Within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5-TR), several criteria are listed for each mental health condition recognized in America. Posttraumatic stress disorder (PTSD) is an interesting case. Beyond the intrusive re-experiencing, mood, reactive, and avoidant symptoms listed within criteria B-E, criterion A distinguishes what events can qualify a person for consideration of this diagnosis.
Criterion A is written as an exposure to an event that causes (or could have caused) death, serious injury, or sexual violence. The traumatic event could be something one experiences directly, witnesses, or learns of (secondary trauma; American Psychiatric Association, 2013).
As a clinician, I have found this troubling. Trauma is an incredibly individualized experience, and I have met many individuals meeting all other criteria for PTSD, but whose circumstances did not fall neatly into criterion A. Does this mean that their condition is not PTSD?
The power-threat-meaning framework recognizes the vast array of factors that can result in psychological and social suffering. It is an alternative to traditional diagnostic systems (Boyle and Johnstone, 2020). Within this model, power is often seen as central to trauma, whether this power is expressed over a person through abuse, loss of health, interpersonal traumas, legal trauma, and so on. It's ironic, given this perspective, that the more traditional models would incite such power in defining what is "bad enough" to merit criteria for PTSD. Do organizations and clinicians have insight to determine what is and is not a qualifying event?
What follows are seven underrecognized sources of trauma, for some people, that I have come across. While these events might not fit within the definition of criterion A of PTSD, many who go through these struggles are vulnerable to PTSD symptoms.
Whether schoolyard bullying, cyberbullying, or the type of experiences many go through in a work environment, bullying ignites a clear power structure. While many who wade through bullying do not develop significant trauma-related challenges, some do. They may find that their perceptions of others, themselves, and the world have changed. Certain events can spark nightmares, and a person might ruminate on their experiences. When there is an ongoing threat, a person could develop a sort of hypervigilance. And this doesn't have to be the "Give me your lunch money" stereotype of physical bullying. Being turned away from one's friend group or made fun of for a disability can be just as damaging.
It's rare for me to hear a person list legal trouble as a traumatic event. Still, when a person has come in contact with the justice system, especially if they had been wrongly accused or if they experienced police contact or incarceration, traumatic symptoms often follow. The person might not feel safe anymore. They may find themselves unable to trust like they once did and in a state of hypervigilance. Rumination over the events as well as nightmares are also prevalent. What is unique about this kind of trauma is that most do not receive much, if any, support when faced with it, and to the contrary often become isolated, further disempowering them.
Estrangement has become increasingly common in the last five years. Whether one is the individual who has initiated the estrangement or the person on the other side, the disappearance of a close family member from one's life can be intensely painful. Unlike other losses, estrangement often has a flavor of shame, and individuals rarely get the same caliber of support. Still, it can in ways mimic a death. Ruminating over why the person doesn't want contact (or the events that led up to the break in contact), dreams of the lost loved one, and changes in ability to trust are just a few of the common responses to estrangement.
While some medical events do qualify for criterion A of a PTSD diagnosis, we don't often think of things like hospitalizations and tests as traumatic. Still, experiences such as these can spark significant anxiety even following the resolution of the health issue. This is a sort of trauma of everyday life. Many work through this, with support; however, for some, the challenges can be longer-lasting.
Rejection of all kinds can be traumatic—in particular, rejection from one's core sources of support. For example, if an individual chooses to come out as queer, but is not accepted by family, that experience can become a trauma. Shame, a sense of betrayal, confusion, and rumination might follow.
While poverty is not a single event, the mounting experiences of not having "enough" in the way of resources can certainly be traumatic. Growing up in poverty can leave a person with a scarcity mindset, and occurrences along the way such as fear of losing housing, watching a parent have to miss meals, or being humiliated in dirty clothing at school can contribute to a fallout of PTSD-like symptoms.
Divorce is not just one event; it is a cascade of events that can be extremely difficult and bring out trauma-based reactions. The events leading up to the divorce, the breakdown of the marriage, the separation, the divorce process, and events to follow, such as ongoing custody battles, can all create a paradigm shift. While some express liberation at their divorce or that the occurrence was not traumatic at all, many express a sense of betrayal. Someone they once may have seen as their best friend may now be an enemy.
There is no "list" of what events are "bad enough" to spark significant trauma-related symptoms. Perhaps criterion A will be revisited in the crafting of the DSM-6. In the meantime, clinicians can do well to thoroughly assess what an individual might experience as traumatic rather than what might be stereotypically typed as "trauma."
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Boyle, M. Johnstone, L. (2020). A Straight-Talking Introduction to the Power Threat Meaning Framework: An Alternative to Psychiatric Diagnosis. PCCS Books.
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