Is trauma the same thing as adversity?

The effects of psychological trauma on physical and mental health are well known. Specifically, having experienced trauma during childhood increases a person’s likelihood of suffering obesity, hypertension, diabetes, stroke, cardiovascular disease and many types of cancer. It has taken a long time for us to accept, but now we know: the (traumatic) environment influences the mind, the mind influences the body, and the body in turn influences the mind. For this reason, 21st century physicians study and take into account emotions and experiences as well as physical symptoms (hence the emergence of “narrative medicine”), and conversely, psychologists now know more about neuroendocrine responses to stress and its influence on the immune system — in essence, the biological substrate that makes “the mind” is not an abstract entity that comes out of nowhere, but an organism produced through evolution.

The effects of trauma on a person’s psychic life are even more evident: the risk of smoking is multiplied by a factor of three, the risk of consuming illicit substances by 11, the risk of depression by four, and the risk of suicide by 2.5. Something happens in the brain of a child who is subjected to trauma that seems to disrupt their adaptation and survival mechanisms. In neuroimaging studies, we see how the gray matter of the hippocampus and the amygdala are reduced in such subjects, and even how it can shorten some areas of the chromosomes, called telomeres, which are responsible for protecting genetic material from becoming broken or damaged. Trauma’s destructive power, then, extends deep into the very mechanisms of genetic transmission (just as genetics predisposes people to certain reactions to trauma). To understand the biology of the mind, we have to think circularly, focusing on the complexity of feedback systems and the synergies between the multiple factors involved, while analyzing the ways that human organisms function in their microsystems.

But how we have conceptualized trauma over the years has a history. Even before Freud, there was talk of traumatic neuroses, generally confined to the context of war. Early psychoanalysis associated neuroses with traumatic experiences, including sexual abuse or maltreatment, but the terrible aftermath of the world wars sent trauma once again back to the front lines, or rather, to the hospitals caring for survivors.

From the Holocaust to Vietnam

Virginia Woolf described the post-traumatic aftermath of a poet returning from the battlefield through her unforgettable depiction of the deterioration and suicide of the character Septimus in the novel Mrs. Dalloway (1925). The experiences of Shoah survivors such as Primo Levi, Elie Wiesel or Jean Améry placed the idea of trauma at the limits of the imaginable. But it was the Vietnam War, with its thousands of defeated veterans in need of psychological care, that prompted the birth of psychotraumatology and the concept of post-traumatic stress disorder (PTSD, which became an official diagnosis in 1980). PTSD presents with recurrent distressing memories, nightmares, intense physiological reactions, efforts to avoid situations similar to the traumatic event, and an altered mental status. Today we know that PTSD is only one of several post-traumatic pathways that an individual can have, and that others who experience trauma may develop depression, bulimia, psychosis or borderline personality disorder.

So, what is trauma and what is not? In essence, trauma is “an extreme situation that endangers the life or integrity of the subject, who experiences intense terror or feeling of helplessness.” This can involve being the victim of a terrorist attack, surviving physical aggression or rape, or experiencing a natural disaster or a serious traffic accident. However, in the definition as it has developed in recent years, the objective event that takes place has been losing importance and the subjective experience — the associated feelings of horror, helplessness or abandonment — has gained prominence. Thus, more recent trauma spectrums refer to “adverse experiences” in a broader sense, including situations of discrimination, poverty, living with a mentally ill person, or having a family member in prison, for example. The concept of trauma has thus been extended to include traumatic experiences of adverse situations. A patient may tell us, for example, that being separated from his parents or being prevented from getting tattoos until he was 18 was a traumatic experience, and though common sense may disincline us to equate such adversities with, say, witnessing the massacres in Rwanda, we can nevertheless respect this subjective experience as a legitimate form of trauma.

Parallel to the hyperinflation of trauma, there has been a related expansion of the category of “adverse situation,” which now includes experiences previously thought of, more modestly, as simply stressful. Some view this as a positive development that validates the subjective experiences of people and asks (not without reason, I agree): Who are we to give our outside opinion on what constitutes legitimate trauma. But there is also the risk that, if everything becomes trauma, then nothing is trauma — that the concept loses its utility and becomes distorted and trivialized when we use the same term to describe totally different situations.

This summer, I read a book by Spanish author Miguel Ángel Oeste titled Yo vengo de ese miedo [I Come From that Fear], a chilling testimony of horrific child abuse. Ángel Oeste writes: “I am no longer a child. But the fear that overwhelms me now is the same fear I suffered as a child.” Similarly, in his book Instrumental: A Memoir of Madness, Medication, and Music, the British pianist and writer James Rhodes recounts the chronic sexual abuse that left him with profound physical and psychological scars, which he only later mitigated through music. I wonder if using the word trauma too elastically, in the face of experiences of violence and abuse like these and so many others, and in the context of our contemporary hypertrophy of subjectivity, might be its own form of betrayal. Guillermo Lahera is Professor of Psychiatry at the University of Alcalá and Section Chief at the Hospital Universitario Príncipe de Asturias. He is the editor-in-chief of The European Journal of Psychiatry.

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