SIG Spotlight: The “Middle-Out” Approach to Conceptualizing (and Reconceptualizing) Traumatic Stress
StressPoints
The diagnostic criteria for posttraumatic stress disorder (PTSD) in the
DSM-5 have become the most inherently complex to date, with 20 possible symptoms, four factors (with some studies recommending seven factors), and 636,120 different symptom combinations (Armour et al., 2016; Galatzer-Levy & Bryant, 2013). In addition to this complexity and heterogeneity, issues of comorbidity have become more common with PTSD than with any other psychiatric disorder (Koenen et al., 2008). For example, approximately half of those with PTSD have a comorbid diagnosis of a depressive disorder (Elhai et al., 2008; Flory & Yehuda, 2015). This diagnostic murkiness raises sobering questions, ranging from the internal coherence, structure, and dimensionality of PTSD to broader nosological issues regarding the logic and methods by which psychiatric disorders are identified, differentiated, and classified. Many categorical diagnostic criteria were constructed to maximize clinical utility. Nevertheless, their relative utility for other research applications, including theory-building; measurement; nosology; and investigations into the etiology, clinical course of, and discriminability between diagnostic constructs, remain questionable as diagnostic classifications often do little to “carve nature at the joints” (Zachar & Kendler, 2017). The release of both
DSM-5-TR and
ICD-11 this year, including the introduction of a new prolonged grief disorder (PGD) in each, underscores the need to clarify clinically important distinctions between related diagnostic entities (e.g., PTSD vs. PGD), as well as to ensure that their internal structures (i.e., dimensionality) and resulting complexity (think diagnostic permutations) does not expand beyond what is truly useful.