What counts as trauma, according to the diagnostic manual therapists use in the US, is exposure to actual or threatened death, serious injury, or sexual violence. The examples it gives were never meant to be the full list; the manual says in its own words that its lists are not limited to those examples (American Psychiatric Association, 2022). So the way I read it, whether something counts as trauma comes down to what it did to you, not how bad it looked from the outside.

What gets to count as trauma, and who gets to decide? I’ve seen that question come up over and over: on email listservs, in therapist Facebook groups, in peer consultation.

A therapist asks if a client’s history is bad enough to be trauma. The most recent version I saw: the client moved a lot as a kid. She went through some bullying. None of it was physical. And now, as an adult, she really struggles, and she shows all the other signs of PTSD.

If trained therapists can’t figure out what counts as trauma, how is anyone in the general public ever going to figure out what they went through and give it a name?

This isn’t a question about whether she went through hardship, or whether her pain is real. It’s a question about whether what she went through meets what therapists call Criterion A of PTSD: the definition of exposure to trauma. You have to meet it before a therapist goes forward with the rest of the PTSD assessment.

We recognize it was hard. We recognize it was painful. But is it bad enough to be trauma? That question isn’t one therapist’s mistake. It’s a pattern, and it’s a big part of why trauma gets missed.

I wrote more about that comparison in Does It Count As Trauma If Others Have Been Through “Worse”?

This isn’t a question about whether she went through hardship, or whether her pain is real. It’s a question about whether what she went through meets what therapists call Criterion A of PTSD: the definition of exposure to trauma. You have to meet it before a therapist goes forward with the rest of the PTSD assessment.

We recognize it was hard. We recognize it was painful. But is it bad enough to be trauma? That question isn’t one therapist’s mistake. It’s a pattern, and it’s a big part of why trauma gets missed.

In the US, the definition of trauma comes from the Diagnostic and Statistical Manual of Mental Disorders, the DSM. It’s a big honking book, the therapist’s encyclopedia of mental health conditions. This part is my read of it, so I’ll show you the text it rests on.

The DSM says exposure means one of three kinds of harm:

• death, actual or threatened
• serious injury
• sexual violence

It also names four ways of being exposed: it happened to you, you saw it happen, you learned it happened to someone close to you, or your work put you in the details of it over and over, the way it can for police officers and first responders (American Psychiatric Association, 2022). That part is a real gate, and I’m not arguing with it.

But a lot of people stop reading there. After the numbered lists, the manual gives examples of traumatic events, and then it says, in its own words, that the list is not limited to those examples (American Psychiatric Association, 2022). The examples were never the boundary.

The manual goes further. It says the disorder may be especially severe or long-lasting when the stressor is interpersonal and intentional (American Psychiatric Association, 2022, p. 305). Someone did it, and they meant to. The manual doesn’t grudgingly let that kind of harm in. It names it as the kind that lasts.

More on this in Does A Manipulative Relationship Count As Trauma If You Were Never Hit?

So here’s how I assess threat. Did you go into fight, flight, or freeze? If you did, your brain read what was happening as a threat and activated the system that exists to keep us alive. That is real or threatened.

Freeze is the one people dismiss, and it’s not the mild one. The shutdown kind of freeze, what researchers call tonic immobility, happens when escape feels impossible and fight or flight are no longer an option (Dokkedahl et al., 2022, p. 2).

Stalking is a clear example. It’s terrifying because it’s the threat of a threat: the constant what if. Research has found that stalking is significantly associated with PTSD, even though it doesn’t meet the manual’s exposure criterion (Dokkedahl et al., 2022, p. 2).

Death

Death isn’t just are you alive or not. It’s your ability to survive. So we’re talking about housing, finances, citizenship status, even your kids. If your partner threatens your citizenship status, or your boss threatens your job, those are threats to your livelihood, which means threats to your life.

Serious injury

The manual names serious injury but doesn’t define serious. So who’s to say serious emotional or psychological injury isn’t serious injury? If something changed the way you see yourself, other people, or the world, or rewired how you think and act and move, it was injurious.

That’s how we actually measure serious: not by the input, but by the consequences. If the output was big, the input was big enough.

Sexual violence

The manual’s examples of sexual violence reach “other unwanted sexual experiences not involving contact,” and it even names coercion (American Psychiatric Association, 2022, p. 305). Coercion. Manipulation. Feeling like no wasn’t an option. These can all be sources of trauma.

But the manual gives examples, not definitions. It never says where the line sits for something like “other unwanted sexual contact” (American Psychiatric Association, 2022, p. 305). And if you’re thinking “But it wasn’t violent,” the way I read public health’s definition, violence is measured by what it does, and psychological harm counts.

If the DSM left these things open, where did all the rigidity come from?

Trauma was first discovered in the 1800s, in women who were being sexually abused, and that research got suppressed. When PTSD became a diagnosis in 1980, it came out of the controversy after the Vietnam War (Dohrenwend, 2010). It was designed around veterans coming home, so it became male-centered and war-centered.

It was also unusual. Unlike most mental health diagnoses, PTSD names its cause: a traumatic event (Dohrenwend, 2010). So people became fixated on what counts as the cause.

Researchers narrow on purpose

When researchers study something, they want narrow samples, because that helps them understand their data. That’s good science. So in the early years of trauma therapy research, a lot of people were excluded from studies.

The problem is what happens next. Those entry rules get read by everyone else as the definition of trauma, when all they ever were was the requirements to get into one study.

Meanwhile, the clients coming to therapists were never coming in with just one clear event. They come in with interpersonal trauma, nuanced trauma, harm from people they thought would keep them safe. When the research doesn’t look like their clients, some therapists stop following it, even though cognitive processing therapy, EMDR, and prolonged exposure have been shown to be highly effective across a wide range of people and types of trauma.

And the research is catching up. I’ve read plenty of research linking psychological abuse, bullying, divorce, and job loss to PTSD symptoms (Dokkedahl et al., 2022; Mooren & van Minnen, 2014; Dohrenwend, 2010).

The loop this creates

Here’s what I think is happening. If psychological harm isn’t counted as exposure, it doesn’t get studied as a cause of trauma. If it doesn’t get studied, there’s never a body of evidence to argue it should count. And round it goes.

Where it has been studied, the findings are hard to ignore. Research on psychological violence in relationships found it plays a vital role in the development of PTSD (Dokkedahl et al., 2022). Those threats “can be very subtle and sometimes unspoken, just presented with a small change in voice or posture, which is not necessarily identifiable by a bystander” (Dokkedahl et al., 2022, p. 6).

Clients say it to me all the time:

“I just wish he’d hit me, so I’d have a good enough reason to leave.”

One of the most common assessment tools is the Life Events Checklist, the LEC-5. It asks about 17 events, and almost all of them are a single, visible thing that happened on a particular day: natural disaster, fire or explosion, transportation accident, physical assault, assault with a weapon, sexual assault, combat (Weathers et al., 2013).

There are only two items where years of psychological harm could go. One is captivity, and its examples are being kidnapped, abducted, held hostage, or a prisoner of war (Weathers et al., 2013). A woman who couldn’t leave her relationship reads that and says no. The other is severe human suffering, which comes with no examples at all.

By the time someone reaches those questions, she has already compared her pain to everything above them. “Oh no, I don’t have it bad like that. Other people have it way worse.” We set her up for that answer.

The Adverse Childhood Experiences questionnaire, the ACEs, does a much better job of capturing nuanced harm in childhood. But calling it adverse minimizes what those experiences can do to a person. Adverse is not the same word as trauma (California Surgeon General’s Clinical Advisory Committee, 2022).

“What was the worst thing?” is the wrong question

The next tools usually ask something like what’s the worst thing you ever went through? But the worst thing isn’t always the thing that caused the PTSD. Sometimes the worst thing is just confirmation of what she already knew: “Yeah, life was hard.”

And the manual already answered this. It says that if a person can’t identify a worst example, it is appropriate to consider the entire exposure as meeting the exposure criterion. It also describes trauma as a series of events by the same person over time, with assault by an intimate partner as its example (American Psychiatric Association, 2022, p. 306). The forms still ask for one worst event.

This isn’t any one client; the details are changed, and I’ve heard versions of it many times. A girl grows up with a parent whose rage is completely unpredictable. Nobody ever hits anybody, but nobody ever knows what’s coming. And the thing that actually did the damage isn’t any of that. It’s the day she came home from school and the hoodie she wore every single day had been bagged up for donation.

It was hers. It was worth nothing to anyone else. And it was aimed at her.

“The worst thing you went through isn’t always the thing that’s still running your nervous system.”

So instead of asking what the worst thing was, I ask two questions.

Is there something painful you went through that you think about when you don’t want to be thinking about it?

Is there something painful you went through that you try your absolute best not to think about?

The issue isn’t diagnosing PTSD. The issue is what gets counted as exposure. And because exposure usually comes from self-report, it depends on what someone has been taught trauma looks like.

No. Exposure to trauma does not equal PTSD. Exposure means we have to assess for PTSD. It doesn’t mean you have it.

In my experience, something like 70% of exposures naturally heal. That changes by the type of exposure, but on average, each time you experience exposure, you’re probably going to heal. The problem is that when the die keeps getting rolled, your odds keep changing.

The rest of the diagnosis is about what happened afterward: intrusive memories, avoidance, changes in how you think and feel, and changes in how alert your body stays (American Psychiatric Association, 2022).

I go deeper into this in Does A Tough Childhood Count As Trauma If Nothing “Big” Happened?

And the bullying? You’re asking a small child to spend up to 40 hours a week around people who exclude her, leave her out, and make her the target of their anger. In one lab study, being socially excluded produced tonic immobility, the shutdown freeze response (Mooren & van Minnen, 2014). Freeze is a threat response. Bullying can be incredibly injurious, even if it was never physical.

Is she worth assessing? Yes. And honestly, the manual’s gate may not let her in: the 2022 revision says bullying counts only where there’s a credible threat of serious harm (American Psychiatric Association, 2022, p. 305). That’s the problem. Not her.

If she doesn’t clear that gate and her symptoms look exactly like PTSD, the manual says she gets an adjustment disorder instead (American Psychiatric Association, 2022, p. 312). Same symptoms, different label: the one built for ordinary life stress. That changes what treatment she’s offered and what anyone takes seriously.

The therapist who asked that question and the woman who can’t name her own worst event are the same problem from two directions. They’re both standing at a gate the field can’t describe.

Cassie McCarthy is a trauma therapist who has practiced since 2008, helping women heal from the kind of pain that rarely gets named for what it is. She is rostered in Cognitive Processing Therapy (CPT), is an AASECT Certified Sex Therapist (CST), and practices by telehealth in Massachusetts, Vermont, Virginia, Illinois, and Florida. If you're in one of those states and want to explore working together, you can reach out to schedule a consult.