The Prevalence of Trauma in American Society
Many people hear the term “Post-Traumatic Stress Disorder” and think of veterans scarred by the horror of combat. While many veterans do suffer from Post-Traumatic Stress Disorder (PTSD), trauma is a far more common experience than many realize. Often, people are experiencing the after-effects of trauma and don’t even realize where these symptoms stem from. So, just how common is it to experience trauma?
According to Centers for Disease Control and Prevention (as cited in The Body Keeps the Score)
1 in 5 Americans was sexually molested as a child
1 in 4 Americans was beaten by a parent to the point of mark being left
25% of people grew up with alcoholic relatives
1/8 of people witnessed their mother being hit as a child
According to the Substance Abuse and Mental Health Services Administration (SAMHSA) and U.S. Department of Health and Human Services (HRSA) Website
61 percent of men and 51 percent of women report exposure to at least one lifetime traumatic event
90 percent of clients in public behavioral health care settings have experienced trauma
The point? The majority of people experience trauma at some point in our lives. We know that this trauma can have a huge impact, and I am not just referring to the scars left by Post-Traumatic Stress Disorder. We also know that trauma can impact health, substance use, and other outcomes that you may not expect, and we will discuss that later in the post in more detail. First, let’s talk about PTSD.
What is Post-Traumatic Stress Disorder?
In order to talk about post-traumatic stress disorder, we need to define it. I am going to copy the DSM-V criteria verbatim, but I am also going to explain it in simpler terms and go into the nuances of different types of trauma that can lead to PTSD in a little more detail in this section.
The DSM-V Definition
Taken directly from the DSM-V, here is the criteria for Post-traumatic Stress Disorder:
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more of the following ways
Directly experiencing the traumatic event(s).
Witnessing, in person, the event(s) as it occurred to others.
Learning that the traumatic event(s) occurred to a close family member or close friend.
Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (for example, first responders collecting human remains; police officers repeatedly exposed to the details of child abuse).
Note: Criterion A does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Dissociative reactions (example: flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme cases being a complete loss of awareness of present surroundings.)
Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Marked psychological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic events.
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations), that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:
Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not other factors such as head injury, alcohol, or drugs).
Persistent and exaggerated negative beliefs about oneself, others, or the world (for example: “I am bad”, “no one can be trusted”, “the world is dangerous”, “my whole nervous system is completely ruined”).
Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame themselves or others.
Persistent negative emotional state (examples: fear, horror, anger, guilt, shame).
Markedly diminished interest or participation in significant activities.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions (examples: inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
Irritable behavior or outbursts typically expressed as verbal or physical aggression towards people or objects.
Reckless or self-destructive behavior.
Hypervigilance (added by me: being extra aware and/or anxious of your surroundings, on the lookout for danger).
Exaggerated startle response.
Problems with concentration.
Sleep disturbance (examples: difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
A Simpler Definition
Okay, that was a lot. Let’s break it down into a way that doesn’t give us a migraine. In order meet the criteria for PTSD, the following must be met:
Exposure to trauma. You need to have been exposed to actual or threatened death, serious injury, or sexual violence, either directly or indirectly (more on indirect exposure later).
Have at least one “intrusion symptom”. I think of intrusion symptoms as the ones that intrude on your life because you cannot control when, where, or how they pop up. These include involuntary distressing memories, dreams, or flashbacks or other dissociative (meaning feeling outside of your present place, time and body) experiences of the traumatic event; and/or intense involuntary distress when you have encounter triggers, such as internal or external cues that remind you of the traumatic event(s).
Avoidance symptoms. You naturally try to avoid things that remind you of your trauma when you have PTSD. This can be manifested by trying to avoid thinking about the event, avoid emotions brought on by the event, or by avoiding people, places, or things (ie, external reminders) that you associate with the event. These are also known as triggers.
Negative changes to your thinking patterns and mood associated with the trauma. The trauma might change your ability to remember things about what happened to you, it might cause you to have negative beliefs about yourself, others, or the world, it may cause you to have blame for yourself or others who did not commit the trauma, it may cause you to feel constant or near-constant difficult emotions, it might cause you to lose joy in activities you once loved, you might feel detached from those you care about, and you might have trouble feeling happiness and satisfaction in things or people you once loved.
Changes in your reactivity. This can include becoming more irritable, some people even become violent or aggressive towards others, themselves, or objects. This might also include hypervigilance, which means that you are very aware of your surroundings and constantly looking for danger. People might have an exaggerated startle response, meaning they are easily jumpy as if they are ready for danger to occur. People might have trouble with sleep or concentration.
Finally, these issues need to last more than one month, cause significant impairment that impact important areas of functioning, and not be due to another issue such as substance use or a medical condition.
Experiencing Trauma Indirectly
You may notice that the DSM-5 does not require that the traumatic event actually happens to the patient in order for the criteria for PTSD to be met. This is because people can actually develop PTSD by witnessing trauma that is being inflicted upon others. Tsavoussis, Stanislaw, Stoicea, & Papadimos (2014) note that witnessing domestic violence can produce post-traumatic stress response in children. This response can not only lead to PTSD, but can also lead children to develop behavioral problems, mental health issues, academic issues, memory problems, lack of inhibition, and attention issues, all potentially persisting into adulthood (Tsavoussis, 2014). Witnessing violence or sexual abuse as a child can also increase the child’s risk for having an abusive partner themselves as an adult (Tsavoussis, 2014).
Children are not the only ones at risk for experiencing trauma through witnessing the suffering of others. The term “vicarious trauma” (also called “secondary trauma”) refers to the trauma of witnessing a traumatic event. This can happen by either witnessing the event directly, or by hearing about it in detail. This is why professionals such as police officers, EMTs, firefighters, counselors/therapists, nurses, doctors, and other medical professionals may be at a particularly high risk for this type of trauma; however, it can happen to anyone. Seeing one’s own family member or loved one being hurt can be particularly traumatic, and witnessing an accident firsthand as a layperson can be extremely traumatizing. It is important to be aware of this because you may not realize that you are at risk for PTSD if you witness a disturbing event, but if you notice the signs and symptoms of PTSD, it’s important to see someone about the trauma you may have experienced.
The Adverse Childhood Experiences (ACEs) Study
Another piece of evidence for the lasting and many impacts of trauma is often referred to as the ACEs study. This stands for “Adverse Childhood Experiences Study”. The ACEs was originally conducted to determine what affects difficult experiences in childhood have on later behaviors in adulthood. 9,508 adults participated in the study. “Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease” (Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, and Marks, 1998). What the study found was that “Adverse Childhood Experiences (ACEs) have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity” (Centers for Disease Control and Prevention). The ACES study is an impressive demonstration of the potential impact of trauma on future outcomes.
I took this version of the ACEs questionnaire from NPR, where you can take a simplified version for yourself if you would like, by clicking here or checking out the citations:
Before your 18th birthday, did a parent or other adult in the household often or very often…swear at you, insult you, put you down, or humiliate you? or act in a way that made you afraid that you might be physically hurt?
Before your 18th birthday, did a parent or other adult in the household often or very often…push, grab, slap, or throw something at you? or ever hit you so hard that you had marks or were injured?
Before your 18th birthday, did an adult or person at least five years older than you ever…touch or fondle you or have you touch their body in a sexual way? or attempt or actually have oral, anal, or vaginal intercourse with you?
Before your eighteenth birthday, did you often or very often feel that…no one in your family loved you or thought you were important or special? or your family didn’t look out for each other, feel close to each other, or support each other?
Before your 18th birthday, did you often or very often feel that…you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Before your 18th birthday, was a biological parent ever lost to you through divorce, abandonment, or other reason?
Before your 18th birthday, was your mother or stepmother: often or very often pushed, grabbed, slapped, or had something thrown at her? or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Before your 18th birthday, did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?
Before your 18th birthday, did a household member go to prison?
I want to pause to acknowledge that the questions included in the ACES are not inclusive and could feel dismissive in a lot of ways. For example, being molested by someone less than five years older than you is still molestation and it’s still horrible and traumatic. Female parents are not always the victims of domestic violence and male parents can also be victims, seeing this can be very traumatic for children as well. People with mental illness can make wonderful parents. All of this is to say that I don’t agree with the wording of the study questions in all areas, and I think if the study was designed today, they would be a bit different, but the outcomes are still astounding, and we will get to those next.
The results of the ACEs study were calculated in a much more scientific way but it went something like this. The ten questions about childhood were tallied up, and you were given a score from zero (no adverse childhood experiences) to ten (all ten types of adverse childhood experiences). The researchers were trying to determine if there was a correlation between the negative things that happened to you as a child, and negative outcomes that might happen as an adult. It turns out, there were many correlations.
First of all, researchers found that most people had adverse childhood experiences, and that if you had one, you tended to have more than one. In fact, of those who had one, eighty-seven percent had at least one other type of adverse childhood experience (Sciaraffa, 2017). Essentially, trauma tends to cluster in peoples’ young lives. For those with a score of four or higher, chances of being a smoker doubled and chances of alcoholism increased seven-fold (Sciaraffa, 2017). Alarmingly, “men with an ACE score of 6 or higher were forty-six times as likely to have injected drugs than men who had no exposure to ACEs” (Sciaraffa, 2017). Overall, higher ACE scores weren’t just associated with behavioral changes, but were actually shown to increase risk of death…yes, you read that correctly, childhood trauma increases the likelihood that you will die at an early age. “Individuals with an ACE score of 4 or higher were twice as likely to have been diagnosed with cancer, twice as likely to have heart disease, and four times as likely to suffer from emphysema or chronic bronchitis. Adults with an ACE score of 4 or higher were twelve times as likely to have attempted suicide than those with an ACE score of 0” (Sciaraffa, 2017).
Toxic Stress
A common explanation for the results of the ACEs study is toxic stress. Learning to deal with stress is a normal and expected part of the developmental process for children. Children learn to deal with stress most effectively when a caring adult is present to ground them and teach them to cope with the stress they are experiencing. Constant activation of the stress response overloads the stress response system, leading to “toxic stress”, which sets the stress response on high alert. The areas of the brain that are devoted to learning and reasoning are weakened, when they should be growing neural connections. Children need nurturing, stable environments in order to grow these important neural connections. This is the likely reason that we see lasting, devastating effects in the children who have high ACEs scores as they grow and become adults. Their brains are flooded with toxic stress, which does not allow them to develop properly. (Center for the Developing Child, “Toxic Stress Derails Healthy Development”).
However, this does not mean there is no hope for people who have experienced childhood trauma (or any trauma, for that matter). All the things that can heal trauma in general can also heal deep, complex childhood trauma. These include therapy, exercise, learning coping skills (such as meditation, relaxation or breathing techniques), medication treatment, and social support. So, if you have experienced trauma, you are not broken, and there is hope. There are people who know how to help you and you can get better. (Center for the Developing Child, “ACEs and Toxic Stress: Frequently Asked Questions).
Complex Trauma
You may have noticed that in the ACEs study, trauma not only tended to cluster, but the more ACEs a person had, the greater their risk factors later in life became. This ties in with the concept of complex trauma. Complex trauma refers to trauma that is more than just one single event. This trauma is “repetitive, prolonged, or cumulative, most often interpersonal, involving direct harm, exploitation, and maltreatment including neglect, abandonment, or antipathy by primary caregivers or other ostensibly responsible adults, and often occur at developmentally vulnerable times in the victim's life, especially in early childhood or adolescence, but can also occur later in life and in conditions of vulnerability associated with disability, disempowerment, dependency, age, infirmity, and others” (Firestone, 2012).
I think of complex trauma this way: it changes the way you look at the world. It is a series of repeated events that occur so many times and by people who break a trust that should run so deeply, that it leaves very, very deep scars in your psyche. Often, when people come to therapy, and they make just an inch of progress in the first couple weeks, they will say “I don’t feel like I’m making progress fast enough!” My answer to them is almost always the same: You just changed something that you spent your whole life establishing and reinforcing. If you changed that, even by a centimeter, that’s huge. In instances of complex trauma, those changes are even more painstaking, even more time consuming, and, ironically, even more necessary. The changes made in therapy are what will allow the survivor to feel any sense of safety in the world again.
I’m definitely more guarded. It’s frustrating because I can’t feel safe, even doing something simple like going to a public restroom. I can’t ever take for granted feeling safe. Other people feel safe doing simple things, and I just don’t have that.
- Mandi, Complex Trauma Survivor
Intergenerational Trauma
Epigenetics is a relatively new field of study which seeks to understand how the expression of our genes is modified in response to our experiences throughout our lifetimes, and then passed to the generation that follows us (Henriques, 2019). At the end of the Civil War, survivors of the Confederate PoW Camps seemed to pass their experiences in the camps to their male offspring…who had never experienced the camps, but still experienced a 11% higher mortality rates than the general population, even when controlling for other factors (Henriques, 2019). The other potential explanation for this, of course, would be that fathers who suffered in PoW camps might be more likely to abuse their sons. This turned out to not be the case (Henriques, 2019), leaving epigenetics as the most likely explanation.
In a study on mice in 2013, researchers zapped mice while also filling their cages with the scent of cherry blossoms. Naturally, the mice came to associate the scent with physical pain and became opposed to the smell of the cherry blossoms themselves. The researchers then had the mice reproduce, but never meet their biological mice parents who knew about the cherry blossom-zapper connection. The offspring of the mice who had been zapped showed a fear response to the smell of cherry blossoms, while mice who did not come from these parents did not (Henriques, 2019). Researchers concluded that the “sensitivity to cherry blossom scent was linked back to epigenetic modifications in their sperm DNA. Chemical markers on their DNA were found on a gene encoding a smell receptor, expressed in the olfactory bulb between the nose and the brain, which is involved in sensing the cherry blossom scent. When the team dissected the pups’ brains they also found there was a greater number of the neurons that detect the cherry blossom scent, compared with control mice” (Henriques, 2019).
So, there is some evidence that mammals can indeed “pass down trauma” in a way. I would say this shows that mammals are able to show their offspring to fear things that they have been shown to be afraid of, which is adaptive…until it isn’t. For example, in the PoW camps, certain behaviors were probably helpful for survival, but those same behaviors were no longer helpful outside of that environment. Fear of the smell of cherry blossoms made sense to the rats who were being zapped, but it doesn’t make sense in a natural environment. As always, our minds’ attempts to protect us are not always effective.
I don’t think genetics are the only reason that trauma can be intergenerational. The symptoms of PTSD would certainly create additional challenges as a parent or caregiver, and, not having a model for a positive caregiver would also make this role more challenging. I do believe that with the reduction in stigma around mental health issues, more people will be getting help for their trauma, and this will lead to more people who have experienced trauma finding ways to be better caregivers and stop the cycle of intergenerational trauma and abuse that has been so pervasive in our culture. Remember, stigma sucks, and just because someone hurt you does not mean you are doomed to hurt others. Reach out and ask for help, and you don’t have to perpetuate that cycle.
TOOLS
Be aware of secondary/vicarious trauma, and seek help if you may have experienced it by witnessing a traumatic event.
Seek help from a therapist who specializes in trauma and/or medication therapy if you have experienced trauma at any point in your life. Remember, trauma can have very negative impacts on your life, but it can also be treated, and this can minimize these impacts!
Know that trauma is a common experience and you may not be aware of other peoples’ triggers. Be respectful and kind and stand up to stigma!
by Leora Mirkin, LCSW
CITATIONS
Center for the Developing Child, & Harvard University. (n.d.). ACEs and Toxic Stress: Frequently Asked Questions. Retrieved from https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/
Center for the Developing Child, & Harvard University. (n.d.). Toxic Stress Derails Healthy Development. Retrieved from https://developingchild.harvard.edu/resources/toxic-stress-derails-healthy-development/
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: Dsm-5. Arlington, VA.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., … Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine, 14(4), 245–258. doi: 10.1016/s0749-3797(98)00017-8
Firestone, L. (2012, July 31). Recognizing Complex Trauma. Retrieved from https://www.psychologytoday.com/us/blog/compassion-matters/201207/recognizing-complex-trauma
Henriques, M. (2019, March 26). Can the legacy of trauma be passed down the generations? Retrieved from https://www.bbc.com/future/article/20190326-what-is-epigenetics
SAMHSA, & HRSA. (n.d.). Trauma. Retrieved from https://www.integration.samhsa.gov/clinical-practice/trauma
Sciaraffa, M. (2017, August 6). Research Update for Practitioners: The ACE Study: National Council on Family Relations. Retrieved from https://www.ncfr.org/cfle-network/summer-2017-ACEs/research-update-practitioners-ace-study
Starecheski, L., & NPR. (2015, March 2). Take The ACE Quiz - And Learn What It Does And Doesn't Mean. Retrieved from https://www.npr.org/sections/health-shots/2015/03/02/387007941/take-the-ace-quiz-and-learn-what-it-does-and-doesnt-mean
Tsavoussis, A., Stawicki, S. P. A., Stoicea, N., & Papadimos, T. J. (2014). Child-Witnessed Domestic Violence and its Adverse Effects on Brain Development: A Call for Societal Self-Examination and Awareness. Frontiers in Public Health, 2. doi: 10.3389/fpubh.2014.00178
van der Kolk, B. (2014). The body keeps the score: brain, mind, and body in the healing of trauma. NY, NY: Penguin Books.
What is vicarious trauma and how to prevent it in EMS. (2018, July 13). Retrieved from https://www.ems1.com/amu/articles/what-is-vicarious-trauma-and-how-to-prevent-it-in-ems-Him7ru5QZf6W7Bcu/