From my perspective, there are two primary reasons people seek out health services—because they’re sick or hurt. Traditionally in psychiatry, this distinction is rarely made with a focus on illness instead. There are diagnostic criteria, a description of a “pathology,” and treatment. Still, it can be asked, are all conditions in psychiatry illnesses?
Historically, I found conceptualizations of the diagnosis of posttraumatic stress disorder (PTSD) problematic in that it seemed to confuse injury for an illness. Acknowledging the significance of this injury is an important part of healing. In 2013, with the release of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, PTSD in addition to many other conditions found home in a new place in the book, a section named “Trauma and Stress-Related Disorders.”
Popular conceptualization of trauma has shifted to acknowledge its status as an injury. Just a person can experience physical trauma, it’s acknowledged that if enough strain is placed on a person’s psyche, psychological trauma can occur. PTSD is a clear example of an injury.
While this is progress, many, myself included, would say that the expansion has a way to go. For example, children often express trauma symptoms differently than adults. Rather than reporting the stereotypical nightmares and flashbacks, for example, many children react to trauma through changes in behavior, concentration, and emotion regulation. As these youth may not meet the criteria for PTSD, many are diagnosed with other conditions such as oppositional defiant disorder or disruptive mood dysregulation disorder. A proposed condition to the American Psychiatric Association of “developmental trauma disorder” (Schmid et al. 2013) captured these differences. It was not included.
Similarly, it has been noted that when someone experiences multiple traumatic events over a long period, such as those experienced by a person growing up in an abusive household, they often develop patterns of instability in moods, relationships, and life. Many of these individuals are given a diagnosis of borderline personality disorder, focusing on the personality piece. Some clinicians have advocated that there may be a subset of individuals whose borderline personality traits are trauma-induced (Ball and Links, 2009). Yet, despite advocacy for an addition of a condition that would encompass these pieces, “complex posttraumatic stress disorder,” to the DSM (Van Der Kolt, 2002), it is not currently acknowledged as a diagnosis in the United States.
Injury Vs Illness: Why Does It Matter?
The mental health field has a shameful history of blaming families when individuals, particularly children, present with difficulties. One of the most troubling examples of this is the 1940s’ phenomenon of the “refrigerator mother.” At that time, when children exhibited traits of autism, the mother would be targeted as the cause. It was said that her coldness would cause the child to be autistic. Today we understand autism as a neurodivergence that has nothing to do with refrigerators or cold parenting. The level of pain this caused children, parents, and families is immeasurable.
Perhaps in reaction to this, it has become somewhat taboo to discuss trauma as a contributing factor in mental health, particularly with children. Some call it blame. Yet, trauma does not mean that there is a “bad person” and a “good person.” Some traumatic experiences do not involve malevolence at all (e.g., natural disasters, fires). Someone can influence a person in a traumatic way unintentionally and even in some cases of abuse there is still some love for the child.
Have we gone too far? Can we have a conversation about the relationship between trauma and certain experiences of mental illness without blaming or villainizing each other?
On the contrary, some have found a mental health diagnosis that doesn’t involve trauma to feel shameful or even blaming—in this case, the person receiving the diagnosis. Yet, we know that many mental health conditions have genetic, neurological, and other biological markers. These are no one’s fault.
A holistic understanding of a person’s challenges is essential to effective care.
Sometimes Both
Many people have experienced some level of trauma. Life is traumatic—grief, illness, fear, current events. As well, not all stress would fall under what one might call traumatic stress. A person can become very stressed with work, school, and the demands of life.
The stress-diathesis model proposes that there can sometimes be an interaction between the level of stress, genetic vulnerability, and the body’s reaction to that stress which can ignite many mental health conditions (Pruessner et al., 2017). A study of individuals receiving support at a community mental health center found that 87 percent had experienced some significant trauma as measured by the Life Events Checklist (Cusack et al., 2006). Perhaps there are times when a mental health condition is both an injury and an illness.
Without acknowledgment of past and current social stressors and trauma, a person’s treatment is likely to be incomplete. Rather than simply dividing conditions into those that are and are not “trauma-induced,” maybe we could use a system to look at a more holistic approach to mental health, taking into account biological, psychological, and social aspects of healing.
