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Trauma

Epistemic status: more like "my impression" rather than "established consensus"

This is also largely under-cited, and flat empirical claims are mixed in with some inference on my part.

The word 'trauma' is often contested politically, which I mostly want to sidestep. I'll explain first some context about the history of the word as I understand it, and then the cluster it's used to refer to in the psychiatry and therapy literatures. See also some context on words and concepts in general, and on nebulosity in particular.

There are some messy ontological and methodological problems in trying to analyze trauma. In contemporary rhetoric, 'trauma' often stands as a disguised query for a question like "who deserves privileges and accommodations because they have suffered." More deeply, whatever notion of trauma we use relies on some assumptions about what constitutes pathology and harm. Broadly speaking, 'trauma' refers to persistent pathological changes to psychology and behavior that arise as a consequence of adverse experiences, as well as the experiences themselves. That is, despite the language of "post-traumatic growth," positive changes that arise from adverse experiences are regarded as quite different from what we would normally be inclined to call trauma, and are treated as desirable, and even sought out deliberately.

In this section and the next several following, I argue for a few claims, some basically orthodox/normative and some disputed but fairly common in the circles I run in:

  • Trauma is the result of unmetabolized adverse experiences (though not all such result in trauma).
  • There are many milder forms of trauma, and there's a broad swath of "trauma smells" that look like trauma.
  • There's a smooth gradient between, on one end, the causal structures and symptoms of PTSD proper, and on the other a lot of things which constitute normative socialization in many cultures.

Defining trauma​

'Trauma' in Greek literally means "wound," and is still used in that sense in physical medicine. [IIRC, Freud copied it from an earlier late 19th century pychiatrist, who I believe was following an earlier mid-19th century author, who wrote about theories of "hysterical trauma." The original theory was that a cluster of patterns of psychological disturbance called "hysteria", which were female coded at the time in Germany, were due to a literal injury of to the uterus (Greek hystera, "womb").] [Again IIRC, the author who directly influenced Freud used the word in a more modern psychological sense.] [Freud's usage is relatively familiar to modern intuitions, though his actual theories are pretty foreign.] [I'm somewhat unclear what happened between Freud and the advent of the modern term PTSD.]

Because of the modern interface of medicine, law, and power, trauma is often understood narrowly in terms of psychiatric diagnostic criteria. There's some substantial confusion here, because the model which the DSM (the standard psychiatric diagnostic manual in the U.S.) uses is explicitly meant to track clusters of symptoms that will likely be tractable to similar interventions, but not necessarily to track natural kinds, let alone sharply defined causal mechanisms.

The DSM and the ICD (the International Classification of Diseases) use very similar definitions for PTSD, and have a very similar list of adjacent stress or trauma-related disorders. While I don't take these definitions as singularly authoritative, I think they're informative as models developed by people earnestly trying to describe and work with this domain, as well as carrying quite a lot of authority, for those who put stock in that.

The criteria for PTSD approximately match the stereotyped image of victims of war, genocide, rape, etc. These involve, briefly: a. flashbacks, intrusive memories, or reactions to associated triggers, b. avoidance of stimuli associated with the trauma, c. persistent emotional distress, alienation, or anhedonia, and d. persistent emotional dysregulation, stress, and fear.1 These may be attributed to acute intense disturbing experiences, or more chronic and sometimes less intense.

The ICD (but not the DSM) also has an adjacent category known as Complex Post-Traumatic Stress Disorder, which involves the same criteria as PTSD, plus distinctly strong feelings of shame and worthlessness, and severe difficulty sustaining relationships.2

(Note also that therapy organizations which have been advocating for the diagnostic status of CPTSD believe that it's something like "responsible for" a large swath of very specific diagnostic categories in the DSM. IIRC the definition they use is different and less restrictive than the one in the ICD.)

Even in the ontologies of the DSM/ICD, there are several other categories of trauma-induced disorders with different symptoms, which are somewhat weirder and less stereotyped, eg. Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. Note again that the ontology of the DSM is constructed in order to identify clusters that will be amenable to similar sorts of treatments, often just on the basis of their overt symptoms, rather than necessarily in terms of their underlying causal structures.3 The resolution at which psychiatric treatment is applied broadly speaking can't track the underlying causal structures, which might be unknown, highly multi-factored, or highly varied. The techniques of psychiatry are often very "try stuff and see what sticks."

"Psychological" as opposed to "psychiatric" models often revolve around detailed inside-view theories of the causal factors responsible for dysfunction, which are empirically much weaker, and which psychiatry usually avoids. (This is sort of a simplification, my understanding is that psychiatric theory does include these kinds of sketchier inside-view models also, even if diagnostic manuals avoid them.) Note also that "psychological" models are willing to use far more flexible admission criteria, rather than psychiatric models, whose diagnostic criteria are often defined in order to have thresholds at large magnitudes of impairment. This is to say that diagnostic criteria often have more to do with contingencies of the modern medical-legal-insurance context, rather than reflecting some sharp boundary in the domain.

In these slightly-less-orthodox models of psychopathology, trauma is regarded as an important causal factor in (and pretty straightfowardly correlated with) a variety of different disorders, eg. Anxiety and OCD.

This is all a very long-winded way of saying, "trauma is not resticted to just whatever the DSM says."

There's obviously then, a big question: within the broader category of "psychological changes that come as a result of adverse experiences," what intuitions can we appropriately apply from the more clear cut "trauma" of the diagnosable-PTSD sort, vs. milder and subtler kinds of changes, in particular re whether they are desirable, and whether they should be regarded as a kind of harm. I'll refer to this question as "what should count as pathological?"

For now I'm going to leave this question up to the judgement of the reader. I'll try to just describe what's actually in the various reports, anecdata, and actual data, and I'll discuss next a particular model, and then trauma smells. I'll discuss this question again partially vis a vis introspection and transformative practice and in detail near the end of the book.

Models, reports, and anecdata​

All of the components of the diagnostic criteria for PTSD (and I left out some detail) are reported in various combinations and severities due to adverse experiences. There's also a variety, both in the normative psychiatric models/ontologies and more "extensive" psychological models, of other kinds of "trauma-induced" pathologies that don't just look like PTSD. Some broad clusters here include exaggerated (to extremes) neuroticism, self-centeredness, neediness, etc.—basically ordinary, if undesirable, tendencies in human psychology in general. Again, there are milder forms reported that seem to be caused by traumatic experiences, which don't necessarily qualify by official criteria.

There are three important (non-exhaustive) clusters of traumatic symptoms reported in the therapy literature (note these are not quite standard terms):

  • Distortion: patterns of variously intense kinds of psychological "lopsidedness," dysfunction, or "distortion" which are claimed to result from abuse or neglect.
  • Rigidity: an intense need to maintain one's behavior, appearance, or sustain positive regard from others in very specific ways, for fear of rejection or some projected memory of violence
  • Dissociation: numbness, dissociation, and deficits in emotional development

Therapy manuals are rife with reports of these sorts of cases, of course aligned very nicely with the views of the given therapy modality or school. The stereotype of at least a modern genre of these stories usually goes something like, "I realized that my exaggerated, dysfunctional, neurotic behavior was the result of unresolved trauma. As a child [and the stories are almost invariably about childhood trauma] I learned those emotional and psychological patterns as a defense mechanism, but now I am able to heal that trauma."

I'm sort of uncertain quite how to take this evidence. It seems to me that schools of therapy often have dodgy epistemic standards, and my impression is that the best "evidence based" therapy actually doesn't work all that well, in the sense of producing robust recovery, etc.4 One plausible model for what's going on here, which I like, is that the effectiveness of therapy is contingent on extreme levels of skill and intuition on the part of the therapist. This level of skill would be difficult to transmit, measure, and document carefully, leading to a pretty severe regression to the mean in each generation of some school of therapy. See more on this subject. Nonetheless this is decent evidence against the accuracy of these models.

Still, my sense is that this broad shape is probably substantially right. Some evidence that contributes to my sense here:

  • IIRC the correlation between eg. ACE (Adverse Childhood Experience) scores and dysfunctional adult outcomes is pretty strong. Similarly, again IIRC, for other quantitative measures of the correlation between trauma and dysfunctional behavior.
  • We have lots of quite tidy evidence about the structure of trauma responses in the extreme cases (actual PTSD), that traumatic psychological adaptations are something like "specific" and "structured," (as in, specific to the details of the trauma, and shaped in a way that reflects it) rather than resulting in someone being only diffusely disturbed.
    • It seems basically plausible that we shouldn't expect this to be specific to extreme cases, and while the evidence from therapists is sketchier and less robust, it still seems pretty substantial to me.
  • This broad claim, that adaptations to traumas are structured with respect to the shape of the trauma, aligns with my own introspection and with introspective reports I take seriously.

In the broader definitions used in the therapy literature, trauma is not just restricted to experiences of intense fear or horror, but also often of experiences of grief and mundane tragedy. Commonly reported as well are chronic, low to medium-grade experiences of alienation, rejection, humiliation, etc.

Reports of the dissociation cluster often come with healing stories, to stereotype, of discovering some great pit of fear, anger, sadness, etc., which the person reports they were "protected from" or which was "held at bay" by the previous dissociation. They then report "processing" those emotions, and recovering the ability to experience some greater breadth of emotions, body sensations otherwise, or of newfound ease and comfort with social interactions.

These reports also usually include variations on the some themes:

  • Recollection or "discovery" of like, something in the genre of the breadth/depth of grief from some incident or chronic adverse experience, and of contortion of their psychology wrt this
    • Commonly, recollection of child abuse, long suppressed
  • Recollection/discovery of unusual or proscribed proclivities, stereotypical stories here are from trans people, queer people more broadly, from the BDSM community, etc.
  • Less commonly, discovery of "held" grief/fear/etc. around the location of a previous physical injury, chronic illness, or body part associated with past embarrassment or shame

The broad thrust of these reports, both in the very modern modalities but also going back at least to Freud, is of discovering a lot of stuructured, highly "semantic" psychological content associated with gross psychological dysfunction or "offness", exagggeration, distortion, etc.

A similar cluster that's often reported includes patterns like tendencies towards hyperfocus or obsession, the apparent absence of normal desires or appreciations (this overlaps with dissociation), compulsive nonconformism, unusual superstitions, etc.

Again, this entire category of evidence is fraught. Many of these reports observe patterns similar to culture-bound disorders where people have experiences of neurosis, grief, etc. in line with very specific patterns in their culture, and often in accord with some changing zeitgeist of eg. western therapy culture. Therapy reports are also problematic because they're heavily primed, even where a therapist is skilled and not setting a narrow frame, clients often come in with a particular image of what healing "should" look like, and will enact that. I'll discuss later my sense of what constitutes real or trustworthy introspection, though broadly this is pretty hard to justify in an "objective" way. Still, I think as a broad shape these are very real phenomena.

Introspective reports from solo-practitioners, meditators, etc., including anecdotes I've collected, overlap substantially with those from the therapy literature, but more varied and probably more dubious. Again I think these are often not trustworthy, but are an important source of evidence as well. Some of the weirder stuff here is also actually attested in the therapy literature, eg. encounters with demonic entities which entered one's psyche during a traumatic event, so-called "genital armoring," or experiences of accessing ancestral or past-life traumatic memories.

Footnotes​

  1. American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, pp. 271-280 ↩

  2. [[cite icd https://icd.who.int/browse/2025-01/mms/en#585833559]] ↩

  3. [[prolly cite scott here talking about the dsm]] ↩

  4. ↩