Defining Trauma

In psychology, trauma is a type of damage to the psyche that occurs as a result of a severely distressing event. Trauma is often the result of an overwhelming amount of stress that exceeds one's ability to cope or integrate the emotions involved with that experience. A traumatic event can involve one experience or repeated events or experiences over time. 

Traumatizing, stressful events can have a long-term impact on mental and physical health. Situations where an individual is exposed to a severely stressful experience involving threat of death, injury, or sexual violence can result in the development of post-traumatic stress disorder (PTSD). With this disorder, the trauma experienced is severe enough to cause stress responses for months or even years after the initial incident. The trauma overwhelms the victim's ability to cope psychologically, and memories of the event trigger anxiety and physical stress responses, including the release of cortisol. People with PTSD may experience flashbacks, panic attacks and anxiety, and hypervigilance (extreme attunement to stimuli that remind them of the initial incident).

DSM-5 Diagnostic Criteria

To be diagnosed with PTSD according to the DSM-5 (2013), a person must first have been exposed to a traumatic event that involves a loss of physical integrity, or risk of serious injury or death, to self or others. In addition, the person must experience intrusions (persistent re-experiencing of the event through flashbacks, distressing dreams, etc.); avoidance (of stimuli associated with the trauma, talking about the trauma, etc.); negative alterations in cognitions and mood (such as decreased capacity to feel certain feelings or distorted self-blame); and alterations in arousal and reactivity (such as difficulty sleeping, problems with anger or concentration, reckless behavior, or heightened startle response). These symptoms must last for more than 1 month and result in clinically significant distress or impairment in multiple domains of life, such as relationships, work, or other daily functioning.

Etiology

PTSD is believed to be caused by the experience of a traumatic event. A person may experience or witness a stressful event involving death, serious injury, or such threat to the individual or others in a situation in which the individual felt intense fear, horror, or powerlessness. PTSD can occur in individuals with no predisposing conditions; however persons considered at-risk include combat military personnel, rape survivors, victims of natural disasters, concentration camp survivors, and victims of violent crime such as domestic or sexual abuse.

While men are more likely to experience a traumatic event, women are more likely to experience the kind of high-impact traumatic event that can lead to PTSD, such as interpersonal violence and sexual assault. Not everyone who experiences trauma will develop PTSD: according to the National Center for PTSD, approximately 20% of women and 8% of men who experience a traumatic event will develop PTSD.

Rates of PTSD are higher in combat veterans than than the average rate for men, with a rate estimated at up to 20% for veterans returning from Iraq and Afghanistan.

PTSD and Combat Exposure

Many veterans of the wars in Iraq and Afghanistan have faced significant physical, emotional, and relational disruptions. Veterans are at a higher risk than the normal male population for developing PTSD.

Treatment

A number of psychotherapies have demonstrated usefulness in the treatment of PTSD and other trauma-related problems. Basic counseling practices common to many treatment responses for PTSD include education about the condition and provision of safety and support. The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral therapy (CBT), variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and many combinations of these procedures.

EMDR and trauma-focused cognitive behavioral therapy (TFCBT) were recommended as first-line treatments for trauma victims in a 2007 review. Cognitive behavioral therapy (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns of thinking and/or behavior responsible for negative emotions. In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress. 

A variety of medications have shown adjunctive benefit in reducing PTSD symptoms; however, there is no clear drug treatment for PTSD. Positive symptoms (those that most individuals do not normally experience but are present in people with PTSD, such as re-experiencing or increased arousal) generally respond better to medication than negative symptoms (deficits of normal emotional responses or thought processes, such as avoidance or withdrawal). 

Complex PTSD

Complex post-traumatic stress disorder (C-PTSD) is a psychological injury that results from exposure to prolonged social and/or interpersonal trauma in the context of dependence, captivity, or entrapment (a situation lacking a viable escape route for the victim), which results in the lack or loss of control, helplessness, and deformations of identity and sense of self. Examples include people who have experienced chronic maltreatment, neglect, or abuse by a care-giver; hostages; prisoners of war; concentration camp survivors; and survivors of some religious cults. C-PTSD is distinct from, but similar to, PTSD; however, C-PTSD was not accepted by the American Psychiatric Association as a mental disorder in the DSM-5. It was first described in 1992 by Judith Herman in her book Trauma & Recovery and an accompanying article.

Six clusters of symptoms have been suggested for diagnosis of C-PTSD: (1) alterations in regulation of affect and impulses; (2) alterations in attention or consciousness; (3) alterations in self-perception; (4) alterations in relations with others; (5) somatization, and (6) alterations in systems of meaning. PTSD descriptions fail to capture some of the core characteristics of C-PTSD, such as captivity; psychological fragmentation; the loss of a sense of safety, trust, and self-worth; and the tendency to be revictimized. C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment—elements that are not adequately described by the diagnosis of PTSD.