One of the things that I have noticed over the years is that most people (including many clinicians and Service members) are confused about the clinical definition of “trauma.” These days, the word “trauma” has become a buzzword in our culture to describe negative life experiences that continue to have an impact on one’s life after the fact. Webster’s dictionary offers several definitions of the word “trauma,” but one of the definitions seems to fit the colloquial conceptualization of “trauma”:
Trauma (n): an emotional upset
This definition seems to imply that almost any event that occasions upsetting emotions could be (and perhaps should be) given the “trauma” label. Undeniably, major life events such as deployment-related stressors (e.g., living in a harsh environment, being separated from family and friends), divorce, and financial problems can all take their toll on Service members, as well as their families. However, should we classify these life events as traumatic stressors?
As clinicians, we need to make a distinction between seminal life events (as my good friend and colleague, Leah Blain, Ph.D., likes to call them) and traumatic stressors. This is important because the label we attach to a major life event is likely to have important implications, not the least of which is a determining an accurate diagnosis. Inaccurate diagnoses may lead clinicians to suggest treatments that may not actually be helpful for the presenting issues of the Service member or Veteran who has made their way to your office. Beyond diagnosis and treatment, labeling an event as a “trauma” when that label is not appropriate could also have other unintended consequences that may impact a Service member’s life.
So what, exactly, constitutes a traumatic stressor and it what ways do these events differ from other major life events? A traumatic stressor is defined by the Diagnostic and Statistical Manual of Mental Disorders: 5th Edition (DSM 5; American Psychiatric Association, 2013) in Criterion A of the diagnostic criteria for Posttraumatic Stress Disorder (PTSD):
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
As you can see, the colloquial definition and the diagnostic definitions of trauma differ in a few very important ways. First, trauma refers to a very specific event in the diagnostic definition (i.e., actual or threatened death, serious injury, or sexual violence). Second, the diagnostic definition focuses more on the characteristics of the event rather than one’s reactions to an event. Therefore, diagnostic accuracy depends on the clinician’s ability to gather details about specific events that the Service member has experienced. The Service member’s perception of the impact of those experiences, while clinically relevant, are actually not diagnostically relevant in terms of determining if a client has experienced a Criterion A stressor. If a Service member reports a non-Criterion A stressor that continues to cause significant distress and/or negative impact on functioning, then it is appropriate to assess the client for an Adjustment Disorder or Other Stressor-Related Disorder.
Now that we’ve reviewed the differences between the colloquial and diagnostic definitions of trauma, here is a little pop quiz to test your knowledge. Which of these commonly reported experiences from Service members would qualify as a Criterion A stressor according to DSM 5 (answers are at the bottom of the blog)?
A. Being injured in a firefight
B. Being yelled at by a drill instructor
C. Witnessing a Service member killed in action
D. Being deployed
F. Video review of UAV (drone) missions
How did you do? Hopefully, this review of DSM 5 criteria has been helpful in highlighting one of the trickier aspects of diagnosing trauma and other stressor-related disorders in Service members.
Andrew Santanello, Psy.D., is a licensed, clinical psychologist and Cognitive Behavioral Therapy trainer at the Center for Deployment Psychology.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Answers to quiz: A, C, F would qualify as Criterion A stressors.