New research published in Biological Psychiatry is challenging the traditional understanding of post-traumatic stress disorder (PTSD) as a condition primarily rooted in fear. The study found that 68% of individuals who had experienced trauma reported that emotional pain—such as guilt, shame, sadness, and loss of joy—had a greater negative impact on their daily lives than fear.
PTSD affects about 8% of people and often occurs alongside depression and anxiety. The current definition of PTSD includes 20 symptoms across four categories: intrusion, avoidance, negative mood and cognition, and hyper-arousal. Researchers in this study identified two main profiles among people with PTSD: one centered on fear, which includes symptoms like flashbacks and hyper-arousal; and another focused on emotional pain, marked by guilt, shame, and lack of pleasure.
Senior investigator Ilan Harpaz-Rotem, PhD, from Yale School of Medicine and VA Connecticut Healthcare System said, "Basic science, including the research done in our lab at Yale, has focused for years on fear learning and safety updating, with minimal attention to the toll of other negative emotions associated with PTSD. We started thinking that fear and emotional pain are potentially driven by two different biological systems that play a critical role in defining how to tailor pharmacological and psychological treatments for PTSD."
The research was conducted in two phases. In the first phase, researchers used an online sample of 838 trauma-exposed individuals to analyze how fear and emotional pain related to specific PTSD symptoms through network analysis. The second phase involved a longitudinal neuroimaging study with 162 recent trauma survivors. This phase used brain connectivity data collected one month after trauma to predict symptom severity 14 months later for both the fear-based and emotional pain-based profiles identified earlier. Results showed that brain connectivity patterns could predict chronic fear-based symptoms but not those linked to emotional pain, indicating possible differences in underlying mechanisms.
John Krystal, MD, Editor of Biological Psychiatry stated: "One of the most challenging aspects of mental health care is simply and accurately characterizing the actual emotional symptoms associated with psychiatric disorders. People may use different words to describe the same experience, and they may apply the same descriptor to different experiences. Neuroimaging may provide a strategy to help to untangle this state of affairs."
Dr. Krystal added: "This study identifies distinct emotional symptoms that are associated with PTSD: fear and emotional pain. These two experiences are represented by different circuits in the brain, and they are differentially associated with other PTSD symptoms. Fear was associated with increased arousal, nightmares, and intrusive trauma memories, while emotional pain was associated with depression-like symptoms and insomnia."
Dr. Harpaz-Rotem explained: "Rather than proposing a new diagnostic category, our goal is to sharpen the clinical understanding of PTSD by identifying the emotional lens of fear or emotional pain through which trauma is most acutely experienced."
Recognizing whether a patient’s distress is mainly due to fear or emotional pain could help clinicians develop more personalized treatment plans. For example, those whose PTSD is driven by fear might benefit more from exposure-based therapies while those affected mainly by emotional pain might need approaches focusing on guilt or negative self-beliefs.
Dr. Ben-Zion concluded: "PTSD is not a single emotional experience. Our goal was to bring the patient's subjective emotional reality to the center of the scientific discussion. Recognizing which emotional system is driving a person's distress can open the door to more precise and compassionate treatment."
