PTSD and Other Trauma
Defining and Demystifying Trauma
“Trauma” is a loaded word in our society, and I find that a discussion of clinical versus popular definitions of the word helps many clients. .
Many people think of trauma or PTSD largely in terms of “big T” Trauma (generally, extreme physical or sexual violence), especially as experienced or witnessed by military personnel, first responders, or others in similar occupations. In clinical practice, the range of experiences that can lead to trauma symptoms is substantially broader than this.
Conversely, in popular culture, people often use the word “trauma” expansively to describe most any experience they find unpleasant. Again, this popular definition of trauma misses the mark (in ways that make many clients uncomfortable to apply the word to themselves), but in this case it is too broad.
In clinical practice, trauma is defined more by the symptoms experienced than by the precipitating event itself. Clinically, trauma is any event that overwhelms our physical, emotional, and mental ability to bear such that we continue to reexperience the past event in our psychological present. Symptoms of clinical trauma may include any combination of the following:
Intrusive thoughts, including flashbacks, nightmares, and other disruptive thoughts.
Avoidance (conscious or unconscious) of cues our brain associates with the event. These cues can be external (people, places, sounds, etc.) or internal (subjects of thought, emotional states, physical feelings, etc.). Avoidance may include substance use, over-achievement/workaholism, or other addictive behaviors (gambling, video games, tech addiction), and may also include dissociation and amnesia.
Mood volatility and negative sense of self / low self-esteem.
Interpersonal challenges, including reactivity, broad distrust of others, and inability to maintain healthy boundaries.
Hypervigilance, including heightened startle response, difficulties concentrating, inability to feel safe in even in familiar places and/or with trusted people, and sleep disturbance.
These symptoms constitute a psychic reexperiencing of trauma, and tend to show up in ways that are:
Sometimes glaring, but often subtle.
Frequently difficult to relate back to the traumatic event itself on an intellectual or logical level.
Often fragmented, periodic, and hard to predict.
Why a PTSD Diagnosis isn’t Especially Important in Practice
Simplifying just a bit, to have a PTSD diagnosis, per the DSM-5, you must:
Have experienced or witnessed a certain kind of catastrophic event,
Be experiencing a certain variety, duration, and severity of traumatic symptoms, which need to have begun within a certain timeframe after the event,
Be experiencing a certain amount of life interference / impairment because of those symptoms, and
Not be able to attribute those symptoms to something else (substance use, neurodivergence, traumatic brain injury, etc.).
I have met many, many clients who are experiencing substantially life interfering symptoms due to a decidedly negative life event (or series thereof) who don’t meet PTSD criteria. This is typically because of (in some combination):
The event was different from what the DSM requires or the client is not even sure what the event actually was (typical of early childhood experiences),
They are experiencing a narrower range of symptoms than the DSM specifies (though those few symptoms are often severe), or
They are experiencing a range of symptoms at a severity or frequency less than what the DSM specifies, but in total those symptoms remain life-interfering.
Frequently, these clients will have come to me with an initial diagnosis of depression, anxiety, OCD, ADHD, or substance use disorder, all of which have substantial overlap with PTSD diagnostic criteria. They may or may not initially connect their current symptomology to difficult past events.
Clearly, in such cases, a lack of a PTSD diagnosis does not matter. Trauma remains a useful clinical framework in which to work on a client’s nightmares, shaky boundaries, poor self-esteem, or other clinically significant trauma symptoms.
Clinical Trauma in Children, and in Adults who were Once Children
If trauma is any event that overwhelms our physical, mental, and emotional ability to bear, it stands to reason that many events that don’t lead to trauma symptoms in adults might lead to trauma symptoms in children. Reality resolutely bears this out.
Children are still developing their ability to accurately assess threats, and do not yet possess the agency and resources to keep themselves safe (especially if threats come from a caretaker on whom they are dependent). In particular, children instinctively recognize attachment to caretakers, even abusive caretakers, as essential to their survival, and any threat to that attachment relationship as a potentially existential threat to themselves.
As such, trauma symptoms frequently show up in those who endured difficult childhoods that many people might not immediately think of as “traumatic.” Such experiences include:
Extended absence of or time away from parents/primary caregivers, even if spent in the care of other competent and loving caregivers.
Witnessing domestic violence or the threat thereof, or being threatened with physical abuse, even if never actually physically abused themselves.
Toxic divorces, custody disputes, and emotional abuse/degradation in which children saw themselves, siblings, or parents devalued by one or both parents.
Poverty, neglect, or even the threat of economic instability (which children may assess as a threat of homelessness or starvation).
Extensive bullying, frequent moving, difficult post-immigration acculturation experiences, or other broad threats to connection with other people (sometimes but not always including threat of physical harm).
Childhood health issues affecting children or their family members, including those that might not have struck caretaking adults at the time, or grown adults looking back, as especially dangerous.
Events like these, sometimes called “little t” trauma in clinical practice, often lead children to experience the trauma symptoms listed previously. As these symptoms tend to reflect an experience that is “stuck,” without treatment the “stuck-ness” and related symptoms will frequently persist into adulthood, and are sometimes compounded by other traumatic events in adulthood. This combination of childhood attachment trauma and adult trauma, if it meets certain symptomological requirements, is referred to as Complex Post Traumatic Stress Disorder (CPTSD). CPTSD is not a diagnosis distinct from PTSD in the DSM-5, but may be added in future iterations of the DSM, and is useful in the understanding of trauma regardless.
Treating Trauma
Trauma is a bad experience that got stuck. Trauma treatment is getting that experience un-stuck. It’s that simple.
There are a number of research-based ways of un-stucking trauma, and I practice several. It is wonderfully rewarding work. As far as big therapeutic wins in relatively short periods of time, I find trauma-focused treatment hard to beat. Lots of bang for your psychotherapeutic buck. Please see the “Treatments Offered” section of my website, especially the pages on EMDR, CPT, and IFS, for more information on this.
What This Means for You
Why mention all this? If something that was extremely stressful or degrading or saddening *to you* at any point in your life is causing mental anguish that you can’t seem to get past, seek treatment, regardless of whether you consider the experience itself “traumatic.” If it bothers you, it’s worth treating, and we can work on it.
Also, if you’ve been working on anxiety, depression, substance abuse, ADHD, OCD, or any other mental health diagnosis that has symptoms that overlap with the symptoms listed above, consider seeking a trauma-based assessment of those symptoms and their possible origin. Likewise if you ever suffered at the hands of narcissistic, overwhelmed, or misattuned parents, even if you love those parents and know they did their best. Do so even if you never suffered a huge catastrophic event, even if your general level of life function is good (or great), and even if you don’t come anywhere near a PTSD diagnosis. Turning a trauma-informed lens on the little things clients are just kind of stuck on is often far more fruitful than they ever would have imagined.