Although she didn’t witness the event herself, Heidi Horsley, PsyD, found herself replaying the last moments of her brother’s life again and again in her mind. He died in a car accident after hydroplaning during a rainstorm.
“That narrative kept going over and over, and I couldn’t get the loop out of my head,” she says. With each replay, she recalls, she ruminated on whether her brother suffered before his death — and she became increasingly worried someone else was going to die. “The safe predictable world you once knew is gone. When my brother died, I didn’t feel like my parents could protect us. I felt my brother died, so I could die.”
Dr. Horsley’s younger brother died when she was 20 years old. Her experience as a young adult eventually prompted Horsley to become a therapist who specializes in grief and trauma. Now an adjunct professor at Columbia University in New York City and the executive director of the Open to Hope Foundation, Horsley says trauma, and its impact on mental health, is widely misunderstood.
Society often expects survivors of emotional trauma to recover much faster than is realistic — to stop talking about the event and move on in a matter of weeks or months. As a result, many individuals come to believe they are suffering from a mental health condition like post-traumatic stress disorder (PTSD) when their reaction may be not only normal but healthy, she explains.
“That’s where people get it wrong,” Horsley says. “[If, for example,] you were assaulted, it is normal to feel like the weight of the world is on you and you have no energy.”
While a certain percentage of individuals do develop mental health conditions, especially PTSD and depression, after a traumatic event, most people recover naturally with time and good social support. In fact, a strong emotional response to trauma may be key to ensuring long-term recovery, Horsley says.
What Is Trauma, and What Causes It?
In both popular culture and the medical field, the term “trauma” can cover a vast array of experiences.
Psychological trauma generally stems from an experience that causes a person to believe in that moment that they, or someone else, is about to die, according to April Naturale, PhD, the assistant vice president of national crisis and wellness programs at Vibrant Emotional Health in New York City, who specializes in helping individuals and families cope with traumatic stress.
These kinds of events activate our fight-or-flight instinct, a stress response that triggers hormones to increase heart rate and prepare the body for action. This process also dials down activity in the parts of our brain that help us think critically and analytically (an energy-preserving mechanism to help us act more quickly in a moment of crisis).
In some cases, Dr. Naturale says, the brain stays stuck in this threat mode for months or years after an incident, which may lead to problems with concentration, sleep, relaxation, and general enjoyment of life.
Genetics and an individual’s natural risk of mental illness appear to play a role in who will develop lasting symptoms after a traumatic experience — but so does the kind of event that caused the trauma.
It seems easier for people to comprehend events involving human error or that things like natural disasters are out of our control, Naturale says. Intentional violence tends to be tougher to accept, she explains.
“What we don’t understand is when someone decides to randomly hurt, kill, or maim a group of people,” Naturale says. “We don’t like to think that anyone might kill us for no reason.” The randomness of certain traumas (whether they’re intentionally inflicted or not) can also be difficult to grapple with.
The number and duration of traumatic events a person experiences also significantly increases his or her mental health risk. Most people can cope with and recover from a single trauma. But when they experience multiple similar events, or when a single crisis persists for an extended period of time, the brain doesn’t have adequate opportunity to heal, Naturale says.
What’s the Difference Between Trauma and PTSD?
Experiencing trauma after a distressing event may lead to one or two of these symptoms, Naturale says. For example, some people who have experienced intimate violence may have dissociation or avoidance, she says. “Having all four of them, plus an inability to function, is likely PTSD.”
PTSD, however, is not the only mental health condition associated with trauma, says Arianna Galligher, the associate director of the stress, trauma, and resilience trauma recovery center at the Ohio State University Wexner Medical Center in Columbus. Trauma may exacerbate mental health conditions that existed before the event, or people may develop symptoms of conditions such as depression or anxiety disorders for the first time in the aftermath of traumatic experiences.
“A lot of people who have experienced traumatic situations may develop a major depressive disorder or anxiety symptoms, rather than PTSD,” Galligher says. “What we really look for in terms of diagnosis is, what’s going on with you, and how do your symptoms impact day-to-day functioning?”
People who fall into a depressed state after a trauma, Horsley says, may feel as though “the world we once knew is over.” They may experience feelings of worthlessness or helplessness, believing there is nothing they can do to prevent future traumatic events, and that life is no longer worth living.
Other people may become so determined to prevent the trauma from happening again that they develop anxiety disorders. They may become extraordinarily cautious and even may develop rituals that they feel will keep them safe, to the point where they may even appear to have obsessive-compulsive disorder (OCD), according to Dr. Ford.
Regardless of which direction the symptoms go, the root of the problem is typically control, Ford says. “The essence of trauma is it takes control away from you or someone you care about,” he says. How a person deals with that loss of control — giving up or redoubling their vigilance — may determine which set of symptoms they experience.
Other Types of Trauma
For emotional trauma that is not PTSD, psychologists have come up with several categories.
When a person is exposed to a prolonged human-caused trauma from which they cannot escape — as in situations such as child abuse, domestic violence, or discrimination — the brain often suppresses emotional reactions in order to remain in survival mode for an extended period of time, Ford says. Later in life when the threat is removed, these emotions begin to emerge, often in unexpected or overwhelming ways.
This can lead people to experience panic attacks or fits of rage. In other cases, Ford says, people exposed to prolonged trauma develop dissociative episodes where they feel disconnected from their own lives. They may experience a sense that things happening to them are not real, or repeatedly zone out and lose track of time.
Waves of seemingly inexplicable emotions may drive some people to self-medicate and develop addictions; others may face social rejection in response to their outbursts, essentially adding new traumas to the old one, Ford says.
Its effects may be felt across cultures of people who have been displaced, enslaved, or subjected to genocide, according to Ford. Stories of these events may be passed down through the generations, transmitting the long-term effects of systemic disadvantages that result from the loss of homes and homelands, poverty, and discrimination.
Symptoms: What Trauma Feels Like
A strong emotional response in the immediate aftermath of a traumatic event is not only normal, it’s to be expected, Naturale says. Many people will experience what she calls an “acute stress response,” so severe that they may become unaware of their surroundings or act out of character or inappropriately. The fight, flight, or freeze response, she says, will suppress the brain’s ability to think and function normally for a short period of time as a means of coping with a crisis.
“You distract yourself for a while, but you think about it again,” she says. “That’s going to continue,” she adds, but should start to diminish over the course of a few weeks.
This acute response, Galligher says, can cause:
- Difficulty concentrating
- Trouble relaxing
- Struggling to fall or stay asleep
- Intense emotions, like anger, anxiety, sadness, or shame
- Emotional numbness
- Feeling detached or estranged from others
- Nausea or gastrointestinal distress
- Sweating or shivering
- Muscle tremors or shaking
- Elevated heart rate or blood pressure
- Fatigue or exhaustion
Most survivors report that symptoms periodically return around significant milestones after the event, such as anniversaries. But for most people who experience trauma, initial symptoms subside after a few months to a year.
“It’s often a struggle to get through the first holiday or the first birthday [after a trauma] — after that, symptoms drop significantly,” Naturale says.
Naturale noted that in her experience working with survivors after 9/11, just sharing this information about normal responses to trauma significantly reduced the incidence of mental health symptoms.
Longer-Term Health Effects of Trauma
In some cases, a traumatic event may have longer-term implications, particularly if the trauma took place during childhood.
How to Cope With Trauma and When to Get Help
A common and healthy way to cope with trauma is to reach out to others to talk through and process what happened.
But not all social interactions are helpful. If an individual’s social network is not supportive and is dismissive of their experience and feelings, Horsley recommends the person find a safe place to talk — which may include therapy or a specialized support group for individuals with similar experiences. Many of these groups are available online, and many are open to survivors free of cost.
Healthy Coping Strategies
It’s important for survivors to give themselves permission to take additional time for self-care, and seek out fun activities that can give them a “break” from the intensity of their emotions, Horsley says. This means covering the basics by getting enough sleep, staying hydrated, and maintaining a good diet. But also looking for hope.
Many people find a new sense of meaning or purpose when they engage with healthy coping mechanisms, Horsley says. Additionally, attending memorials for the lost may fill a need to pay tribute to loved ones. Support groups can lead to new understanding or even advocacy.
Potentially Unhealthy Coping Strategies
Horsley cautions that not everything that technically qualifies as coping leads to positive outcomes. Comfort foods may help us get through a difficult time, for example, but excessive reliance on food as a sole coping mechanism may lead to other negative long-term health consequences. Similarly, Horsley says, individuals who turn to drugs and alcohol as a means of self-medicating for trauma are technically coping — but creating more problems for themselves down the road.
“Alcohol is a depressant; it will make you more sad and upset,” she says.
Though healthy coping strategies can vary from person to person, social support is important for everyone, Naturale says. Isolation, unemployment, or a lack of access to supportive resources represent significant risk factors for developing mental illness following a traumatic event.
“Ninety percent of people get better in a reasonable amount of time with good social support and good coping,” she says.
If you’re unsure whether the people in your social network would be supportive, Naturale says, it never hurts to err on the side of caution and speak to a licensed therapist. A few educational sessions to focus on what to expect after trauma and how to cope may go a long way to promote recovery.
While she does not believe therapy is necessary for everyone who experiences a traumatic event, survivors should seek professional help if they feel as though they cannot connect with others and must isolate themselves; if they are experiencing thoughts of suicide; or if they find ongoing depression or anxiety is interfering with their day-to-day life months after a traumatic event, Naturale says.
If you are actively in crisis and need immediate support, call 911. You can also call the National Suicide Prevention Lifeline at 800-273-8255 or text 741-741 to reach a trained counselor with Crisis Text Line.
Editorial Sources and Fact-Checking
- Trauma. American Psychological Association.
- Physical Trauma. National Institute of General Medical Sciences. July 13, 2020.
- Bremner J. Neuroimaging in Posttraumatic Stress Disorder and Other Stress-related Disorders. Neuroimaging Clinics of North America. November 2007.
- Goldmann E, Sandro G. Mental Health Consequences of Disasters. Annual Review of Public Health. March 2014.
- Kessler R, et al. Trauma and PTSD in the WHO World Mental Health Surveys. European Journal of Pyschotraumatology. July 31, 2017.
- Xue C, et al. A Meta-Analysis of Risk Factors for Combat-Related PTSD among Military Personnel and Veterans. PLoS One. March 20, 2015.
- DSM-5 Diagnostic Criteria for PTSD. Trauma-Informed Care in Behavioral Health Services. Substance Abuse and Mental Health Services Administration (US). 2014.
- Brady K, Killeen T, Brewerton T, Lucerini S. Comorbidity of Psychiatric Disorders and Posttraumatic Stress Disorder. Journal of Clinical Psychiatry. 2000.
- Complex PTSD. U.S. Department of Veterans Affairs.
- Herman J. Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma. Journal of Traumatic Stress. July 1992.
- Bremness A, Polzin W. Commentary: Developmental Trauma Disorder: A Missed Opportunity in DSM V. Journal of the Canadian Academy of Child and Adolescent Psychiatry. May 2014.
- Sar V. Developmental Trauma, Complex PTSD, and the Current Proposal of DSM-5. European Journal of Pyschotraumatology. March 7, 2011.
- Greene C, Haisley L, Wallace C, Ford J. Intergenerational Effects of Childhood Maltreatment: A Systematic Review of the Parenting Practices of Adult Survivors of Childhood Abuse, Neglect, and Violence. Clinical Psychology Review. August 2020.
- Understanding the Impact of Trauma. Trauma-Informed Care in Behavioral Health Services. Substance Abuse and Mental Health Services Administration (US). 2014.
- Cassiers L, et al. Structural and Functional Brain Abnormalities Associated With Exposure to Different Childhood Trauma Subtypes: A Systematic Review of Neuroimaging Findings. Frontiers in Psychiatry. August 3, 2018.
- Hanson J, Hariri A, Williamson D. Blunted Ventral Striatum Development in Adolescence Reflects Emotional Neglect and Predicts Depressive Symptoms. Biological Psychiatry. November 2015.
- Calem M, et al. Meta-Analysis of Associations Between Childhood Adversity and Hippocampus and Amygdala Volume in Non-Clinical and General Population Samples. NeuroImage: Clinical. February 2017.
- Bremner J. Traumatic Stress: Effects on the Brain. Dialogues in Clinical Neuroscience. December 2006.
- Platt J, Keyes K, Koenen K. Size of the Social Network Versus Quality of Social Support: Which Is More Protective Against PTSD? Social Psychiatry and Psychiatric Epidemiology. December 3, 2013.
- Isobel S, et al. Intergenerational Trauma and Its Relationship to Mental Health Care: A Qualitative Inquiry. Community Mental Health Journal. May 2021.
- Bhattacharya S, et al. Stress Across Generations: DNA Methylation as a Potential Mechanism Underlying Intergenerational Effects of Stress in Both Post-traumatic Stress Disorder and Pre-clinical Predator Stress Rodent Models. Frontiers in Behavioral Neuroscience. May 2019.
- The Legacy of Trauma. American Psychological Association. February 2019.