What is (and is not) a Trauma?
Trauma. The word means different things to different people and in different circumstances. Sometimes the word refers to intense distress. Sometimes it means actual physical tissue damage. Sometimes it means an emotional upset. And all of these definitions are legitimate and understood in specific contexts.
There is no shortage of distressing and intensely emotionally upsetting situations in today’s world. So many of us have been under intense stress and strain almost continuously for years, whether from the global pandemic, political upheaval, social justice, disasters, loss, etc. It is hard sometimes to even comprehend the scope and scale of the disruptions and distress collectively, and the expected fallout in day to day functioning. Behavioral health providers everywhere are stretched thin trying to provide as much capacity as possible to all those in need of healing services, while at the same time consumers are finding it more and more difficult to find a behavioral health provider with openings and a scope of practice fitting their needs.
June is PTSD Awareness Month. It strikes me that we need a month of focused attention to raise awareness of PTSD given the current environment. So many of us have become well-acquainted with trauma and loss in the past few years. And yet not everything that is a valid, real, distressing experience is a trauma, and the confusion could result in less effective or delayed care.
The DSM-5 defines a trauma, for the purposes of diagnosing PTSD, as “exposure to actual or threatened death, serious injury, or sexual violence” experienced either directly by oneself, witnessing it happening to others, learning about it happening to a close family member or friend, or experiencing extreme or repeated exposure to aversive details of such an event. Examples of a “criterion A” trauma might include combat, physical assault, sexual assault, abuse, motor vehicle accident, natural disaster, torture, kidnapping, industrial accident, or any other experience that includes actual or threatened death, serious injury, or sexual violence. Additionally, it is important to remember that the perception of the subject is vitally important to whether an experience is a trauma. For example, if a survivor of a minor motor vehicle accident honestly believed that they could have been seriously injured or killed, it is less important whether they were objectively in danger of death/injury than whether they believed they were in such danger. It is no less a trauma simply because a disinterested third party might determine that the likelihood of death or injury was minimal if the survivor believed they were in danger.
The diagnostic criteria of PTSD is unusual in the DSM in that exposure to a traumatic experience is necessary, though not sufficient, for a diagnosis of PTSD. Most people who experience a traumatic event have very common responses to the trauma, and most naturally recover from their responses back to normal functioning in the days or weeks following the trauma. If those responses last longer than would normally be expected, we may refer to those responses as symptoms, and depending on the constellation of symptoms a person may meet diagnostic criteria for PTSD. It is the combination of the trauma experience and the resulting symptom constellation that characterizes PTSD.
If a person has not experienced a criterion A trauma, regardless of the symptoms they are currently experiencing, then their clinical presentation would very probably be better conceptualized as something else–perhaps an Adjustment Disorder, a mood disorder, an anxiety disorder, a grief reaction, or any number of other possible descriptions. That is NOT to say that if someone’s experience does not meet the definition of a trauma that they are not having legitimate symptoms, or are unworthy of clinical attention, or even that they could not benefit from clinical intervention. Instead, it is likely that they will be better served by treating their presenting symptoms with an approach consistent with those symptoms.
Now, of course the “vocabulary police” (and no they do not exist, but sometimes don’t we wish they did? :)) are not going to come haul someone away for saying “trauma” or “PTSD” when a presentation does not meet the DSM definition precisely. Indeed, in typical conversational language the word “trauma” is generally understood to include a much wider range of experiences and resulting distress. But when precision for the purpose of diagnosis and treatment planning is required, we’ll want to be careful to correctly identify traumas and distinguish them from other distressing experiences that are best understood as something else.
Let me give an example. On the Social Readjustment Rating Scale (SRRS) (also known as the Holmes and Rahe scale), divorce is listed as the second-most distressing life event, second only to death of a spouse or one’s own child. Any of my friends who have gone through a divorce seem to agree that divorce is extremely painful, heart-wrenching, and horrible. Several have found therapy to be quite useful in processing their divorce, working on personal issues, and rebuilding afterwards. Some have described their divorce as “traumatic,” and I would never minimize or dismiss their pain by trying to “correct” their vocabulary. I wouldn’t do that with a patient either. It does not take anything away from the intensity of the pain to conceptualize their experience as something other than a trauma–even if they use that word themselves. In these situations, interventions focused on divorce recovery are much more likely to result in positive outcomes than most evidence-based psychotherapies for PTSD, such as Prolonged Exposure therapy, Cognitive Processing Therapy, Trauma Focused CBT, etc. However, if in the context of a divorce one spouse threatens the other, physically assaults or injures them, threatens death, etc, then YES that person has experienced a trauma. But the threat, assault, injury, etc is the trauma–not the divorce itself.
Similarly, not getting an expected promotion, having an argument with a friend, breaking up with a romantic partner, losing an election, facing medical separation from the military, failing a class, or being the victim of slander are probably not traumas in and of themselves, but might be the context in which a trauma could occur.
The point is this–in the context of clinical assessment, diagnosis, and treatment planning, it is important to clearly recognize what is and is not a trauma. Not everything that is legitimately distressing is a trauma. But that is ok. The results of a careful assessment are good news, whether trauma or not, or whether PTSD or something else. Careful assessment leads to better understanding and appropriate treatment with the best likelihood for positive outcomes. There are several effective treatments for trauma and PTSD. Similarly there are several effective treatments and approaches for other non-traumatic distressing experiences and presentations.
If you are seeking care for a possible trauma, ask your provider for a careful assessment of your trauma history and current symptoms. And be kind to each other. You never know what burden someone may be carrying.