The Middle‐Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions

Dimensional models of psychopathology are gaining empirical support and are, thus, increasingly common in research and clinical practice. This is true for traumatic stress studies, although the movement toward dimensional conceptualizations of traumatic stress may be somewhat slower, perhaps due at least in part to how trauma is diagnosed. The purpose of this special section is to collect and showcase cutting‐edge basic, applied, and conceptual work on dimensional models of traumatic stress. Its goal is to highlight the utility of such models and to facilitate greater connection between traumatic stress studies and the broader dimensional movement in psychopathology.

Section: Introduction To the Special Sectionmentioning

confidence: 99%

Dimensional approaches to studying, assessing, and treating traumatic stress: Introduction to the Special Section

Yalch

2024

The Middle‐Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions

Adams,

Layne,

Contractor

et al. 2023

Self Cite

Alternative models of traumatic stress and broader psychopathology have been proposed to address issues of heterogeneity, comorbidity, clinical utility, and equitable representation. However, systematic and practical methods and guidelines to organize and apply these models remain scarce. The Middle‐Out Approach is a novel, integrative, contextually informed framework for organizing and applying existing empirical methods to evaluate current and alternative traumatic stress reactions. Rather than beginning to identify traumatic stress reactions from the top‐down (i.e., disorder‐first approach) or bottom‐up (i.e., symptom‐first approach), constructs are evaluated from the middle out (i.e., presentation‐first approach), unconstrained by higher‐order disorders or lower‐order diagnostic symptoms. This approach provides innovation over previous methods at multiple levels, including the conceptualization of traumatic stress reactions as well as the type of assessments and data sources used and how they are used in statistical analyses. Conceptualizations prioritize the identification of middle‐order phenotypes, representing person‐centered clinical presentations, which are informed by the integration of multidimensional, transdiagnostic, and multimodal (e.g., psychosocial, physiological) assessments and/or data sources. Integrated data are then analyzed concurrently using person‐centered statistical models to identify precise, discrete, and representative health outcomes within broader heterogeneous samples. Subsequent variable‐centered analyses are then used to identify culturally sensitive and contextually informed correlates of phenotypes, their clinical utility, and the differential composition within and between broader traumatic stress reactions. Examples from the moral injury literature are used to illustrate practical applications that may increase clinical utility and the accurate representation of health outcomes for diverse individuals and communities.

Identifying transdiagnostic traumatic stress reactions in U.S. military veterans: A nationally representative study

Pugach,

Adams,

Wisco

et al. 2024

Traumatic stress reactions (TSRs) exist on a continuum that includes posttraumatic stress disorder (PTSD), highly comorbid psychopathology, and resilience, highlighting the need for comprehensive and integrative approaches capable of capturing the full spectrum of heterogeneous reactions. Here, we used a transdiagnostic and multidimensional method to characterize clinical phenotypes of TSRs in a nationally representative sample of U.S. military veterans. The Middle‐Out Approach was used to evaluate self‐reported PTSD, generalized anxiety, major depressive symptoms, and physical and mental functioning to identify discrete latent classes of TSRs and their demographic, military and trauma history, and psychosocial correlates. Cross‐sectional data were analyzed from 3,727 U.S. veterans who participated in the National Health and Resilience in Veterans Study. Latent class analysis identified five classes of veterans: low TSR (61.3%), anxious/depressive (16.6%), avoidant arousal (9.2%), dysphoric arousal (8.2%), and high TSR (4.7%). Veterans in the dysphoric arousal and high TSR classes demonstrated lower functioning than other classes, which showed similar levels of moderate‐to‐high functioning despite symptom differences. Classes distinguished between resilience to PTSD symptoms versus resilience to all symptoms and functioning domains and were differentially associated with demographic characteristics, trauma and military histories, and psychosocial characteristics. The results suggest that veterans exhibit different clinical phenotypes of TSRs, which may help inform etiology, diagnostic subtypes, and personalized treatment. Further, although most veterans with psychopathology experience functional impairment, a sizable subset demonstrates high functioning despite psychopathology symptoms.