“Life since the explosion has been very different,” said Akram Zaatari, the Beirut-based artist and co-founder of the Arab Image Foundation. Pushing through the repercussions of a history of war and conflict, an economic collapse, a pandemic, and now the August 4 explosion, Lebanese people have witnessed and experienced severe atrocity.

The impact of such atrocities might not be visible to the naked eye, but can be seen in clinics and heard in most narratives. The nature of psychological trauma is cruel, and often leaves a scar for a very long time.

This article focuses on subthreshold trauma-related symptoms and the specific trauma-related psychological disorders in the hopes of equipping you with enough knowledge to seek help if you notice any red-flags that you or the people close to you are experiencing.

What is trauma?

One of the most important public health problems in the world is the human response to psychological trauma. People confront traumatic events with such horror and threat that they may temporarily or permanently alter their capacity to cope, their biological threat perception, and their self-concepts.

In this context, trauma is defined as “a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury.” The word originated in Greece during the late 17th century and means “wound.”

The impact of trauma can be subtle, insidious, or outright destructive.

Trauma, including one-time, multiple, or long-lasting repetitive events, affects everyone differently. How an event affects an individual depends on many factors, including characteristics of the individual, sociocultural factors, the type and characteristics of the event or events, developmental processes, and the meaning of the trauma.

Some individuals exhibit resilience or brief subclinical symptoms or consequences, while others might display criteria associated with a psychiatric disorder –such as Post Traumatic Stress Disorder (PTSD). The impact of trauma can be subtle, insidious, or outright destructive.

Only between 6 percent to 10 percent of individuals who experience a traumatic event, continue to develop PTSD. However, several reactions post trauma can be distressing and debilitating in terms of normal functioning even though they do not constitute a diagnosis per se.

The table in this article highlights that by gathering immediate and delayed reactions of psychological trauma, as identified by prominent authors in the field: John Briere, Catherine Scott, Edna Foa, Dan Stein, Alexander McFarlane, Robert Pietrzak, Rise Goldstein, Steven Southwick, and Bridget Grant.

The reactions listed in the table can be transient, only arising in a specific context; intermittent, appearing for several weeks or months and then receding; or a part of the individual’s regular pattern of functioning. These patterns are often termed subthreshold trauma symptoms. These symptoms can be misdiagnosed as anxiety or other mental disorders.

How do we diagnose it?

It is not uncommon for individuals to self-diagnose with PTSD. Diagnosing an individual with any mental disorder is not a straightforward matter. Even if someone meets all diagnostic criteria, it does not necessarily mean that they will receive the diagnosis.

Many other factors such as levels of functioning are taken into consideration –or at least should be taken into consideration. Beware of websites that let you “self-diagnose.” For clarity nonetheless, diagnostic criteria of PTSD are listed in this article.

Seek professional help from a service-provider who is qualified and gained enough experience with clients experiencing trauma related difficulties in the context of Lebanon.

International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) are systems that identify and classify mental disorders. While these two systems share similarities, they are different in some ways. Other systems also exist, but these are the two most commonly used ones.

Although symptoms of PTSD in adulthood usually begin within 3 months of a trauma, there can be a delay of months or even years before symptoms appear for some people. A diagnosis of “Complex PTSD” and “Adjustment Disorder” is also present.

Hudnall Stamm and Matthew Friedman pointed out however that even if symptoms of PTSD are present, it does not necessarily mean that those set of diagnoses characterize best post-traumatic distress among non-Western individuals.

Somatic and psychological symptoms, as well as beliefs about the origins and nature of traumatic events, often do not fit diagnostic systems clearly. Likewise, religious, and spiritual beliefs can affect how survivors experience traumatic events and whether they report the distress.

It is absolutely crucial that if need be, that you seek professional help from a service-provider who is qualified and gained enough experience with clients experiencing trauma related difficulties in the context of Lebanon.



What else is trauma associated with?

In addition to PTSD, trauma can be associated with Acute Stress Disorder (ASD). Symptoms in ASD develop within 4 weeks of the trauma and can cause extreme levels of distress. Research shows, however, that most people who have ASD never develop PTSD. This disorder is mainly associated with one specific traumatic experience rather than long-term exposure to traumatic stress. 

Symptoms vary and can include sleep disturbance, hypervigilance, irritability, and an altered sense of the reality of one’s surroundings or oneself. Individuals experiencing ASD might seem self-centred and unconcerned about the needs of others as they constantly talk about the event during the first 4 weeks.

Make sure to always check on your psychological health as often as you check on – if not more– your physical health.

A lot of the time, individuals with ASD describe, in repetitive detail, what happened. And may seem obsessed with trying to understand the traumatic event. Often, partial amnesia is also present and the individual repetitively questions others to fill in the details.

Individuals with ASD also seek assurance from others that the event happened in the way they remember it, as well as that they could not have prevented the event, and that they are not “going crazy.”

There are concrete differences between ASD and PTSD. The main one is the amount of time that the symptoms have been present. PTSD continues beyond the 4-week period, while ASD resolves 2 days to 4 weeks after the traumatic event.

Trauma is also associated with the onset of other mental disorders, especially mood disorders, anxiety disorders, personality disorders, and substance use disorders.

Mental disorders can occur at the same time with the traumatic event or appear sometime later. Trauma can also exacerbate symptoms of other disorders which have been present prior to the traumatic event. It can also precipitate the onset of a mental disorder that the individual is predisposed to.

Trauma deals a blow that does not differentiate between colors and sects. It can cause suffering, and many individuals can be hurt. While many individuals might recover on their own in a short amount of time, some might find it extremely difficult to adjust and cope.

Luckily, with proper care, treatment, and social support, a lot of the symptoms can be mitigated. Make sure to always check on your psychological health as often as you check on – if not more– your physical health.

When seeking help, make sure that you look into reliable resources and engage with qualified and experienced professionals in mental health who specialize in trauma.

If you are having thoughts about harming yourself, call the Embrace Hotline at 1564. If you are experiencing distress and/or are not functioning in your daily life as you used to, seek help by calling Embrace’s walk-in clinic on 81003870.

Immediate and delayed reactions of psychological trauma

Immediate Emotional ReactionsDelayed Emotional Reactions

– Numbness and detachment
– Anxiety or severe fear
– Guilt (including survivor guilt)
– Exhilaration as a result of surviving
– Anger
– Sadness
– Helplessness
– Feeling unreal; depersonalization (ex., feeling as if you are watching yourself)
– Disorientation
– Feeling out of control
– Denial
– Constriction of feelings
– Feeling overwhelmed
– Irritability and/or hostility
– Depression
– Mood swings, instability
– Anxiety (ex., phobia, generalized anxiety)
– Fear of trauma recurrence
– Grief reactions
– Shame
– Feelings of fragility and/or vulnerability
– Emotional detachment from anything that requires emotional reactions (ex., significant and/or family relationships, conversations about self, discussion of traumatic events or reactions to them)
Immediate Cognitive ReactionsDelayed Cognitive Reactions
– Difficulty concentrating
– Rumination or racing thoughts (ex., replaying the traumatic event over and over again)
– Distortion of time and space (ex., traumatic event may be perceived as if it was happening in slow motion, or a few seconds can be perceived as minutes)
Memory problems (ex., not being able to recall important aspects of the trauma)
Strong identification with victims

– Intrusive memories or flashbacks
– Reactivation of previous traumatic events
– Self-blame
– Preoccupation with event
– Difficulty making decisions
– Magical thinking: belief that certain behaviors, including avoidant behavior, will protect against future trauma
– Belief that feelings or memories are dangerous
– Generalization of triggers (ex., a person who experiences a home invasion during the daytime may avoid being alone during the day)
– Suicidal thinking
Immediate Behavioral ReactionsDelayed Behavioral Reactions

– Startled reaction
– Restlessness
– Sleep and appetite disturbances
– Difficulty expressing oneself
– Argumentative behavior
– Increased use of alcohol, drugs, and tobacco
– Withdrawal and apathy
– Avoidant behaviors
– Avoidance of event reminders
– Social relationship disturbances
– Decreased activity level
– Engagement in high-risk behaviors
– Increased use of alcohol and drugs
Withdrawal
Immediate Physical ReactionsDelayed Physical Reactions

– Nausea and/or gastrointestinal distress
– Sweating or shivering
– Faintness
– Muscle tremors or uncontrollable shaking
– Elevated heartbeat, respiration, and blood pressure
– Extreme fatigue or exhaustion
– Greater startle responses
– Depersonalization

– Sleep disturbances, nightmares
– Somatization (ex., increased focus on and worry about body aches and pains)
– Appetite and digestive changes
– Lowered resistance to colds and infection
– Persistent fatigue
– Elevated cortisol levels
– Hyperarousal
– Long-term health effects including heart, liver, autoimmune, and chronic obstructive pulmonary disease
Immediate Existential ReactionsDelayed Existential Reactions

– Intense use of prayer
– Restoration of faith in the goodness of others (ex., receiving help from others)
– Loss of self-efficacy
– Despair about humanity, particularly if the event was intentional
– Immediate disruption of life assumptions (ex., fairness, safety, goodness, predictability of life)

– Questioning (ex., “Why me?”)
– Increased cynicism, disillusionment
– Increased self-confidence (ex., “If I can survive this, I can survive anything”)
– Loss of purpose
– Renewed faith
– Hopelessness
– Re-establishing priorities
– Redefining meaning and importance of life
– Reworking life’s assumptions to accommodate the trauma (ex., taking a self-defence class to re-establish a sense of safety)

DSM-5 diagnostic criteria for PTSD

The following criteria apply to adults, adolescents, and children older than 6 years.

  1. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
    • Directly experiencing the traumatic event(s).
    • Witnessing, in person, the event(s) as it occurred to others.
    • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
    • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
  2. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
    • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.
    • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific re-enactment may occur in play.
    • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
    • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  3. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
    • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
    • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  4. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
    • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs).
    • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
    • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
    • Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
    • Markedly diminished interest or participation in significant activities.
    • Feelings of detachment or estrangement from others.
    • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
  5. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
    • Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
    • Reckless or self-destructive behavior.
    • Hypervigilance.
    • Exaggerated startle response.
    • Problems with concentration.
    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
  6. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.
  7. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  8. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

  1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
  2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify whether:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

ICD-11 diagnostic criteria for PTSD:

May develop following exposure to an extremely threatening or horrific event or series of events. It is characterised by all of the following:

  1. Re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. Re-experiencing may occur via one or multiple sensory modalities and is typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations.
  2. Avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event(s).
  3. Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises.

The symptoms persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.


If you are interested in learning more about trauma, here are a few recommended resources:

BooksWebsites
The Body Keeps the Score, by Bessel van der Kolk
Waking from Sleep, by Steve Taylor
Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society, by Bessel van der Kolk, Alexander McFarlane, and Lars Weisaeth
Mental Health Foundation
American Psychiatric Association 
American Psychological Association
Natali Farran is a neuropsychologist who primarily worked as a senior research assistant at the American University of Beirut. She is currently a clinical doctoral candidate at King’s College London. She is a certified mental health ambassador and the recipient of the Rajaa Salam Scholarship Award, Salaam Rishani Doctoral Scholarship, as well as the Rosa Burden North Bristol NHS Trust Prize, and the Cheyne McCallum North Bristol NHS Trust Prize.