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Defining Trauma
Proponents of German New Medicine contend that trauma is a key factor in the development of mental and physical illnesses. Recent studies support this, revealing that traumatic experiences, such as childhood maltreatment, are strongly linked to a wide array of health outcomes. However, while trauma is commonly understood as exposure to specific types of events, its definition varies significantly across contexts. This variability has important implications for diagnosis and treatment. In this blog, I explore differing definitions of trauma and introduce a framework for understanding it more effectively.
Historical Understandings
The word ‘trauma’ originates from the Greek language and its literal meaning is “wound”. For a significant period of time, the term was predominantly used to refer to physical injuries across medical settings-a usage that persists today (e.g. trauma to the head). During the late 19th century the term was adapted to psychological injury to refer to distress and overwhelm in mental health settings. However, it was predominantly during and after the world wars that psychological trauma began to be more consistently studied and conceptualised, due to states of ‘shell shock’ being observed among many soldiers. Research was then extended to other areas, including natural disasters and differing forms of violence (see Herman). Following this, the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychological Association formulated the category of post-traumatic stress disorder (PTSD). While the DSM’s understanding of trauma has been adapted, it remains the dominant conceptual framework within mental health settings today.
Contemporary Understandings
The DSM-5 defines trauma as “exposure to actual or threatened death, serious injury or sexual violence” which is either directly experienced, witnessed or learned about. The DSM emphasises specific types of external events that cause physical or psychological injury. The likely rationale for this being that the research underpinning the DSM criteria suggested that extreme events cause post traumatic stress symptoms. Indeed, studies consistently indicate that exposure to severe physical or sexual violence often results in acute or chronic trauma symptoms.
However, studies also suggest that seemingly “minor” events can also lead to PTSD symptoms, and that not everyone that is exposed to extreme threats is necessarily traumatised. For instance, Robert Scaer found, through his clinical practice, that many of his patients that presented with whiplash injury or low-speed accidents developed PTSD. Upon examination of their prior records, he found that his patients had suffered trauma and chronic stress – risk factors that quite possibly contributed to the onset of their PTSD. Similarly, while many soldiers were diagnosed with “shell shock” during the wars, a significant number did not develop any symptoms, despite exposure to life-threatening events.
Subjective experiences play a crucial role in the development of trauma symptoms and help explain the variability in responses. Factors such as past trauma, chronic stress, event appraisal, social support, belief systems, and health status influence whether someone develops PTSD symptoms.
Defining Trauma Beyond Life-Threatening Events
Defining trauma solely in terms of exposure to extreme life-threatening or physically violent events does not appropriately capture the diversity of people’s lived experiences. This is what Scaer observed throughout his many years of clinical practice. I’ve also worked with numerous clients presenting with physical and mental conditions that were thought to stem from genes or chemical imbalances, however addressing specific traumatic conflicts such as emotional abuse or separation from loved ones, healed the conditions altogether. Trauma can result from small “t” events such as death of a pet, a minor RTA or more serious incidents of bullying, harassment, and grooming. Furthermore, defining trauma only in terms of exposure to extreme events may deter people from seeking help, as they might not perceive their experiences meet trauma “criteria”. In turn, this may lead to misdiagnoses and reliance on medication, when the root cause is unresolved emotional distress.
What is Trauma?
If defining trauma in terms of exposure to life-threatening events is problematic, due to the influence of subjective factors, then how might we conceptualise it? Research into patient experiences offers insight. In the 1980s, Dr. Ryke Geerd Hamer studied brain CT scans and psychological histories of thousands of his patients. He discovered that “shock” and emotional distress in response to unexpected events were at the root of their illnesses. Surprisingly, this distress was not limited to life-threatening situations – it could also occur when faced with perceived harm in the context of relational disputes, abandonment or feeling rejected.
Subsequent research has consistently found that trauma involves a state of shock and intense distress. This state of shock can manifest in various ways including numbness, disbelief, dissociation, physical stillness or paralysis. It is a survival response that aids coping with overwhelming distress such as fear, sadness, pain, disgust, or helplessness. PTSD symptoms typically develop when this state of shock persists unresolved. Furthermore, it is accepted that traumatic shock and emotional distress occur in response to environmental stimuli experienced as threatening or harmful. Moreover, reviews highlight that trauma generally occurs in response to specific or unexpected incidents – it typically takes people “off guard”, occurring suddenly and when least expected, which is in contrast to general everyday stress responses. Lastly, as highlighted by the DSM, harmful or threatening events can be directly experienced, witnessed or even learned about.
We can of course adopt a simple definition, one that is true to the original meaning of the word, which is that it’s a (psychological) injury. However, for purposes of trauma diagnosis and effective treatment, it is necessary to understand its specific characteristics. What the research points to is that trauma is a state of psychological and physiological shock and overwhelming distress in response to unexpected events. If these symptoms are not adequately resolved then they persist and additional features may manifest such as chronic intrusive memories, avoidance, negative alterations in cognition and mood, hypervigilance, dissociation, sleep disturbance, chronic pain, tension, and impairment to daily functioning. In extreme cases, co-morbid conditions can also manifest.
Further Considerations
Depending on the nature of the traumatic event, and individual differences, symptom severity and manifestation may vary. For instance, one incident of abuse may result in feeling numb and scared but not completely overwhelmed. Indeed not all abuse incidents involve an immediate threat to life or physical injury. Manipulative and coercive forms of psychological abuse can also result in symptoms of trauma. Similarly, a child may be abandoned by a parent, which can cause shock and difficulty coping, however this does not qualify as exposure to extreme violence nor considered an immediate threat to life.
Conclusion
The DSM implies a focus only on explicit threats of physical harm, which excludes many events that can cause shock and overwhelming distress. This is why the definition provided by the DSM is problematic because it doesn’t take into consideration a diverse range of incidents that can result in trauma responses. For purposes of identifying and healing trauma, conceptualising it as a state of psycho-biological shock and distress that occurs in response to a precise unexpected event(s) in time, is a more concise and empirically supported definition; one that better reflects diverse experiences and helps guide more effective treatment approaches.
I hope you found this article useful. If you would like further information or for any other questions or queries then feel free to get in touch.
Sadaf
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