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Evidence-Based Answers to Questions

About Trigger Warnings for
Clinically-Based Distress: A Review
for Teachers
Guy Boysen

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 Scholarship of Teaching and Learning in Psychology © 2017 American Psychological Association
2017, Vol. 3, No. 2, 163–177 2332-2101/17/$12.00 http://dx.doi.org/10.1037/stl0000084

TEACHER-READY RESEARCH REVIEW

Evidence-Based Answers to Questions About Trigger Warnings for

Clinically-Based Distress: A Review for Teachers

Guy A. Boysen
McKendree University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

According to the popular press, students have been increasingly demanding warnings
This document is copyrighted by the American Psychological Association or one of its allied publishers.

before being exposed to potentially distressing classroom material. The validity of these
types of trigger warnings has been a topic of vigorous debate. Based on a review of
posttraumatic stress disorder (PTSD) research and closely related topics, this article
answers questions that teachers might ask about the validity of the scientific assump-
tions behind trigger warnings and their use in the classroom. External stimuli causing
distress is a feature common to many mental disorders, and trauma-based triggers of
distress are an essential feature of PTSD. However, development of PTSD after a
traumatic experience is relatively rare. Environmental triggers are often difficult to
predict, but warnings may reduce distress among people with PTSD by allowing
exposure to be controlled. To the extent that trigger warnings allow avoidance of
hyperarousal when trying to learn, they should increase students’ classroom perfor-
mance. However, avoidance of trauma reminders contributes to the persistence of
PTSD symptoms. Although clinical research generally supports the notion of trigger
warnings as an accommodation for individual students diagnosed with PTSD, the
effectiveness of trigger warnings in the classroom is unknown. In addition, trigger
warnings may be a legitimate accommodation for students with psychiatric disabilities,
but this does not mean that they are relevant to nonclinical issues.

Keywords: trigger warning, posttraumatic stress, trauma, teaching

A debate has emerged in higher education as classroom, but there is a large research literature
to whether or not teachers should provide warn- on trauma and distress that can provide answers
ings before covering content that might trigger to fundamental questions about teaching and
distress among students, especially trauma- trigger warnings. What counts as a trauma?
based distress. The appropriateness of such trig- Does every student who experiences trauma
ger warnings have elicited divergent reactions require a trigger warning? Can teachers accu-
(e.g., Bass & Clark, 2015; Stokes, 2014), with rately predict triggers? Do warnings actually
some arguing that the high rate of traumatic reduce distress? The current review answers
experiences among students makes trigger these and other questions on the basis of empir-
warnings necessary in all classes and others ical research so that college teachers can make
arguing that such a practice would be misguided evidence-based decisions about the use of trig-
at best and harmful at worst. However, both ger warnings in the classroom.
sides have formed their arguments almost ex- The practice of offering trigger warnings
clusively on anecdotes and rhetoric. No pub- emerged from online culture where people used
lished research has directly examined the effect them to signal that material could cause distress
of using or not using trigger warnings in the among individuals with traumatic experiences
(Wyatt, 2016). The logic behind such warnings
stems from the typical symptoms of posttrau-
matic stress disorder (PTSD), which can include
Correspondence concerning this article should be ad-
dressed to Guy A. Boysen, Department of Psychology,
flashbacks and extreme distress in response to
McKendree University, 701 College Road, Lebanon, IL reminders of trauma (American Psychiatric As-
62254. E-mail: gaboysen@mckendree.edu sociation, 2013). Part of the ethical and profes-
163
 164 BOYSEN

sional responsibilities of college teachers is to ings about all of potentially triggering topics
provide students with appropriate accommoda- listed on the survey, there was no topic for
tions for documented disabilities (Scott, 1997). which the majority of participants regularly of-
However, the practice of accommodating stu- fered warnings. When asked directly if they
dents has slipped into a controversial new area provide trigger warnings, 49% reported they did
with trigger warnings. According to the popular not, 31% reported that they did, and 20% were
press, students have been asking teachers across unfamiliar with the term. Among the teachers
many disciplines for trigger warnings related to who were familiar with the concept, 44% had a
an increasingly large number of topics (Wilson, negative opinion of trigger warnings, 25% had a
2015). Although trigger warnings have received positive opinion, and 31% were neutral. When
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

a great deal of attention in media, the topic is asked how helpful or harmful they believed
This document is copyrighted by the American Psychological Association or one of its allied publishers.

just beginning to receive scholarly analysis. trigger warnings are to students’ mental health,
Because trigger warnings are a relatively new 40% believed that they are neither helpful nor
topic in the scholarship of teaching, no standard harmful, 34% believed they are helpful, and
operational definition exists. In the current re- 25% believed they are harmful. Overall, these
view, trigger warnings are defined as teachers results demonstrate striking ambivalence. How
offering prior notification of an educational is it possible that mental health experts teaching
topic so that students may prepare for or avoid a course full of sensitive topics are so conflicted
distress that is automatically evoked by that with regard to a practice frequently portrayed as
topic due to clinical mental health problems. essential for the protection of students’ mental
Although such distress can be a result of PTSD health?
specifically, it may also be a result of other One potential reason why trigger warnings
mental health problems. Teachers may deliver produce such divergent reactions among teach-
trigger warnings in any medium and at any ers is because there are cogent arguments both
point before introducing the topic. By this def- for and against their use. Although most of the
inition, making students aware that a topic is arguments have no basis in scientific research
simply difficult or uncomfortable is not a trigger on trauma, distress, or pedagogy, they are,
warning; the definition would also exclude nonetheless, worthy of consideration. Argu-
warnings about content that is inherently likely ments for trigger warnings center on the ac-
to elicit strong reactions among a significant knowledgment of disability and respect for the
proportion of students regardless of their trauma rights of people with disabilities (Carter, 2015;
or mental health history (e.g., pictures of med- Manne, 2015; Wyatt, 2016). Supporters argue
ical injuries, pornography). There may be sound that trauma-based mental disorders are a form
pedagogical rationales for such warnings, but of disability without distinction from other
they are too far removed the concepts of clinical more widely recognized forms of mental illness
triggers and distress to be considered trigger such as attention-deficit/hyperactivity disorder,
warnings. In addition, with trigger warnings, the learning disabilities, or autism (Carter, 2015).
goal is to avoid distress that is automatically Thus, trigger warnings are simply a necessary
evoked by a stimulus, not the stimulus itself. accommodation for students with a specific dis-
Thus far, only one empirical study on trigger ability (Wyatt, 2016). It is important to empha-
warnings has emerged, and it demonstrated size that warnings related to students’ nonclini-
wide differences in teachers’ attitudes and prac- cal discomfort with sensitive topics is not part
tices. In order to examine how mental health of this debate. Although the popular press might
experts handle possible triggers in their class- emphasize students seeking accommodations
rooms, the study included a survey of abnormal for issues they simply find difficult or uncom-
psychology instructors (Boysen, Wells, & Daw- fortable, such efforts do not appear to have
son, 2016). The survey asked teachers how fre- support among scholarly commentators (Carter,
quently they offer warnings before covering 2015; Manne, 2015). The scholarly arguments
abnormal psychology topics such as suicide, for trigger warnings exclusively center on men-
traumatic experiences, and self-harm; it also tal disability and posttraumatic stress more spe-
assessed their general attitudes about trigger cifically.
warnings. Although there was a significant mi- Critics of trigger warnings have produced a
nority (37%) of teachers who provided warn- variety of arguments against them, but they
 TRIGGER WARNING REVIEW 165

generally fall into three broad categories: social, ness of trigger warnings in the classroom have
professional, and practical. Individuals might not emerged, but there is an extensive literature
object to trigger warnings on social grounds on trauma and distress that has clear pedagogi-
because they see them as an inappropriate form cal implications for psychology and other dis-
of political action or because they encourage ciplines. Trigger warnings are relevant to col-
overindentification with victimhood (Wyatt, lege teaching in general, but psychology should
2016). From a professional standpoint, some have a special role in the evaluation of trigger
argue that trigger warnings are antithetical to warnings. Not only are many topics within psy-
higher education’s goal of challenging students chology courses potential triggers, but psychology
to struggle with difficult intellectual material is at the forefront of clinical science and evidence-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

(American Association of University Profes- based pedagogy. As such, psychology should lead
This document is copyrighted by the American Psychological Association or one of its allied publishers.

sors, 2014; Wyatt, 2016). Perhaps the greatest the way in assessing the pedagogical value of
professional concern, however, is the potential trigger warnings, and the dual purposes of this
for trigger warnings to infringe on academic review are to (a) summarize clinical research to
freedom (American Association of University help teachers make evidence-based decisions
Professors, 2014; Wyatt, 2016). Requiring about trigger warnings and (b) establish a starting
warnings for certain topics could impinge on point for the scientific consideration of classroom
teachers’ ability to freely choose their course trigger warnings inside and outside of psychology.
materials and approach to instruction. The current review is organized around seven
Although philosophical and professional ar- questions teachers might ask about the scientific
guments are important, trigger warnings have validity of the assumptions behind trigger warn-
also been dismissed as simply having no prac- ings and their use in the classroom. Because
tical use. Some have argued that offering gen- trigger warnings in the classroom represent a
eral warnings to all students about topics that generalization of PTSD-related phenomena, the
the teacher perceives as potentially triggering is review emphasizes answers to these questions
unlikely to be helpful for students with or with- on the basis of the clinical literature related to
out PTSD. To begin, there may be no way to PTSD but occasionally diverges into other areas
address all possible triggers because virtually of basic research when there are obvious con-
anything can be trigger for a person with post- nections. Research has demonstrated that the
traumatic stress (American Association of Uni- mental health of college students is similar to
versity Professors, 2014; Veraldi & Veraldi, their noncollege-attending peers across a num-
2015; Wyatt, 2016). Furthermore, trigger warn- ber of disorders including PTSD (Blanco et al.,
ings may actually be harmful because they al- 2008; Hunt & Eisenberg, 2010; Walsh et al.,
low students to avoid the exposure needed to 2012). Thus, the review includes generaliza-
overcome anxiety surrounding trauma-related tions based on research conducted on the gen-
stimuli. Finally, there is an overall criticism that eral population. Because of the diversity of top-
trigger warnings are unlikely to be effective ics and sheer size of applicable literature, the
because the logic behind them represents an focus of this review is on highlighting well-
inaccurate overgeneralization of scientific con- established, uncontroversial trends rather than
cepts from the clinical literature to a nonclinical on systematically reviewing all relevant studies.
setting (Veraldi & Veraldi, 2015). Does the In addition, this review does not touch on the
science behind trigger warning support their use purely philosophical issues related to trigger
in the classroom? The purpose of the current warnings such as their appropriateness in rela-
review is to provide teachers with an answer to tion to political action and academic freedom;
that question. such ideological issues do not have research-
College teachers face a genuine dilemma in based answers.
making a pedagogical decision about trigger
warnings; the topic is controversial precisely Are There Really Triggers to
because there are legitimate arguments on both Trauma-Based Distress?
sides of the debate. Nonetheless, teachers inter-
ested in taking an evidence-based approach to The central assumption behind trigger warn-
trigger warnings do have research on which to ings is that reminders of trauma are a significant
base their decision. Direct tests of the effective- source of distress. The source of this assump-
 166 BOYSEN

tion seems to be official definitions of trauma- posttraumatic memories tend to be negative

based mental disorders. The Diagnostic and (Berntsen & Rubin, 2008). They often consist of
Statistical Manual of Mental Disorders (DSM) vivid images that feel like they are occurring in
organizes posttraumatic reactions into a single the here and now (Hackmann, Ehlers, Speckens,
section on “Trauma- and Stressor-Related Dis- & Clark, 2004; Michael, Ehlers, Halligan, &
orders” that includes PTSD and acute stress Clark, 2005). As an overall group, intrusions
disorder, which is a short-term variation of represent the most commonly reported PTSD
PTSD (American Psychiatric Association, symptoms (Breslau, Reboussin, Anthony, &
2013). The DSM diagnosis for PTSD requires Storr, 2005; Calhoun et al., 2012; Carmassi et
symptoms related to the intrusion of trauma- al., 2013; Davidson, Hughes, Blazer, & George,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

based associations (American Psychiatric Asso- 1991).

This document is copyrighted by the American Psychological Association or one of its allied publishers.

ciation, 2013). Intrusion symptoms serve as the Research has also demonstrated that intrusion
logical foundation for trigger warnings. PTSD symptoms are associated with significant dis-
diagnosis requires one of the following intru- tress. At the most basic level, people diagnosed
sion symptoms related to a traumatic event: with PTSD experience more distress when hav-
ing involuntary memories than do people who
recurrent, involuntary, and intrusive dis- do not have PTSD (O’Kearney & Parry, 2014;
tressing memories of the traumatic Parry & O’Kearney, 2014; Pfaltz, Michael,
event(s); Meyer, & Wilhelm, 2013). Indirect evidence for
distress can also be seen in the fact that people
recurrent distressing dreams;
with PTSD report more effort in avoiding intru-
dissociative reactions (e.g., flashbacks) in sive, trauma-based thoughts than healthy people
which the individual feels or acts as if the report for avoiding thoughts of their worst life
traumatic event(s) were recurring; event or people with panic disorder report for
intense or prolonged psychological distress avoiding thoughts about their worst panic attack
at exposure to internal or external cues that (Pfaltz et al., 2013). Finally, severe distress in
symbolize or resemble an aspect of the response to involuntary trauma memories is as-
traumatic event(s); or sociated with the severity of PTSD symptoms;
people with high levels of overall pathology are
marked physiological reactions to internal or likely to also experience a high level of distress
external cues that symbolize or resemble an from intrusion symptoms (Berntsen & Rubin,
aspect of the traumatic event(s). (American 2008, 2014; Glad, Jensen, Hafstad, & Dyb,
Psychiatric Association, 2013, p. 271) 2016; Kleim, Graham, Bryant, & Ehlers, 2013;
Michael et al., 2005).
Examination of these symptoms illustrates There is clear evidence that intrusive symp-
that trigger-based distress is central to the diag- toms are a source of distress, but the connection
nosis of PTSD. Both memories and flashbacks to trigger warnings may require further clarifi-
could be triggered by external reminders. In cation. Some intrusion symptoms are unavoid-
addition, Symptoms 4 and 5 consist of reactions able (e.g., a spontaneous flashback), but others
to trauma cues—they are triggered reactions may be avoided if there are known, predictable
(Friedman, Resick, Bryant, & Brewin, 2011). triggers (e.g., avoiding the location of a trau-
Intrusion symptoms’ placement in the diag- matic event). From the standpoint of trauma-
nostic criteria of PTSD is based on a strong related distress, it is not exposure to trauma-
foundation of empirical research. Although con- related stimuli itself that is distressing—rather,
ceptualization of memory in an academic set- it is the stimuli’s tendency to cause involuntary
ting tends to focus on active, intentional intrusion symptoms. Thus, students seeking
searches for information (e.g., recalling test an- trigger warnings are ultimately motivated by a
swers), memory retrieval can also occur invol- desire to avoid distress caused by intrusive
untarily without conscious effort (Brewin, symptoms, not by a motivation to avoid the
Gregory, Lipton, & Burgess, 2010). Involuntary stimuli itself. This distinction is why warnings
memories are a common, mostly positive, phe- about topics that are simply sensitive or that are
nomenon among nonclinical populations (Bern- inherently arousing should not be considered
tsen & Rubin, 2008, 2014), but involuntary, trigger warnings.
 TRIGGER WARNING REVIEW 167

In summary, the existence of trauma-based slau et al., 1998; Kilpatrick et al., 2013). Even
triggers of distress is well-supported. Triggers that number is an underestimate of sorts, how-
and negative reactions to them are inherent to ever, because it is typical for people to have ex-
the DSM criteria for PTSD. People with PTSD perienced multiple traumatic events (Breslau et
are particularly subject to intrusive symptoms in al., 2004, 2006; Creamer et al., 2001; Kessler et
which they reexperience trauma-based memo- al., 1995; Stein et al., 1997). For example, one
ries and images, and these symptoms are a study found that 60% of people with at least one
source of significant distress. traumatic experience actually had four or more
traumatic experiences (Breslau et al., 2004).
Does Every Student Who Has Experienced Trauma is exceedingly common, but clinically
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Trauma Need a Trigger Warning? significant effects of trauma are not.

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Similar trends emerge in the frequency of

There is clear evidence that reminders of trauma and diagnosis when examining college
trauma are distressing for people diagnosed students specifically. Estimates of the preva-
with PTSD, but the prevalence of trauma and lence of trauma among college students consis-
PTSD is an important factor to consider as well. tently exceeds 60%, with multiple traumatic
Although people colloquially describe a wide events being the norm (Bernat, Ronfeldt, Cal-
variety of unpleasant events as being traumatic, houn, & Arias, 1998; Elhai et al., 2012; Marx &
the DSM definition of trauma includes a rela- Sloan, 2003; Read, Ouimette, White, Colder, &
tively narrow set of experiences. Specifically, Farrow, 2011; Vrana & Lauterbach, 1994). Ev-
the DSM defines trauma as “exposure to actual idence gathered using both representative and
or threatened death, serious injury, or sexual convenience samples indicate that PTSD has
violence” or learning of such trauma unexpect- the same prevalence among college students
edly befalling a close friend or family member and the general population (Bernat et al., 1998;
(American Psychiatric Association, 2013, p. Borsari, Read, & Campbell, 2008; Read et al.,
271). “Repeated or extreme exposure to aver- 2011; Walsh et al., 2012). Overall, fewer than
sive details of the traumatic event” can also 10% of people, including college students, who
count as a trauma (e.g., a police officer inter- experience DSM-defined trauma go on to de-
viewing witnesses), but it cannot occur solely velop PTSD (Breslau et al., 1998); therefore,
through consumption of media (American Psy- the vast majority of traumas are not associated
chiatric Association, 2013, p. 271). As the DSM with clinically based triggers of distress.
definition illustrates, trauma is does not apply to Traumatic experiences are common when
any and all events that people feel are sensitive considering their lifetime prevalence, but not all
or distressing. Rather, someone’s life or per- traumatic experiences are equally likely to lead
sonal safety must be seriously threatened for an to PTSD. A loved one’s unexpected death or
event to count as a trauma in the clinical sense. injury is the single most common type of trau-
Experiences must be relatively extreme to matic experience (Breslau et al., 1998, 2004,
meet the diagnostic criteria of PTSD, but even 2006; Calhoun et al., 2012; Creamer et al.,
severely traumatic experiences rarely lead to a 2001). Among college students, unexpected
diagnosis. Epidemiological research indicates deaths, accidents, and illnesses tend to be the
that about 7% of the U.S. population will meet most common traumatic events (Elhai et al.,
the criteria for PTSD at some point in their 2012; Moser, Hajcak, Simons, & Foa, 2007;
lifetime (Kessler et al., 2005; Kessler, Sonnega, Marx & Sloan, 2003; O’Bryan, McLeish, Krae-
Bromet, Hughes, & Nelson, 1995), but that rep- mer, & Fleming, 2015; Read et al., 2011). Al-
resents just a fraction of the people who have though these types of trauma are common, the
had experiences that meet the DSM definition of risk of developing PTSD is higher for other
a traumatic event (Breslau & Kessler, 2001; traumas.
Breslau et al., 1998, 2004, 2005, 2006; Calhoun The type of event that is most likely to result
et al., 2012; Creamer, Burgess, & McFarlane, in PTSD is assaultive violence (Breslau et al.,
2001; Dulin & Passmore, 2010; Kessler et al., 1998, 2004, 2005; Calhoun et al., 2012;
1995; Stein, Walker, Hazen, & Forde, 1997). Creamer et al., 2001; Kessler et al., 1995; Kil-
By some estimates, 90% of people experience a patrick et al., 2013). Assaults accounted for
traumatic event at some point in their life (Bre- about 40% of PTSD cases (Breslau et al., 1998).
 168 BOYSEN

Within the broad category of assault, military Triggers of intrusive symptoms of PTSD can
combat and sexual assault are especially likely be difficult to predict for several reasons. A
to result in PTSD (Calhoun et al., 2012; fundamental difficulty is that intrusive symp-
Creamer et al., 2001; Kessler et al., 1995; Kil- toms often occur without any conscious trigger.
patrick et al., 2013). Among college students, One study asked trauma survivors to keep a
8% of veterans report a diagnosis of PTSD diary of their intrusive memories and what trig-
(Widome et al., 2011). In addition, epidemio- gered them: They were unable to identify a
logical research has found that 13% of college- trigger 39% of the time (Kleim et al., 2013).
attending and noncollege-attending women re- Another difficulty is that the triggers are often
port sexual victimization, and 45% of them not logically related to the characteristic that
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

meet the criteria for PTSD (Walsh et al., 2012). made an event traumatic (Ehlers, 2010; Ehlers
This document is copyrighted by the American Psychological Association or one of its allied publishers.

There are also individual differences in people’s et al., 2004; Hackmann et al., 2004). To cite
risk for developing PTSD. Males experience some real-life examples, a woman saw the let-
more traumatic events than do females, but ap- ters “MOO” printed at a gas station and relived
proximately twice as many females as males the experience of being attacked by a bull
develop PTSD after a trauma (Breslau et al., (Ehlers et al., 2004). In another case, bright
1998, 2004, 2005, 2006; Carmassi et al., 2013; sunlight elicited intrusions for a man who had
Kessler et al., 1995); this gender difference ex- been in a car crash and saw lights coming to-
tends to college students as well (Bernat et al., ward him. In another, a door served as a trigger
1998; Moser et al., 2007; Read et al., 2011). for a woman because that is where her assailant
In summary, not every student who expe- stood prior to an assault. Why would the trig-
riences a trauma will require trigger warn- gers of intrusive symptoms frequently be things
ings. As they are defined clinically, traumatic other than the most obviously traumatic aspect
events include only a narrow subset of ex- of an event? The most likely explanation is that
treme threats to safety. Furthermore, only a intrusions center on events that occur immedi-
small fraction of people who experience these ately before a trauma so they can function as a
threats go on to be diagnosed with PTSD. warning of future threats (Ehlers, 2010; Ehlers
Finally, people who experience traumas that et al., 2004; Hackmann et al., 2004).
are unrelated to assaultive violence are less In summary, triggers are difficult, and some-
likely to have PTSD, as are men who experi- times impossible, to predict. Some triggers are
ence any type of trauma. logically based on the features of a traumatic
event. However, other triggers are unknown or
Can Triggers Be Predicted? based on details identifiable only to the person
who experienced the trauma.
Triggers of trauma-based distress do exist,
but the relation between trauma and triggers is If a Trigger Is Known, Does Preparation
more complex than might be expected. The to Face It Help?
logic of trigger warnings is that teachers should
provide them before covering sensitive topics, People with PTSD are often aware of what
and this presumes a predictable relation be- causes their intrusion symptoms, and this may
tween traumas and subsequent triggers. Some allow them to psychological prepare themselves
triggers do share a coherent tie to the traumatic before facing a triggering event— but is prepa-
event (Ehlers, Hackmann, & Michael, 2004). ration actually useful? It may very well be that
For example, in one series of studies, assault trigger warnings elicit just as much stress as
victims diagnosed with PTSD looked at pictures triggers do themselves. Or, warnings could
depicting an assault, and this was sufficient to serve a sensitizing function and trigger distress
trigger intrusive memories in the majority of that might not have otherwise been experienced.
participants (Michael et al., 2005). In another There is no direct research documenting the
study, victims of a shooting were most fre- effect of trigger warnings, but some research
quently triggered by loud noises, screams, and may generalize to this issue. Memories of
sirens similar to those that occurred during the trauma that people with PTSD recall voluntarily
traumatic event (Glad et al., 2016). Triggers are seem to elicit significantly different reactions
not always so predictable, however. than memories of trauma that emerge involun-
 TRIGGER WARNING REVIEW 169

tarily. The involuntary memories tend to be stimuli may serve such a purpose for people
more intrusive, vivid, and emotional; they also with PTSD.
lead to an increased sense of occurrence in the
here and now (Kleim et al., 2013; Rubin, Boals, Is Trauma Special in Terms of Having
& Berntsen, 2008). Another line of research Triggers of Distress?
suggests that people with PTSD have particu-
larly strong reactions to aversive stimuli that is The trigger warning phenomena originated as
unpredictable (Grillon et al., 2009; Simmons et a response to the symptoms of PTSD, but this
al., 2013). For example, in one study research- does not mean that PTSD is the only disorder
ers exposed people with PTSD, generalized associated with distress triggered by environ-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

anxiety disorder, or no disorder to unpleasant mental stimuli. PTSD is known for its unique
This document is copyrighted by the American Psychological Association or one of its allied publishers.

stimuli such as loud noises that were either association with flashbacks in which people ex-
expected or unexpected (Grillon et al., 2009). perience vivid memories that feel like they are
The results showed that startle response, a phys- occurring in the here and now (Brewin, Lanius,
iological sign of anxiety, was significantly Novac, Schnyder, & Galea, 2009; Kleim et al.,
higher among participants with PTSD com- 2013). However, intrusive thoughts tend to be
pared with the other groups when facing unpre- vivid, visual, and emotional across all types of
dictable stimuli but not when facing predictable disorders, not just PTSD (Brewin et al., 2010).
stimuli. Although a direct test of trigger warn- In fact, research indicates that distressing invol-
ing efficacy has not emerged in the literature, untary thoughts occur across a wide variety of
research does suggest that people with PTSD mental health problems, including agoraphobia,
may uniquely benefit from the ability to predict bipolar disorder, depression, eating disorders,
distressing stimuli before they occur. generalized anxiety, health anxiety, obsessive–
Evidence for the benefit of being warned compulsive disorder, panic disorder, schizo-
about oncoming stressors has also emerged phrenia, and social phobia (Brewin et al., 2010;
from basic research. Predictability and control Brewin et al., 2009; Friedman et al., 2011).
are essential components of stress and the stress Some studies have directly compared intrusive
response (Koolhaas et al., 2011). People prefer memories among people diagnosed with PTSD
predictable threats and find them less stressful and individuals with other diagnoses, and the
and anxiety-producing (Grupe & Nitschke, results indicate that involuntary memories
2013). Going beyond simple predictability, among people with diagnoses such as PTSD,
warnings before stressors allow people to feel as depression, and panic disorder lead to similar
if they have more personal control over the levels of distress and dysfunction (Parry &
situation, and it has long been known that per- O’Kearney, 2014; Pfaltz et al., 2013).
sonal control over aversive events can reduce Although the focus thus far has been on dis-
stress (Averill, 1973; Thompson, 1981). Fur- tress due to intrusive thoughts of trauma, envi-
thermore, warnings can allow for the implemen- ronmental stimuli can trigger a number of dif-
tation of strategies to regulate the stress re- ferent distressing reactions among people with
sponse. For example, coping strategies, such as mental disorders (American Psychiatric Associ-
distraction, can be effective in reducing the neg- ation, 2013). In other words, the concept of
ative effects of pain (Fernandez & Turk, 1989; providing warnings to reduce distress could ap-
McCaul & Malott, 1984). Taken together, re- ply to any number of disorders. For example,
search suggests that warnings, to the extent that phobias consist of excessive fears of situations
they increase predictability, control, and coping or objects, and exposure to the feared item
strategies, should reduce the negative conse- prompts immediate anxiety. In panic disorder,
quences of stressful situations. people often have situational cues that elicit
In summary, people with PTSD appear to panic attacks. People with obsessive– compul-
exhibit less severe reactions to trauma intru- sive disorder can become distressed by obses-
sions when they occur voluntarily. Furthermore, sive thoughts prompted by, for example, things
unpredictable stimuli may be uniquely aversive that are not clean or their inability to engage in
to people with PTSD. In general, people have a ritualistic, compulsive response after touching
healthier reactions to predictable and controlla- unclean things. Individuals with autism spec-
ble stressors, and warnings of trauma-related trum disorder may be distressed by breaks in
 170 BOYSEN

routine or sensory experiences such as loud warnings (Gilbertson et al., 2006; Vasterling,
noises. Although this is not an exhaustive list, Brailey, Constans, & Sutker, 1998). Research
the implication of these examples is clear: has documented deficits in their ability to focus
PTSD is just one of many mental disorders that attention (Gilbertson et al., 2006; Samuelson et
have specific triggers of distress. al., 2006; Vasterling et al., 2002), maintain in-
In summary, environmentally cued distress formation in short-term memory (Brandes et al.,
occurs in many mental disorders. Flashbacks 2002; Brewin, Kleiner, Vasterling, & Field,
and other memory intrusions in PTSD tend to be 2007; Samuelson et al., 2006; Vasterling et al.,
especially vivid and are experienced as if they 1998), and store information in long-term mem-
are happening in the here and now, but intru- ory (Brewin et al., 2007; Gilbertson et al., 2006;
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

sions occur in many other disorders as well. In Vasterling et al., 1998, 2002). Furthermore,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

addition, if phenomena other than intrusive PTSD symptoms are associated with reduced
memories are considered, triggers of distress are intelligence (Brandes et al., 2002; Breslau et al.,
common to a number of different mental disor- 2006; Gilbertson et al., 2006; Vasterling et al.,
ders. 2002). In fact, lower intelligence predicts in-
creased exposure to traumatic events (Breslau et
Will Anxiety Due to Exposure to Trauma al., 2006). As this last finding suggests, cogni-
Stimuli Lead to Impairments in Learning? tive deficits likely represent a person’s vulner-
ability to PTSD rather than his or her reaction to
Aside from reducing distress, one reason to trauma itself (Brandes et al., 2002; Gilbertson et
provide trigger warnings is to help students with al., 2006). Overall, with or without trigger
PTSD be successful in the classroom. There is warnings related to their trauma, people with
no direct evidence that warning students, with PTSD may have subtle impairments in thinking
or without PTSD, about potentially sensitive that hinder classroom performance.
issues results in increased academic perfor- In summary, there is no direct evidence test-
mance. However, some nonclinical research ing trigger warnings’ effect on learning. How-
suggests a mechanism by which trigger warn- ever, there is evidence indicating that avoiding
ings could aid in learning. The well-known Ye- extreme levels of anxiety will increase perfor-
rkes-Dodson law predicts that performance is mance for all students. With or without expo-
ideal at medium levels of arousal and is hin- sure to triggers, people with PTSD exhibit cog-
dered at extremely high or low levels of arousal. nitive deficits that could hinder classroom
One implication of this law is that high levels of performance.
anxiety and stress can hinder cognitive perfor-
mance (Beilock, Kulp, Holt, & Carr, 2004; Ey- Is Avoidance of Trauma-Related
senck, Derakshan, Santos, & Calvo, 2007; Leon Triggers Healthy?
& Revelle, 1985; Moran, 2016; Rai, Loschky,
& Harris, 2015). In general, people who are in Avoidance of trauma-related stimuli may re-
an overly anxious state will have difficulty duce distress in the short term, but that does not
learning complex information. Well-known ac- automatically translate into long-term benefits
ademic examples of detrimental effect of anxi- for mental health. In fact, the clinical literature
ety on performance include test anxiety clearly demonstrates that avoidance of trauma-
(Chapell et al., 2005; Hembree, 1988), math related thoughts and emotions maintains and
anxiety (Keeley, Zayac, & Correia, 2008), and exacerbates symptoms of PTSD (Andrews et
stereotype threat (Schmader, 2010). Keeping al., 2013; Brockman et al., 2016; Ehring,
students with or without PTSD alert but not Ehlers, & Glucksman, 2008; Kumpula, Orcutt,
anxious enough to be panicked or distracted Bardeen, & Varkovitzky, 2011; Maack, Tull, &
should benefit performance. Gratz, 2012; McNeill & Galovski, 2015; Meyer,
Anxiety in response to trauma reminders Morissette, Kimbrel, Kruse, & Gulliver, 2013).
could theoretically hinder learning among peo- Research consistently documents a significant
ple with PTSD, but there is also evidence that correlation between trauma-avoidant behaviors,
people diagnosed with PTSD have subtle cog- broadly defined, and increased PTSD symp-
nitive deficits that could affect academic perfor- toms. Although researchers have defined avoid-
mance regardless of the presence of trigger ance using many different behaviors, the same
 TRIGGER WARNING REVIEW 171

relationship exists for avoidance of intrusive ful rather than harmful, however, it must occur
thoughts specifically (Michael et al., 2005). in a safe, therapeutic setting.
There is even research to suggest that avoid-
ance plays a causal role in the development of Discussion
PTSD. Specifically, avoidance seems to me-
diate the relationship between experiencing a Teaching Implications
trauma and exhibiting symptoms of PTSD
(Dulin & Passmore, 2010; Kashdan, Morina, The decision to give or not give trigger warn-
& Priebe, 2009; Orcutt, Pickett, & Pope, ings in class represents a pedagogical choice
2005; Polusny et al., 2011; Reddy, Pickett, & that can be informed by research evidence.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Orcutt, 2006). Clinical research supports the basic phenome-

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Because of the importance of avoidance as an non of trauma-based triggers of distress, and

etiological factor, exposure to trauma-related students with documented PTSD diagnoses
stimuli is a central component of effective could request trigger warnings as an accommo-
PTSD treatment. The American Psychiatric As- dation for a disability. With such an accommo-
sociation practice guidelines cite exposure ther- dation, students may be able to reduce distress
apy, cognitive– behavioral therapy, and eye and increase performance by controlling expo-
movement desensitization and reprocessing as sure and arousal. These points are well-
preferred forms of psychotherapy for PTSD grounded in empirical research.
(Ursano et al., 2010). Each of these approaches Implementation of trigger warnings is not
to therapy requires people with PTSD to face without potential difficulty, however. The de-
trauma-related stimuli in a safe setting, and each bate over trigger warnings often leads to inac-
is effective at reducing symptoms of PTSD curate conflation of trauma and issues that are
(Bisson, Roberts, Andrew, Cooper, & Lewis, merely sensitive. PTSD can only be diagnosed
in relation to a fairly narrow set of experiences
2013; Seidler & Wagner, 2006). Of particular
that are mostly related to severe personal dan-
note is that exposure therapy, which exclusively
ger. According to the Americans with Disabil-
focuses on bringing people in contact with
ities Act, accommodations for disability require
trauma stimuli, is as effective as other, more
a documented “physical or mental impairment
elaborate, forms of therapy (Bradley, Greene, that substantially limits one or more major life
Russ, Dutra, & Westen, 2005; Van Etten & activities.” Thus, requests for trigger warnings
Taylor, 1998). in relation to issues that are sensitive but non-
Exposure to trauma-related stimuli may be a traumatic have no basis in the symptomology of
central factor in the treatment of PTSD, but it is PTSD, and without a diagnosis they are not part
not the only factor. For exposure to be helpful, of the protections that might be offered as a
it must occur in a therapeutic setting. The legitimate accommodation for disability. In ad-
American Psychiatric Association’s practice dition, even students with legitimate PTSD di-
guidelines emphasize the importance of main- agnoses may have triggers that seem idiosyn-
taining a safe treatment environment (Ursano et cratic to an outside observer, and teachers who
al., 2010). The guidelines state that clients with provide warnings for seemingly obvious trig-
PTSD require assurances of safety and trust gers (e.g., scenes of war, depictions of assault)
when initially facing traumatic stimuli in ther- may not be able to avoid triggering some stu-
apy. Exposure to trauma stimuli in unsafe situ- dents’ reexperiencing symptoms. Like other ed-
ations can increase symptoms. Therefore, the ucational accommodations for disability, effec-
treatment guidelines also suggest that clients tive trigger warnings may need to be
receive training in relapse prevention by help- individually designed so that they can match the
ing them plan for how to deal with their reac- needs of each student.
tions to trauma-related stimuli outside of the Teachers should also consider that distress in
safety of therapy. reaction to environmental cues is a common
In summary, avoidance behaviors maintain feature of many different mental disorders. If
and exacerbate symptoms of PTSD. Effective the purpose of trigger warnings is to accommo-
treatment for PTSD includes overcoming avoid- date students with disabilities and reduce dis-
ance through exposure. For exposure to be help- tress, then students with other disorders have a
 172 BOYSEN

valid claim for receiving warnings about topics methods by which they covey such warnings. It
before they are covered. Consider the case of is important to conduct such research on broad
phobias. Should teachers warn students before samples of teachers because practices may vary
the mention of topics related to common pho- widely by instructional topic. Analogous re-
bias such as snakes, spiders, and blood/ search is needed to document students’ perspec-
injections? Arguably, teachers’ answer to this tives on trigger warnings. The assumption
question should be the same as their answer to seems to be that students are overly sensitive
the question of whether or not to offer warnings and desirous of warnings for all types of issues,
for trauma-related stimuli. Phobias are twice as but empirical data is needed before this stereo-
common as PTSD (Kessler et al., 2005), which type can be deemed accurate. Nonetheless, if
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

makes it difficult to argue that PTSD is a greater topics do emerge for which a significant minor-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

issue in college classroom than are phobias. ity of students feel that warnings are always
Accommodating phobias and PTSD differently needed, this would be relevant information for
would suggest the privileging of one form of teachers attempting to decide if they should
distress over another. The choice to treat PTSD administer trigger warnings.
differently than other disorders may be politi- Although basic information is needed about
cally or personally motivated, but, given the teaching practices, the more important research
commonality of environmentally triggered dis- questions pertain to direct tests of the effective-
tress across mental disorders, it is difficult to ness of trigger warnings. Researchers should
argue that such a choice is evidence-based. expose students to potentially triggering topics
Teachers who keep students alert but not either with or without a warning to determine if
panicked are likely to see increased perfor- the intended effects occur and if there are any
mance, but they may also consider the potential unintended effects. Specially, anxiety, arousal,
for adverse effects of warnings. Classroom and mood should be measured before and after
studies on the adverse effects of warnings have exposure to potentially triggering topics, with
not yet been published, but such a phenomenon students randomly assigned to receive or not
would be consistent with longstanding knowl- receive a trigger warning. It would also be ben-
edge of the suggestive power of warnings. No- eficial to investigate if trigger warnings increase
cebo effects occur in medicine when the sug- students’ performance on objective measures of
gestion of medical side effects actually learning. If initial evidence suggests that trigger
produces those effects after the administration warnings have a positive impact, then there are
of placebos (Barsky, Saintfort, Rogers, & Bo- a host of questions that need to be explored in
rus, 2002). In addition, psychologists have long relation to the most effective way to administer
known that demand characteristics in research such warnings in terms of timing, medium, and
can affect participants’ behavior (Orne, 1962). content. Finally, researchers should consider
In fact, giving students a trigger warning so that how individual differences impact all of the
they have the choice to escape potential distress aforementioned research topics. For example,
in class is particularly reminiscent of Orne and factors such as gender, mental health history,
Scheibe’s (1964) “panic button” study in which experience with trauma, and personality may
they showed that informing participants that an affect both students’ desire for trigger warnings
experimental procedure was so forbidding as to and the impact that trigger warnings have on
require a panic button led participants to act as them.
if they needed one.
Conclusion
Topics for Future Research
Although there is a claim to be made for
There are many unanswered questions about using trigger warnings as an accommodation for
classroom trigger warnings that should guide documented cases of PTSD (and other disorders
future research. At the most basic level, stan- with triggers of intrusive distress), no published
dard pedagogical practice with regard to trigger evidence has emerged to indicate widespread
warnings is unknown. Descriptive research is pursuit of such accommodations among stu-
needed to document the topics that prompt dents. The relatively low prevalence of PTSD
teachers to offer trigger warnings, as well as the suggests that students who want trigger warn-
 TRIGGER WARNING REVIEW 173

ings are likely to be individuals who have ex- stress symptoms in a nonclinical sample of college
perienced trauma (but not diagnosis of PTSD) students. Journal of Traumatic Stress, 11, 645–
or who have particular sensitivities to certain 664. http://dx.doi.org/10.1023/A:1024485130934
topics, neither of which are conditions that are Berntsen, D., & Rubin, D. C. (2008). The reappear-
eligible for disability-based accommodation. ance hypothesis revisited: Recurrent involuntary
memories after traumatic events and in everyday
Nonetheless, trigger warnings might be offered
life. Memory & Cognition, 36, 449 – 460. http://dx
for those students as well. For example, what .doi.org/10.3758/MC.36.2.449
teacher would refuse a student’s request for a Berntsen, D., & Rubin, D. C. (2014). Involuntary
suicide trigger warning if that student had just memories and dissociative amnesia: Assessing key
lost a loved one to suicide? Teachers are free to assumptions in posttraumatic stress disorder re-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

accommodate students as they see pedagogi- search. Clinical Psychological Science, 2, 174 –
This document is copyrighted by the American Psychological Association or one of its allied publishers.

cally fit—this might mean letting students know 186. http://dx.doi.org/10.1177/2167702613496241

that they can ask for warnings individually or it Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R.,
might mean giving general warnings before & Lewis, C. (2013). Psychological therapies for
delving into issues with a high likelihood of chronic post-traumatic stress disorder (PTSD) in
causing stress. However, the effectiveness of adults. The Cochrane Library, 12, CD003388.
such informal accommodations needs to be de- Blanco, C., Okuda, M., Wright, C., Hasin, D. S.,
termined before arguing that such warnings Grant, B. F., Liu, S. M., & Olfson, M. (2008).
should be standard practice for all teachers. Mental health of college students and their non-
college-attending peers: Results from the National
Epidemiologic Study on Alcohol and Related Con-
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