#traumatisation

So – the trauma in PTSD criterion A doesn’t have to be something you’ve experienced firsthand! Trauma is, in DSM terms, something you can be exposed to in one of four different ways. First, direct experience. Second, witnessing the event in person (e.g. seeing someone else in a car crash). Third, leaning that a close family  member or close friend was involved in a traumatic event. If this traumatic event was actual/threatened death, this has to be due to violence or an accident… so, apparently, having your parent be stabbed is traumatic, but having them unexpectedly die of cancer isn’t. And finally, being repeatedly or intensely exposed to trauma details (the DSM provides the example of ‘first responders collecting human remains’).

(Warning: trauma dump ahead, with mentions of parental death, neurodegenerative disease, surgical complications, and brain injuries. Skip this paragraph if this is triggering.)

Whether ‘loved one or partner dying’ counts as traumatic in DSM terms apparently hinges on ‘was it violence or an accident’. I think this is a pretty weird distinction, especially since ‘accidental’ is a weird term.  For example, when my grandfather had his oesophagus removed, the surgery went wrong, causing a hypoxic brain injury that led to his death three weeks later. I’ve seen my mother’s reaction to this – it was clearly a VERY traumatic event – and I’m fairly sure it counts as ‘accidental’. On the other hand, my father’s youngest brother also died unexpectedly – he had a heart attack, and was gone very quickly. And I don’t know if this is accidental in the DSM sense. But the thing is, even if my father doesn’t seem traumatised by this, I don’t see how a sudden death in a hospital is necessarily ‘more traumatic’ than a sudden death at home. Both are still devastating in different ways. Moreover, I do not like the fact that the DSM-5 definition, by nature, excludes certain deaths by disease. While it is true that death is a natural part of life, it could be pretty damn traumatic to watch a relative die an excruciating death by cancer. Likewise, I have a friend whose father died of Huntington’s Disease… yeah, I can’t imagine how that could have not been traumatic. 

In DSM-5-TR, if you’re having an intense and prolonged reaction to a loved one’s death, and this bereavement results in a psychological wellbeing decline that gets in the way of life, school, work, and/or family, it might be classified as Prolonged Grief Disorder. Technically, Prolonged Grief Disorder is in the ‘trauma and stressor-related disorders’ chapter. I think that some of the overlap between PTSD symptoms and Prolong Grief Disorder symptoms is… interesting. For example:

Prolonged Grief Disorder Criterion C3: ‘Avoidance of reminders that the person is dead (in children and adolescents, may be characterised by efforts to avoid reminders’… vs PTSD Criterion C2: ‘Avoidance of or efforts to avoid external reminders[…] that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)’.

Prolonged Grief Disorder Criterion C6: ‘Emotional numbness (absence or marked reduction of emotional experience) as a result of the death’… vs PTSD Criterion C7: ‘Persistent inability to experience positive emotions’ (i’m aware there’s a difference with the persistent negative feeling of PTSD as opposed to the persistent numbness of prolonged grief, buttttt)

I don’t wanna say they’re the same disorder, as there are some significant differences, but I also think that the DSM-5’s arbitrary definition of what constitutes a traumatic death seems limited. If someone is showing PTSD symptoms in response to a relative’s nonviolent, nonaccidental death, then Prolonged Grief ain’t gonna fit, but it also still isn’t officially PTSD. Officially, the DSM-5 says that if PTSD symptoms occur in response to something that isn’t ‘traumatic’ (e.g. a parent dying nonviolently and non-suddenly), then that’s Adjustment Disorder. However, Adjustment Disorder is basically a catch-all term for ‘you are doing badly because of a stressor, but let’s not call it trauma’. I would argue that this is a really stupid diagnostic  distinction, since if you have PTSD symptoms, surely it’s better to diagnose PTSD instead of ‘not sick enough, so less specific diagnosis that functionally is almost never used outside of crisis scenarios anyway’?

So: in conclusion, a loved one dying is always considered a massive stressor by DSM-5 standards… but not necessarily traumatic unless it meets some (slightly arbitrary) criteria.