Trauma

FREUD AND HIS FOLLOWERS

POST–WORLD WAR II DEVELOPMENTS

BIBLIOGRAPHY

Until the middle of the nineteenth century, the word trauma was used primarily to designate physiological injury emanating from an external event. Beginning in the 1860s, however, the term acquired additional significance when survivors and witnesses of industrial accidents began to show symptoms of trauma in the absence of any observable physical injury. These symptoms typically included mutism, amnesia, tics, paralysis, recurrent nightmares, and, in some extreme cases, psychic dissociation. Observing a pattern that linked exposure to an overwhelming event with forms of mental disorder, doctors coined the term traumatic neurosis.

One of the most remarked-upon features of this neurosis was the incapacity of the victim to recall the event that precipitated it, coupled with a simultaneous sensation of its recurrence in the present. For this reason, trauma quickly became understood not merely as a psychic injury but also as a wound in the memory. It therefore demanded particular techniques of memory recovery, which ranged over the century from hypnosis to narcotic therapies.

FREUD AND HIS FOLLOWERS

The crisis of memory was variously understood as a function of repression and/or nonsymbolic apprehension of an event. In Austrian Sigmund Freud’s (1856–1939) later writings, trauma was conceived as the result of extreme psychic excitement, in which the mind’s consciousness— which he analogized as a protective shield—was traversed by overwhelming stimuli, which were then registered in a different part of the mind, namely its unconsciousness. Precisely because the traumatic event had never become an object of consciousness, Freud theorized, it was unavailable for narration, objective reflection, and the analytic distance of the kind that would secure the subject against its frightening effects. For this reason, treatment focused on the method of abreaction, an induced revival of the event in which a subject, working with the therapist, would be able to render it conscious. The abreaction was also intended to produce a discharge, which then relieved the patient of a crippling, nervous energy.

Whether the efficacy of the treatment lay in the revival and cognitive apprehension and contextualization of the event or in the simple emotional relief obtained from the process was a matter of some controversy. Some argued that any event, even a false or confabulated one, could serve the purpose of treatment if its recall relieved patients of their symptoms. In the 1980s and 1990s, debates about the dubious validity of the “recovered memories” used in cases of alleged satanic or mass sexual abuse in the United States can be traced to this history of confabulation, coupled with the centrality of hypnosis in the treatment of trauma. Freud and his followers nonetheless insisted that the purpose of treatment was an intellectual reconciliation with the truth of experience, and hence the cathartic function of abreaction was played down in favor of a synthetic narrative or “talking cure.”

Freud and his followers developed their theories and treatments largely in response to two kinds of phenomena, namely female hysteria (initially believed by Freud to be caused by sexual seduction of the girl) and “war neuroses.” In both cases, charges of dissimulation (fakery) were often leveled against sufferers, and it was for this reason that Freud argued so fervently against the therapeutic deployment of fiction.

During wartime, the possibility of dissimulated illness acquired additional salience because soldiers who manifested acute forms of traumatic neurosis were relieved of their military duties. It was, in fact, the proliferation of cases of war neuroses (or “shell shock”) that led to the burgeoning study of trauma in the early twentieth century. The centrality of war in the development of trauma theory has continued unabated since then.

POST–WORLD WAR II DEVELOPMENTS

Since World War II (1939–1945), two major developments have affected trauma theory: the experience of mass or collective trauma, especially that associated with the Nazi death camps, and the recognition of delayed developments of traumatic symptoms, or post-traumatic stress disorder (PTSD). In the first instance, individual experience has become paradigmatic of a general historical condition, and a person’s incapacity to represent traumatic events has been translated into a suspicion of historical narratives that claim to represent the truth of collective violence. In the second, a historically verifiable event has been used to liberate individuals for recognition, treatment, and material compensation.

In some cases, events of mass suffering—such as the Holocaust, the atomic bombing of Hiroshima and Nagasaki, the Middle Passage of slavery, or the rape camps of Bosnia—are deemed uniquely unrepresentable. This is an argument of scale, but an ethico-political injunction emanates from it, prohibiting or restricting efforts to represent such horrors on the grounds that their actuality would be betrayed or diminished in the process. In some versions of this argument, the question of scale is either linked to or substituted with one of structure, according to which all representation is deemed inadequate or incommensurate with actual historical events (Caruth 1996). For proponents of this position, the purpose of historical narration is the communication of traumatic effects to others—secondary witnesses and historical heirs—a process that is said to facilitate identification between those who have survived and those who have not. This argument has been widely criticized, however, because it fails to differentiate between those who suffered or witnessed events firsthand and those whose encounters with trauma were mediated by narratives of others who suffered them in actuality.

The question of PTSD has attracted similarly widespread debate. Observing that the syndrome was recognized only through advocacy on behalf of U.S. military veterans (PTSD was added to the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association in 1980), some have suggested that presentation of symptoms and prevalence rates are influenced by the possibility of compensation for injuries. Moreover, as the authority of PTSD and American psychiatry has assumed international dimensions, new questions have arisen about the cross-cultural validity of the concept of trauma. In Vietnam, for example, there is considerable resistance to the idea of veterans suffering from PTSD. In Japan the diagnosis was rarely made prior to the Kobe earthquake of 1995, despite the country’s long experience of acute postwar ailments.

Two factors explain the differential diagnosis of PTSD on a global scale, one cultural, the other politico-economic. First, there are many culturally distinct vocabularies and methodologies for identifying and treating shock and its psychosomatic aftermath. In some Buddhist societies of Southeast Asia, a sudden fright or accident is said to cause a dissociation of the person’s spiritual being and requires rituals that call back or rebind dislodged spiritual essences. In parts of Africa and in aboriginal America, shock may be adduced as a causal factor in some illnesses and is often said to precipitate birth crises. It may be treated with combinations of naturopathic and ritual methods.

Second, the widespread recognition of shock as a source of injury and the prevalence of ideas of dissociation that accompany vernacular knowledge about shock resonate strongly with Western medical concepts of trauma, though Western medicine increasingly attributes the disturbing symptoms of PTSD to chemical transformations of the brain, especially in the hippocampus, amygdala, and cerebral cortex. The diagnosis of PTSD, however conceived, has nonetheless been promoted by international humanitarian organizations as a mechanism for obtaining financial resources and mental health services for populations—displaced by war and natural disaster—that would otherwise lack them. Invoking PTSD as a basis for claiming human rights is not without risks, however. The inherent focus on traumatic events in its diagnosis (which requires that the symptoms of hyperarousal and/or withdrawal be linked to an originating event) often displaces concern for the structural sources of long-term social and psychic suffering, including that caused by homelessness, poverty, unemployment, or long-term political oppression. Moreover, the proliferating tendency to invoke trauma as a synonym for unpleasant experiences in popular media and public discourse threatens to dissipate the term’s medical as well as its ethico-political force. Beyond the risks that it is subject to both trivialization and economic utilitarianism, however, most theorists agree that trauma is a phenomenon whose increasing occurrence is inextricably tied to the industrialization of war and the massifications of modernity.

BIBLIOGRAPHY

Antze, Paul, and Michael Lambek, eds. 1996. Tense Past:Cultural Essays in Trauma and Memory. New York: Routledge.

Bracken, Patrick J., and Celia Petty, eds. 1998. Rethinking the Trauma of War. London: Free Association.

Breslau, Joshua. 2004. Introd. to Cultures of Trauma: Anthropological Views of Posttraumatic Stress Disorder in International Health. Spec. issue, Culture, Medicine, and Psychiatry 28 (2): 113–126.

Caruth, Cathy, ed. 1995. Trauma: Explorations in Memory.Baltimore, MD: Johns Hopkins University Press. Caruth, Cathy. 1996. Unclaimed Experience: Trauma, Narrative,and History. Baltimore, MD: Johns Hopkins University Press.

Ferenczi, Sándor. 1988. The Clinical Diary of Sándor Ferenczi, ed. Judith Dupont. Trans. Michael Balint and Nicola Zarday Jackson. Cambridge, MA: Harvard University Press.

Freud, Sigmund. 1955a. Beyond the Pleasure Principle. In Vol. 18 of The Standard Edition of the Complete Psychological Works of Sigmund Freud. Trans. and ed. James Strachey. London:Hogarth Press. (Orig. pub. 1920.)

Freud, Sigmund. 1955b. Introd. to Psycho-Analysis and the War Neuroses. In Vol. 17 of The Standard Edition of the Complete Psychological Works of Sigmund Freud. Trans. and ed. James Strachey. London: Hogarth Press. (Orig. pub. 1919.)

Kardiner, Abram. 1941. The Traumatic Neuroses of War. Washington, DC: National Research Council.

Laplanche, Jean. 1976. Life and Death in Psychoanalysis. Trans. Jeffrey Mehlman. Baltimore, MD: Johns Hopkins University Press.

Leys, Ruth. 2000. Trauma: A Genealogy. Chicago: University of Chicago Press.

Young, Allan. 1995. The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press.

Rosalind C. Morris

TRAUMA

In its psychoanalytical sense, trauma denotes an event of such violence and suddenness that it occasions an inflow of excitation sufficiently strong to defeat normally successful defense mechanisms; as a general rule trauma stuns the subject and, sooner or later, brings about a disorganization of the psychic economy.

Trauma (a wound), a term borrowed from ancient Greek, was at first used in surgery to denote a violent injury from an external cause that breached the body's integrity. (Traumatism is used occasionally as a synonym, and occasionally to refer to any condition resulting from trauma.) The term eventually made its way into common usage, its psychological sense coming to the fore as its employment spread from medicine to psychoanalysis.

In the context of late-nineteenth-century causation, the notion of trauma was inseparably linked to the ideas of shock and physical breach, and it was regularly invoked to explain a variety of syndromes, among them traumatic neurosis. Freud was part of this current of thought, and, following Charcot, assigned trauma a determining role in the etiology of hysteria; then, along with Breuer (1893a), he moved from the idea of real, physical trauma to that of a "psychical trauma" (pp. 5-6), with the stress laid no longer on the reality of the event but rather on its mental representation, experienced as an internal "foreign body," which is the source of the excitation. This was a radical shift relative to the theories of the time, and an epistemological leap of great import, for it was the foundation stone of psychoanalysis.

What made an experience traumatic for Freud was indeed the incapacity of the psychical apparatus to discharge the excessive excitation in accordance with the principle of constancy, whether that excitation arose from the pathogenic action of a single brutal event or of a series of incidents having a cumulative effect. This economic view of things was part of psychoanalysis from the beginning, and it is crucial to the understanding of the psychoanalytical notion of trauma. Even at this early period, Freud distinguished two models: the first, evidenced by hysteria, involved the absence of discharge, whereas in the second, operative in the actual neuroses, discharge took place but did so at the wrong time and place, and independently of the object. The economic perspective provided the connection and continuity between the successive theories proposed by Freud as he considered trauma in terms of a causal relationship: the first of these theories was modeled on Charcot's hystero-trauma, but this traumatic theory was very soon replaced by the theory of seduction. Founded on clinical observation, this theory led Freud to assert that the trauma was always of a sexual nature and that it had two moments: the first, the moment of fright, confronted the child prematurely with the sexual conduct of an adult seducer; this the child experienced uncomprehendingly, and its meaning and traumatic effect came into play only after puberty, on the occasion of a second scene that served to reactualize the repressed memory of the earlier one. When the frequency with which his patients produced accounts of such early events obliged Freud to question their reality and treat them instead as products of fantasy, the theory of seduction lost a good deal of its interest; at the same time, its temporal aspect—the process of "deferred action" (après coup ) of which the case of Emma provided the archetypal instance—remained essential to Freud's explanation of the trauma, whose importance in the triggering of neuroses, however, he now qualified by taking into account such factors as individual predisposition, the trauma's place in the subject's history and mental organization, and the circumstances of the event.

The thinking sparked by the war neuroses gave the notion of trauma a new lease on life, while so reinforcing the energetic point of view that in 1916 Freud did not hesitate to say that "the term 'traumatic' has no other sense than an economic one" (1916-17a [1915-17], p. 275). Thus a trauma, by its simple intensity, could produce an instinctual hypercathexis capable of breaching the protective shield against stimuli. In order to stem this influx, which the ego, not having been prepared by anxiety to confront the danger, was all the more incapable of neutralizing, the psychical apparatus would mobilize all available energy and establish countervailing charges. Should these defensive strategies be insufficient, the apparatus would have to bind the excitation compulsively, "beyond the pleasure principle," so as to lower it gradually to a tolerable threshold (1920g, p. 31).

In Beyond the Pleasure Principle, where the importance assigned to the compulsion to repeat led Freud into speculation about the death instinct, the question arose of what principle governed repetition. Was it Thanatos, striving for absolute discharge, as in certain behaviors analogous to the traumatophilia described by Karl Abraham in 1907? Or Eros, aiming to attain mastery through the gradual resolution of tension and thence accede to the power of symbolization, as well illustrated by repetitive dreams recounted in the analytic session and by reproductions in the transference? In fact, where the work of analysis made it possible for the subject to recover and work through repressed material, the binding function could triumph over death-oriented repetition. In that case, deferred effects, by making reorganizations possible, would have been the motor of change.

Finally, in the context of Freud's revised theory of anxiety (1926d), the stress fell on the state of helplessness: what the baby experiences, subjected without recourse to a state of tension in the absence of its mother, was taken as the prototype of all traumatic situations. In this instance with the signal function of anxiety as yet not developed, the ego is overwhelmed by an eruption of instinctual forces it is powerless to contain.

Freud's reflections of 1926 have given rise to the present-day notion of narcissistic trauma, which refers to the ego's inability to bind excitation resulting from a loss, whether the loss of an object or a loss of a narcissistic kind. This classification is justified in terms of the symptomatology often presented by patients (rumination, repetitive dreams), who may thus be thought to be expressing a pathological mourning under the influence of deferred effects (après coup ).

This category has led to a questionable broadening of the concept, for it tends to water down the specificity assigned to trauma in Freud's early works: Systematically treating all and every physical or psychic injury as a trauma runs counter to the psychoanalytic view, for which a trauma cannot be reduced to the level of events alone; at the same time, this level should always be taken into account, precisely because not to do so is to court the danger of further pathological development in a traumatic mode.

FranÇoise Brette

See also: Activity/Passivity; Actual; Amnesia; Annihilation anxiety; Anxiety dream;Árpád the Little Chanticleer (case of); Beyond the Pleasure Principle ; Breakdown; Choice of neurosis; Complementary series; Deferred action; Deprivation; Disorganization; Dream of the Wise Baby; Fixation; Fright; Helplessness; Incompleteness; Memory; Mnemic symbol; Narcissistic injury; Negative therapeutic reaction; Nightmare; Pain; Phylogenesis; Pleasure in thinking; Protective shield, breach of; Proton-Pseudos ; Psychic causality; Psychic reality; Real trauma; Real, the; Reminiscence; Repetition compulsion; Sexual trauma; Tact; Trauma of Birth, The ; Traumatic neurosis; War neurosis.

Bibliography

Abraham, Karl. (1979). The experiencing of sexual traumas as a form of sexual activity. In Selected papers on psychoanalysis. New York: Brunner/Mazel. (Original work published 1907)

Brette, Françoise. (1988). Le traumatisme et ses théories. Revue française de psychanalyse, 52 (6), 1259-84.

Freud, Sigmund. (1916-17a [1915-17]). Introductory lectures on psycho-analysis. SE, 15-16.

——. (1920g). Beyond the pleasure principle. SE, 18: 1-64.

——. (1926d). Inhibitions, symptoms and anxiety. SE, 20: 87-172.

Freud, Sigmund, and Breuer, Josef. (1893a). On the psychical mechanism of hysterical phenomena: Preliminary communication. SE, 2: 1-17.

——. (1895d). Studies on hysteria. SE,2.

Further Reading

Levine, Howard (Ed.). (1990). Adult analysis and childhood sexual abuse. Hillsdale, NJ: Analytic Press.

Sandler, Joseph, et al. (1991). Conceptual research in psychoanalysis: Psychic trauma. International Review of Psychoanalysis, 18, 133-142.

Terr, Lenore. (1990). Too scared to cry: Psychic trauma in childhood. New York: Harper and Row.

Van Der Kolk, Bessel, et al. (1996). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford.

Trauma

Seat Belts Saved Marcus

What Is Trauma?

Trauma Emergencies

Preventing Trauma

The Trauma May Last

Resources

Trauma occurs when a person experiences a sudden or violent injury. Safety and prevention of injury should be foremost in people’s minds. It is easier to prevent than to treat trauma.

KEYWORDS

for searching the Internet and other reference sources

Accidents

Burns

Emergency medicine

Injuries

Prevention

Safety

Shock

Violence

Seat Belts Saved Marcus

Marcus was 16 years old and in a car with four other teenagers. The driver was going too fast, missed a curve, and smashed into a tree. The compact car flipped over, tossing the teens who were not wearing seat belts out of the car. Paramedics found Marcus conscious and still belted in the back seat with only a broken arm and leg. The four other passengers died. “Without them,” Marcus said of seat belts, “I’d be dead.”

What Is Trauma?

Trauma may be physical or psychological. Physical trauma is an injury or wound caused by external force or violence: motor vehicle accidents, falls, burns, drowning, elecric shock, stabbings, gunshots, and other physical assaults. Physical trauma may cause permanent disability, and it is the leading cause of death for people under age 40 in the United States. Even surgery is a trauma—it is planned and controlled, but the body reacts in many of the same ways.

The majority of deaths occur in the first several hours after trauma. Trauma also may cause psychological shock that produces confusion, disoriented feelings and behaviors, and long-term after effects.

Trauma Emergencies

Traumatic injuries may include broken bones, severe sprains, head injuries, burns, and internal or external bleeding. They may occur at any time, and they are medical emergencies that require immediate treatment.

Burns

Burns are tissue damage that results from scalds, fires, flammable liquids, gases, chemicals, heat, electricity, sunlight, or radiation. There are approximately 2 million burn injuries each year in the United States. Burn injuries may cause swelling, blistering, dehydration, infection, and destruction of skin and other body organs. Treatment of burns may require antibiotics, transfusions, and surgery.

Traumatic brain injury (TBI)

Traumatic brain injury is the form of trauma most likely to result in permanent disability or death, with gun injuries as the leading cause, followed by motor vehicle accidents, and falls. In the United States, estimates of the number of people affected by traumatic brain injuries each year include:

• 1 million people treated in hospital emergency rooms
• 230,000 people survive
• 80,000 people discharged with TBI-related injuries
• 50,000 people die.

Traumatic brain injuries affect many different parts of the body, and they may impair vision, memory, mood, concentration, strength, coordination, and balance. TBIs sometimes cause epilepsy and coma. They affect males about twice as often as females, with people between the ages of 15 and 24 at highest risk.

Shock

Shock may occur if the body’s circulatory system shuts down as a result of trauma. Shock may result from internal or external bleeding, dehydration, vomiting, other loss of body fluids, burns, drug overdoses, severe allergic reactions, bacteria in the bloodstream (septic shock), and severe emotional upset. The symptoms of shock include cold and sweaty skin, weak and rapid pulse, dilated pupils, and irregular breathing. Doctors who treat trauma patients often begin transfusions of salt solutions to maintain fluid levels and blood pressure and prevent shock even before they treat other traumatic injuries.

Preventing Trauma

In the United States, trauma kills more people under age 40 than any other disease or medical condition. It is one of the most preventable cause of death. Preventive measures include:

• Motor vehicle seatbelts, restraints, and airbags
• Child safety seats for cars
• Bicycle helmets
• Home smoke detectors
• Firearm safety procedures
• Enforcement of vehicle, firearm, and workplace safety laws.

The Trauma May Last

Survivors of traumatic events, or other situations that involve intense fear and loss of control, are at risk for psychological problems in addition to their physical ones. Emotional support and counseling immediately after the trauma are important as people adjust to the sudden (and often irreversible) changes the trauma causes in their lives. If left untreated, they may develop post-traumatic stress disorder, which can interfere with activities of daily living long after physical wounds have healed. Signs and symptoms of ongoing psychological trauma include:

• Dreams, flashbacks, or intrusive thoughts during which people re-experience the traumatic event
• Avoiding places and people that remind them of the traumatic event
• Insomnia or difficulty concentrating
• Anxiety or depression
• Physical problems that did not exist before the trauma.

Preventing traumatic injury requires individual, group, and government attention to public health and safety.

See also

Broken Bones and Fractures

Burns

Concussion

Hemorrhage

Post-Traumatic Stress Disorder

Seizures

Shock

Strains and Sprains

Resources

U.S. National Institute of General Medical Sciences (NIGMS), 45 Center Drive, MSC 6200, Bethesda, MD 20892-6200. The NIGMS website posts facts and figures about trauma, burn, shock, and injury in the United States, with referrals to other resources. http://www.nih.gov/nigms/news/facts/traumaburnresources.html

U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road N.E., Atlanta, GA 30333. The CDC website posts fact sheets about firearm injuries and fatalities, sexual assault (rape), traumatic brain injury, and other health topics, http://www.cdc.gov/health/diseases.htm

American Trauma Society, 8903 Presidential Parkway, Suite 512, Upper Marlboro, MD 20772-2656. The American Trauma Society website features a Caution board game for children and a Troo the Traumaroo injury prevention program for children. Telephone 800-556-7890 http://www.amtrauma.org

trau·ma / ˈtroumə; ˈtrô-/ • n. (pl. -mas or -ma·ta / -mətə/ ) a deeply distressing or disturbing experience: they were reluctant to talk about the traumas of the revolution. ∎  emotional shock following a stressful event or a physical injury, which may be associated with physical shock and sometimes leads to long-term neurosis. ∎ Med. physical injury.ORIGIN: late 17th cent.: from Greek, literally ‘wound.’

trauma (traw-mă) n.
1. a physical wound or injury. t. scores numerical systems for assessing the severity and prognosis of serious injuries.

2. (in psychology) an emotionally painful and harmful event, which may lead to neurosis. See post-traumatic stress disorder.
—traumatic (traw-mat-ik) adj. www.trauma.org Website of the British Trauma Society