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CASE REPORT
published: 02 February 2021
doi: 10.3389/fpsyt.2021.480852
Frontiers in Psychiatry | www.frontiersin.org 1February 2021 | Volume 12 | Article 480852
Edited by:
Jean Marc Guile,
University of Picardie Jules
Verne, France
Reviewed by:
Silke Schauder,
University of Picardie Jules
Verne, France
Leyla Akoury,
American University of
Beirut, Lebanon
*Correspondence:
Layla Tarazi-Sahab
layla.sahab@usj.edu.lb
Specialty section:
This article was submitted to
Child and Adolescent Psychiatry,
a section of the journal
Frontiers in Psychiatry
Received: 25 June 2019
Accepted: 04 January 2021
Published: 02 February 2021
Citation:
Tarazi-Sahab L, El Husseini M and
Moro M-R (2021) Case Report: When
Does Puberty Become Traumatic?
Front. Psychiatry 12:480852.
doi: 10.3389/fpsyt.2021.480852
Case Report: When Does Puberty
Become Traumatic?
Layla Tarazi-Sahab 1,2
*, Mayssa El Husseini 3,4 and Marie-Rose Moro 2,5, 6
1Laboratory of Psychology, Saint Joseph University, Beirut, Lebanon, 2INSERM U.1178 Santé Mentale et Santé Publique,
Châtenay-Malabry, France, 3MCU Picardie University, Amiens, France, 4CHSSC EA 4289, Maison de Solenn, Cochin
Hospital, AP-HP, Paris, France, 5Descartes University, Paris, France, 6Department of Child and Adolescent Psychiatry,
Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
Puberty provokes physiological upheaval that can be psychologically traumatic and
destabilizing for the child. Before the transformations of puberty, the body is a protective
vessel that acts as a stable reference for the child. A child’s emotional security is
derived from a sense of predictability and well-being. However, the nascent sexuality
and burgeoning libido experienced during puberty can trigger unsettling changes in the
psycho-affective and psycho-dynamic equilibrium of the child as he or she transforms
into an adolescent. This article presents puberty as a transformative experience with
traumatic impact that needs to be considered in therapy conducted with adolescents.
At best, pubescent trauma can cause superficial issues in a child’s adaptive abilities; at
worse, it can lead to pathological symptoms. This article presents a qualitative study
derived from a clinical case of an adolescent girl who expresses her pubescent suffering
through social withdrawal and mutism. The study determines several symptomatic and
traumatic indicators caused by the sudden physiological transformations of puberty,
such as perceived breaches in a child’s sense of safety and the child’s ability to predict.
The study also explores the feelings of helplessness, vulnerability, and aloneness that
pubescent adolescents endure, which are then exacerbated by the sensed inability to
turn to parents for help or peers for support.
Keywords: puberty, trauma experience, clinical situation, psychodynamical adaptation, case report, enactment,
social withdrawal
BACKGROUND
Trauma: A Complex Concept
The original physiological concept of trauma defined trauma as “a contusion that occurs in the
body or a wound that may or may not break the skin.” However, the psychological definition
of trauma has evolved into a much more complex concept, with nuanced, differentiated, and
multi-dimensional impacts that are focalized more on processes rather than on symptoms (1).
Indeed, the psychological dimensions of trauma are as diverse as the sources of trauma. The
intensity of a traumatic event, the degree of vulnerability caused by that trauma, and the modalities
of traumatic expression all must be considered. At the level of a person’s inner reality, we find
that trauma often can cause an (unexpected and violent) intrusion that disrupts a person’s feeling
of internal balance. Furthermore, the “traumatic dose” induced by a traumatic or stressful event
also must be used as a diagnostic criterion when assessing the risks and degrees of symptomatic
emergence. As such, experts are continually evolving toward defining a traumatic event according
to the feeling of danger, terror, and dread that it induces rather than its factual characteristics (2).
Tarazi-Sahab et al. When Does Puberty Become Traumatic?
Coping strategies and resilience with respect to trauma also
vary in degree from one individual to another, and explain the
range of reactions of individuals in the same population or group
subjected to the same event. For example, patients diagnosed with
Post Traumatic Disorder (PTSD) will express varying degrees
of intrusion symptoms and alterations in cognition, mood, and
reactivity, and subsequently will use varying degrees of avoidance
and other coping measures to protect themselves. These variants
in reactions complicate the logic of cause and effect in the face
of trauma. According to linear logic, a traumatic event implies
PTSD. But, poly-causal logic considers that a multitude of factors
may interconnect to mitigate traumatic symptoms.
The Case for Pubescent Trauma Among
Adolescents
The hypothesis presented in this study is that the sudden and
abrupt transformations caused by puberty in certain adolescents
can be deeply traumatic and can lead to disruptive feelings
and clusters of intrusion symptoms similar to those experienced
by patients suffering from PTSD. Puberty is a sensitive period
impacted by trauma and stress, which confer substantial risk for
the development of anxious behavior (3).
The authors of this study encounter the traumatic nature of
puberty every day in our respective clinics. One particular clinical
case, however, has been selected to illustrate our hypothesis that
certain adolescents perceive puberty as an attack against their
body with unpredictable and disruptive outcomes, including
feelings of vulnerability and loss of control that must be
recognized in therapy in order to assist adolescents cope with
their stress and ease their pain.
Since stress mechanisms are often conflated, clinical findings
can take many forms (4). Trauma is dependent on exogenous
and endogenous variables. There is the external or exogenous
event, to which the psychic apparatus will respond and adjust
itself. Endogenously, the trauma and its symptoms arise from
an internalized experience of danger that draws alarm signals
and provokes anxiety, as well as instinctive excitations or
perceived threats to the ego. The latter aspect of trauma is
rarely considered in psychiatric literature reviews that tend to
focus more on external rather than endogenous factors. The
objective of this study is to highlight the traumatic impact and
emergent symptoms of puberty that are endogenous, and which
do not necessarily align with the more classic definitions of
PTSD and ASD, yet result in similar disruptive, and sometimes
severe, symptoms. Broadening the scope of traumatic experience
beyond extraneous events attributed to PTSD and ASD during
puberty is thus essential in order to more comprehensively
understand the impact of puberty and the suffering it inflicts
upon certain adolescents.
When a traumatic event causes a disruption to an individual’s
internal balance or presents a perceived or real threat to his or
her integrity, this experience can create a rupture that impacts
the subject’s equilibrium and relationship to him/herself as
well as to his/her environment. Additionally, an increase in
unmanageable excitation accumulating in the psychic apparatus
will activate the system that counters excitatory excesses. During
traumatic events, this precious “principle of constancy” (5) that
maintains balance, allows the individual to function normally,
and to work and enjoy life, may fail. If attempts to remedy this
psychodynamic destabilization with the usual means does not
succeed, a disturbance in the subject’s subjectivation processes
may ensue, causing a phenomenological splitting of the self,
disturbances to his/her consciousness (6), and invalidation of the
traumatized individual’s access to his/her peaceful relationship
with the world.
All these indicators of trauma can be found in an analogous
manner in an adolescent’s experience of puberty, even if the
event of puberty is not in itself external. In the case of
adolescents, traumatic events can result in such destabilizing
and undesirable effects of considerable intensity that they can
immobilize coping strategies and repress defense mechanisms
that constitute an adolescent’s ability to maintain affect “under
surveillance.” [(7), p. 283] Psychological coping tools presented
in therapy can help adolescents manage the emotional and
intellectual dimensions of pubescent trauma by helping them
better manage the incomprehensible, and better deal with the
feelings of threats to the ego, the physical imbalances, and
other such symptomatic disruptions in order to assure a proper
functioning of psychic processes.
In the clinical case that is the subject of this study, we will show
how puberty can induce an external, somatic traumatism that
exacerbates the internal, psychic transformations of adolescence.
Additionally, we will demonstrate how certain enactment
symptoms during puberty represent the manner in which
adolescents try to cope with and avoid the unmanageable,
unbearable, and frightening internal psychic space caused by
a traumatic pubescence, and how these are similar to the
mechanisms used by PTSD patients to cope with and avoid the
place of their traumatic experience.
Clinical Case and Therapeutic Processes:
Indication, Onset, and Dynamics of
Transference
S. is a slightly overweight 12-year old girl. S. is referred to
my clinic1by her school psychologist because she is socially
withdrawn and barely participates in class. S. has three siblings
and seemingly does not suffer from any extraordinary issues
or problems with her family. S. used to be a good student,
but her grades have dropped dramatically in the past several
months. She responds aggressively when pressured to speak or
to participate in a discussion. Her school psychologist is worried
about depression and refers S. to my clinic for an examination of
her symptomatology and for psychodynamic therapy.
Establishing the therapeutic process initially is challenging
because S. and her family are reluctant to cooperate. The first
appointment is canceled by the parents because S. has promised
“to make more of an effort.” However, the school continues to
insist upon the parents that they need to address their daughter’s
deteriorating situation at school and her increasingly anti-social
behavior. When S. finally comes to her appointment at the
1The patient was referred to the clinic of one of the three therapists presenting
this paper.
Frontiers in Psychiatry | www.frontiersin.org 2February 2021 | Volume 12 | Article 480852
Tarazi-Sahab et al. When Does Puberty Become Traumatic?
clinic, her symptoms of relational avoidance and aggression have
continued for over 7 months.
In the first two sessions, S. sits silently as she and I listen to her
mother’s anamnesis and account of S.’s problems at school. There
is no mention of any difficulties at home, although the mother
concedes that S. can be impulsive and impolite when interacting
with her family memers. When I ask S. to elaborate or ask how she
feels about something her mother has said, S. avoids responding
to me directly and instead tries to correct her mother’s narrative
by whispering to her.
The dynamics of this transference reveals that the young girl
is intimidated by the context of this new, clinical environment.
I understand that she is “telling me” indirectly that she has yet
to complete the separation process from her mother. In my own
countertransference, I accept treating her like a child and receive
her with her mother at my clinic until she feels more secure.
Typical of patients who find that words fail them, S. uses her body
language and attitude to express what she feels.
The real onset of therapy commences at the end of the third
session, when I am able to convince S. that I genuinely recognize
her deep suffering. I promise her that I can help, and she is
comforted when I tell her that she can stop the discussions, or
refuse to answer any of my questions, at any time. By the fourth
session, she accepts to attend a session with only me in the room.
To further reduce her resistance and to help lessen her
antagonism, I establish a positive rapport with her by telling
her that I understand that she wants to regain power over her
own body and to be in control over what she is experiencing.
Gradually, she begins to relax as she becomes convinced that
I empathize with her internal journey. She feels that I accept
her understanding and “rationalization” of matters. I coax her
gently but persistently to talk about her feelings. Eventually, she
begins to express that she feels misunderstood. She justifies taking
distance from her friends because she “prefers to be alone.” I
understand that taking distance is the only tool she has to avoid
dealing with feelings that she finds difficult to express and issues
she finds difficulty in facing. After this breakthrough session, S.
is more trusting of her therapist and the therapeutic relationship
becomes more fluid.
The therapy S. requires is typical of an adolescent whose body
has been suddenly and abruptly transformed by puberty. She
perceives the physiological changes impacting her body as being
an aggression imposed on her from the outside. She feels violated
by this attack on familiar parts of her inner and outer being
without her permission. She has lost parts of herself that she had
come to know and had learned to master as she grew up. The
physical experience wrought upon S. by puberty is so sudden that
the transformations in her size and weight feel frightening and
dangerous. Her fears and confusion are particularly aggravated
as she cannot find the words to articulate her new affect.
Thus, the therapy to remedy S.’s response to the pubescent
trauma she is experiencing consists of addressing her fears and
confusions and restoring trust in herself by discussing some of
the disturbing physiological changes to her body caused by her
experience of puberty and talking about the emotional turmoil
that she is suffering as a consequence of these changes. When we
talk about her experience with puberty, S. mentions that she felt
her brothers did not change so much, or were not as impacted
in their sensory world and body experience as she. I explain to
her that everyone’s experience with puberty is unique, but that
trauma in itself is a similar experience for all of us. I explain to her
that everyone experiences different traumas at different points in
our lives; and, we all must deal with these traumas at some point
in our lives.
AWARENESS-RAISING AND PUBERTY
The Sudden Rupture of a Safe Haven
Educating adolescents about puberty can prevent turmoil if
information is provided in the right way, in the right dosages,
and at the right time. However, too much information about
puberty at the wrong time can add to the trauma an adolescent
is already experiencing.
For example, S. recalls that she felt “abnormal” after reading
a pamphlet about adolescence, because she did not recognize
or feel the sexual needs the pamphlet described as “normal.”
Subsequently, S. stigmatized herself as being “asexual”2.
Discussions with S. and other young people lost in their sexual
identity reveal that they desperately want to stop the initiation
into adulthood and the processes leading to their sexualization.
Pubescent anxiety is intensified by the psychosocial upheaval
caused by changes in status and role and the gender and other
identity issues that arise from the body being attacked by what
adolescents feel is “the unknown.” Furthermore, adolescents feel
their bodies no longer serves as a point of reference because
of the disruptions caused by puberty, such as metamorphoses
in secondary sexual characteristics and transformations in size
and weight. These sudden ruptures in the safe haven represented
by the once childhood body and its references are yet another
dimension of the pubescent experience that are symptomatic
of trauma.
On Being “Alone With Nonsense”
The feeling of being alone in having to deal with all “this
nonsense” is also symptomatic of trauma. S. does not want me
to link her experience with puberty to that of others. “That’s
nonsense,” she replies when I tell her that everyone experiences
this turmoil. She repeats this phrase, “It’s all nonsense” in order
to avoid any explanation she does not want to hear.
The unpredictability and sudden sexual arousal experienced
during puberty are so disturbing for S. that she wants to just
skip the entire initiation into adulthood and sexualization process
and every reference to it. Any discussion about seduction,
desire, attraction, lust, or sexual inclination are avoided and
lead to reactions of disgust. In fact, S. represses anything that
may evoke the disturbances she currently feels from bodily
contact. From a libidinal point of view, there is a high risk of
being overwhelmed when encountering this strange, anxiety-
provoking, and seemingly imposed experience. I help her
recognize these fears about her emerging sexuality so that she
2Some adolescents quickly proclaim they are “homosexual” because they “love” a
same sex friend and are not interested in mingling with the other sex, although
it may just be that the adolescent’s sexual desires and inclinations have not yet
fully developed.
Frontiers in Psychiatry | www.frontiersin.org 3February 2021 | Volume 12 | Article 480852
Tarazi-Sahab et al. When Does Puberty Become Traumatic?
does not feel so overwhelmed and react to the subject with such
instant and intense avoidance.
In fact, not only is referring to experiences or issues as
“nonsense” typical of trauma, but so is the manner in which S.
feels a sense of helplessness—at least with her own limitations—
despite the developed intellectual capacities she has gained
through adolescence. S finds herself in solitude and alone in
her struggle. These expressions confirm our hypothesis that S.’s
“fundamental assumptions that the world is benevolent and
meaningful” have been shattered (8), and that her experience is
as traumatic as any other patient suffering from PTSD or ASD.
Through our sessions, I work incrementally with S. to reduce
this recalcitrance. As soon as S. begins to actively express what
she wants, the therapy becomes more effective.
She wants “to find herself” and implores that “this is not
me.” She wants to regain her old belief of invulnerability and
predictability. She says, “I want to go back to the time when I
had a grip. I was a perfect girl. I could rule my world.” She does
not want to feel passive. She yearns to regain the safe, secure
relationship to herself she once had, and she seeks to preserve
her childhood illusion of omnipotence. She also has no tolerance
for bereaving the loss of her infantile power.
But, the growing process—puberty—has decided differently
for her.
Nowhere to Turn
The third characteristic of the traumatic experience is the
inability to turn to others for help. Among her symptoms,
S. does not respond to her parents’ questions. She often
responds to “how are things?” with “nothing” or “everything is
fine.” This dysfunctional communication is not only frustrating
and confusing for S.’s parents but it leaves S. feeling even
more alone.
S. senses that she has lost her parents as an “auxiliary” of
the Self. The instinct to protect herself leads her to try and
take possession of the containment and protection functions
that her parents once provided. To achieve this autonomy,
this newly “sexualized” teenager finds herself bound to separate
psychologically from her parents. However, this disengagement
also imparts a feeling of danger.
Nevertheless, the process has begun. As another consequence
of puberty, she has become individualized and has embarked
on a “work of disengagement” (9) that transforms the relational
bonds that once provided her with security. Now, the Oedipal
conflict is enacted as the body becomes capable of fulfilling
Oedipal desires. Because of “incestuous potentiality” (10), S.
starts looking for ways of being—without her parents—to
prove her independence to herself. This rupture in the original
containing envelope makes an adolescent more vulnerable and
sensitive to intrusion. Unfortunately, it can also render family
support ineffective.
Thus, S. feels she has to physically distance herself from
her parents. This separation invites in a new relational style
between an adolescent and his/her parents, and can risk
family integration. An adolescent also may vacillate with
hostility between his/her need to be independent and the
need for help from his/her parents because of the unbearable
sexualization of the relationship and the taboo associated with
this experience.
Therapeutic Outcomes: Social Withdrawal
and Reintegration
By the seventh session, S. has begun to accept that other
adolescents are experiencing similar pubescent challenges and
processes. Subsequently, S. tries to re-establish a relationship
with her group of friends. However, at the following therapy
session, she reports that she does not like what she sees and
hears among her friends. “They only talk about silly things
like fashion or gossip about other girls.” She feels she has lost
her friends and says, “I don’t understand them. Why are they
this way?”
This question is a transformative moment in S.’s therapy as
she finally tries to use me as a source of identificatory and
narcissistic support to appease her traumatic and sensed solitary
experience. From this pivotal session forward, she becomes more
open and flexible, and begins to show trust in herself and in her
own judgments.
The development of S.’s interpersonal reasoning leads to a
greater understanding about the feelings of others. This empathy
is then translated and utilized to understand her own emotions.
She begins to see how her relationship with others is impacted
by motive and behavior. S. becomes more open to accepting
my guidance in examining how her over-investment in Self and
in image have become a way of protecting her vulnerability
and the fragility of her “being.” Subsequently, she begins to
make the connection that her friends feel and do the same—
resorting to humor or other forms of rationalization as defense
mechanisms to protect themselves and to try to control how
they feel.
This evolution of S.’s understanding and interpersonal
reasoning not only helps alleviate her own inner turmoil and
psychodynamic upheaval, but she also begins to impact her group
of friends positively. In turn, the group responds positively to
her need for community and become her source of support and
solidarity—so much so that she no longer seeks this security from
her family (11). S. has progressed so much that she even attempts
to assist a friend who has been inflicting harm upon himself. She
and her friends intervene on their friend’s behalf and make sure
that the school psychologist is made aware of his self-harming
behavior. In effect, S. and her friends become his narcissistic
support facilitators.
In one of our sessions, S. shares that she understands the
strange contradiction in his intention “to hurt himself in order
not to suffer anymore.” She explains that she feels this paradox
echoes in her because she felt the same way not so long ago. This
recognition assures me that S. is finally ready to conclude her
therapy and move on.
CONCLUSION
During the transition from puberty into adolescence and onto
adulthood, young adolescents will feel an “internal loss of a
part of the Self” (12). They will experience deep-set anxiety
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Tarazi-Sahab et al. When Does Puberty Become Traumatic?
and upheaval about puberty, sexual identity, gender roles, and
career choices. If an adolescent’s environment, parents, and
peers are incapable of providing a protective container for the
traumatic upheavals wrought upon the adolescent by puberty,
the development and the mechanisms for healthy growth can
become inaccessible.
It is worthy to note that not all adolescents experience a
deeply traumatic puberty. Some are able to see their peers or
siblings as mirrors or use them for support. However, when
overwhelmed by a more traumatic pubescence, adolescents will
act out in an attempt to regain self-control over disturbing
and disruptive exogenous and endogenous physiological and
psychological experiences. Mutism, social withdrawal, and self-
harm are only some of the behaviors that adolescents may adopt
to resolve the loss of control and feeling of helplessness and
aloneness they encounter when suffering the traumas of puberty.
Feelings of confusion, anxiety, mood swings, low self-confidence,
and depression are typical of this age group.
These symptoms can render puberty traumatic, making
affected adolescents even more vulnerable to stressors (13,14). In
such cases, psychodynamic intervention and cognitive processing
therapy allow adolescent patients to overcome the trauma of
puberty by mitigating its negative consequences and exploring
new, positive ways of perceiving their bodily transformations.
Such interventions and therapy can be critical as adolescence is
a period of intervention and an opportunity for the mind to plan
for the future (14).
It is also abundantly clear that there are considerable inter-
individual variations in subjective responses to these objective
pubertal facts, depending on one’s perception of what is or is
not traumatic. However, despite the fact that the puberty as a
trauma may not be systematically confirmed in all adolescents, it
should be an assumption adequately considered when working in
the field of adolescent mental health. Considering the symptoms
and emotions associated with puberty as a reaction to the trauma
of puberty may help clinicians focus more effectively on that
experience and its outcomes as it pertains to both mental and
physiological health.
Furthermore, clinicians should remain mindful that the depth
and richness of adolescents’ creativity can enable them to
transform their traumatic symptoms in a manner that will
maintain the negative illusion that they can run away from this
invasion on their inner world, rather than confront it. Some
adolescents need to be helped by their clinicians to distinguish
and choose between “fight” and “flight” when coping with their
traumatic pubescent experiences. They will need their clinicians
to help them incrementally and progressively employ more
positive and resilient coping mechanisms that will “allow them
to bounce back and move onto the work of building the rest
of their lives, with the memory of the trauma.” (15) Indeed,
adolescents’ feelings of self-esteem and self-worth are augmented
when they realize that they have overcome this frightening,
traumatic challenge to their inner world.
DATA AVAILABILITY STATEMENT
All datasets generated for this study are included in the
article/supplementary material.
ETHICS STATEMENT
The ethical approval no USJ-2019-172 (Saint Joseph University
of Beirut) was obtained for this study. Written informed consent
to participate in this study was provided by the participants’ legal
guardian/next of kin.
AUTHOR CONTRIBUTIONS
All authors listed have made a substantial, direct and intellectual
contribution to the work, and approved it for publication.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
The reviewer SS declared a shared affiliation, with no collaboration, with one of the
authors ME to the handling Editor.
Copyright © 2021 Tarazi-Sahab, El Husseiniand Moro. This is an open-access article
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The use, distribution or reproduction in other forums is permitted, provided the
original author(s) and the copyright owner(s) are credited and that the original
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No use, distribution or reproduction is permitted which does not comply with these
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