How do we decide what counts as trauma – and have we got it all wrong?

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Daniel Stolle

GIVING birth. A car accident. Racial abuse. Many of us feel we have experienced things we would describe as traumatic. Look no further than the past few years. Beyond the sickness and deaths wrought by covid-19, many psychologists warned that the pandemic was a mental health crisis in the making, with cases of post-traumatic stress disorder (PTSD) predicted to soar.

Consult the medical textbooks, however, and you find that such experiences don’t generally qualify as trauma. People who suddenly lost a loved one to covid-19, and those working in hospitals and care homes might meet the criteria. But relentless news updates about a mysterious deadly disease, job loss, social isolation and living under lockdown – none of these fits the bill. “People called the pandemic traumatic, and it’s not,” says George Bonanno at Columbia University in New York.

In our propensity to view things as traumatic, we may also be overplaying the impact, Bonanno argues. His research has shown that, given time, most of us will recover even from the most horrifying experiences. In light of this, says Bonanno, the word “trauma” has lost all meaning. But others believe the strict medical definition should be expanded to cover a wider set of human experiences.


This explosive debate – reignited by the pandemic and the Black Lives Matter movement, and continuing at a time when war is high on the news agenda – has big implications. Ultimately, our understanding of what trauma is, and which experiences qualify, determines whether people are being unnecessarily diagnosed and treated for PTSD, or are living with the symptoms unable to get the treatment they need.

The medical profession has long recognised the importance of trauma, even if it has struggled to define it. The first edition of the “psychiatrist’s bible”, the US Diagnostic and Statistical Manual of Mental Disorders, or DSM, published in 1952, mentions a “gross stress reaction” that can result from severe situations such as catastrophe or combat. But it wasn’t until 1980 that PTSD was introduced.

The symptoms of PTSD include recurrent disturbing memories, dreams or flashbacks, stress reactions to certain cues, avoidance behaviours, low mood or feelings such as guilt or shame. Importantly, however, an experience cannot be termed traumatic unless it fits with a list of potential traumas that are collectively called “criterion A”. This list has widened over the years and today includes actual or threatened death, serious injury and sexual violence. A person must have experienced, witnessed or had repeated professional exposure to one of these events, in order to qualify for a PTSD diagnosis.

The public perception of trauma has also changed, says epidemiologist Karestan Koenen at Harvard University. “When I started in the field, if you said ‘trauma’, the only thing people associated with it were war veterans,” she says. “Now, the public has a much broader view.”

This broader definition has been described by some psychologists as “concept creep“. “People use it indiscriminately now,” says Bonanno. “Suddenly, people were saying they were traumatised from relatively mundane things.” That is a problem, because if a broader range of human experiences are considered traumatic, more people will meet the criteria for a PTSD diagnosis – and some may receive unnecessary treatment as a result. “It could potentially harm them. At minimum, it would waste their time,” says Bonanno.

For others, the criteria are too narrow. In 2017, Lisa van den Berg at Leiden University in the Netherlands and her colleagues assessed PTSD symptoms in 1433 volunteers who were already participating in a study on depression and anxiety. The team found that PTSD symptoms following an event that wouldn’t meet the latest DSM criteria (DSM-5) for being traumatic were just as severe or more severe than those following an event that would be considered a trauma.

Atypical trauma

Koenen also wonders whether the criteria should be broadened. Over her years of research, she had seen women develop the symptoms of PTSD following events that wouldn’t have necessarily met the DSM-5 list, including miscarriage and sexual harassment.

In one case, a woman had been through a particularly acrimonious divorce, during which her ex-husband had kidnapped her children. “Nothing she described in that event fits on a typical trauma scale,” says Koenen. “It really challenged my thinking. How do we define trauma, and what questions should we ask?”

So, between 2018 and 2021, her team surveyed more than 33,000 current and former nurses in the US about their experiences of trauma. The survey encompassed traumas that would fit the DSM-5 definition, but also included an option for responders to describe “other” events they felt were traumatic. “That ‘other’ category has the highest prevalence of PTSD associated with it,” says Koenen.

Rigidly applying the DSM-5’s criteria in the pandemic could mean that people who have found the experience traumatic are unable to access treatment, argue Marielle Wathelet at Lille Regional University Hospital in France and her colleagues. “In the covid-19 pandemic, the strict application of DSM-5 criterion A could leave a large number of patients without the appropriate care,” they recently wrote in a paper.

Yara Mekawi at the University of Louisville in Kentucky, who studies the impact of racial discrimination on mental health, also feels that meeting a set of criteria for trauma makes no sense. If two people have the same PTSD symptoms and the difference between them is that one person meets the DSM-5 criterion A but the other doesn’t, why would they be treated differently, she asks. “It’s not like there’s a blood test or biological basis for it.”

And yet, under criterion A, people who repeatedly witness threats to the lives of others in a professional capacity, such as police officers and first responders, qualify for a PTSD diagnosis. Why don’t Black people in the US who were repeatedly exposed to distressing footage of Black individuals being manhandled and murdered over the past few years, asks Mekawi. “If you’re being inundated with images of someone from your racial group being brutalised, why would that be disqualified as a criterion A trauma?” she says.

“It’s a good question and I don’t know the answer,” says Robert Ursano at the Uniformed Services University in Bethesda, Maryland, who was one of the panel of experts who decided the DSM-5 PTSD criteria.

New Yorkers head back to work in the Wall Street area six days after the attack on the World Trade Center. (Photo by Jacques Langevin/Sygma/Sygma via Getty Images)

New Yorkers head back to work in the days after the 9/11 attacks

Jacques Langevin/Sygma via Getty Images

Ursano stresses that miscarriage and racial abuse are “tremendously terrible events, no question about it”. But he maintains that there must be a threat to life – which can occur in some cases of each experience – to qualify for a PTSD diagnosis. He points to a lack of research – it isn’t yet clear if these experiences lead to PTSD in the way other experiences do, he says.

While we lack the evidence to answer this question, we do have a growing body of research to answer another question: how resilient are people to trauma? And these findings are further stoking the fire around the debate.

It is perfectly normal to experience some PTSD symptoms after a potentially traumatic event. Someone who has been in a car accident and sustained minor injuries, for instance, might have dreams about the accident, flinch at the sound of screeching brakes and temporarily avoid driving. These would all be considered symptoms of PTSD, but are to be expected following such an experience. The person would only be advised to seek treatment if the symptoms didn’t begin to improve within a month or so, or if they significantly affected quality of life.

Nightmare events

For the majority of us, this doesn’t happen. Most people won’t develop lasting symptoms, even after horrifying experiences. For example, multiple studies suggest that around 8 per cent of people who experience the horrors of war go on to develop PTSD.

The 9/11 terrorist attacks in the US also offer up some insights. Images of planes crashing into the World Trade Center in Manhattan, New York, were broadcast globally, and the attacks dominated the news for months, particularly in the US. “Within days, there were these very dramatic pronouncements that we were heading for a mental health crisis of unprecedented magnitude,” says Bonanno.

Bonanno, who was living in New York City at the time, was one of the many people who developed symptoms of PTSD in the days following the attacks. “The planes fly right over my apartment,” he says. “I had nightmares about planes crashing.”

In one survey of 988 adults living in the area, conducted between five and eight weeks after the attacks, 58 per cent reported at least one PTSD symptom, with insomnia and intrusive memories being the most common. But symptoms began to ease with time. Among residents of Manhattan, the incidence of PTSD appeared to drop from around 7.5 per cent a month after the attacks to 0.6 per cent six months after the events.

Rates of PTSD were higher among those who were more directly affected by the events. A month on from the attacks, 37 per cent of those who were in the World Trade Center complex at the time had probable PTSD. A separate study by the same team suggests this figure had dropped to 15 per cent within two to three years. We can expect symptoms that developed during the pandemic to decline in the same way, says Bonanno.

In a study conducted with colleagues from Columbia University, as well as Tsinghua University in Beijing, Bonanno assessed PTSD symptoms in 326 residents of China’s Hubei province between April and October 2020, following the implementation of a strict covid-19 lockdown in January. By the end of this period, just 7 per cent of people had symptoms that might qualify for a PTSD diagnosis.

Studies like these have important take-home messages, says Bonanno. One is that simply hearing about an event doesn’t necessarily make it traumatic for you. Another is that, on the whole, people tend to be remarkably resilient. “There isn’t an event I’ve studied yet where even the majority develop PTSD,” he says. “Usually it’s a very small percentage – 5 or 10 per cent.”

According to Bonanno’s research, the way individuals recover from a traumatic event can take one of a handful of trajectories. Over the past few decades, he has identified three common ones.

In the resilience trajectory, people move on and continue with their lives. This is the most positive and also the most common, occurring in 62 to 73 per cent of people depending on the study.

Then there are around 7 per cent of people who tend to show high levels of PTSD in the first few months of an event, but display improvement within about six months or so. They usually recover within a year or two.

WUHAN, CHINA - JANUARY 31: (CHINA OUT) A woman wears a protective mask walk in the street as man sit in the roadside on January 31, 2020 in Wuhan, China. World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus said on January 30 that the novel coronavirus outbreak has become a Public Health Emergency of International Concern (PHEIC). (Photo by Stringer/Getty Images)

Streets in Wuhan, China, are all but deserted in January 2020, as a strict lockdown is imposed

Stringer/Getty Images

The third common trajectory is that followed by people whose PTSD symptoms last for years. Their symptoms are severe enough to affect their ability to function in life. And it can take several years for their symptoms to improve.

Even so, people are complicated, and it isn’t always possible to file complex cases into one of three neat categories. And while Bonanno’s recent book, The End of Trauma, focuses on these three trajectories, in reality, there are many more, he says.

Koenen, too, has been trying to better understand how people will respond to trauma. Since 2016, her team has been working with hospitals around the US to assess people who seek care in emergency departments following a potentially traumatic experience. Volunteers are then followed up for a year, during which they undertake surveys and cognitive tests. Blood and saliva samples are scoured for biological clues that might one day predict a person’s response to trauma.

A handful of key factors have now been identified that play a role in resilience. The worst symptoms tend to develop after experiencing violence from another person, for example. And people who have had higher amounts of trauma in their lives tend to develop more severe symptoms from further trauma.

Bonanno has found that the way a person thinks can improve their odds of recovery. He refers to a “flexibility mindset”, a set of characteristics that tend to be associated with better outcomes. In his research, people who are generally confident, optimistic and braced for challenges, as well as able to understand their situation and how to improve their lot, tend to fare the best.

This was borne out in his Hubei study: optimism and a flexible mindset, as well as good health and family support, appeared to be key to following a resilience trajectory following lockdown.

But resilience isn’t a baked-in personality trait. “I don’t like the term resilient, because it seems to imply that someone is resilient or not, a yes or no,” says Koenen. People might be more resilient in some aspects of life, and less so in others, for instance. Koenen has seen people who, following a trauma, perform well at school, but struggle in their relationships. “Resilience is really multidimensional,” she says.

How to boost resilience has been a hot topic of research – whether through positive thinking, meditation or even using a pill. But such approaches can be misguided, says Mekawi. “Based on my experience, people who have resources, who have stability, and who have space to process their trauma are more resilient,” she says. “I think the idea of taking a pill to boost resilience is just so bizarre. Why not change our social structure to support people?”

And given the ever-changing nature of our understanding of what trauma is, we can afford some flexibility in our definition, says Mekawi. “Trauma is a social construct… there’s no single truth that everyone is going to agree on,” she says. “There’s no reason to gatekeep trauma.”

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