Trauma experience involves the exposure to actual or threatened death, serious injury, or sexual violence at any point in the life course. Trauma impact includes clinical outcomes, specifically posttraumatic stress disorder (PTSD), but also emotional disorder (depression, anxiety) and behaviors and symptoms including deliberate self-harm and dissociative states. Impacts in childhood include lifelong sensitivity or vulnerability to later trauma experience and disorder through psychological, biological, and social pathways.
Incidence and Risk
Clinical conditions directly related to trauma have relatively low prevalence in Western societies with PTSD lifetime prevalence estimated at 5–10% in US studies (Kessler 2000) and 1–3% in Europe (Darves-Bornoz et al. 2008). There is a 1:2 male-to-female ratio, in spite of men reporting greater trauma exposure. Higher rates are observed in political conflict situations (for example, war, terrorism), in the military and those exposed to natural disasters. It is also more common among those with mixed clinical pictures.
Trauma experience involves both relational and nonrelational experiences. The former involves trauma in close relationships (partner or parental violence or sexual violence as well as sudden, violent, or suicide-related bereavement). Nonrelational trauma involves that arising from accidents (house fires, car or aeroplane accidents) as well as political conflict (terrorist or war violence) and natural disaster (such as floods, earthquakes). Trauma events are more common that the diagnosed disorder: a German study found 26% of males and 18% of females had at least one such traumatic event despite PTSD only at 2% (Perkonnig et al. 2000).
Trauma events required for a clinical diagnosis of PTSD include exposure to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. This is either through direct exposure or it can include witnessing the trauma, learning that a relative or close friend was exposed to a trauma or indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first emergency service responders) (DSM-5, APA). The category of witness to trauma events is a new development and potentially expands the category, particularly for professionals treating others exposed to trauma. This is often termed “secondary trauma.”
Other categories of negative life events discussed in relation to trauma (referred to as “small t” trauma) are life-changing events (such as acrimonious divorce, children placed into care) which are not life threatening. However, arguably these could now be included as witness/secondary trauma events in the wider classification. These events are also argued to sensitize to further trauma events and increase risk of a wider range of disorders and those comorbid.
Child maltreatment (e.g., physical or sexual abuse) also comes under the trauma-exposure category. Although usually viewed as sensitizing or vulnerability-inducing experiences, there are exponents of childhood PTSD who would view childhood trauma as provoking early life disorder (Ardino 2011). Childhood trauma usually includes physical or sexual abuse, but traumatic parental bereavement may also be included. It is debatable whether some types of psychological abuse (e.g., terrorizing) can also be included where threats to life are made as well as witnessing of domestic violence between parents. Neglect is usually not considered a trauma, despite its later impacts being equal to that of abuse for a range of clinical disorders. Trauma in early life is relatively common, with as many as one in four affected to age 17. Multiple trauma and previous adversities are not uncommon, these having a dose-response effect on adult disorder (Chapman et al. 2004). Such experience forms a general vulnerability not only to PTSD but also depression, borderline personality disorder, dissociative disorder, eating disorder, and others (van der Kolk 2003).
There are differences in the way individuals respond to trauma. The majority will feel distress, but this can dissipate within months, particularly for adult trauma experiences. However lasting impacts affect many, these include mistrust and insecure attachment style which impedes support and help-seeking, helplessness, low self-esteem, and self-blame which impede coping. Although not differing on general demographics apart from gender, traumatized individuals reported more trait anxiety and lower self-esteem, are higher on Neuroticism, more introverted, and less emotionally stable than nontraumatized participants. Traumatized individuals also reported more cognitive disturbances, emotional blunting, and interpersonal withdrawal. There are some differences in those with single trauma having lower interpersonal dependency and those with chronic or recurrent having higher levels.
There is however the potential for posttraumatic growth. This occurs when the subsequent coping and overcoming of negative trauma aspects leads to an increase in functioning from the basic pretrauma level. Examples include after breast cancer surgery where the life-threatening impacts cause a more positive assessment of meaning of life (Pat-Horenczyk et al. 2007).
In DSM-5 diagnostic terms, six criteria (A-F) are identified for PTSD. In addition to the initial trauma identification (Criterion A), the symptoms fitting other criteria are required for more than 1 month (Criterion F). This involves re-experiencing of the trauma (Criterion B) including, for example, intrusive thoughts, nightmares, and flashbacks particularly after exposure to traumatic reminders. It can also involve avoidance of thoughts or feelings of the trauma-related stimuli (Criterion C). Another aspect involves negative thoughts or feelings that began or worsened after the trauma, including inability to recall key features of the trauma or overly negative thoughts and assumptions about the self or the world (Criterion D). Finally, Criterion E, involves trauma-related arousal and reactivity including irritability or aggression, hypervigilance, and difficulty sleeping.
It is common for PTSD to co-occur with other emotional disorder as well as symptoms such as dissociation and depersonalization, deliberate self-harm and self-hatred, as well as impairments in experiencing pleasure (van der Kolk 2001). Dissociation includes disruption to integrated functioning of consciousness, memory, identity, or perception of the environment (“spacing out” or an extreme of compartmentalizing which involves disconnection of memory). These can be recognized as part of a spectrum of trauma-related impacts also termed “complex trauma” response.
PTSD is treatable and individuals can be helped to overcome the impacts of their trauma experience. “Containing” the trauma is considered critical to therapeutic working through encouraging the client to think, feel, and narratively talk through the experience while feeling safe. A meta-analysis shows a range of interventions are effective (Bisson et al. 2007): this includes trauma-focused cognitive behavior therapy, including group therapy, as well as EMDR (eye movement desensitization and reprocessing) and stress management.
PTSD is the only clinical disorder that includes the provoking agent (i.e., trauma) in its diagnostic definition, even though negative life events are also known to trigger other disorders, such as depression. Accurate measures of life event experience ideally require intensive assessments to cover the context, range, and timing of negative experiences in relation to disorder onset (Brown and Harris 1978). This approach if applied to trauma may provide informative the context, multiplicity, chronicity, and timing of exposure for greater understanding of why some individuals succumb. Little is currently known, for example, about the emergence or clustering of a target trauma with other severe life events.
Models of Trauma
The mechanisms that transform a stressful experience into a maladaptive anxiety disorder such as PTSD are not fully understood. It seems likely that the trauma must produce significant arousal and in a situation where the individual is helpless. In addition, trauma that threatens family integrity appears to make a strong contribution to the development of PTSD. Allen (2001) describes “stress pile up” over the life course as a mechanism for PTSD and depression. Early life trauma he views as sensitizing, and in conjunction with a high stress lifestyle can then produce adult trauma events (for example, in relationships or being in violent neighborhoods). Allen places attachment experience centrally in adding to sensitization or conversely, resilience. There are clear biological correlates of trauma which are particularly important in the developmental period, add to the vulnerability. This includes neuroplasticity and brain abnormalities with impacts of information processing and cognitive and neuropsychological deficits (McCrory et al. 2010). The HPA (hypothalamic-pituitary-adrenal) axis is particularly implicated with increased cortisol as a threat response, related to fight or flight. When the stress-induced increase in cortisol secretion is perpetuated and overactivated, the individual can be left in a state of constant hyperarousal which can contribute to neurological damage over time and lowered threshold for other disorders.
Trauma is important both in its experiential and clinical aspects as a social ill affecting large numbers worldwide. Additional research is required in understanding more of trauma impacts at different ages and of clustering of adverse experience around a key trauma. Effects are varied, and resilience does occur, but trauma experience is an important source of clinical illness and individual distress. The lifespan developmental aspects and the bio-psycho-social models suggest that childhood experiences of trauma are particularly critical to understanding the impacts of later life trauma.
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