Gentle word of caution before we start…
Before we begin, please be mindful that some contents in this passage may trigger discomfort and unease if you have a prior history of trauma and abuse. Feel welcome to pause or tune out and dip in only when you are ready to return to this article.
Being compassionate to your own needs and being respectful of where you are in your recovery is crucial in your healing journey.
According to the Merriam-Webster dictionary, trauma is a Greek word for “wound”. While the Greeks used this to refer to physical injury in older times, this term is now commonly used to refer to emotional or psychological wounds.
Traumatic stress relates to extreme stress that overwhelms a person’s ability to cope.
David Spiegel described psychological trauma as the experience of “being objectified, a victim of someone’s rage, or nature indifference” (e.g., in the case of natural disasters) or of one’s physical and psychological limitations. Spiegel noted that along with the pain and fear associated with adverse events, there can also be an intolerable sense of helplessness induced by these events, potentially resulting in significant impact on the sense of self. In modern psychology, we are familiar with the impact of person’s sense of self, the way they see others and the world.
Types of trauma
Trauma can be classified into Type I and Type II trauma (Terr, 1991). Not everyone who experiences a traumatic event would go on to develop Posttraumatic stress disorder (PTSD). Existing resilience factors, the level of support one receives after the event and how the person perceives the threatening situation are a few factors that impact on the severity of posttraumatic stress symptoms.
Notably, the type of trauma a person experiences is one of a number of factors that determine the impact of the trauma, including how likely it is that the person will develop Posttraumatic Stress Disorder (PTSD) or Complex PTSD (CPTSD).
Type I trauma
This refers to exposure to an acute or single-incident traumatic events, e.g., a sudden and unexpected trauma, a single episode or experience of trauma. They are sometimes called “Big T” trauma or acute trauma. Type I trauma is commonly associated with Acute Stress Disorder, Posttraumatic stress disorder (PTSD) and other mental health conditions including specific phobias, anxiety, depression, substance abuse and adjustment disorders.
Some examples of Type I trauma are:
- Medical trauma
- Severe illness or injury
- Physical and/or sexual assault
- Traumatic loss (of a loved one, fire, tragic losses)
- Being a victim of or witness to violence
- Experiencing or witnessing a natural disaster
- Road accident
- Military combat incident
- Hospitalization/psychiatric hospitalization
- Difficult childbirth
- Post suicide attempt trauma or losing a loved one to suicide
- Life threatening illness or diagnosis
Type II trauma
This relates to multiple, long-standing or repeated exposure to traumatic events; and is associated with broader psychological consequences and coping deficits.
The concept of Complex trauma, which describes trauma experienced as part of childhood or early stages of development is derived from the concept of Type II trauma and the two terms have sometimes been used interchangeably.
It is important to note that this type of trauma often involves repetitive trauma that often occurs in the context of an interpersonal relationship where someone may feel trapped emotionally and/or physically. As it usually occurs in the context of a primary relationship, survivors of Type II trauma often feel coerced or powerless to prevent the trauma. Consequently, they can develop struggles in trust due to the fundamental betrayal of trust in their primary relationship(s).
Type II trauma also often occurs in combination with other traumas or cumulatively (known as "polyvictimization").
Understandably, exposure to multiple, chronic or recurrent traumatic experiences (as in the case of Type II or Complex trauma) involves a higher risk of PTSD or Complex PTSD, as well as other wide ranging and long term impact as a result of the survival-driven responses.
Some examples of Type II /Complex trauma include:
- chronic or repetitive experiences such as child abuse and neglect
- war or living in a war zone, military combat, concentration camps
- Domestic violence (Intimate Partner Violence)
- Physical, Emotional, Psychological or Financial abuse (typically overlaps)
- Ritual or Organized abuse
- Elder abuse
- Community violence
Other types of “less talked about” trauma:
Historical, Collective or Intergenerational Trauma
This is characterized by psychological or emotional difficulties which can affect different communities, cultural groups and generations. Adaptive coping patterns can be passed intergenerationally. Examples might include: Racism, Slavery, Forcible removal from a family or community, Genocide, War
Vicarious or Secondary Trauma
This type of trauma can occur when someone speaks to someone who has experienced a trauma or witnessed a trauma firsthand. The person listening can experience secondary trauma and experience symptoms experienced by the person explaining the trauma. For instance, professionals who frequently work with survivors of trauma and abuse and emergency workers such as police officers, fire-fighters, and paramedics are at high risk of exposure to this type of trauma.
Little t trauma
Little t traumas are experiences which are part of the everyday and are an expected part of life. They may however be very traumatic, depending on individuals’ life circumstances around when it occurs. Examples might include loss of a loved one (not traumatic bereavement), moving to a new house, or losing a job.
“Death by a thousand cuts”: The insidious impact of psychological malsupport
For those who grew up in environments that were chronically critical, invalidating, lonely, dismissive, insulting, or all of the above, navigating life can often feel like stumbling through the world wounded by invisible cuts and bruises. Such experiences fall under the type of complex trauma exposure known as psychological malsupport (e.g., emotional abuse, emotional neglect). In this category of trauma, there is an emphasis on ‘needs not met’ (i.e., trauma of omission vs trauma of commission).
There is a well written article on this subject at https://www.complextrauma.org/complex-trauma/death-by-a-thousand-cuts/. However, please be mindful of potential overwhelming feelings that may surface when browsing through this material as they can be very triggering for those who have had such experiences. Again, do pace yourself as you read through this material. Healing takes place in its own pace and time. Always respect what you can manage in your journey of self-discovery and healing.
Trauma and Stress related disorders
Trauma and stressor- related disorders refer to a category of mental health conditions (in the DSM) that is linked to the exposure of a stressful event. Individuals who are subjected to above mentioned trauma may develop symptoms that can fit into the mental health condition in this diagnostic category. The Trauma and Stressor-related disorders include the following mental health conditions:
- Disinhibited social engagement disorder
- Reactive attachment disorder
- Acute stress disorder
- Adjustment Disorders
- Posttraumatic stress disorder
- Other Specified Trauma and Stressor-Related Disorder
Reactive attachment disorder and Disinhibited social engagement disorder both result from social neglect during childhood (a lack of appropriate care-giving), and onset is during childhood.
At the moment, trauma and/or abuse are the only recognized causes of Posttraumatic Stress Disorder and Acute Stress Disorder. Acute Stress Disorder refers to an intense, unpleasant and dysfunctional reaction beginning shortly after an overwhelming traumatic event and lasts less than a month. These comprised of re-experiencing of the trauma, avoidance of trauma reminders, and heightened sense of threat as well as a significant change in moods or cognitive functioning (e.g., concentration difficulties, distorted thoughts in relation the trauma, persistent and exaggerated negative beliefs about self, others or the world).
It should be noted that humans are generally resilient individuals, and most are able to recover from single traumatic event given the right support. Nonetheless, on occasions (depending on the type of trauma experienced, prior life experiences and other personal and environmental factors), some individuals’ distressing symptoms may persist beyond a month. When this happens, they may have developed Posttraumatic Stress disorder (PTSD).
Delayed trauma and stress-related symptoms
It is also possible for someone to seemingly “recover” from a single trauma event (e.g., serious car accident) who then went on to develop PTSD years later after experiencing a trigger of the original traumatic experience (near miss car accident). In such cases, the individual might have utilized some strategies to cope with symptoms of the initial trauma, which re-surface when triggered by unexpected trauma reminders. These individuals may have developed other mental health symptoms (e.g., anxiety, depression, specific phobias, OCD) in the meantime while masking their past untreated traumatic experience(s). Thus, a comprehensive history intake by mental health professionals is often helpful when an individual presents with chronic mental health condition in a mental health setting.
Generally, both Acute stress disorder and posttraumatic stress disorder require the trauma to be a major trauma (i.e., 'Type I trauma' noted above). Thus, 'Type II trauma' (e.g., emotional abuse and physical neglect) are not considered “severe enough” to meet the present diagnostic criteria under the DSM 5. However, the role of multiple and more “minor” traumatic experiences and its long-lasting negative impact on mental and physical health functioning is now being increasing recognized, and the term Complex PTSD has been used to described someone who has experienced Type II trauma.
Recognized by the International Classification of Diseases (ICD-11), Complex PTSD is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g., torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).
The criteria for Complex PTSD consist of 6 symptoms clusters:
- the three PTSD criteria of re-experiencing of the trauma, avoidance of trauma reminders, and heightened sense of threat (hypervigilance, startle response), and
- three disturbances of self-organisation (DSO) symptoms
- DSO are defined as emotional dysregulation, interpersonal difficulties, and negative self-concept.
Another key criteria for the diagnosis of Complex PTSD is that the individual’s functioning must be significantly impacted by these trauma symptoms. Only either Complex PTSD or PTSD can be diagnosed at any point in time. In terms of symptoms overlap, Complex PTSD would supersede the diagnosis of PTSD.
Brief note on trauma-related dissociation
Dissociation is a process in which a person disconnects from their thoughts, feelings, memories, behaviors, physical sensations, or sense of identity. Dissociation is common among people seeking mental health support.
Trauma-Related Dissociation is described as a way in which individuals who are exposed to traumatic events ‘escape mentally’ when physical escape is not viable, or when they are so emotionally overwhelmed that they cannot cope any longer. Dissociation can thus be understood as individuals' way to survive through the traumatic events by ‘switching off’ or compartmentalizing some aspects of their experience. These reactions are usually temporary but, in cases of severe or repeated trauma, dissociation may last longer. This can be frightening and difficult to explain to others. Prolonged dissociation can have a significant impact on an individual’s physical, vocational, and social functioning.
Interventions and support for PTSD and Complex PTSD
There are various evidenced-based supports and complementary support for individuals with PTSD and Complex PTSD, just as there are various support and resources for individuals coping with PTSD and Complex PTSD.
Broadly, psychological interventions require the prerequisite of emotional safety and stabilization prior to processing (or reviewing the traumatic memories) of individuals. The therapeutic needs of individuals exposed to past traumatic experiences vary widely. It is not necessary for all individuals to revisit details of past trauma to heal. Some interventions focused on improving an individual’s quality of life in the present moment, while others involve supporting individuals process parts or specific aspects of past traumatic memories at some point in their therapy journey to bring about closure or aspects of further healing. It is always good practice for treating professionals to discuss respectfully and collaborate with individuals to agree on a support approach and therapy goals that are aligned with the individual’s needs.
Readers who are interested in finding out more information about PTSD and Complex PTSD may find the below websites helpful:
Note: Please pace yourself when reading trauma and trauma-related materials. If you find yourself becoming distressed by the information you read, take a break from the materials or spend some time to ground yourself. Being mindful of the impact of your exposure to information or situation that made you feel unsafe and implementing immediate self-care is the first step towards empowering yourself in your recovery journey.
- Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of psychiatry, 148(1), 10-20. Read more: http://traumadissociation.com/trauma-abuse#traumatypes
- “Death by a thousand cuts”: The insidious impact of psychological malsupport at https://www.complextrauma.org/complex-trauma/death-by-a-thousand-cuts/
- ICD-11 complex post-traumatic stress disorder: simplifying diagnosis in trauma populations | The British Journal of Psychiatry | Cambridge