Understanding trauma as contextualized adverse life events that threaten the individual: Commentary in response to Marx et al. (2024)

In their article, Marx et al. (2024) heat up again the traditional—yet necessary—debate about Criterion A in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) posttraumatic stress disorder (PTSD) diagnostic criteria. Criterion A has been the “admission ticket” for a PTSD diagnosis since its inclusion in DSM-III (APA, 1980). Therefore, the debate about the definition of a traumatic stressor has always been inherently emotionally charged, aiming to do justice to trauma survivors. Marx et al. (2024) have taken on this challenge by providing a comprehensive, well-balanced overview of historical developments and different opinions from which they derive recommendations that may facilitate a new fruitful dynamic in an entrenched debate. In this commentary, I do not wish to critique their key messages but rather to stimulate the debate by providing a person-oriented and research-focused perspective.

The impact of psychological trauma varies between individuals, within individuals, and across time, urging scholars and clinicians to consider event features (e.g., event type, duration, number) along with person-related factors (e.g., cognitive abilities for situational risk assessment) that both influence the individual perception of and cognitions related to adverse life events (Kube et al., 2020). However, this contextual perspective is not adequately mirrored in the debate. Although the likelihood of exposure to some trauma types varies across the lifespan, the intensity and magnitude of these events also depend on the developmental stage that determines the individual degree of threat of and response to life events. For example, childhood trauma is related to not only PTSD but also other severe mental disorders, such as borderline personality disorder (Herzog et al., 2022). Here, I want to highlight a crucial feature that makes an event traumatic for an individual: threat. In a study investigating 600 events, the most important features found to distinguish upsetting versus traumatic events were actual death, the threat of death, and the presence of a human perpetrator (Jones, 2021). Particularly, perceived threat is a key feature responsible for driving an individual's intrusion symptoms—a unique PTSD symptom—following trauma (Kube et al., 2020), emphasizing a subjective component in the perception, appraisal, and response to life events. Of note, studies have revealed a high discrepancy between participants’ and assessors’ categorizations of traumatic events regarding their “worst” part (Benfer et al., 2023) and observer- and patient-reported treatment outcomes (Resick et al., 2023). Relatedly, the current debate has failed to discuss the new World Health Organization (WHO) trauma definition: Instead of DSM-5’s checklist-like listing, the International Statistical Classification of Diseases and Related Health Problems (11th ed.; ICD-11; WHO, 2019) provides a guideline for the traumatic stressor criterion (i.e., exposure to an extremely threatening or horrific event or situation) that favors a definition along event features without neglecting person-related factors. Whether or not they are oriented toward the ICD, future definition efforts in the DSM should involve the perspective of diverse traumatized people to capture more adequately the subjective response to life events (e.g., patient and public involvement).

The heterogeneity in psychopathology (Bryant et al., 2023) and treatment effects (Herzog & Kaiser, 2022) in PTSD were also not factored in the debate, although changes in the DSM have contributed to this finding. Compared to 79,794 distinct combinations according to the DSM-IV (APA, 1994), there are 636,120 potential clinical presentations of PTSD per the DSM-5 (Galatzer-Levy & Bryant, 2013). This is a direct result of the DSM-IV to DSM-5 revision, which included an expansion of Criterion A that allowed for the inclusion of perpetration-focused, non–danger-based events (e.g., moral injury; Stein et al., 2012) and related unique symptoms (e.g., chronic guilt) in addition to maltreatment-focused, danger-based events (e.g., life threat) and related symptoms (e.g., fear). Because some traumatic events share multiple features, drawing a clear separating line is neither intended nor useful; however, all potential consequences that directly result from changes to Criterion A with regard to practice and research (e.g., the heterogenization of PTSD) should be considered in future debates.

AUTHOR NOTE

This work was supported by a postdoctoral fellowship of the German Academic Exchange Service (DAAD).

The wishes to thank Richard J. McNally (Harvard University), who provided feedback on an earlier version of this commentary.