The Trauma Definition Reconsidered: The Meaning of Emotional Maltreatment for Traumatic Stress Studies
Frank Neuner, PhD
October 7, 2014
The premise of traumatic stress studies is that extremely stressful events are specifically and causally related to a group of symptoms defined as posttraumatic stress disorder (PTSD). However, although PTSD research has been one of the most fruitful branches of psychiatry and clinical psychology in the last decades, research has failed to prove this core foundation. Contrary to the early assumption, only a minority of survivors of extremely stressful events develops PTSD. At the same time, PTSD symptoms may even result from events such as divorce and other relational problems that have been considered as stressful, but not as traumatic (Rosen & Lilienfeld 2008).
However, the major presumption of PTSD research has been repeatedly fixed by definition. Both major diagnostic manuals, the DSM and the ICD, keep up a trauma definition that ties PTSD (and with it the whole field of traumatic stress studies) to a pre-defined group of events. While some researchers have suggested to discard this gate criterion (Brewin, Lanius, Novac, Schnyder, & Galea, 2009), the latest revisions of the DSM (and to a lesser extent also the forthcoming ICD (Maercker et al., 2013) explicitly limit PTSD to events that involve actual or threatened death, serious injury, threat to physical integrity, or sexual assaults.
While this trauma definition prevents the inflation of the trauma term, it determines the way to think about traumatic stress in theory and therapy and defines the scope of the leading traumatic stress institutions.
However, traumas according to DSM are not necessarily the most stressful or harmful types of experiences. In particular, the restriction of trauma to physical threat is problematic for one of the largest groups of trauma survivors: victims of child abuse. Among the different types of child maltreatment, only sexual and physical abuse qualifies as traumatic according to DSM.
Although these types of abuse have traditionally received the most attention in prevention, therapy, as well as in research, emotional types of abuse and neglect can be more detrimental for development, although they do not necessarily involve any physical threat. Emotional abuse (also called psychological abuse) refers to behavior that makes a child feel unwanted and worthless, endangered or only valuable in meeting someone else’s needs (Hart et al, 2011). It includes rejection, degrading, humiliation and confining or limiting social contacts.
Emotional neglect is closely related to emotional abuse and describes a pattern of parental behavior that results in denying the emotional responsiveness through ignoring the child’s needs for affection and love. Several multivariate analyses of the relationship between various types of abuse and neglect and psychopathology show that emotional maltreatment may override the impact of physical and sexual abuse for the explanation of social anxiety (Iffland, Sansen, Catani, & Neuner, 2012), substance abuse (Potthast, Neuner, & Catani, 2014), dissociative symptoms (Haferkamp et al. 2014), as well as biological indicators such as higher levels of basal cortisol (Carvalho Fernando, 2012).
At the same time, child maltreatment is associated with a wide range of psychological disorders in addition to PTSD (Teicher & Samson, 2013), and PTSD may not even be the most common psychopathological consequence of child abuse. As long as traumatic stress studies is equalized with PTSD research it risks being of limited relevance for victims of child maltreatment, who are probably the largest group of trauma survivors.
This is unfortunate, as the comprehensive study of the psychopathology of child maltreatment could profit from theories and therapies that have been developed in PTSD research, although they have to be reformulated or complemented to include the reactions to relational traumas such as emotional abuse. At the same time, it is not unlikely that specific trauma mechanisms operate in disorders that have currently different names in the diagnostic manuals.
The potential as well as the challenge of this type of research is that it may reveal that the phenomenological presentation of a mental disorder alone is not a sufficient guide to identify psychopathological mechanisms, as subjects with a history of child abuse who suffer from PTSD, depression or social anxiety disorder may in the end not be as different as the current diagnostic manuals suggest.
About the Author
Frank Neuner, PhD, is head of Clinical Psychology at Bielefeld University and the university outpatient clinic at Bielefeld University. He has gained an international reputation for the co-development of Narrative Exposure Therapy, a short-term mental health intervention for traumatic stress. His expertise is in the epidemiology, etiology, and treatment of severe trauma-associated psychological disorders following repeated intense adversities like war and child abuse.
References
Brewin, C. R., Lanius, R. A., Novac, A., Schnyder, U., & Galea, S. (2009). Reformulating PTSD for DSM-V: Life after criterion A. Journal of Traumatic Stress, 22(5), 366-73. doi:10.1002/jts.20443
Carvalho Fernando, S., Beblo, T., Schlosser, N., Terfehr, K., Otte, C., Löwe, B., Wolf, O.T., Spitzer, C., Driessen, M., Wingenfeld, K., 2012. Associations of childhood trauma with hypothalamic-pituitary-adrenal function in borderline personality disorder and major depression. Psychoneuroendocrinology 37, 1659–1668.
Haferkamp, L., Bebermeier, A., Möllering, A., & Neuner, F. (2014) Dissociation is associated with emotional maltreatment in a sample of traumatized women with a history of child abuse, Journal of Trauma and Dissociation, in press
Hart, S.N. et a. (2011) Psychological maltreatment. In Myers, J.E.B. (ed) APSAC Handbook on child maltreatment, 3rd. ed. (p. 125-145), Thousand Oaks, CA: Sage Publications Ltd.
Iffland, B., Sansen, L. M., Catani, C., & Neuner, F. (2012). Emotional but not physical maltreatment is independently related to psychopathology in subjects with various degrees of social anxiety: A web-based internet survey. BMC Psychiatry, 12, 49. doi:10.1186/1471-244X-12-49
Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., van Ommeren, M., Jones, L. M., Reed, G. M. (2013). Diagnosis and classification of disorders specifically associated with stress: Proposals for ICD-11. World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 12(3), 198-206. doi:10.1002/wps.20057
Potthast, N., Neuner, F., & Catani, C. (2014). The contribution of emotional maltreatment to alcohol dependence in a treatment-seeking sample. Addictive Behaviors, 39(5), 949-58. doi:10.1016/j.addbeh.2014.01.015
Rosen, G.M. & Lilienfeld, S. O. (2008) Posttraumatic stress disorder: An empirical evaluation of core assumptions, Clinical Psychology Review, 28, 837–868
Teicher, M. H., & Samson, J. A. (2013). Childhood maltreatment and psychopathology: A case for ecophenotypic variants as clinically and neurobiologically distinct subtypes. The American Journal of Psychiatry, 170(10), 1114-1133. doi:10.1176/appi.ajp.2013.12070957