Post-Traumatic Stress Disorder (PTSD) And Complex Post-Traumatic Stress Disorder (CPTSD)

What Is Post-Traumatic Stress Disorder?

Signs and Symptoms of PTSD

The DSM-5 and ICD-11 criteria for PTSD overlap but differ in their emphasis and structure.

DSM-5 Criteria:

PTSD requires exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. Symptoms fall into four clusters:

• Re-experiencing: Intrusive thoughts, flashbacks, or nightmares.

• Avoidance: Avoiding reminders of the trauma.

• Negative alterations in cognition and mood: Persistent negative beliefs (e.g., “I am unlovable”) or emotional numbing.

• Hyperarousal: Symptoms such as heightened startle responses, irritability, or insomnia.

ICD-11 Criteria:

PTSD is diagnosed with three core symptoms:

• Re-experiencing: Intrusive memories or flashbacks with vivid “here-and-now” qualities.

• Avoidance: Active avoidance of trauma-related stimuli.

• Persistent heightened sense of threat: Hypervigilance or exaggerated startle responses.

Unlike DSM-5, ICD-11 excludes some symptoms (e.g., guilt or dissociation), focusing instead on core trauma responses. CPTSD is defined separately, adding disturbances in self-organization, emotional dysregulation, and interpersonal difficulties.

Incidence and Predictors of PTSD

The lifetime prevalence of PTSD in the general U.S. population is approximately 6.8% (Kessler et al., 2005). Rates vary depending on the type of trauma, with interpersonal trauma such as sexual violence associated with higher rates (Charuvastra & Cloitre, 2008). Globally, prevalence rates are influenced by cultural, contextual, and sociopolitical factors, with higher rates in conflict-affected regions.

Predictors of PTSD include:

• Trauma type and severity: More severe or prolonged trauma correlates with higher PTSD risk (Brewin et al., 2000).

• Social support: Greater social support is protective, while isolation increases risk (Ozer et al., 2003).

• Pre-trauma vulnerabilities: Factors such as prior mental health conditions, childhood adversity, and genetic predispositions heighten susceptibility (Yehuda et al., 2015).

Psychological Models and Theories of PTSD

Cognitive Model (Ehlers & Clark, 2000)

The cognitive model suggests that PTSD is maintained by poor integration of trauma memories, leading to intrusive re-experiencing. Excessively negative appraisals of the trauma and maladaptive coping behaviors (e.g., avoidance) further perpetuate distress.

Emotional Processing Theory (Foa & Kozak, 1986)

This model suggests that PTSD involves a maladaptive fear structure in memory. Treatment must integrate new, corrective information that conflicts with the fear structure.

Dual Representation Theory (Brewin et al., 1996)

The dual representation theory proposes that trauma memories are stored in two systems:

• Situationally accessible memory (SAM): SAM stores vivid, sensory-rich intrusions of the traumatic event, which are often fragmented and involuntarily triggered by cues resembling aspects of the trauma.

• Verbally accessible memory (VAM): VAM represents the narrative and verbally expressed aspects of the traumatic experience. VAM is consciously accessible and linked to the ability to reflect on and integrate the experience into one's broader life story.

PTSD is believed to arise when SAM dominates, resulting in intrusive and disorganized recollections.

Shattered Assumptions Theory (Janoff-Bulman, 1992):

Trauma can disrupt an individual’s fundamental beliefs about the world’s safety and predictability, and their perceived competence and invulnerability. This leads to considerable cognitive and emotional distress, including anxiety and physiological reactivity.

Polyvagal Theory (Porges, 1995):

This theory explains how trauma dysregulates the autonomic nervous system, resulting in chronic hyperarousal or dissociation.

Evidence-Based Psychological Approaches to PTSD

PTSD treatment focuses on trauma processing and reducing distress. Evidence-based approaches include:

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT, CT-PTSD):

TF-CBT and CT-PTSD combine exposure techniques, cognitive restructuring, and skills training to address trauma memories, challenge unhelpful beliefs, and reduce avoidance behaviors (Ehlers et al., 2003).

Prolonged Exposure Therapy (PE):

A form of TF-CBT that involves repeated, controlled exposure to trauma-related stimuli to reduce distress and avoidance (Foa et al., 1999).

Cognitive Processing Therapy (CPT):

This approach focuses on identifying and restructuring maladaptive trauma-related beliefs, such as guilt or self-blame (Resick et al., 2017).

Eye Movement Desensitization and Reprocessing (EMDR):

EMDR uses bilateral sensory stimulation (e.g., guided eye movements) to facilitate trauma memory processing and reduce distress (Shapiro, 2001).

Narrative Exposure Therapy (NET):

NET helps individuals develop a coherent trauma narrative, contextualizing distressing memories within their broader life story (Robjant & Fazel, 2010).

Resources for Working with PTSD

Psychology Tools offers a range of resources to support PTSD treatment:

• Handouts explaining PTSD and its symptoms.

• Exercises for grounding, emotion regulation, and trauma processing.

• Worksheets for cognitive restructuring and exposure planning.

• Audio resources, including guided relaxation exercises.

• Self-help programs for patients and clinicians.

References and Further Reading

• Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for PTSD. Journal of Consulting and Clinical Psychology, 68(5), 748–766.

• Ehlers, A., & Clark, D. M. (2000). A cognitive model of PTSD. Behaviour Research and Therapy, 38(4), 319–345.

• Ehlers, A., Clark, D. M., Hackmann, A., et al. (2003). A randomized controlled trial of cognitive therapy for PTSD. Behavior Research and Therapy, 41(4), 329-331.

• Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear. Psychological Bulletin, 99(1), 20–35.

• Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (1999). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Oxford University Press.

• Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. Free Press.

• Porges, S. W. (1995). Orienting in a defensive world: Polyvagal contributions. Psychophysiology, 32(4), 301–318.

• Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Press.

• Robjant, K., & Fazel, M. (2010). The emerging evidence for narrative exposure therapy: A review. Clinical Psychology Review, 30(8), 1030-1039.

• Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. Guilford Press.

• Sloan, D. M., Feinstein, B. A., Gallagher, M. W., & Beck, J. G. (2018). Group versus individual treatment for PTSD. Behavior Therapy, 49(3), 416-428.

• Yehuda, R., Daskalakis, N. P., Lehrner, A., et al. (2015). Intergenerational transmission of trauma effects. American Journal of Psychiatry, 171(8), 872–878.