Moving From Traumatic Events to Traumatic Experiences in the Study of Traumatic Psychopathology

Abstract

Trauma is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as an event that includes “actual or threatened death, serious injury, or sexual violence” (p. 271). The list of traumatic events included in the DSM-5 represents a long history of psychiatry and psychology’s attempts to define trauma and differentiate these events from less severe stressors. In this commentary, we suggest that this strict distinction between traumatic events and stressful events is not useful for public health. The current DSM-5 list of traumatic events may work well for identifying people with the most severe experiences and highest conditional probability of distress who need clinical care. However, the public health field has different priorities. If we think about posttraumatic psychological distress on a population scale, it is not only helping those with the most severe experiences that is needed; rather, public health requires paying attention to all people experiencing distressing stress and trauma reactions. We propose that context is crucial to the development of a population-relevant definition of trauma and provide examples of situations in which stressors have resulted in posttraumatic psychological distress and in which traumatic event reactions have been mitigated by the context in which they occur. We discuss trauma context from an epidemiologic perspective and conclude with recommendations for the field.

This article is part of a Special Collection on Mental Health.

Abbreviations

DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

PTSD

posttraumatic stress disorder

Editor’s note: The opinions expressed in this article are those of the authors and do not necessarily reflect the views of the American Journal of Epidemiology.

The modern definition of trauma was first introduced in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, in 1980, along with the diagnosis of posttraumatic stress disorder (PTSD), and reflected, in significant part, the emerging understanding of posttraumatic stress symptoms that were present among veterans who had served in the Vietnam War (1). The definition of trauma has evolved in the time since, and today, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines trauma as an event that includes “actual or threatened death, serious injury, or sexual violence” (2, p. 271). This definition is embedded as “criterion A” within the diagnostic criteria for PTSD. Examples of traumatic events listed in the DSM-5 include combat exposure, physical and sexual assault, and natural disasters.

The list of events currently included in the DSM-5 represents a long history in the mental health field of attempting to succinctly define what qualifies as traumatic. Central to attempts to define trauma over time is the idea that inherently some events are traumatic while other events are not so classifiable. These latter events are often considered stressors, and it has been implicit in the field that it is possible to distinguish these events from those that are traumas. The current approach to defining trauma therefore assumes that certain events will be traumatic to everyone who experiences them, while other events will be less severe to everyone who experiences them and thus do not quality as traumas. Further, this assumes that the former can lead to PTSD, while the latter do not.

We suggest that this strict distinction between traumatic events and stressful events is not useful for our understanding of posttraumatic psychological distress at the population level. In this article, we suggest that a more useful approach would be defining trauma according to experiences (the combination of objective events and a context that elicits a positive or negative event reaction) rather than attempting to generate mutually exclusive lists of stressful and traumatic objective events. We describe, in terms of sensitivity and specificity, why we may observe discrepancies in the use of events to classify experiences, and why this is important for public health. We next discuss trauma context as critical to determining whether a specific event becomes a traumatic experience and provide examples and discuss trauma context from an epidemiologic methodological perspective. Finally, we end with some thoughts about future directions for the field of traumatic stress research.

USING EVENTS TO CLASSIFY EXPERIENCES

Although the DSM-5 includes a list of events that are used in public health to define trauma, and this approach has been the norm for decades, there are many examples in the literature of posttraumatic psychological distress following events that are currently not considered to be traumas according to the DSM-5 (e.g., racial discrimination, sex- and gender-based discrimination, climate change, financial stress) (3, 4). The use of the term “stressor” has historically been a catchall for other perturbations that do not meet some (relatively arbitrary) standard for a traumatic event. But insofar as it is clear from the literature and everyday life that we are missing much that becomes a traumatic experience, it stands to reason that this category includes many potentially qualifying events, and as such should occasion a reexamination of our conceptualization of trauma.

The current approach of using an objective list of events to define trauma can be thought of in terms of sensitivity and specificity, where discrete events (what we measure) are being used to classify a more amorphous set of traumatic experiences (what researchers and clinicians want to know). The events included in the DSM-5 are a sensitive approach to classifying the experience of trauma. That is, because the events included in the DSM-5 are severe, the probability is high (although likely not perfect) that people who have been through one or more of these events have had a traumatic experience. However, as is usually the case in the tradeoff between sensitivity and specificity, these events perform poorly in terms of their specificity in classifying traumatic experiences. That is, the probability that people who have not been through these specific events have not had a traumatic experience at all is lower, likely much lower, than 100%. The current definition of trauma may adequately capture some people who have truly had traumatic experiences through assessment of certain specific named events, but it probably misses a substantial proportion of people who have not been through one of these specific events but nevertheless have had experiences they conceptualize as traumatic.

From a public health perspective, this distinction is crucial. If we think about one ultimate public health goal of preventing posttraumatic psychological distress among people who experience trauma, we should aspire to identify as many of the people who could benefit from public health interventions as possible. High sensitivity of trauma classification is important from the perspective of clinical care, and it is not surprising that over the years discussions about the definition of trauma that have resulted in the current definition have primarily been led by clinicians. In clinical care, we want to ensure that the people receiving expensive, resource-intensive clinical services are the most in need and most likely to benefit from the care they receive. This is likely to be the people with the most severe forms of trauma who have the highest conditional probabilities of posttraumatic psychological distress. However, the field of public health has a different set of priorities. If we think about prevention of posttraumatic psychological distress on a population scale—in other words, moving a full distribution of posttraumatic reactions in a less severe direction—it is not only helping those with the most severe experiences that will have this impact. Moving this curve requires prevention among all of the people who have had an experience they conceptualize as traumatic and who are at risk for posttraumatic psychological distress. The currently accepted and categorically determined traumatic events do not fully characterize this population, and the current list of events that constitute trauma has limited utility to identify the full range of experiences that would be expected to lead to posttraumatic distress on a population level.

CONTEXT OF EVENTS DETERMINES TRAUMATIC EXPERIENCES

If the currently defined list of objective traumatic events is not as useful as is necessary for identifying all people who may benefit from population-level posttraumatic mental health interventions, we may wish to consider what additional information would be needed. We suggest that the context in which events occur, including perceptions of the event and resources in place to mitigate or catalyze negative responses, is just as important to defining which stressful and traumatic events might result in posttraumatic psychological distress as the objective events themselves. The implication for building a population-relevant definition of traumatic experiences is that one simply cannot understand most traumatic and stressful experiences and associated outcomes without understanding context.

Support for this argument begins with the widely accepted observation that trauma reactions are dependent on perception of the event—objective assessment of an event is often not what matters most to predicting negative psychological outcomes (5, 6)—and perception depends on many varying event and life circumstances for any one individual. Consider the following examples where context can determine whether a stressor rises to the level of a traumatic experience and, conversely, where negative reactions to traumatic events are mitigated by contextual factors.

As a first example, job loss is a stressor and not a trauma, but research has shown that job loss in the years following the US terrorist attacks of September 11, 2001 (“9/11”) was associated with subsequent probable PTSD among people who were directly exposed to the attacks (7). The same association has been shown for job loss during the coronavirus disease 2019 (COVID-19) pandemic and PTSD symptoms (8). Job loss, in the context of the simultaneous occurrence of a mass stressor, may make this stressful event rise to the level of a traumatic experience which can elicit posttraumatic psychological distress.

As a second example, divorce is a stressor and not a trauma. However, in the context of high-conflict divorces, children experience posttraumatic stress symptoms (9). In this example, children’s general position of vulnerability probably affects their perceptions of and reactions to a high-conflict divorce and intensifies the effect of this stressful event to something that is akin to a traumatic experience.

Third, poverty increases vulnerability following natural disasters (10), and similarly, socioeconomic resources accounted for a large amount of variation in PTSD symptom severity following 9/11, after adjustment for level of exposure to the attacks (11). This suggests that people who experience a traumatic event but have access to better socioeconomic resources are less likely to have posttraumatic psychological distress than those with fewer resources.

Taken together, this work begs the question—can an event itself ever be categorically described as traumatic or stressful? Are job loss and divorce only ever stressful events or can they become traumatic experiences if they occur within a negative broader context? Are natural disasters and events like 9/11 unqualified traumatic experiences or are they traumatic events that become traumatic experiences in the context of perception, limited resources, and positions of vulnerability, among other things? From a public health perspective, these questions are crucial to decisions about population-wide prevention and intervention.

From an epidemiologic methodological perspective, context could be considered a third variable relevant to the association between stressful or traumatic events and posttraumatic psychological distress. Context could be a cause of posttraumatic psychological distress that co-occurs with stress or trauma or perhaps even a common cause of stressful or traumatic events and posttraumatic psychological distress. This proposed variable structure implies that context may require adjustment in studies of events and negative psychological outcomes. A likely more informative examination of context would be as a modifier that will enable identification of the subgroups for whom specific stressful or traumatic events are likely to be traumatic experiences. Another possibility is that context is not a separate third variable but rather is inherently part of the exposure definition of trauma. This would point us to define trauma not as a clearly defined list of objective events, but rather as an objective event occurring in a subjective context. Despite conflicting examples from the literature and the world around us, the current definition of trauma reflects the former and not the latter.

FUTURE DIRECTIONS AND CONCLUSIONS

There are several recommendations for the field that could result from this line of reasoning. First, we must reckon with the events that are not currently conceptualized as traumatic which become traumatic experiences for a given individual, depending on context. This is most germane to public health prevention and attempts to move the entire curve of posttraumatic psychological distress, but it also has implications for clinical care and improvements in access to more intensive interventions for persons in need who fall outside of the current strict trauma definition. Along these lines, we should consider moving away from attempting to create a closed list of traumatic events and acknowledge that few events are inherently traumatic experiences all of the time in isolation from the context in which they occur. Third, because context is often not considered in research on trauma, not all of the elements of context that could catalyze stressful or traumatic events to become traumatic experiences or mitigate negative responses have been elucidated. This is an expansive and important line of future inquiry. Together, these approaches will yield improvements in classification of traumatic experiences and our ability to identify who may most benefit from public health prevention and intervention resources.

While change of this magnitude could take years, if not decades, those working in the field could begin important new initiatives towards this end now. There must be additional epidemiologic research on posttraumatic psychological distress following events that are not currently considered traumas to better identify who can be expected to have these reactions. Despite how compelling research in this area has been, it is limited in scale compared with examinations of defined traumatic events. In addition, while identifying persons who would benefit from prevention of posttraumatic psychological distress at the population level is a worthy goal, development of additional prevention and intervention options in this space should simultaneously be a top priority.