A contextual approach to trauma experience: lessons from life events research

There has been much debate over what constitutes trauma experience and how this is differentiated from other very negative life events in the diagnosis of PTSD. We believe the DSM implication that trauma events are uniquely different from other types of negative life events and are limited to a few specific types of predetermined event identified categorically hinders the utility of current trauma definitions in research and practice. Whilst we do not take issue with the standard definition of trauma events, a binary checklist-style approach to identifying such events has a potential for missing relevant experience. Instead, we argue that trauma events should be considered to be at one end of a continuum of threat/severity, with potential for more or less ‘threat to life’ in a range of domains. Furthermore, a wider assessment of events could elucidate a greater range of co-existing trauma events, those sub-threshold experiences related to phasing of trauma, and other unrelated negative life events which may contribute to context and impact. In this critique of definitions of trauma events we argue that the current definition of PTSD criterion-A events limits their utility in both research and clinical practice. Following intensive life event assessments such as the LEDS (Life Events and Difficulties Schedule) the application of dimensions underlying a cross spectrum of events includes loss (of person, role, plan or ideas about the self), danger (future loss/threat to security), humiliation (devaluation of self/rejection) and entrapment (sense of imprisonment) can be used to further categorise events or trauma, and specify their likely impact. Data is provided of the overlap of ‘markedly’ threatening negative events (using the LEDS) and those constituting trauma using a commonly used checklist in a high-risk community sample of women. This yielded high specificity (97%; CI = 95.60-97.71) but low sensitivity (41%; (95% CI = 27.57-54.97) with around a third rated on both. Most of the trauma events involved loss and danger categorisation and only in one instance humiliation. Other markedly threatening, non-trauma events, involved not only loss and danger but also humiliation and entrapment. We discuss how a more in-depth assessment of trauma events utilising these dimensions and with the new Computerised Life Events Assessment Record (CLEAR), could aid us in our understanding of trauma events and lead to more personalised treatment possibilities.

This article has been published in a revised form in Psychological Medicine https://doi.org/10.1017/S0033291719000850. This version is free to view and download for private research and study only. Not for re-distribution or re-use. © Cambridge University Press 2019