network
(including the clinician’s overall understanding of a patient’s prob- analysis of symptom dynamics can be used in a clinical context to
lems and the processes that cause and maintain these problems) are inform case conceptualization. Furthermore, the network of interac-
also more congruent with dimensional approaches than categorical tions between risk, maintenance and protective factors, symptoms,
approaches202,208 because clinicians consider the varying severity of functioning and other clinically relevant features, can be formalized
multiple symptoms and impairments constituting a client’s multifac- mathematically as a testable, patient-specific model. Translating case
eted clinical presentation. Indeed, clinicians often find dimensional conceptualizations into mathematical language enables specific rela-
approaches more informative for treatment planning209,210. Further, tionships included in the conceptualization to be tested or simulated.
patients’ transdiagnostic dimension levels predict which individuals For example, clinicians could apply computational models to estimate
are likely to actually pursue specific forms of treatment211. Finally, whether an intervention targeting a suspected risk factor might be
transdiagnostic treatments, such as the Unified Protocol212, target the effective in preventing symptom elevation or long-term functional
common cores of multiple forms of psychopathology (for example, impairment in an individual patient. Specific idiographic network
internalizing) in effective and efficient ways relative to treating specific model components could be added or removed as appropriate and in
disorders individually213–215. There are several reviews on the clinical util- collaboration with a patient. In the course of therapy, models can be
ity of transdiagnostic dimensional approaches202,203,216,217. More research updated with real-life information (such as an actual outcome of the
is needed to demarcate ranges or thresholds on psychopathology implemented treatment) to allow model personalization and learning.
dimensions to facilitate assessment and intervention decisions203. More Although promising, the above will require numerous observations
research is also needed to determine the extent to which dimensions per patient as well as training to develop the necessary mathematical
derived from group-level analyses will be informative for individual competencies in a given clinic. Web-based tools are being constructed
patients. to overcome barriers to clinical implementation, with the goal of ena-
To enhance the accessibility of transdiagnostic dimensional bling clinicians to estimate network models, to use their own obser-
approaches for clinicians, a free electronic instrument, the HiTOP vations to complement data-driven estimation, and to help generate
Digital Assessment and Tracker, that automatically generates a patient’s intuitive feedback231.
profile and compares it to normative community ranges was devel- In sum, idiographic modelling, including but not limited to net-
oped. Clinicians can also refer to recommended actionable ranges work approaches, is becoming increasingly important in psychopathol-
to guide their decision-making. These ranges are being empirically ogy research, especially as an approach for personalized classification
tailored to specific purposes (such as severity levels recommended for and intervention design (for a review see ref. 81).
initiating psychotherapy) and can be cross-walked to the ICD-11 codes
for billing and administrative purposes. This multi-level depiction of Clinical staging approaches
a patient’s problems aims to help clinicians to focus their assessment Clinical staging approaches are increasingly visible and utilized
and intervention strategy. Consequently, treatments might be selected in clinical practice. One application is linking particular stages to spe-
to alleviate broad psychopathology dimensions, often employing cific interventions based on severity. For instance, Stage 1 might sug-
transdiagnostic approaches such as the Unified Protocol, or to target gest application of transdiagnostic psychosocial interventions. Later
narrow symptoms. A compendium of potentially useful therapeutic stages, which are associated with greater risk, require more specific
techniques for each spectrum is available to clinicians204. and intensive intervention that might have adverse effects. For exam-
ple, Stage 2 might support the use of antipsychotic or antidepressant
Network approaches medication, whereas Stage 4 might indicate the need for drugs such
One aim of studying networks is to reveal the interrelations among as clozapine, which is associated with an increased risk for developing
variables, such as symptoms, in order to provide guidance for clini- agranulocytosis (a life-threatening blood disorder)232.
cians. Although many networks are fitted to group-level data of mul- Clinical staging attempts to address a fundamental challenge
tiple participants simultaneously (Fig. 2a), person-specific networks in psychiatry: how to link diagnosis to treatment, prognosis and
(Fig. 2b), based on intensive within-person longitudinal data, might underlying biology. In doing so, clinical staging seeks to transcend
indicate potential treatment targets (that is, which specific symptoms simpler matrix models such as the Research Domain Criteria matrix.
should be targeted in interventions)218. Such person-specific networks The staging model is particularly relevant to the mental healthcare
of within-person longitudinal data have been used to provide auto- of young people because the majority of mental disorders begin to
mated feedback to healthy participants219–221 and in clinical practice, for emerge prior to young adulthood145. Traditional diagnostic systems
example, by discussing individual affect or symptom networks in psy- largely capture adult-type and late-stage disorders. By contrast, clini-
chotherapy sessions222. However, to date, only feasibility studies on the cal staging supports early intervention and prevention that alleviate
integration of person-specific networks in clinical settings exists99,223–228. distressing symptoms and functional impairment, irrespective of
One randomized controlled trial evaluating the effectiveness of person- diagnostic labels or reaching threshold-level criteria, and reduce
alized network modules for the reduction of depressive symptoms is the risk of illness progression and extension through stage-specific

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interventions based on risk–benefit principles121,133,233. Sequential clin- The network approach focuses mainly on the (temporal) interrela-
ical trials, particularly involving transdiagnostic samples, are needed tions between elements of a system of symptoms. As such, the network
to strengthen the selection of safe and proportional stage-matched approach does not primarily aim to provide a classification of mental
interventions234. disorders but rather provides a theoretical and statistical framework
Transition across stages is not inevitable and the clinical staging for investigating symptom clusters and transitions. To date, the net-
model highlights the potential for timely and quality treatment to avert work approach has not been used for classification research itself, and
transition or progression. However, it is assumed that there is a higher future research will determine how much the network approach can
risk of illness progression, persistence or recurrence at later stages. contribute to new nosologies. Although the network approach has
Hence, treatment delivered early in the course of illness should be more gained notable traction within clinical psychology, some conceptual
effective and safer than treatment delivered later when symptoms and issues remain that need to be addressed. These include which statistical
functional impairment have become entrenched and neurobiological models are best suited for which purposes; what nodes to include in
damage has occurred. The aspirational goal for researchers and clini- network models and how edges ought to be estimated (for instance, as
cians alike is to move from a purely clinical staging model to establish linear or nonlinear); what measurements are best suited for network
a clinicopathological staging model, akin to the maturation of such analysis; how to interpret estimated network structures; and the use
models in oncology, in which clinical and prognostic utility and the and predictive utility of graph theoretical measures such as central-
personalization of care are strengthened by the addition of patho- ity and density. The explicit conceptual focus on temporal issues of
physiological biomarkers (assuming that such markers can be validated network approaches (such as the sequential unfolding of psychopa-
and are malleable). This sort of broader staging model framework thology over time), the increasing empirical focus on temporal issues,
could also potentially refine the boundaries of individual stages and and idiographic analysis all bring with them great potential to move
reduce focus on traditional diagnostic categories for later stages in beyond the current state of largely cross-sectional and between-person
instances where syndromal diagnosis alone offers limited specificity classification research paradigms.
for treatment selection152. Clinical staging approaches aim to improve the utility of mental
disorder diagnosis and classification. This framework has clear implica-
Summary and future directions tions for clinical practice, particularly in facilitating prevention, early
Transdiagnostic dimensional, network and clinical staging approaches intervention, prediction and the selection of stage-matched interven-
all attempt to overcome limitations of official classification systems. tions. From the earliest stages of illness, the clinical staging model sup-
Each has demonstrated promising characteristics to support subse- ports the deployment of proportional and pre-emptive interventions
quent research and clinical endeavours. Despite their limitations, these based on risk–benefit considerations as well as patient choice. Active
three approaches represent a major shift towards truly evidence-based research is refining the boundaries between stages, particularly from
classification, assessment and intervention. a biomarker perspective140. Like network approaches, clinical staging
Transdiagnostic dimensional approaches focus on overcoming approaches might help to guide the development and selection of more
the limitations of traditional nosologies in accounting for high rates of personalized interventions.
comorbidity, arbitrary thresholds for diagnosis, overlapping criteria, Although there is much research to be done within the three app­
and their failure to describe within-diagnosis heterogeneity. Over roaches, a particularly promising future direction is a move towards their
time, official nosologies have delineated more and more putatively integration, given that they have developed relatively independently238.
distinct diagnoses. Transdiagnostic dimensional approaches take Fundamentally, the putative incompatibility between the three app­
the opposite approach, wherein broad sets of symptoms or diagnoses roaches is a misperception. For instance, some statistical factor models
are modelled simultaneously to identify their common sources of applied in transdiagnostic dimensional approaches can be thought of as
covariation, which act as the building blocks of psychopathology. a class of network models239,240. Indeed, there are ongoing attempts to
The resulting dimensions are organized into hierarchies (such as merge statistical network models with factor models241 as well as efforts
HiTOP) from fine-grained to very specific. Findings from different to potentially enhance network theories by incorporating notions about
studies, samples, measures and constructs (such as those from stud- common causes that are a major focus of transdiagnostic dimensional
ies of normal-range personality, personality psychopathology and approaches91,92. Thus, the symptoms and disorders investigated in net-
mental disorders) converge on a consensus structure that links vari- work approaches could be refined by developments in transdiagnostic
ation in both normative and pathological variables to relatively few classification242, and network approaches could be applied to factor ana-
core factors. These dimensions outperform traditional diagnoses in lytic approaches to link transdiagnostic dimensions to one another tem-
prospective prediction of important outcomes, clinical utility and porally and to model associations among symptoms and syndromes that
the ability to account for symptom patterns that are not included are not captured fully by the dimensions. Clinical staging approaches
as diagnoses in official nosologies. The usefulness of these models can incorporate diagnostic constructs emerging from transdiagnostic
ranges from assessing a single patient to understanding broad popu- dimensional approaches directly into their framework of disorder
lation mental health disparities215,217,235–237. Transdiagnostic dimen- development and severity, and network approaches might help to link
sions represent empirically derived constructs, whereas traditional different stages of disorder to various risk or resilience factors and out-
nosologies to a large extent emerged from subjective expert opinion. comes as well as to link patient staging levels longitudinally. Although
Perhaps most importantly, extensively replicated findings suggest overcoming current levels of fragmentation across approaches will
that transdiagnostic dimensions (the model) map closely onto the require theoretical and methodological advances, such integration
lived experiences of patients (the data)24. Consequently, it is pos- might hold the key to major advances in the conceptualization and
sible to fully characterize an individual’s symptoms and problems classification of mental disorders.
rather than attempt to fit the individual into a predetermined category
(diagnosis). Published online: xx xx xxxx

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References 35. Goldberg, L. R. An alternative ‘description of personality’: the big-five factor structure.
1. Diagnostic And Statistical Manual Of Mental Disorders 5th edn (American Psychiatric J. Pers. Soc. Psychol. 59, 1216–1229 (1990).
Association, 2013). 36. Costa, P. T. Jr & McCrae, R. R. Four ways five factors are basic. Pers. Individ. Differ. 13,
2. International Classification Of Diseases For Mortality And Morbidity Statistics 11th revn 653–665 (1992).
(World Health Organization, 2018). 37. Digman, J. M. Personality structure: emergence of the five-factor model. Annu. Rev.
3. Eaton, N. R., South, S. C. & Krueger, R. F. in Contemporary Directions In Psychopathology: Psychol. 41, 417–440 (1990).
Scientific Foundations Of DSM-V And ICD-11 (eds Millon, T., Krueger, R. & Simonsen, E.) 38. John, O. P., Naumann, L. P. & Soto, C. J. in Handbook Of Personality: Theory And Research
223–241 (Guilford, 2010). (eds Robins, R. W., John, O. P. & Pervin, L. A.) 114–158 (Guilford, 2008).
4. Borsboom, D., Cramer, A. O., Schmittmann, V. D., Epskamp, S. & Waldorp, L. J. The small 39. Krueger, R. F. & Markon, K. E. The role of the DSM-5 personality trait model in moving
world of psychopathology. PLoS One 6, e27407 (2011). toward a quantitative and empirically based approach to classifying personality and
5. Fried, E. I. & Nesse, R. M. Depression is not a consistent syndrome: an investigation psychopathology. Annu. Rev. Clin. Psychol. 10, 477–501 (2014).
of unique symptom patterns in the STAR*D study. J. Affect. Disord. 172, 96–102 (2015). 40. Markon, K. E., Krueger, R. F. & Watson, D. Delineating the structure of normal and
6. Krueger, R. F. & Eaton, N. R. Personality traits and the classification of mental abnormal personality: an integrative hierarchical approach. J. Pers. Soc. Psychol. 88,
disorders: toward a more complete integration in DSM-5 and an empirical model of 139–157 (2005).
psychopathology. Pers. Disord. 1, 97–118 (2010). 41. Suzuki, T., Samuel, D. B., Pahlen, S. & Krueger, R. F. DSM-5 alternative personality disorder
7. Galatzer-Levy, I. R. & Bryant, R. A. 636,120 ways to have posttraumatic stress disorder. model traits as maladaptive extreme variants of the five-factor model: an item-response
Perspect. Psychol. Sci. 8, 651–662 (2013). theory analysis. J. Abnorm. Psychol. 124, 343–354 (2015).
8. Vize, C. E., Ringwald, W. R., Edershile, E. A. & Wright, A. G. C. Antagonism in daily life: an 42. Chmielewski, M., Bagby, R. M., Markon, K., Ring, A. J. & Ryder, A. G. Openness to
exploratory ecological momentary assessment study. Clin. Psychol. Sci. 10, 90–108 (2022). experience, intellect, schizotypal personality disorder, and psychoticism: resolving the
9. Krueger, R. F. et al. Progress in achieving quantitative classification of psychopathology. controversy. J. Pers. Disord. 28, 483–499 (2014).
World Psychiat. 17, 282–293 (2018). 43. Krueger, R. F. & Hobbs, K. A. An overview of the DSM-5 alternative model of personality
10. Regier, D. A. et al. DSM-5 field trials in the United States and Canada. Part II: Test–retest disorders. Psychopathology 53, 126–132 (2020).
reliability of selected categorical diagnoses. Am. J. Psychiat. 170, 59–70 (2013). 44. Krueger, R. F., Derringer, J., Markon, K. E., Watson, D. & Skodol, A. E. Initial construction
11. Kim, W., Woo, Y. S., Chae, J.-H. & Bahk, W.-M. The diagnostic stability of DSM-IV of a maladaptive personality trait model and inventory for DSM-5. Psychol. Med. 42,
diagnoses: an examination of major depressive disorder, bipolar I disorder, and 1879–1890 (2012).
schizophrenia in Korean patients. Clin. Psychopharmacol. Neurosci. 9, 117–121 (2011). 45. Kotov, R. et al. The hierarchical taxonomy of psychopathology (HiTOP): a quantitative
12. Kozak, M. J. & Cuthbert, B. N. The NIMH research domain criteria initiative: background, nosology based on consensus of evidence. Annu. Rev. Clin. Psychol. 17, 83–108 (2021).
issues, and pragmatics. Psychophysiology 53, 286–297 (2016). 46. Kotov, R. et al. Validity and utility of hierarchical taxonomy of psychopathology (HiTOP):
13. Marquand, A. F., Wolfers, T., Mennes, M., Buitelaar, J. & Beckmann, C. F. Beyond lumping I. Psychosis superspectrum. World Psychiat. 19, 151–172 (2020).
and splitting: a review of computational approaches for stratifying psychiatric disorders. 47. Waszczuk, M. A. et al. Redefining phenotypes to advance psychiatric genetics:
Biol. Psychiat. Cogn. Neurosci. Neuroimaging 1, 433–447 (2016). implications from hierarchical taxonomy of psychopathology. J. Abnorm. Psychol. 129,
14. Cuthbert, B. N. Research domain criteria: toward future psychiatric nosologies. 143–161 (2020).
Dial. Clin. Neurosci. 17, 89–97 (2015). 48. Simms, L. J. et al. Development of measures for the hierarchical taxonomy of
15. Hyman, S. E. Can neuroscience be integrated into the DSM-V? Nat. Rev. Neurosci. 8, psychopathology (HiTOP): a collaborative scale development project. Assessment 29,
725–732 (2007). 3–16 (2022).
16. Shackman, A. J. & Fox, A. S. Getting serious about variation: lessons for clinical 49. Lahey, B. B. et al. Is there a general factor of prevalent psychopathology during
neuroscience (a commentary on ‘the myth of optimality in clinical neuroscience’). adulthood? J. Abnorm. Psychol. 121, 971–977 (2012).
Trends Cogn. Sci. 22, 368–369 (2018). 50. Caspi, A. et al. The p factor: one general psychopathology factor in the structure of
17. Borsboom, D. A network theory of mental disorders. World Psychiat. 16, 5–13 (2017). psychiatric disorders? Clin. Psychol. Sci. 2, 119–137 (2014).
18. Cuthbert, B. N. & Insel, T. R. Toward the future of psychiatric diagnosis: the seven pillars 51. Caspi, A. & Moffitt, T. E. All for one and one for all: mental disorders in one dimension.
of RDoC. BMC Med. 11, 126 (2013). Am. J. Psychiat. 175, 831–844 (2018).
19. Hofmann, S. G. & Hayes, S. C. The future of intervention science: process-based therapy. 52. Fried, E. I., Greene, A. L. & Eaton, N. R. The p factor is the sum of its parts, for now.
Clin. Psychol. Sci. 7, 37–50 (2019). World Psychiat. 20, 69–70 (2021).
20. Lilienfeld, S. O. & Treadway, M. T. Clashing diagnostic approaches: DSM–ICD versus 53. Smith, G. T., Atkinson, E. A., Davis, H. A., Riley, E. N. & Oltmanns, J. R. The general factor
RDoC. Annu. Rev. Clin. Psychol. 12, 435–463 (2016). of psychopathology. Annu. Rev. Clin. Psychol. 16, 75–98 (2020).
21. McGorry, P. D., Hickie, I. B., Yung, A. R., Pantelis, C. & Jackson, H. J. Clinical staging of 54. Achenbach, T. M. & Verhulst, F. Achenbach System Of Empirically Based Assessment
psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective (ASEBA) (Burlington, 2010).
interventions. Aust. NZ J. Psychiat. 40, 616–622 (2006). 55. Harkness, A. R., McNulty, J. L. & Ben-Porath, Y. S. The personality psychopathology five
22. Sharp, C. & Wall, K. DSM-5 level of personality functioning: refocusing personality (PSY-5): constructs and MMPI-2 scales. Psychol. Assess. 7, 104–114 (1995).
disorder on what it means to be human. Annu. Rev. Clin. Psychol. 17, 313–337 (2021). 56. Widiger, T. A. et al. Personality in a hierarchical model of psychopathology. Clin. Psychol.
23. Sauer-Zavala, S. et al. Current definitions of ‘transdiagnostic’ in treatment development: Sci. 7, 77–92 (2019).
a search for consensus. Behav. Ther. 48, 128–138 (2017). 57. Brandes, C. M. & Tackett, J. L. Contextualizing neuroticism in the hierarchical taxonomy
24. Eaton, N. R., Rodriguez-Seijas, C., Carragher, N. & Krueger, R. F. Transdiagnostic factors of psychopathology. J. Res. Pers. 81, 238–245 (2019).
of psychopathology and substance use disorders: a review. Soc. Psychiat. Psychiatr. 58. Lynam, D. R. & Miller, J. D. The basic trait of antagonism: an unfortunately
Epidemiol. 50, 171–182 (2015). underappreciated construct. J. Res. Pers. 81, 118–126 (2019).
25. Eaton, N. R. et al. The structure and predictive validity of the internalizing disorders. 59. Mullins-Sweatt, S. N., DeShong, H. L., Lengel, G. J., Helle, A. C. & Krueger, R. F.
J. Abnorm. Psychol. 122, 86–92 (2013). Disinhibition as a unifying construct in understanding how personality dispositions
26. Haslam, N., Holland, E. & Kuppens, P. Categories versus dimensions in personality undergird psychopathology. J. Res. Pers. 80, 55–61 (2019).
and psychopathology: a quantitative review of taxometric research. Psychol. Med. 42, 60. Watson, D., Stanton, K., Khoo, S., Ellickson-Larew, S. & Stasik-O’Brien, S. M. Extraversion
903–920 (2012). and psychopathology: a multilevel hierarchical review. J. Res. Pers. 81, 1–10 (2019).
27. Lahey, B. B., Krueger, R. F., Rathouz, P. J., Waldman, I. D. & Zald, D. H. A hierarchical causal 61. Widiger, T. A. & Crego, C. HiTOP thought disorder, DSM-5 psychoticism, and five factor
taxonomy of psychopathology across the life span. Psychol. Bull. 143, 142–186 (2017). model openness. J. Res. Pers. 80, 72–77 (2019).
28. Ruscio, A. M. Normal versus pathological mood: implications for diagnosis. Annu. Rev. 62. Kessler, R. C. et al. Development of lifetime comorbidity in the World Health Organization
Clin. Psychol. 15, 179–205 (2019). world mental health surveys. Arch. Gen. Psychiat. 68, 90–100 (2011).
29. Pincus, H. A., Davis, W. W. & McQueen, L. E. ‘Subthreshold’ mental disorders: a review 63. Conway, C. C. et al. A hierarchical taxonomy of psychopathology can transform mental
and synthesis of studies on minor depression and other ‘brand names’. Br. J. Psychiat. health research. Perspect. Psychol. Sci. 14, 419–436 (2019).
174, 288–296 (1999). 64. Waszczuk, M. A. et al. The prognostic utility of personality traits versus past psychiatric
30. Kotov, R. et al. The hierarchical taxonomy of psychopathology (HiTOP): a dimensional diagnoses: predicting future mental health and functioning. Clin. Psychol. Sci. 10,
alternative to traditional nosologies. J. Abnorm. Psychol. 126, 454–477 (2017). 734–751 (2021).
31. Krueger, R. F. & Eaton, N. R. Structural Validity And The Classification Of Mental Disorders 65. Naragon-Gainey, K. & Watson, D. The anxiety disorders and suicidal ideation: accounting
(Oxford Univ. Press, 2012). for co-morbidity via underlying personality traits. Psychol. Med. 41, 1437–1447 (2011).
32. Forbes, M. K. et al. Three recommendations based on a comparison of the reliability 66. Sunderland, M. & Slade, T. The relationship between internalizing psychopathology and
and validity of the predominant models used in research on the empirical structure of suicidality, treatment seeking, and disability in the Australian population. J. Affect. Disord.
psychopathology. J. Abnorm. Psychol. 130, 297–317 (2021). 171, 6–12 (2015).
33. Greene, A. L. et al. Are fit indices used to test psychopathology structure biased? 67. Kim, H. et al. Internalizing psychopathology and all‐cause mortality: a comparison of
A simulation study. J. Abnorm. Psychol. 128, 740–764 (2019). transdiagnostic vs. diagnosis‐based risk prediction. World Psychiat. 20, 276–282 (2021).
34. Greene, A. L. et al. Misbegotten methodologies and forgotten lessons from Tom Swift’s 68. Forbush, K. T. et al. A new approach to eating‐disorder classification: using empirical
electric factor analysis machine: a demonstration with competing structural models of methods to delineate diagnostic dimensions and inform care. Int. J. Eat. Disord. 51,
psychopathology. Psychol. Meth. https://doi.org/10.1037/met0000465 (2022). 710–721 (2018).

Nature Reviews Psychology

Review article

69. Watts, A. L., Lane, S. P., Bonifay, W., Steinley, D. & Meyer, F. A. Building theories on top 101. Groen, R. N. et al. Comorbidity between depression and anxiety: assessing the role of
of, and not independent of, statistical models: the case of the p-factor. Psychol. Inq. 31, bridge mental states in dynamic psychological networks. BMC Med. 18, 308 (2020).
310–320 (2020). 102. Rodebaugh, T. L. et al. Does centrality in a cross-sectional network suggest intervention
70. Levin-Aspenson, H. F., Watson, D., Clark, L. A. & Zimmerman, M. What is the general targets for social anxiety disorder? J. Consult. Clin. Psychol. 86, 831–844 (2018).
factor of psychopathology? Consistency of the p factor across samples. Assessment 28, 103. Spiller, T. R. et al. On the validity of the centrality hypothesis in cross-sectional
1035–1049 (2021). between-subject networks of psychopathology. BMC Med. 18, 297 (2020).
71. Watts, A. L., Poore, H. E. & Waldman, I. D. Riskier tests of the validity of the bifactor model 104. Hallquist, M. N., Wright, A. G. & Molenaar, P. C. Problems with centrality measures in
of psychopathology. Clin. Psychol. Sci. 7, 1285–1303 (2019). psychopathology symptom networks: why network psychometrics cannot escape
72. Fried, E. I. Studying mental health problems as systems, not syndromes. Curr. Dir. psychometric theory. Multivar. Behav. Res. 56, 199–223 (2019).
Psychol. Sci. 31, 500–508 (2022). 105. Dablander, F. & Hinne, M. Node centrality measures are a poor substitute for causal
73. Robinaugh, D. J., Hoekstra, R. H., Toner, E. R. & Borsboom, D. The network approach inference. Sci. Rep. 9, 6846 (2019).
to psychopathology: a review of the literature 2008–2018 and an agenda for future 106. DeYoung, C. G. & Krueger, R. F. To wish impossible things: on the ontological status of latent
research. Psychol. Med. 50, 353–366 (2020). variables and the prospects for theory in psychology. Psychol. Inq. 31, 289–296 (2020).
74. Wichers, M., Wigman, J. & Myin-Germeys, I. Micro-level affect dynamics in psychopathology 107. Granger, C. W. Investigating causal relations by econometric models and cross-spectral
viewed from complex dynamical system theory. Emot. Rev. 7, 362–367 (2015). methods. J. Econom. Soc. 37, 424–438 (1969).
75. Borsboom, D. in Philosophical Issues In Psychiatry IV: Psychiatric Nosology (ed. Kendler, K. S.) 108. Bringmann, L. F. et al. Assessing temporal emotion dynamics using networks.
80–97 (Oxford Univ. Press, 2017). Assessment 23, 425–435 (2016).
76. Borsboom, D. et al. Kinds versus continua: a review of psychometric approaches to 109. Forbes, M. K., Wright, A. G., Markon, K. E. & Krueger, R. F. Evidence that psychopathology
uncover the structure of psychiatric constructs. Psychol. Med. 46, 1567–1579 (2016). symptom networks have limited replicability. J. Abnorm. Psychol. 126, 969–988 (2017).
77. Cramer, A. O., Waldorp, L. J., Van Der Maas, H. L. & Borsboom, D. Comorbidity: a network 110. Forbes, M. K., Wright, A. G., Markon, K. E. & Krueger, R. F. Quantifying the reliability and
perspective. Behav. Brain Sci. 33, 137–150 (2010). replicability of psychopathology network characteristics. Multivar. Behav. Res. 56,
78. Beltz, A. M., Wright, A. G., Sprague, B. N. & Molenaar, P. C. Bridging the nomothetic and 224–242 (2019).
idiographic approaches to the analysis of clinical data. Assessment 23, 447–458 (2016). 111. Haslbeck, J., Ryan, O., Robinaugh, D. J., Waldorp, L. J. & Borsboom, D. Modeling
79. Wright, A. G., Beltz, A. M., Gates, K. M., Molenaar, P. & Simms, L. J. Examining the dynamic psychopathology: from data models to formal theories. Psychol. Meth. 27, 930–957 (2021).
structure of daily internalizing and externalizing behavior at multiple levels of analysis. 112. Epskamp, S., Borsboom, D. & Fried, E. I. Estimating psychological networks and their
Front. Psychol. 6, 1914 (2015). accuracy: a tutorial paper. Behav. Res. Meth. 50, 195–212 (2018).
80. Bulteel, K., Tuerlinckx, F., Brose, A. & Ceulemans, E. Improved insight into and prediction 113. Forbes, M. K., Wright, A. G., Markon, K. E. & Krueger, R. F. On unreplicable inferences
of network dynamics by combining VAR and dimension reduction. Multivar. Behav. Res. in psychopathology symptom networks and the importance of unreliable parameter
53, 853–875 (2018). estimates. Multivar. Behav. Res. 56, 368–376 (2021).
81. Wright, A. G. & Woods, W. C. Personalized models of psychopathology. Annu. Rev. Clin. 114. Borsboom, D. et al. False alarm? A comprehensive reanalysis of “Evidence that
Psychol. 16, 49–74 (2020). psychopathology symptom networks have limited replicability” by Forbes, Wright,
82. Olthof, M. et al. Critical fluctuations as an early-warning signal for sudden gains and Markon, and Krueger (2017). J. Abnorm. Psychol. 126, 989–999 (2017).
losses in patients receiving psychotherapy for mood disorders. Clin. Psychol. Sci. 8, 115. Borsboom, D., Robinaugh, D. J., Group, T. P., Rhemtulla, M. & Cramer, A. O. Robustness
25–35 (2020). and replicability of psychopathology networks. World Psychiat. 17, 143–144 (2018).
83. Helmich, M. A. et al. Early warning signals and critical transitions in psychopathology: 116. Fried, E. I. et al. Replicability and generalizability of posttraumatic stress disorder (PTSD)
challenges and recommendations. Curr. Opin. Psychol. 41, 51–58 (2021). networks: a cross-cultural multisite study of PTSD symptoms in four trauma patient
84. Wichers, M., Smit, A. C. & Snippe, E. Early warning signals based on momentary affect samples. Clin. Psychol. Sci. 6, 335–351 (2018).
dynamics can expose nearby transitions in depression: a confirmatory single-subject 117. Fried, E. I., van Borkulo, C. D. & Epskamp, S. On the importance of estimating parameter
time-series study. J. Pers. Oriented Res. 6, 1–15 (2020). uncertainty in network psychometrics: a response to Forbes et al. (2019). Multivar. Behav.
85. Wichers, M., Groot, P. C., Psychosystems, E. & Group, E. Critical slowing down as a Res. 56, 243–248 (2020).
personalized early warning signal for depression. Psychother. Psychosom. 85, 114–116 (2016). 118. Lin, S.-Y., Fried, E. I. & Eaton, N. R. The association of life stress with substance use
86. van de Leemput, I. A. et al. Critical slowing down as early warning for the onset and symptoms: a network analysis and replication. J. Abnorm. Psychol. 129, 204–214 (2020).
termination of depression. Proc. Natl Acad. Sci.USA 111, 87–92 (2014). 119. Epskamp, S. & Fried, E. I. A tutorial on regularized partial correlation networks. Psychol.
87. Helmich, M. A. et al. Detecting impending symptom transitions using early-warning Meth. 23, 617–634 (2018).
signals in individuals receiving treatment for depression. Clin. Psychol. Sci. 120. Bringmann, L. F. Person-specific networks in psychopathology: past, present and future.
https://doi.org/10.1177/21677026221137006 (2021). Curr. Opin. Psychol. 41, 59–64 (2021).
88. Schreuder, M., Wigman, J., Smit, A., Hartman, C. & Wichers, M. Anticipating transitions 121. McGorry, P. D. & Hickie, I. B. Clinical Staging In Psychiatry: Making Diagnosis Work For
in mental health in at-risk youth: a large-scale diary study into early warning signals. Research And Treatment (Cambridge Univ. Press, 2019).
Eur. Psychiat. 64, S455–S455 (2021). 122. McGorry, P. et al. Biomarkers and clinical staging in psychiatry. World Psychiat. 13,
89. Robinaugh, D. J., Haslbeck, J. M., Ryan, O., Fried, E. I. & Waldorp, L. J. Invisible hands and 211–223 (2014).
fine calipers: a call to use formal theory as a toolkit for theory construction. Perspect. 123. Iorfino, F. et al. Clinical stage transitions in persons aged 12 to 25 years presenting to
Psychol. Sci. 16, 725–743 (2021). early intervention mental health services with anxiety, mood, and psychotic disorders.
90. Borsboom, D., van der Maas, H. L. J., Dalege, J., Kievit, R. A. & Haig, B. D. Theory JAMA Psychiat. 76, 1167–1175 (2019).
construction methodology: a practical framework for building theories in psychology. 124. Filia, K. et al. Clinical and functional characteristics of a subsample of young people
Perspect. Psychol. Sci. 16, 756–766 (2021). presenting for primary mental healthcare at headspace services across Australia.
91. Fried, E. I. Lack of theory building and testing impedes progress in the factor and Soc. Psychiat. Psychiatr. Epidemiol. 56, 1311–1323 (2021).
network literature. Psychol. Inq. 31, 271–288 (2020). 125. Purcell, R. et al. Demographic and clinical characteristics of young people seeking help
92. Bringmann, L. F. & Eronen, M. I. Don’t blame the model: reconsidering the network at youth mental health services: baseline findings of the Transitions Study. Early Interv.
approach to psychopathology. Psychol. Rev. 125, 606–615 (2018). Psychiat. 9, 487–497 (2015).
93. Bringmann, L. F. et al. What do centrality measures measure in psychological networks? 126. Hickie, I. B. et al. Applying clinical staging to young people who present for mental
J. Abnorm. Psychol. 128, 892–903 (2019). health care. Early Interv. Psychiat. 7, 31–43 (2013).
94. Pe, M. L. et al. Emotion-network density in major depressive disorder. Clin. Psychol. Sci. 127. Romanowska, S. et al. Social and role functioning in youth at risk of serious mental
3, 292–300 (2015). illness. Early Interv. Psychiat. 14, 463–469 (2020).
95. Wigman, J. T., de Vos, S., Wichers, M., van Os, J. & Bartels-Velthuis, A. A. A transdiagnostic 128. Cross, S. P., Hermens, D. F. & Hickie, I. B. Treatment patterns and short‐term outcomes in
network approach to psychosis. Schizophr. Bull. 43, 122–132 (2017). an early intervention youth mental health service. Early Interv. Psychiat. 10, 88–97 (2016).
96. van Borkulo, C. et al. Association of symptom network structure with the course of 129. Nogovitsyn, N. et al. Aberrant limbic brain structures in young individuals at risk for
depression. JAMA Psychiat. 72, 1219–1226 (2015). mental illness. Psychiat. Clin. Neurosci. 74, 294–302 (2020).
97. Schweren, L., Van Borkulo, C. D., Fried, E. & Goodyer, I. M. Assessment of symptom 130. Scott, E. M. et al. Dysregulated sleep–wake cycles in young people are associated with
network density as a prognostic marker of treatment response in adolescent depression. emerging stages of major mental disorders. Early Interv. Psychiat. 10, 63–70 (2016).
JAMA Psychiat. 75, 98–100 (2018). 131. Stowkowy, J. et al. Sleep disturbances in youth at‐risk for serious mental illness.
98. De Vos, S. et al. An investigation of emotion dynamics in major depressive disorder Early Interv. Psychiat. 14, 373–378 (2020).
patients and healthy persons using sparse longitudinal networks. PLoS One 12, e0178586 132. Romanowska, S. et al. Neurocognitive deficits in a transdiagnostic clinical staging model.
(2017). Psychiat. Res. 270, 1137–1142 (2018).
99. Lutz, W. et al. Using network analysis for the prediction of treatment dropout in patients 133. McGorry, P. D. & Mei, C. Clinical staging for youth mental disorders: progress in reforming
with mood and anxiety disorders: a methodological proof-of-concept study. Sci. Rep. 8, diagnosis and clinical care. Annu. Rev. Dev. Psychol. 3, 15–39 (2021).
7819 (2018). 134. Sacks, D. D. et al. White matter integrity according to the stage of mental disorder in youth.
100. Boschloo, L., van Borkulo, C. D., Borsboom, D. & Schoevers, R. A. A prospective study on Psychiat. Res. Neuroimag. 307, 111218 (2021).
how symptoms in a network predict the onset of depression. Psychother. Psychosom. 85, 135. Hermens, D. F. et al. Neuropsychological profile according to the clinical stage of young
183–184 (2016). persons presenting for mental health care. BMC Psychol. 1, 8 (2013).

Nature Reviews Psychology

Review article

136. Eggins, P. S., Hatton, S. N., Hermens, D. F., Hickie, I. B. & Lagopoulos, J. Subcortical 169. Koval, P. et al. Emotional inertia and external events: the roles of exposure, reactivity, and
volumetric differences between clinical stages of young people with affective and recovery. Emotion 15, 625–636 (2015).
psychotic disorders. Psychiat. Res. Neuroimag. 271, 8–16 (2018). 170. Kuppens, P., Allen, N. B. & Sheeber, L. B. Emotional inertia and psychological
137. Lagopoulos, J. et al. Microstructural white matter changes are correlated with the stage maladjustment. Psychol. Sci. 21, 984–991 (2010).
of psychiatric illness. Transl. Psychiat. 3, e248 (2013). 171. Kuppens, P. et al. Emotional inertia prospectively predicts the onset of depressive
138. Lagopoulos, J., Hermens, D. F., Naismith, S. L., Scott, E. M. & Hickie, I. B. Frontal lobe disorder in adolescence. Emotion 12, 283–289 (2012).
changes occur early in the course of affective disorders in young people. BMC Psychiat. 172. Ebner-Priemer, U. W., Eid, M., Kleindienst, N., Stabenow, S. & Trull, T. J. Analytic
12, 4 (2012). strategies for understanding affective (in)stability and other dynamic processes in
139. Naismith, S. L. et al. Circadian profiles in young people during the early stages of psychopathology. J. Abnorm. Psychol. 118, 195–202 (2009).
affective disorder. Transl. Psychiat. 2, e123 (2012). 173. Myin‐Germeys, I. et al. Experience sampling methodology in mental health research:
140. Shah, J. L. et al. Transdiagnostic clinical staging in youth mental health: a first new insights and technical developments. World Psychiat. 17, 123–132 (2018).
international consensus statement. World Psychiat. 19, 233–242 (2020). 174. Sperry, S. H., Barrantes-Vidal, N. & Kwapil, T. R. The association of affective temperaments
141. Cross, S. P., Scott, J. & Hickie, I. B. Predicting early transition from sub-syndromal and bipolar spectrum psychopathology: an experience sampling study. Motiv. Emot. 42,
presentations to major mental disorders. BJPsych Open 3, 223–227 (2017). 126–136 (2018).
142. Carpenter, J. S. et al. Combining clinical stage and pathophysiological mechanisms 175. Trull, T. J., Lane, S. P., Koval, P. & Ebner-Priemer, U. W. Affective dynamics in
to understand illness trajectories in young people with emerging mood and psychotic psychopathology. Emot. Rev. 7, 355–361 (2015).
syndromes. Med. J. Aust. 211, S12–S22 (2019). 176. Yang, X. et al. Socioemotional dynamics of emotion regulation and depressive
143. Hartmann, J. A. et al. Broad clinical high‐risk mental state (CHARMS): methodology of symptoms: a person-specific network approach. Innov. Aging 2, 15–16 (2018).
a cohort study validating criteria for pluripotent risk. Early Interv. Psychiat. 13, 379–386 177. Elmer, T., Geschwind, N., Peeters, F., Wichers, M. & Bringmann, L. Getting stuck in social
(2019). isolation: solitude inertia and depressive symptoms. J. Abnorm. Psychol. 129, 713–723
144. Hartmann, J. A. et al. Pluripotential risk and clinical staging: theoretical considerations (2020).
and preliminary data from a transdiagnostic risk identification approach. Front. Psychiat. 178. van Winkel, M. et al. Unraveling the role of loneliness in depression: the relationship
11, 553578 (2021). between daily life experience and behavior. Psychiatry 80, 104–117 (2017).
145. Caspi, A. et al. Longitudinal assessment of mental health disorders and comorbidities 179. Hong, R. Y. & Paunonen, S. V. Personality vulnerabilities to psychopathology: relations
across 4 decades among participants in the Dunedin birth cohort study. JAMA Netw. between trait structure and affective‐cognitive processes. J. Pers. 79, 527–562 (2011).
Open 3, e203221 (2020). 180. Myin-Germeys, I., Krabbendam, L., Jolles, J., Delespaul, P. A. & van Os, J. Are cognitive
146. McGorry, P. & Nelson, B. Why we need a transdiagnostic staging approach to emerging impairments associated with sensitivity to stress in schizophrenia? An experience
psychopathology, early diagnosis, and treatment. JAMA Psychiat. 73, 191–192 (2016). sampling study. Am. J. Psychiat. 159, 443–449 (2002).
147. Scott, J. et al. Prevalence of self‐reported subthreshold phenotypes of major mental 181. Nieman, D. H. et al. Protocol across study: longitudinal transdiagnostic cognitive
disorders and their association with functional impairment, treatment and full‐threshold functioning, psychiatric symptoms, and biological parameters in patients with a
syndromes in a community‐residing cohort of young adults. Early Interv. Psychiat. 15, psychiatric disorder. BMC Psychiat. 20, 212 (2020).
306–313 (2021). 182. Sadikaj, G., Moskowitz, D. S., Russell, J. J., Zuroff, D. C. & Paris, J. Quarrelsome behavior
148. Lahey, B. B., Zald, D. H., Hakes, J. K., Krueger, R. F. & Rathouz, P. J. Patterns of heterotypic in borderline personality disorder: influence of behavioral and affective reactivity to
continuity associated with the cross-sectional correlational structure of prevalent mental perceptions of others. J. Abnorm. Psychol. 122, 195–207 (2013).
disorders in adults. JAMA Psychiat. 71, 989–996 (2014). 183. Trull, T. J. Ambulatory assessment of borderline personality disorder. Psychopathology
149. Plana-Ripoll, O. et al. Exploring comorbidity within mental disorders among a Danish 51, 137–140 (2018).
national population. JAMA Psychiat. 76, 259–270 (2019). 184. Dejonckheere, E. et al. Complex affect dynamics add limited information to the
150. Chanen, A. M., Berk, M. & Thompson, K. Integrating early intervention for borderline prediction of psychological well-being. Nat. Hum. Behav. 3, 478–491 (2019).
personality disorder and mood disorders. Harv. Rev. Psychiat. 24, 330–341 (2016). 185. Russell, J. J., Moskowitz, D. S., Zuroff, D. C., Sookman, D. & Paris, J. Stability and variability
151. Hartmann, J. A., Nelson, B., Ratheesh, A., Treen, D. & McGorry, P. D. At-risk studies and of affective experience and interpersonal behavior in borderline personality disorder.
clinical antecedents of psychosis, bipolar disorder and depression: a scoping review J. Abnorm. Psychol. 116, 578–588 (2007).
in the context of clinical staging. Psychol. Med. 49, 177–189 (2019). 186. Keltner, D. & Kring, A. M. Emotion, social function, and psychopathology. Rev. Gen.
152. McGorry, P. & Van Os, J. Redeeming diagnosis in psychiatry: timing versus specificity. Psychol. 2, 320–342 (1998).
Lancet 381, 343–345 (2013). 187. Cía, A. H. et al. Lifetime prevalence and age-of-onset of mental disorders in adults
153. Kendler, K. S. Classification of psychopathology: conceptual and historical background. from the Argentinean study of mental health epidemiology. Soc. Psychiat. Psychiatr.
World Psychiat. 17, 241–242 (2018). Epidemiol. 53, 341–350 (2018).
154. Leibenluft, E. Categories and dimensions, brain and behavior: the yins and yangs of 188. Forbes, M. K., Rapee, R. M. & Krueger, R. F. Opportunities for the prevention of mental
psychopathology. JAMA Psychiat. 71, 15–17 (2014). disorders by reducing general psychopathology in early childhood. Behav. Res. Ther. 119,
155. Boffa, R. J., Constanti, M., Floyd, C. N. & Wierzbicki, A. S. Hypertension in adults: summary 103411 (2019).
of updated NICE guidance. Br. Med. J 367, l5310 (2019). 189. Kessler, R. C. et al. Lifetime prevalence and age-of-onset distributions of DSM-IV
156. Jablensky, A. Psychiatric classifications: validity and utility. World Psychiat. 15, 26–31 disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiat. 62,
(2016). 593–602 (2005).
157. Hamaker, E. L. Why Researchers Should Think “Within-Person”: A Paradigmatic Rationale 190. McElroy, E., Belsky, J., Carragher, N., Fearon, P. & Patalay, P. Developmental stability of
43–61 (Guilford, 2012). general and specific factors of psychopathology from early childhood to adolescence:
158. Fisher, A. J. Toward a dynamic model of psychological assessment: implications for dynamic mutualism or p‐differentiation? J. Child. Psychol. Psychiat. 59, 667–675 (2018).
personalized care. J. Consult. Clin. Psychol. 83, 825–836 (2015). 191. van Dijk, I., Krueger, R. F. & Laceulle, O. M. DSM-5 alternative personality disorder model
159. Fisher, A. J. & Boswell, J. F. Enhancing the personalization of psychotherapy with dynamic traits as extreme variants of five-factor model traits in adolescents. Pers. Disord. 12,
assessment and modeling. Assessment 23, 496–506 (2016). 59–69 (2021).
160. Molenaar, P. C. A manifesto on psychology as idiographic science: bringing the person 192. See, A. Y., Klimstra, T. A., Cramer, A. O. & Denissen, J. J. The network structure of
back into scientific psychology, this time forever. Measurement 2, 201–218 (2004). personality pathology in adolescence with the 100-item personality inventory for DSM-5
161. Piccirillo, M. L. & Rodebaugh, T. L. Foundations of idiographic methods in psychology Short-Form (PID-5-SF). Front. Psychol. 11, 823 (2020).
and applications for psychotherapy. Clin. Psychol. Rev. 71, 90–100 (2019). 193. Zhang, W., Wang, M., Yu, M. & Wang, J. The hierarchical structure and predictive validity
162. Bolger, N., Davis, A. & Rafaeli, E. Diary methods: capturing life as it is lived. Annu. Rev. of the personality inventory for DSM-5 in Chinese nonclinical adolescents. Assessment
Psychol. 54, 579–616 (2003). 29, 1559–1575 (2021).
163. McNeish, D. & Hamaker, E. L. A primer on two-level dynamic structural equation models 194. Patalay, P. et al. A general psychopathology factor in early adolescence. Br. J. Psychiat.
for intensive longitudinal data in Mplus. Psychol. Methods 25, 610–635 (2020). 207, 15–22 (2015).
164. Bringmann, L., Lemmens, L., Huibers, M., Borsboom, D. & Tuerlinckx, F. Revealing the 195. Achenbach, T. M. Bottom-up and top-down paradigms for psychopathology: a
dynamic network structure of the beck depression inventory-II. Psychol. Med. 45, half-century odyssey. Annu. Rev. Clin. Psychol. 16, 1–24 (2020).
747–757 (2015). 196. Eaton, N. R., Krueger, R. F. & Oltmanns, T. F. Aging and the structure and long-term
165. Snippe, E., Doornbos, B., Schoevers, R. A., Wardenaar, K. J. & Wichers, M. Individual and stability of the internalizing spectrum of personality and psychopathology. Psychol.
common patterns in the order of symptom improvement during outpatient treatment for Aging 26, 987–993 (2011).
major depression. J. Affect. Disord. 290, 81–88 (2021). 197. Greene, A. L. & Eaton, N. R. The temporal stability of the bifactor model of comorbidity:
166. Beck, E. D. & Jackson, J. J. in Measuring And Modeling Persons And Situations 465–497 an examination of moderated continuity pathways. Compr. Psychiat. 72, 74–82 (2017).
(Elsevier, 2021). 198. Murray, A. L., Eisner, M. & Ribeaud, D. The development of the general factor of
167. Trull, T. J. & Ebner-Priemer, U. The role of ambulatory assessment in psychological psychopathology ‘p factor’ through childhood and adolescence. J. Abnorm. Child.
science. Curr. Dir. Psychol. Sci. 23, 466–470 (2014). Psychol. 44, 1573–1586 (2016).
168. Trull, T. J. & Ebner-Priemer, U. W. Ambulatory assessment in psychopathology research: 199. Snyder, H. R., Young, J. F. & Hankin, B. L. Strong homotypic continuity in common
a review of recommended reporting guidelines and current practices. J. Abnorm. Psychol. psychopathology-, internalizing-, and externalizing-specific factors over time in
129, 56–63 (2020). adolescents. Clin. Psychol. Sci. 5, 98–110 (2017).

Nature Reviews Psychology

Review article

200. Eaton, N. R. et al. Genes, environments, personality, and successful aging: toward a 230. Burger, J. et al. Bridging the gap between complexity science and clinical practice
comprehensive developmental model in later life. J. Gerontol. A 67, 480–488 (2012). by formalizing idiographic theories: a computational model of functional analysis.
201. Forbes, M. K., Tackett, J. L., Markon, K. E. & Krueger, R. F. Beyond comorbidity: toward a BMC Med. 18, 99 (2020).
dimensional and hierarchical approach to understanding psychopathology across the 231. Burger, J. et al. A clinical PREMISE for personalized models: towards a formal integration
life span. Dev. Psychopathol. 28, 971–986 (2016). of case formulations and statistical networks. J. Psychopathol. Clin. Sci. 131, 906–916
202. Hopwood, C. J. et al. Integrating psychotherapy with the hierarchical taxonomy of (2022).
psychopathology (HiTOP). J. Psychother. Integr. 30, 477–497 (2020). 232. Wiciński, M. & Węclewicz, M. M. Clozapine-induced agranulocytosis/granulocytopenia:
203. Ruggero, C. J. et al. Integrating the hierarchical taxonomy of psychopathology (HiTOP) mechanisms and monitoring. Curr. Opin. Hematol. 25, 22–28 (2018).
into clinical practice. J. Consult. Clin. Psychol. 87, 1069–1084 (2019). 233. Hickie, I. B. et al. Right care, first time: a highly personalised and measurement‐based
204. Mullins‐Sweatt, S. N. et al. Treatment of personality pathology through the lens of the care model to manage youth mental health. Med. J. Aust. 211, S3–S46 (2019).
hierarchical taxonomy of psychopathology: developing a research agenda. Pers. Ment. 234. Nelson, B. et al. Staged treatment in early psychosis: a sequential multiple assignment
Health 14, 123–141 (2020). randomised trial of interventions for ultra high risk of psychosis patients. Early Interv.
205. Clark, L. A., Watson, D. & Reynolds, S. Diagnosis and classification of psychopathology: Psychiat. 12, 292–306 (2018).
challenges to the current system and future directions. Annu. Rev. Psychol. 46, 121–153 235. Eaton, N. R. Measurement and mental health disparities: psychopathology classification
(1995). and identity assessment. Pers. Ment. Health 14, 76–87 (2020).
206. Markon, K. E., Chmielewski, M. & Miller, C. J. The reliability and validity of discrete and 236. Rodriguez-Seijas, C., Eaton, N. R. & Pachankis, J. E. Prevalence of psychiatric disorders at
continuous measures of psychopathology: a quantitative review. Psychol. Bull. 137, 856 the intersection of race and sexual orientation: results from the national epidemiologic
(2011). survey of alcohol and related conditions — III. J. Consult. Clin. Psychol. 87, 321–331
207. Clark, L. A. & Watson, D. in Methodological Issues And Strategies In Clinical Research (2019).
(ed. Kazdin, A. E.) 187–203 (American Psychological Association, 2016). 237. Rodriguez-Seijas, C. et al. Diversity and the hierarchical taxonomy of psychopathology
208. Waszczuk, M. A. et al. What do clinicians treat: diagnoses or symptoms? The incremental (HiTOP). Nat. Rev. Psychol. https://doi.org/10.1038/s44159-023-00200-0 (2023).
validity of a symptom-based, dimensional characterization of emotional disorders in 238. Eaton, N. R. The broad importance of integration: psychopathology research and
predicting medication prescription patterns. Compr. Psychiat. 79, 80–88 (2017). hierarchy as construct. Eur. J. Pers. 31, 539–540 (2017).
209. Hansen, S. J. et al. Mental health professionals’ perceived clinical utility of the ICD‐10 vs. 239. Molenaar, P. C. Latent variable models are network models. Behav. Brain Sci. 33, 166
ICD‐11 classification of personality disorders. Pers. Ment. Health 13, 84–95 (2019). (2010).
210. Morey, L. C., Skodol, A. E. & Oldham, J. M. Clinician judgments of clinical utility: 240. Eaton, N. R. Latent variable and network models of comorbidity: toward an empirically
a comparison of DSM-IV-TR personality disorders and the alternative model for DSM-5 derived nosology. Soc. Psychiat. Psychiatr. Epidemiol. 50, 845–849 (2015).
personality disorders. J. Abnorm. Psychol. 123, 398–405 (2014). 241. Epskamp, S., Rhemtulla, M. & Borsboom, D. Generalized network psychometrics:
211. Rodriguez-Seijas, C., Eaton, N. R., Stohl, M., Mauro, P. M. & Hasin, D. S. Mental disorder combining network and latent variable models. Psychometrika 82, 904–927
comorbidity and treatment utilization. Compr. Psychiat. 79, 89–97 (2017). (2017).
212. Barlow, D. H., Harris, B. A., Eustis, E. H. & Farchione, T. J. The unified protocol for 242. McFarland, D. J. & Malta, L. S. Symptoms as latent variables. Behav. Brain Sci. 33, 165–166
transdiagnostic treatment of emotional disorders. World Psychiat. 19, 245 (2020). (2010).
213. Dalgleish, T., Black, M., Johnston, D. & Bevan, A. Transdiagnostic approaches to mental 243. Rush, A. J. et al. The inventory for depressive symptomatology (IDS): preliminary findings.
health problems: current status and future directions. J. Consult. Clin. Psychol. 88, Psychiat. Res. 18, 65–87 (1986).
179–195 (2020). 244. Michelini, G., Palumbo, I. M., DeYoung, C. G., Latzman, R. D. & Kotov, R. Linking RDoC
214. Ellard, K. K., Fairholme, C. P., Boisseau, C. L., Farchione, T. J. & Barlow, D. H. Unified and HiTOP: a new interface for advancing psychiatric nosology and neuroscience.
protocol for the transdiagnostic treatment of emotional disorders: protocol Clin. Psychol. Rev. 86, 102025 (2021).
development and initial outcome data. Cogn. Behav. Pract. 17, 88–101 (2010). 245. Brown, T. A. Confirmatory Factor Analysis For Applied Research (Guilford, 2015).
215. Eaton, N. R., Rodriguez-Seijas, C. & Pachankis, J. E. Transdiagnostic approaches to sexual 246. Kline, R. B. Principles And Practice Of Structural Equation Modeling 4th edn (Guilford,
and gender minority mental health. Curr. Dir. Psychol. Sci. 30, 510–518 (2021). 2015).
216. Conway, C. C., Krueger, R. F. & Board, H. C. E. Rethinking the diagnosis of mental disorders: 247. Conway, C. C., Forbes, M. K., South, S. C. & the HiTOP Consortium. A hierarchical
data-driven psychological dimensions, not categories, as a framework for mental-health taxonomy of psychopathology (HiTOP) primer for mental health researchers.
research, treatment, and training. Curr. Dir. Psychol. Sci. 30, 151–158 (2021). Clin. Psychol. Sci. 10, 236–258 (2022).
217. Rodriguez-Seijas, C., Eaton, N. R. & Krueger, R. F. How transdiagnostic factors of 248. Beltz, A. M. & Gates, K. M. Network mapping with GIMME. Multivar. Behav. Res. 52,
personality and psychopathology can inform clinical assessment and intervention. 789–804 (2017).
J. Pers. Assess. 97, 425–435 (2015). 249. Bringmann, L. F. et al. A network approach to psychopathology: new insights into clinical
218. von Klipstein, L., Riese, H., Servaas, M. N. & Schoevers, R. A. Using person-specific longitudinal data. PLoS One 8, e60188 (2013).
networks in psychotherapy: challenges, limitations, and how we could use them anyway. 250. Costantini, G. et al. State of the aRt personality research: a tutorial on network analysis
BMC Med. 18, 345 (2020). of personality data in R. J. Res. Pers. 54, 13–29 (2015).
219. Krieke, L. V. D. et al. HowNutsAreTheDutch (HoeGekIsNL): a crowdsourcing study of 251. Epskamp, S., Cramer, A. O., Waldorp, L. J., Schmittmann, V. D. & Borsboom, D. qgraph:
mental symptoms and strengths. Int. J. Meth. Psychiat. Res. 25, 123–144 (2016). network visualizations of relationships in psychometric data. J. Stat. Softw. 48, 1–18
220. van Roekel, E. et al. Study protocol for a randomized controlled trial to explore the (2012).
effects of personalized lifestyle advices and tandem skydives on pleasure in anhedonic 252. Van Borkulo, C. D. et al. A new method for constructing networks from binary data.
young adults. BMC Psychiat. 16, 182 (2016). Sci. Rep. 4, 5918 (2014).
221. Bastiaansen, J. A. et al. Self-monitoring and personalized feedback based on the
experiencing sampling method as a tool to boost depression treatment: a protocol Author contributions
of a pragmatic randomized controlled trial (ZELF-i). BMC Psychiat. 18, 276 (2018). All authors contributed to the writing and editing of this article. N.R.E. was additionally
222. Kroeze, R. et al. Personalized feedback on symptom dynamics of psychopathology: responsible for article structure and integration.
a proof-of-principle study. J. Pers. Oriented Res. 3, 1–10 (2017).
223. Frumkin, M. R., Piccirillo, M. L., Beck, E. D., Grossman, J. T. & Rodebaugh, T. L. Feasibility and Competing interests
utility of idiographic models in the clinic: a pilot study. Psychother. Res. 31, 520–534 (2021). The authors declare no competing interests.
224. Riese, H., Von Klipstein, L., Schoevers, R., van der Veen, D. & Servaas, M. Personalized
ESM monitoring and feedback to support psychological treatment for depression: Additional information
a pragmatic randomized controlled trial (Therap-i). BMC Psychiat. 21, 143 (2021). Supplementary information The online version contains supplementary material available at
225. Rubel, J. A., Fisher, A. J., Husen, K. & Lutz, W. Translating person-specific network https://doi.org/10.1038/s44159-023-00218-4.
models into personalized treatments: development and demonstration of the dynamic
assessment treatment algorithm for individual networks (DATA-IN). Psychother. Peer review information Nature Reviews Psychology thanks the anonymous reviewers for their
Psychosom. 87, 249–251 (2018). contribution to the peer review of this work.
226. Fisher, A. J., Reeves, J. W., Lawyer, G., Medaglia, J. D. & Rubel, J. A. Exploring the
idiographic dynamics of mood and anxiety via network analysis. J. Abnorm. Psychol. 126, Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims
1044–1056 (2017). in published maps and institutional affiliations.
227. Reeves, J. W. & Fisher, A. J. An examination of idiographic networks of posttraumatic
stress disorder symptoms. J. Trauma. Stress. 33, 84–95 (2020). Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this
228. Roefs, A. et al. A new science of mental disorders: using personalised, transdiagnostic, article under a publishing agreement with the author(s) or other rightsholder(s); author
dynamical systems to understand, model, diagnose and treat psychopathology. self-archiving of the accepted manuscript version of this article is solely governed by the
Behav. Res. Ther. 153, 104096 (2022). terms of such publishing agreement and applicable law.
229. Bastiaansen, J. A. et al. Time to get personal? The impact of researchers choices on
the selection of treatment targets using the experience sampling methodology.
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