Do Traumatic Events Always Lead to Mental Disorders Like PTSD?

The DSM’s definition of events that cause PTSD remains quite narrow, but some advocate for its expansion

There’s a good deal of debate around the diagnosis of PTSD (Post-Traumatic Stress Disorder). The DSM has remained committed to a fairly narrow definition of the disorder, limiting relevant traumatic events to experiencing or directly witnessing events in the order of severe bodily harm and/or fear of death. In practice, many clinicians take at least somewhat of a broader stance.

There’s a growing contingent that wants to vastly expand our understanding of what events can cause PTSD. This contingent believes expansion would legitimize the reality and intensity of those experiences. It’s also an attempt to ground an understanding of many emotional problems that are commonly understood as biological in origin as, in fact, products of traumatic circumstances. Take an adult who currently experiences anxiety and depression symptoms. As a child, they may have had an alcoholic single parent who was frequently unavailable, tasking the child with taking care of themselves and their siblings. The argument here suggests that the childhood experience should be considered trauma in order to both validate the experience itself and formulate an understanding of the adult suffering and distress. Some have also advocated for a new diagnosis called Complex Post-Traumatic Stress Disorder (CPTSD) to capture the experience of ongoing intense, scary, deprivation events.

Why this debate matters is two-fold. First, what we call a disorder (or if we call it a disorder at all) has an impact on insurance reimbursement, disability, FMLA leave, and even sentencing hearings in criminal situations. Secondly, it also has an impact on how we treat individual suffering. For the latter, expanding the definition has strong and weak points. On the one hand, acknowledging suffering is a core tenet of humanistic care—suffering comes from somewhere and what happened to us, such as the circumstances of our childhood, matters. Yet, on the other hand, trauma can also become a ubiquitous shorthand for all forms of suffering, wrongs, or abuse, narrowing both the array of experiences we can have and too quickly limiting the ways we can make meaning from them.

It's helpful (though not always easy) to separate traumatic events and traumatic effects

Trauma is usefully separated into two categories: traumatic events and traumatic effects. Traumatic events are the scary things that happen to us, which can be formative, meaning shape us significantly. Traumatic effects are the ways those events affect us, including symptoms that would be significant enough for the diagnosis of PTSD. In other words, events and effects are two different things.

Granted, this can be difficult to parse out. Part of what’s hard in separating traumatic events from traumatic effects is how trauma evokes an embodied response that is autonomic. This is the part of the nervous system that responds unmediated by conscious, reflective thought (e.g. if someone tosses a ball at you and you flinch, you’re not “thinking” about lifting your arms to block the ball. It happens automatically aka autonomically). Because this is the system that’s operative when trauma is at play, our ability to discern the differences between the cause (the event) and the effect (the response) is complicated.

Conflating traumatic events and effects erases our capacities to endure and grow

Roughly since 9/11, there has been a cultural shift in how we talk about trauma, specifically conflating events and effects. If something traumatic happened to someone, for instance, we commonly say that person “has been traumatized.” This leaves out the myriad ways that we respond implicitly/automatically, as well as the myriad ways we can choose to respond in the aftermath of an immediate event. By conflating the two, we index out our capacities—innate, in our communities, and in our internal and external ways of being in the world—that help us endure and even, grow from these experiences. We can move toward help, comfort, empowerment, justice, and compassionate others that can help us work through the event with the goal of preventing a traumatic event from producing a traumatic response.

Scary, awful, bad things happen a good deal of the time and don’t result in trauma symptoms. Many people experience traumatic events and don’t become traumatized. This is not to say traumatic events don’t impact us. They do, regardless of how we respond or who we are. The question is not whether they impact us, but whether that impact must become (or must be prima facie understood as) trauma of the sort we might call PTSD.

There are both internal and external reasons why a traumatic event may or may not lead to PTSD

What makes a traumatic event lead to a trauma response? There are many answers, both internal and external. First, people who have experienced a lot of trauma may be more susceptible to experiencing trauma symptoms. They are more vulnerable to certain emotional experiences when trauma from the past wasn’t healed. Their nervous systems are depleted from these past experiences and they lack an infrastructure of relationships and developed capacities.

That being said, the opposite can also be true. People who have experienced a lot of trauma and worked through it sometimes build the capacity to handle trauma differently and survive better. Or they’ve experienced a good deal of trauma and have become skilled at checking out or overriding their experiences. Therefore, they create an illusion that they’re handling a traumatic event okay.

Other factors are external. For instance, if someone is unhoused, working through trauma may be more difficult than if they had a supportive family system or social community to help them. Notably, faith and a faith-based community are often protective factors. Therapy too can be among the things that prevent traumatic events from having lasting effects. In fact, the sooner a traumatic event can be properly worked through, whether in therapy or in the context of family or community, the more likely it is to be without lasting effect. 

Why? We are social creatures. Other people, organized well, can offer safety (reestablishing safety is the first order of business when safety has been disrupted). Additionally, a community can help us make meaning from the event. We can tell the story of what happened and be heard and received (and believed). We can work to understand that it happened. We can look at its implications for our lives. We can make art or music from it. We can integrate it into the lore of our community. We can commune with others who have had similar experiences and we can seek justice and engage in practices that reduce the likelihood of it happening again.