What is trauma?
Trauma comes from a Greek word meaning a physical wound.1 The term stayed true to its origins for centuries and was used primarily in reference to physical injuries. Around the late 1890s, trauma took on a psychological dimension with the return of soldiers from increasingly lethal wars and the rise of psychology as a scientific discipline.2 Terms like nostalgia (American Civil War), shell shock and neurosis (World War I), combat fatigue (World War II), and post-traumatic stress disorder (Vietnam War) referred to psychological trauma.2 As psychologists studied and developed treatments for soldiers (almost all White men), trauma slowly expanded to include railway and mine accidents, civilian survivors of war, sexual and physical assault, childhood sexual abuse, natural disasters, the Holocaust, and other experiences with populations that endured long-term effects.2,3 In 1980, the Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM-3) by the American Psychiatric Association redefined previous diagnoses of battered child syndrome, rape trauma syndrome, battered women syndrome, and Post-Vietnam syndrome as post-traumatic stress disorder (PTSD).3
An explanation of how trauma developed as a concept, and as a field, helps situate the current lack of consensus on what trauma means. There is a general consensus on separating trauma into physical and psychological domains (albeit the two often co-occur). Most debates surround psychological trauma. Only in the past few decades has the field of trauma studies developed and started to reconceptualize our understanding of psychological trauma. There is no universal definition of trauma and variations exist across and within disciplines. The goal of this discussion, therefore, is to work through these varying definitions and weave together a working definition that is true to psychological trauma as a concept.
Psychiatry tends to reinforce its historical origins, limiting trauma to “exposure to actual or threatened death, serious injury, or sexual violence,” whereas psychology and behavioral health have moved to open the concept, defining trauma as “any disturbing experience that results in significant fear, helplessness, dissociation, confusion, or other disruptive feelings intense enough to have a long-lasting negative effect on a person’s attitudes, behavior, and other aspects of functioning” (Table 1).
Table 1. Most common definitions of psychological trauma across three prominent disciplines.
|Discipline||Definition of psychological trauma|
|Psychology||“Any disturbing experience that results in significant fear, helplessness, dissociation, confusion, or other disruptive feelings intense enough to have a long-lasting negative effect on a person’s attitudes, behavior, and other aspects of functioning. Traumatic events include those caused by human behavior (e.g., rape, war, industrial accidents) as well as by nature (e.g., earthquakes) and often challenge an individual’s view of the world as a just, safe, and predictable place.”4 — American Psychological Association (APA)|
|Psychiatry||“Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: directly experiencing the traumatic event(s); witnessing, in person, the traumatic event(s) as it occurred to others; learning that the traumatic event(s) occurred to a close family member or close friend (in case of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental); or experiencing repeated or extreme exposure to aversive details of the traumatic event(s).”5 — Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association|
|Behavioral Health||“Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”6 — Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS)|
Notice the commonalities in the Psychology and Behavioral Health definitions. Both define psychological trauma as a three-pronged concept: event, experience, and effect. The Substance Abuse and Mental Health Services Administration (SAMHSA) refers to these as the “Three Es.”6 Each of the Es are subject to variation and further complicate, but diversify, our understanding of what trauma means. This diversification lends itself to the universalism versus cultural relativism debate.7
Universalists, in essence, postulate that our brains have a universal, biological response to trauma, and this response manifests as a core set of symptoms.8 Fight-or-flight (the Hypothalamic-Pituitary-Adrenal (HPA) axis) is a well-known part of this response. Cultural relativists, on the other hand, suggest that our response to trauma is shaped by culture and life experiences. Psychologists have studied how people understand and respond to trauma across the world. Trauma responses that do not fit neatly in the DSM criteria are often called “idioms of distress.” An example of such is the “thinking a lot” idiom among Cambodian refugees, which manifests as prolonged ruminative and depressed patterns of thought. In this population, researchers showed “thinking a lot” better predicted PTSD than the DSM symptom criteria.9 If all people expressed the same core set of symptoms, as universalists posit, the DSM criteria should have been as valid in Cambodian refugees as it is in American soldiers. The truth thus likely lies somewhere between these two perspectives, with neuroscientists proving a biological basis to trauma and social scientists confirming differences across age, culture, race, and other factors (Table 2).
Table 2. Working factors affecting the event, experience, and effect of psychological trauma. Anthropology, neuroscience, sociology, public health, medicine, economics, and other disciplines have contributed heavily to our understanding of these influencing factors.
|Factor||Definition and relation to psychological trauma|
|Age||0 – 6||Early childhood trauma. Young children tend to be more vulnerable to the trauma due to complete dependence on their caregivers, a rapid psychological and physiological development period, and lack of coping skills.10–12|
|0 – 17||Childhood trauma. Childhood trauma includes early childhood. Prevalence of childhood trauma is high—at least 1 in 7 children experience trauma—and various negative, long-term health effects have been studied.13,14|
|18 – 65||Adult trauma. Almost 90% of adults have experienced a traumatic event as defined by the DSM-5.15 This estimate is averaged across the entire United States population. Most studies examine adult trauma.|
|65+||Elderly trauma. Trauma among older adults tends to be injury-based and/or interpersonal trauma. Studies have demonstrated a negative impact of trauma on aging and brain health.16|
|Duration / Incidence||Acute||A single occurrence of trauma (e.g., rape).|
|Chronic||Repeated and prolonged occurrences of the same type of trauma (e.g., domestic violence).|
|Complex / Cumulative||Varied and multiple traumas, often with origins in childhood (e.g., childhood sexual abuse and addiction in the home).|
|Macro and micro societies||Culture||Culture, as we define it, refers to “a system of meanings, knowledge, and action, which provides individuals with socially sanctioned strategies to create, interpret, analyze, and recreate their world and experiences through their interactions with each other.”17,18 These systems are always evolving, often known as cultural co-construction, via “dialogue among equal partners across class, ethnic/racial, disciplinary, cultural, and other boundaries that integrate knowledge, values, perspectives, and methods derived from all parties.”17 Culture influences the type of trauma (event) we are exposed to, how we experience and conceptualize trauma, and what/how we understand and cope with effects (i.e., resilience).|
|Environment (Nurture)||Environment falls under the umbrella of culture. Our environment is essentially our communities—our systems—and include our home and family dynamics, social support and relationships, institutional settings (e.g., school, work), and other parts of our lives.19 The influence of our environment on trauma reflects the age-old nature versus nurture debate. In this case, nurture tends to prevail, but nature also has a role and the two must be considered in conjunction.|
|Biology||Genetics / Epigenetics (Nature)||Trauma affects and is affected by your individual (genetics) and intergenerational genetics (epigenetics).20 These concepts are easiest to illustrate with examples: Genetics. Studies on US soldiers pre- and post-exposure to combat have shown different genetic changes in those who developed post-traumatic stress disorder, as defined by the DSM-5, and those who did not. Soldiers with PTSD had higher methylation (i.e., small molecules attached to their DNA) of the IL18 gene, whereas those without PTSD had decreased methylation of IL18 and H19.21 When these soldiers were exposed to a stress test, those with PTSD showed rapid changes in methylation—illustrating how responsive our genome is to past and future trauma. Epigenetics. Epigenetic changes are such genetic changes that are transmitted to the offspring of trauma survivors. Research on the children of Holocaust survivors demonstrates abnormal methylation of the NR3C1 gene (thought to influence the biological response to stress).22 It is well-established that the offspring of trauma survivors are more likely to experience trauma themselves, but we have to be careful in how much we attribute to epigenetics versus environment. Most neuroscientists and psychologists agree it is a mix of both.|
Defining trauma according to event(s), experience, and effects, and incorporating these influencing factors into each E, is complex, but more accurate than historical definitions. A common question among clinicians, researchers, and the general public is what is considered a traumatic event(s). The answer depends on experience and effects, as an event traumatic for one individual might not be for another, but a list of common event(s) was consolidated (Table 3).
Table 3. A working classification of possible psychological trauma event(s). Many of these terms are closely related and/or overlapping, but were included due to their prevalence in the literature.
|Possible psychological trauma event(s)||Synonymous terms||Working definition and examples|
|Intergenerational||Transgenerational||Trauma survivors passing trauma to their children. Children raised in environments of domestic violence often become victims/survivors or perpetrators of the same situation later in life.|
|Collective||Mass||Trauma experienced by a population.|
|Political violence||Trauma related to political goals, such as conflict and war, torture, oppression, genocide, and terrorism.|
|Historical||Past collective trauma with an intergenerational dimension, including, but not limited to, slavery and the Holocaust.|
|Community violence||Trauma, usually interpersonal, between people or groups who do not necessarily know each other. Examples include gang violence and gun violence (e.g., school shootings).|
|Financial||Poverty and economic hardship.|
|Systemic||Institutional; Structural; Colonial||Trauma originating from and/or perpetuated by institutional and societal systems, usually in the form of discrimination and/or violence on the basis of race, color, religion, sex, national origin, age, disability, marital status, or political affiliation. Common sources are the justice system (e.g., law enforcement, legislation, prisons), foster care, and housing.|
|Secondary||Vicarious||Secondhand exposure to trauma. A health professional who treats victims of gun violence, or a social worker rehoming victims/survivors of child abuse and neglect.|
|Interpersonal||Interpersonal trauma is physical, sexual, emotional, mental, and/or spiritual abuse involving interaction between people.|
|Domestic violence (DV)||Domestic violence is interpersonal trauma within the home or living situation.|
|Sexual violence||Rape; Sexual Assault (SA)||Sexual violence includes any sexual activity without explicit consent.|
|Intimate partner violence (IPV)||Interpersonal trauma within a personal, intimate relationship.|
|Youth violence||Bullying||Interpersonal trauma, usually physical force or power, in the context of bullying, gang violence, threats with weapons and gun violence, and/or assault.|
|Elder abuse||Interpersonal and/or financial trauma against older adults.|
|Health||Trauma surrounding chronic illness and/or death, whether it is experienced personally or witnessed from a loved one.|
|Criminal||Trauma related to organized crime and informal systems.|
|Human trafficking||Human trafficking is incredibly complex and highly related to other forms of trauma. The simplest understanding is “the use of force, fraud, or coercion to obtain labor and/or a sex act.”23 There are three main umbrellas—sex trafficking, labor trafficking, and debt bondage—and dozens of types within each.|
|Childhood||Trauma during childhood is a large area of inquiry in trauma studies and worth expanding on. There are two major lists of potential childhood traumas: the ACEs (Adverse Childhood Experiences) study24 and the National Child Traumatic Stress Network (NCTSN).25|
The last caveat (more of a connotation) to our working definition of trauma is its dichotomous nature. We often think of life as pre- and post-trauma. Trauma, in reality, is woven into the fabric of our lives. Bessel van der Kolk, a well-known psychiatrist and researcher in the United States, illustrates this point:
“We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body. This imprint has ongoing consequences for how the human organism manages to survive in the present. Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think” (Van der Kolk, 2014).
At last, we have an answer to what seems to be a simple question: What is trauma? Borrowing from Van der Kolk, the American Psychological Association, and SAMHSA, trauma is an event, series of events, or set of circumstances experienced as mentally, socially, emotionally, and/or spiritually harmful, and results in short- or long-term adverse effects on functioning and lifelong changes to the mind, brain, and body. This, however, is a working definition and partial answer to our original question. As we discussed in these past few pages, our understanding of trauma is so diverse and multidimensional that a single definition cannot do the concept justice. But, until we invent the words to do so, our working definition is a pretty good start.
Disclaimer: The views and opinions outlined in this article are solely the author’s and do not reflect the views and opinions of AMWA Carolinas.
About the Author
Elle Strand graduated from Duke University with a BS in Biology and a BA in Global Health. Her long-term goal is to implement trauma-informed protocols and communication in clinical medicine and international research practices.
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