Excessive anger is often observed in people with PTSD and other anxiety-related disorders. In PTSD, a propensity towards excessive anger may be apparent before exposure to a trauma, for example as a personality trait. Or it could be a result of exposure to the trauma itself and a symptom of PTSD. Elevated anger in people with PTSD has clinical implications as it may be a barrier to effective treatment outcomes. Therefore, anger and aggression are key targets for improvement early in the treatment process.

What is the evidence for anger and aggression in people with PTSD?

Moderate to high quality evidence finds a large increase in difficulty with anger in people with PTSD than in people without PTSD. There were high levels of anger and hostility in veterans, police, and firefighters prior to exposure to trauma and development of PTSD.

In veterans post-deployment, the overall prevalence of any aggressive behaviour is around 36%, which is significantly higher than in veterans who have not had combat exposure. Veterans deployed to combat situations who subsequently develop PTSD show the highest levels of aggressive behaviour, particularly if they also misuse alcohol.

August 2021

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Many people with PTSD experience worrying, fear, and sleep problems. These may disrupt daily functioning, but may not meet the criteria for an anxiety disorder. They may be associated directly with the trauma itself, such as being diagnosed with a physical illness or being exposed to forced displacement or war. They may also be aggravated by other, core symptoms of PTSD, including emotional distress, physical reactivity after exposure to reminders, and upsetting memories, nightmares, and flashbacks. This topic concentrates on the presence and severity of subclinical anxiety symptoms in people with PTSD. Please also see the related disorder topic that is located under the co-occurring mental disorders category.

What is the evidence for anxiety in people with PTSD?

Moderate to high quality finds a medium association between more severe PTSD symptoms and increased levels of anxiety. This association was found in North Korean refugees and in cancer patients. There was also a medium association found between more severe PTSD symptoms and more anxiety sensitivity. This sensitivity relates to fear of the physical sensations associated with anxiety, fear of cognitive incapacitation, and fear of social or public observation of anxiety.

August 2021

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Attention may be compromised in people with PTSD. Several tasks have been developed to assess attention. The most common task is The Stroop Colour Word Test, which presents colour names printed in an ink congruent to the colour name (e.g. blue), or incongruent to the colour name (e.g. blue). Participants are asked to either read the word or name the ink colour. A Stroop interference index is calculated by subtracting response times in the colour-naming condition from those in the incongruent condition. This serves as a measure of the attentional engagement, with more engagement indicating an attentional bias. The emotional Stroop task replaces colour-words with neutral and emotionally loaded stimuli (e.g., the word “violence” painted in blue compared to a neutral word in the same colour). Other tasks include the Continuous Performance Test that uses both visual and auditory stimuli and requires participants to respond to targets and ignore distractors. Also, the Trail Making Test requires participants to connect, in order, letters and/or numbers as quickly as possible.

What is the evidence for attention in people with PTSD?

Moderate to high quality evidence finds medium-sized effects of poorer attention in people with PTSD than in healthy controls (people not exposed to trauma and those without PTSD). Similar findings were apparent in both children and adults. People with PTSD had greater attentional interference with PTSD-relevant stimuli and with emotionally positive stimuli than with emotionally neutral stimuli. In sexual victimisation survivors with or without PSTD, a small effect showed more attentional bias for sexual threat stimuli in those with PTSD.

August 2021

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Avoidance is a core symptom of PTSD, with at least one avoidance symptom required for a diagnosis. People often try to cope with the trauma by avoiding distressing memories, thoughts, or feelings associated with the event. This may be effective in the short-term, but in the long term it may be associated with poorer outcomes.

What is the evidence for avoidance symptoms in people with PTSD?

Moderate to low quality evidence finds three clusters of avoidance symptoms. These are avoidance of thoughts and feelings, avoidance of activity, and avoidance of memory.

Avoidance of thoughts/feelings;

I tried not to talk about the trauma. I tried not to think of things that remind me of something bad that happened to me. I tried not to think about the trauma. I avoided thinking about or talking about a stressful experience from the past. I avoided thinking about or talking about the trauma.

Avoidance of activity;

I felt less connected to people after the trauma. I avoided situations because they reminded me of a stressful experience. I tried to avoid situations or people that reminded me of the trauma. I avoided situations that might remind me of something terrible that happened to me. I tried to avoid activities, people or places that remind me of the traumatic event. I avoided activities that reminded me of the trauma.

Avoidance of memory;

I stayed away from reminders of the trauma. I tried to forget about the bad things that happened to me. I had trouble remembering important parts of the stressful experience. I could not remember much about bad things that have happened to me. I had difficulty remembering. I had difficulty remembering some things that happened during the event/trauma.

August 2021

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Cognitive failures or “slips” are experienced by everyone from time to time and represent a brief lapse in concentration in real world settings. They are influenced by factors such as personality, mood, stress, and time of day. People with psychological disorders are thought to be more vulnerable to cognitive failures, possibly due to increased problems with related cognitive processing such as attention.

Several self-report tools have been developed to measure cognitive failures. One common tool is the Cognitive Failures Questionnaire (CFQ), which requires individuals to indicate how frequently they have experienced a list of minor perceptual, memory, and action failures in everyday life.

What is the evidence for cognitive failures in people with PTSD?

Moderate quality evidence finds increased severity of PTSD symptoms is related to more cognitive failures.

August 2021

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Depression symptoms are common in people with PTSD. It is characterised by a depressed mood and a loss of interest or pleasure in activities. Symptoms of depression can also include changes in appetite, weight, sleep, or psychomotor activity, decreased energy, feelings of worthlessness or guilt, difficulty concentrating or making decisions, and thoughts of death or suicide. Depression may also be associated with increased hopelessness, which is the absence of positive future orientation.

This topic concentrates on the occurrence of depressive symptoms rather than depressive disorders in PTSD. Please see the co-occurring mental disorders topic for information on comorbid depressive disorders in people with PTSD.

What is the evidence for depression symptoms in people with PTSD?

Moderate to high quality evidence finds a medium-sized correlation between increased PTSD symptoms and increased depressive symptoms. This was found in North Korean refugees and in cancer patients. In North Korean refugees, the relationship was stronger in adults than in youths, and stronger in refugees with more than five years outside of North Korea, although the effect sizes were all medium-sized.

August 2021

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Dissociation is a disruption in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, or behaviour. Common dissociative experiences include mild forms of absorption, such as daydreaming. Less common and more severe dissociative experiences include amnesia, derealisation, depersonalisation, and fragmentation of identity. Dissociation is not required for a diagnosis of PTSD.

Trait dissociation is a stable characteristic that may be a vulnerability factor for PTSD. In contrast, state dissociation occurs in response to situations. Peritraumatic dissociation is a form of state dissociation and refers to dissociation that occurs during a trauma. It may be a causal factor for PTSD.

What is the evidence for dissociation symptoms in people with PTSD?

Moderate to low quality evidence found people with PTSD had higher scores on the Dissociative Experiences Scale than people with other psychiatric disorders. These included borderline personality disorder, conversion disorder, schizophrenia, somatic symptom disorder, substance-related and addictive disorders, eating disorders, and affective disorders. People with PTSD had lower dissociation scores than people with dissociative disorders. People with PTSD also report symptoms of depersonalisation. Depersonalisation items endorsed by people with PTSD include; “I felt split into two people and one of me is watching what the other is doing”, “things around me felt unreal or dreamlike”, “I felt like I was in a dream”, “I felt that I was in a daze”, and “I’m not feeling like my actual self”.

Moderate quality evidence found an association between increased state/peritraumatic dissociation and increased self-reported meta-memory fragmentation. Meta-memory involves thinking about or recalling an event and making self-report ratings on the quality of the memory. There was no relationship between state/peritraumatic dissociation and narrative fragmentation, which involves recalling an event that is analysed by a clinician. There were also no relationships between trait dissociation and either meta-memory or narrative fragmentation.

Moderate to low quality evidence finds around 50% of people with PTSD report hearing voices, and there were significant associations between hearing voices and having dissociation symptoms.

August 2021

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Traumatic distress consists of negative emotions experienced during or shortly after a traumatic event. Responses of fear, helplessness, and horror represent a subset of distress reactions that currently define trauma exposure in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), along with life threat. It is unclear if traumatic distress affects the development or persistence of core symptoms across time. Core PTSD symptoms include intrusions, avoidance, hyperarousal, and negative thoughts and mood.

What is the evidence for distress in people with PTSD?

Moderate to high quality evidence found increased severity of PTSD symptoms was related to increased feelings of distress. There may be declines in distress over time, in particular before one-month compared to after one-month post-trauma.

August 2021

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Episodic future thinking may be disrupted in people with PTSD. It refers to thought processes that contribute to the mental construction, imagination, or simulation of possible future events. Episodic future thinking plays a role in planning, problem-solving, coping, regulating emotional states and goal-motivated behaviour.

What is the evidence for episodic future thinking in people with PTSD?

Moderate to low quality evidence found no differences in episodic future thinking between people with PTSD and people without PTSD.

August 2021

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Executive functions are a group of cognitive processes including control, mental flexibility, planning, inhibition, decision-making, initiation, abstraction, self-monitoring, and pursuit of goals. Executive functions are important in situations involving error correction and behaviour evaluation in response to environmental feedback.

What is the evidence for executive functioning?

Moderate to high quality evidence found poorer executive functioning in adults and children with PTSD compared to people without the disorder who were, or who were not, exposed to trauma. There were no significant associations between symptom severity and executive functioning.

August 2021

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