Understanding PTSD and Trauma: When Trauma Doesn’t Look Like Trauma

An image that many people associate with the words “PTSD” (Post Traumatic Stress Disorder) and “trauma” is a combat veteran diving for cover at the sound of a car backfiring, in a state of panic, temporarily disconnected from the present moment, and flooded with images of war and overwhelming fear. While this depiction is not inaccurate, it can limit how we perceive and thus identify trauma, especially with young people. While it is true that PTSD sufferers often appear highly anxious, withdrawn, and jumpy, it is important to note that the effects of trauma manifest in many ways.

A school professional encountering a student who frequently exhibits defiant, angry, or aggressive behavior might have the impulse to label the child as “oppositional” or simply “a problem kid.” It is rare, however, that children and adolescents choose to be difficult. What does frequently underlie problematic behavior, however, is a history of trauma, an experience that is all too common among today’s students. According to data reported by The National Center for PTSD about 15% to 43% of girls and 14% to 43% of boys go through at least one trauma, and of those, 3% to 15% of girls and 1% to 6% of boys go on to develop PTSD.

Young people don’t always express pain in a way that is easily recognizable to adults. Aggressive and off-putting behavior for many children is a learned, adaptive, survival mechanism that serves a useful purpose in dangerous and unpredictable environments. It cannot easily be “turned off” even in seemingly “safe” places. Complicating the matter, children are often exposed to prolonged, “complex”, trauma that occurs during key developmental phases, and research has shown that these ongoing traumatic experiences alter the brain and can have a long-term negative impact on social, behavioral, and academic functioning.

Defining Trauma, PTSD, and Complex Trauma

“A traumatic experience is any event in life that causes a threat to our safety and potentially places our own life or the lives of others at risk.” These events include natural disasters, combat experiences, physical or sexual assaults, fires, serious accidents, and for a child, the death of a parent. Following such events individuals often experience extreme distress and a temporary disruption of normal daily activities even in the absence of physical injuries. Experiences that are one-time events are typically referred to as “acute trauma” while “chronic trauma” refers to multiple traumas over time, either the same recurring trauma, such as abuse, or different traumas.

“Complex trauma” is a clinical syndrome that occurs when a caregiver is the abuser and/or is unable to protect an individual from another abuser (e.g., a partner), or from severe community stressors such as a frequent exposure to violence. It is typically associated with traumatic events that are prolonged in duration and that occur early in life. Given the interpersonal nature of the experience, complex trauma can seriously disrupt an individual’s ability to develop secure, trusting relationships and can interfere with one’s ability to develop a healthy sense of self.

PTSD is a clinical diagnosis in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition), the diagnostic manual used most often by American mental health professionals. DSM-5 does not currently include a separate complex trauma diagnosis, although the ICD-11, the 11^th revision of the International Classification of Diseases developed and annually updated by the World Health Organization (WHO), does include Complex PTSD (C-PTSD) as a distinct diagnosis.

To meet the DSM-5 criteria for a diagnosis of PTSD the following conditions must be met:

1. The individual must have been exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, including direct exposure, witnessing the trauma, learning that the trauma happened to a close relative or close friend, or indirect exposure (vicarious trauma) to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics).
2. The traumatic event must be persistently re-experienced, for example by unwanted upsetting memories, nightmares, flashbacks, and emotional distress or physical reactivity after exposure to traumatic reminders.
3. The individual must display avoidance of trauma-related stimuli, including trauma-related thoughts or feelings and trauma-related reminders. Dissociation, or a detachment from being in the moment, is not uncommon.
4. The individual must display at least 2 of the following after the traumatic event: inability to recall key features of the trauma; overly negative thoughts and assumptions about oneself or the world; exaggerated blame of self or others for causing the trauma; negative affect; decreased interest in activities; feelings of isolation; difficulty experiencing positive affect.
5. The individual must exhibit at least 2 of the following indications of trauma-related arousal and reactivity: irritability or aggression; risky or destructive behavior; hypervigilance; heightened startle reaction; difficulty concentrating; difficulty sleeping.
6. The symptoms must have lasted for more than 1 month.
7. The symptoms create distress or functional impairment (e.g., social, occupational, academic).
8. The symptoms are not due to medication, substance use, or other illness.

Complex PTSD has been described as an enhanced version of PTSD, with all the clinical features of PTSD plus three additional clusters of symptoms: emotional dysregulation, negative self-cognitions, and interpersonal difficulties. As with complex trauma, complex PTSD is defined by its threatening and entrapping context, generally interpersonal in nature. Individuals with complex PTSD typically experience feelings of shame, threat, despair, and alienation and see themselves as permanently damaged and ineffective. They may appear hostile and/or socially withdrawn and often engage in emotionally volatile relationships. They struggle with self-regulation and have difficulty maintaining a consistent and positive sense of self.

Children who have experienced complex trauma frequently display a wide range of developmental impairments and thus present a complicated diagnostic picture. These difficulties include a confusing array of behavioral, emotional, learning, relationship, and health problems that can increase the possibility of misdiagnosis and thus contribute to the selection of ineffective treatments approaches.

It is important to note that individuals diagnosed with borderline personality disorder (BPD) also suffer with extreme emotional dysregulation, have an unstable sense of identity, and have severe relationship difficulties. It has been estimated that 30 to 90% of individuals with BPD have experienced prolonged childhood trauma, including abuse and/or neglect and a combination of adverse childhood experiences (ACES).

The Body’s Response to Trauma

The human body is genetically programmed to respond to traumatic experiences with what is typically known as the “fight or flight” response. This response involves the activation of the sympathetic nervous system and is designed to prepare an individual to either fight or flee when confronted with a threat. Physiological changes include increased heart rate, rapid breathing, sweating, and increased muscle tension, all aimed at preparing the body to escape or neutralize the threat.

Trauma experts often add other “f’s” to the fight-flight response definition, including “freeze”, “fawn”, and “flop”:

• “Freeze” occurs when fight or flight are not available options. The body becomes immobilized and can best be described as “playing dead” to avoid detection until the danger has passed.
• “Fawn” is defined as people-pleasing behavior to avoid conflict and appease an aggressor in order to remain safe. This response is often seen in adults who see no opportunity to escape from abusive relationships. In children or teens fawning might be confused with extreme maturity when in fact the child has adopted adult behaviors and mannerisms as a survival mechanism (also known as parentification).
• “Flop”, also known as the “submit” response, involves a total collapse in the face of a completely overwhelming traumatic situation. It includes feelings of helplessness, hopelessness, and resignation when confronted with a seemingly insurmountable threat, and can lead to a total bodily collapse, up to and including a loss of consciousness and control over bodily functions.

Putting Trauma in Perspective

Increased mental health awareness is a good thing. There are times, however, when clinical terms enter the public lexicon and become subject to distortion and misuse. Terms like “schizo”, “bipolar”, and “split personality”, for example, have been adopted as slang in ways that contribute to misinformation and confusion. Similarly, it seems that people are increasingly describing any bad experience as “traumatic”, thus clouding the way we think about trauma and diminishing how we might react to the pain experienced by those who have been exposed to life-threatening events or situations.

In an online article published during the height of the Covid-19 crisis Psychologist Daniela Montalto, PhD and her colleagues at NYU-Langone Health explained the difference between trauma and adverse childhood experiences in an attempt to help us more accurately describe and understand their impact on young people. Furthermore, they emphasized that only 8 to 12 percent of people who have experienced a traumatic event develop significant symptoms, and of those, 90 percent have a complete remission of symptoms within 8 months. They also point to the concept of post-traumatic growth, something experienced by more than half of individuals who are confronted with a traumatic life event.

“Post-traumatic growth” is a term coined by Dr. Richard Tedeschi of the University of North Carolina. It refers to a person finding a renewed appreciation for life, a greater sense of personal strength, and deeper interpersonal connections in the aftermath of a traumatic experience. One defining characteristic of post-traumatic growth is the acceptance that certain things cannot be changed, also called “acceptance coping”.

In no way are these professionals suggesting, of course, that trauma is a necessary or desirable pre-requisite for personal growth. At the same time, adopting a growth mindset can be a very important part of healing and recovery for individuals who are struggling to move forward after a traumatic experience, and in general is a good way to approach adversity and setbacks of all kinds.

How Educators Can Help

There are numerous ways that school professionals can be part of the healing process for students who have experienced acute, prolonged, or complex traumas:

• First, remember the common signs of PTSD so that mental health referrals can be made in a timely manner: flashbacks, panic/anxiety, jumpiness, nightmares/sleep terrors/sleeplessness, avoidance of people-places-things related to the trauma, aggressive outbursts, irritability, suicidal ideation, a strong startle response, difficulty concentrating, a tense and guarded demeanor – these all can be signs of PTSD. To fully meet the diagnostic criteria for PTSD an individual’s symptoms must interfere significantly with normal life activities, but even sub-clinical manifestations should be investigated.
• In addition to the symptoms described above, students suffering with complex trauma syndrome may exhibit angry outbursts and oppositional behaviors as they have learned that extreme reactions may be the only available defense when threatened. They have difficulty regulating their emotions, appear wary and mistrustful, often have very low self-esteem, and see themselves as worthless and broken. They may appear hyperactive and act in disorganized, unpredictable ways and at times might dissociate and appear to be day dreaming. Trauma at any age can disrupt one’s sense of trust and safety but given that complex trauma typically begins at an early age it can fundamentally interfere with the development of attachment to others.
• Difficult though it may be at times, adopt a trauma-informed stance when dealing with angry, disrespectful, or disruptive students. Allow the student to have physical space and speak in a low, calm, and neutral voice, preferably audible only to the student in question. Assume that the student is hurting, not trying to provoke you, and inquire from a “what happened, how can I help you” perspective rather than from a blaming “what did you do now?” perspective. Validate students’ feelings and experiences before offering alternative perspectives and behavioral choices.
• Traumatized students can be easily triggered by loud and chaotic environments so establish and adhere to classroom routines that promote a sense of predictability and calm. Practice responding in consistent, predictable ways to all students’ behaviors and expressed needs.
• Keep in mind that some students may be more vulnerable to a complex trauma response, for example those who reside in chaotic and/or poor families or in violent communities.
• Model resilience and hopefulness, staying mindful of and supporting post-traumatic growth experiences.
• Engage school-based child study team and mental health staff along with parents in discussions about interventions for individual students, being careful not to jump to diagnostic conclusions (maybe it’s not ADHD, learning disabilities, or oppositional behavior, for example, maybe it’s trauma). There are effective, evidence-based treatments available that typically combine cognitive behavioral and mindfulness/self-regulation strategies. Trauma Informed CBT (T-CBT) and the ARC (Attachment, Regulation, Competency) Framework are two research-based treatment approaches. ARC programs work with caregivers and children to foster strong connections and safe family environments while helping children learn emotion regulation skills and a variety of executive function and social skills.
• Monitor and address your own stress level – teachers and other helpers are vulnerable to the symptoms of vicarious trauma that can affect not only their own health but also their ability to be effective with students.

Resources:

Trauma and teenagers – common reactions – Better Health Channel

PTSD and DSM-5 – PTSD: National Center for PTSD (va.gov)

Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? – PMC (nih.gov)

What Is Complex Trauma? – Child Mind Institute

Understanding the Difference Between a Difficult Moment & a Trauma | NYU Langone News

Posttraumatic Growth | Psychology Today