What Is Trauma?

1 1 what Is Trauma? The term psychological trauma has been applied in so many contexts byso many people that it has lost some of its original meaning. Often,traumais used to refer both to negative events that produce distress and tothe distress itself. Technically, trauma refers only to the event, not the reac-tion, and should be reserved for major events that are psychologically over-whelming for an individual. The Diagnostic and Statistical Manual of MentalDisorders,4th edition, Text Revision (DSM-IV-TR;American PsychiatricAssociation [APA], 2000) specifically defines a trauma asdirect personal experience of an event that involves actual or threatened deathor serious injury, or other threat to one s physical integrity; or witnessing anevent that involves death, injury, or a threat to the physical integrity of anotherperson; or learning about unexpected or violent death, serious harm, or threatof death or injury experienced by a family member or other close associate(Criterion A1).

2 The person s response to the event must involve intense fear,helplessness, or horror (or in children, the response must involve disorganizedor agitated behavior) (Criterion A2). (p. 463)DSM-IV-TRprovides a list of potentially traumatic events, includingcombat, sexual and physical assault, robbery, being kidnapped, being takenhostage, terrorist attacks, torture, disasters, severe automobile accidents, andlife-threatening illnesses, as well as witnessing death or serious injury by vio-lent assault, accidents, war, or disaster. Childhood sexual abuse is includedeven if it does not involve threatened or actual violence or 2/15/2006 1:39 PM Page 3 Although the DSM-IV-TRdefinition is useful, some have criticized therequirement that trauma be limited to threatened death or serious injury, orother threat to one s physical integrity, since many events may be traumaticeven if life threat or injury is not an issue (Briere, 2004). The earlier DSM-III-R(APA, 1987) definition also included threats to psychologicalintegrity asvalid forms of trauma .

3 Because DSM-IV-TRdoes not consider events to betraumatic if they are merely highly upsetting but not life threatening forexample, extreme emotional abuse, major losses or separations, degradationor humiliation, and coerced (but not physically threatened or forced) sexualexperiences it undoubtedly underestimates the extent of actual trauma inthe general population. It also reduces the availability of a stress disorderdiagnosis in some individuals who experience significant posttraumaticdistress since Criterion A is a prerequisite for the diagnosis of posttraumaticstress disorder (PTSD) or acute stress disorder (ASD).The issue of whether an event has to satisfy current diagnostic definitionsof trauma in order to be, in fact, traumatic, is an ongoing source ofdiscussion in the field. Our own conclusion is that an event is traumatic if itis extremely upsetting and at least temporarily overwhelms the individual sinternal resources.

4 This broader definition is used throughout this book, sincepeople who experience major threats to psychological integrity can suffer asmuch as those traumatized by physical injury or life threat, and can respondequally well, we believe, to trauma -focused therapies. This is solely a treat-ment issue, however; the DSM-IV-TRversion of trauma should be strictlyadhered to when making a formal stress disorder Types of TraumaSurveys of the general population suggest that at least half of all adults in theUnited States have experienced at least one major traumatic stressor (Elliott,1997; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Although suchstressors are common, their ability to produce significant psychological dis-turbance varies as a function of a wide variety of other variables, as is dis-cussed in Chapter 2. The following pages detail most of the major types oftraumatic events potentially experienced by those seeking mental health ser-vices.

5 There are myriad ways in which an individual can be traumatized, notall of which are easily expressed in an initial clinical interview. This is impor-tant to keep in mind frequently, clients will not report events they haveexperienced unless they are specifically asked about those events in a non-judgmental, supportive context (see Chapter 3). Each type of trauma is4 trauma , Effects, and 2/15/2006 1:39 PM Page 4described only briefly; the reader is referred to the Suggested Reading sectionat the end of the chapter for references to more detailed DisastersNatural disasters can be defined as large-scale, not directly human-caused,injury- or death-producing environmental events that adversely affect a signif-icant number of people. Disasters are relatively common in the United States;surveys suggest that between 13 and 30 percent of individuals have beenexposed to one or more natural disasters in their lifetimes (Briere & Elliott,2000; Green & Solomon, 1995).

6 Typical disasters include earthquakes, largefires, floods, avalanches, hurricanes, tornados, and volcanic eruptions. Theextent of physical injury, fear of death, and property loss during disastersappear to be the most traumatizing aspects of these events (Briere & Elliott,2000; Maida, Gordon, Steinberg, & Gordon, 1989; Ursano, Fullerton, &McCaughey, 1994). When mental health workers are involved in assistingdisaster victims, it is usually within the context of governmental or quasi-governmental agencies (for example, the Red Cross) that have been mobilizedrelatively soon after the event. At such times, as described in Chapter 10, theclinician s initial job usually involves triage and providing support, comfort,and psychological first aid, as opposed to trauma therapy, per Interpersonal ViolenceIntentional violence that involves high numbers of injuries or casualties but does not occur in the context of war is a newer category in the traumafield.

7 The Oklahoma City bombing on April 19, 1995 (North et al., 1999), theterrorist attacks on the World Trade Center and the Pentagon on September11, 2001 (Galea et al., 2002), and the July 7, 2005, attacks on the Londonmass transit system are obvious cases of mass trauma . There is an unfortu-nately large number of other examples, however, including terrorist attacksthroughout the world and mass human rights abuses by totalitarian regimes(Alexander & Brenner, 2001; Pfefferbaum et al., 2001). The September 11attacks stimulated a dramatic increase in North American research on theeffective short-term treatment of mass trauma , as described in Chapter 10. Asnoted later, this research suggests that it is as important to know what nottodo as it is to know what todo when working acutely with victims of masstrauma. It is a goal of international groups like the International Society forTraumatic Stress Studies (ISTSS; ) to disseminate thisinformation worldwide, since there is little reason to believe that terroristattacks or other mass traumas will decrease in the foreseeable Is trauma ?

8 2/15/2006 1:39 PM Page 5 Large-Scale Transportation AccidentsTransportation accidents involve events such as airline crashes, trainderailments, and maritime (for example, ship) accidents. These events ofteninvolve multiple victims and high fatality rates. Although the incidence ofsuch events is not easily determined, large-scale transportation accidents canbe especially traumatic to survivors, since such events frequently occur over arelatively extended period of time during which the victims are exposed toongoing terror and fear of death. Immediate response to airliner accidentsin the United States is controlled primarily by the Federal AviationAdministration (FAA) and the National Transportation Safety Board (NTSB),who work in concert with local emergency services, the relevant airline com-pany, and others in providing assistance to traumatized survivors and or Other Domestic FiresAlthough fires are often listed as disasters in the trauma literature, asignificant number of victims seen by trauma clinicians have experiencedsmaller-scale fires.

9 These include house fires, often caused by smoking in bedor by electrical short circuits, and gas explosions due to leaking propanetanks, stoves, or heaters. Physical injuries from fire can be particularlytraumatic. The lasting effects of serious burns a long recovery period, recon-structive surgeries, the development of visible and/or painful scars, and some-times chronic pain and reduced mobility mean that the traumatic event, insome ways, continues and repeats over time (Gilboa, Friedman, Tsur, &Fauerbach, 1994). This sustained traumatization, in turn, can interfere withposttraumatic Vehicle AccidentsApproximately 20 percent of individuals in the United States have experi-enced a serious motor vehicle accident (MVA) (Blanchard & Hickling, 1997).A substantial number of these people go on to develop significant psycholog-ical disturbance, especially if the accident involved major injury or resultedin the death of others. In the latter case, grief and self-blame may increase sub-sequent psychological effects.

10 In addition, survivors of major MVAs maysustain traumatic brain injury, which can further complicate assessment andtreatment (Harvey & Bryant, 2002; Hickling, Gillen, Blanchard, Buckley, &Taylor, 1998). Despite the fact that serious MVAs are more likely thanmany other noninterpersonal traumas to produce PTSD and other forms of6 trauma , Effects, and 2/15/2006 1:39 PM Page 6dysfunction, clinicians often inappropriately overlook such traumas wheninterviewing clients about negative life and Sexual AssaultRapecan be defined as nonconsensual oral, anal, or vaginal sexual pene-tration of an adolescent or adult (if the victim is a child , see child Abuse )through the use of threat or physical force, or when the victim is incapable ofgiving consent (for example, when under the influence of drugs or alcohol, orwhen he or she is otherwise cognitively impaired). The term sexual assaulttypically denotes any forced sexual contact short of rape, although someauthorities consider sexual assault to involve any forced sexual contact,including rape.