What are the symptoms of Post-Traumatic Stress Disorder (PTSD)?

PTSD Symptoms

PTSD is characterized by four core symptom clusters that must persist for at least one month following trauma exposure: intrusive re-experiencing symptoms, avoidance behaviors, negative alterations in cognition and mood, and marked changes in arousal and reactivity. 1, 2

Diagnostic Requirements

PTSD diagnosis requires initial exposure to trauma through direct experience, witnessing trauma, learning about trauma to close others, or repeated exposure to traumatic details, followed by symptoms causing significant functional impairment for more than one month. 1

Core Symptom Clusters

Intrusive/Re-experiencing Symptoms (at least 1 required)

• Recurrent, involuntary, and intrusive distressing memories of the traumatic event 1, 2
• Traumatic nightmares with content related to the event 1, 2
• Flashbacks (dissociative episodes where the patient acts as if the trauma is reoccurring in the present) 1, 2
• Intense psychological distress when exposed to trauma-related cues 3, 2
• Physiological reactivity (physical symptoms like rapid heartbeat, sweating) after exposure to traumatic reminders 3, 2

Avoidance Symptoms (at least 1 required)

• Avoidance of trauma-related thoughts, feelings, or internal reminders 1, 2
• Avoidance of external reminders including people, places, conversations, activities, objects, or situations that trigger memories of the trauma 3, 2

Negative Alterations in Cognition and Mood (at least 2 required)

• Inability to recall key features or important aspects of the traumatic event (dissociative amnesia) 3, 1
• Persistent and exaggerated negative beliefs about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous") 1, 2
• Persistent distorted cognitions about the cause or consequences of the trauma leading to blame of self or others 3, 1
• Persistent negative emotional state including fear, horror, anger, guilt, or shame 3, 2
• Markedly diminished interest or participation in significant activities 3, 2
• Feelings of detachment or estrangement from others 2
• Persistent inability to experience positive emotions (happiness, satisfaction, loving feelings) or restricted range of affect 3, 2
• Sense of foreshortened future (not expecting to have a career, marriage, children, or normal life span) 2

Alterations in Arousal and Reactivity (at least 2 required)

• Irritable behavior and angry outbursts with little or no provocation, typically expressed as verbal or physical aggression toward people or objects 1, 2
• Reckless or self-destructive behavior 1
• Hypervigilance (being constantly "on guard" or watchful) 3, 2
• Exaggerated startle response 1, 2
• Problems with concentration or mind going blank 1, 2
• Sleep disturbance including difficulty falling or staying asleep, or restless unsatisfying sleep 1, 2

Complex PTSD Additional Features

Complex PTSD includes all standard PTSD symptoms plus three additional domains: severe and persistent disturbances in affect regulation, negative self-concept (feelings of worthlessness, failure, or being permanently damaged), and difficulties sustaining relationships. 3, 4 These symptoms develop following exposure to prolonged or repeated traumatic events. 3

Important Clinical Distinctions

Flashbacks are dissociative PTSD symptoms, not psychotic phenomena, despite their vivid and intrusive nature. 4 This distinction is critical to avoid misdiagnosis and inappropriate treatment with antipsychotics as primary therapy.

The symptom presentation is highly heterogeneous—over 636,000 different symptom combinations can meet diagnostic criteria. 5 Research identifies four common typologies: Dysphoric (23.8%), Threat-Reactivity (26.1%), High Symptom (33.7%), and Low Symptom (16.3%). 5

Common Pitfalls

Many patients do not voluntarily report PTSD symptoms, requiring direct screening rather than waiting for spontaneous disclosure. 1 Sleep disturbances are extremely common and may be the presenting complaint, necessitating evaluation for both PTSD and obstructive sleep apnea. 1, 6 Comorbid depression and anxiety disorders occur in the majority of cases and require concurrent assessment. 1, 6