PTSD in Women: the Unique Signs

With the 2020 Productivity Commission’s Inquiry into Australian Mental Health highlighting the need to address trauma as a major social and environmental determinant of poor mental health, and prominent media coverage of recent research indicating women to be more at risk of trauma-related disorders than men, it is timely to examine Post Traumatic Stress Disorder (PTSD) from a psychosocial perspective.

This article is the first in a series that aims to summarise our current understanding of Post Traumatic Stress Disorder, PTSD symptoms in women and how women, in particular, may experience it. To truly put this endeavour in perspective, we must acknowledge that, until recently, only 2% of neurobiological research had been conducted in females(1.).

Editor’s note: For brevity, and in accordance with the majority of extant research it cites, this article primarily uses biological (sex chromosome) correlates when referring to ‘women’ or ‘men’, whilst acknowledging that sex and gender are inseparable and neither can be fully understood in the absence of the other.

Content Warning: This article mentions trauma-related topics that could potentially be triggering.

Experts say millions of people are affected by trauma, which has become a buzzword and a meme. So why aren’t more of them being treated?

Dani Blum, The New York Times, 2022.

Quoted in the same article, which revivified interest in PTSD as an ‘under-diagnosed’ mental health condition, was Dr Bessel van der Kolk, a leading expert and mental health professional in the field of treating trauma:

Breaking down the acronym from the centre, the ‘TS‘ stands for traumatic stress, where trauma means experiencing an event (a ‘stressor’) that is too big for the mind, brain, and nervous system to assimilate, thus forming a memory of the event that gets ‘stuck’ because the event is perceived as a serious threat to life. These are a broad way to identify the symptoms of PTSD.

When we first created this diagnosis of PTSD, we said it came from an extraordinary event outside of the range of human experience- that’s how completely out to lunch we were- to think that trauma is exceptional!

Breaking down the acronym from the centre, the ‘TS’ stands for traumatic stress, where trauma means experiencing an event (a ‘stressor’) that is too big for the mind, brain, and nervous system to assimilate, thus forming a memory of the event that gets ‘stuck’ because the event is perceived as a serious threat to life.

The brain has several mechanisms to keep something stuck so that the person will remember it, and try to avoid getting hurt in the same way in the future. It is a survival instinct^(2.)

From broader trauma theory, a similar definition may be gleaned:

..trauma refers to a person’s emotional response to an overwhelming event that disrupts previous ideas of an individual’s sense of self and the standards by which one evaluates society^(3.).

After (Post) the event, it is common to have reactions such as upsetting memories of the experience, increased jumpiness, or trouble sleeping. These responses are often referred to as post-traumatic stress (PTS).

For most people, these responses diminish naturally with time (especially for one-off traumatic events). Still, for others, the opposite occur – the memories are amplified- and may continue causing problems with daily life and develop into the chronic psychological condition called PTS Disorder.

Critically, this adaptive ‘inability to forget’ is central to the mechanics of Post Traumatic Stress Disorder and has a flow-on effect that may further erode mental wellbeing as our perception of the threat itself is altered- the world may ‘become a scarier place’.

Additionally, it has become increasingly accepted by mainstream medicine that PTSD symptoms in women may manifest as a range of physical ailments that might not at first have been considered as connected to the condition (see van der Kolk’s seminal 2014 book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma.

Thus PTSD therapy has, broadly speaking, two targets: ‘un-sticking’ the stuck memory, and ‘re-booting’ our perception of threats.

There are four different “clusters” of symptoms associated with PTSD:

Intrusion, where you might repeatedly have thoughts, or involuntary memories, flashbacks or nightmares that involve a sense of reliving the traumatic event (also called re-experiencing symptoms). Such reminders can be initiated by people, places, sounds, or even smells. These reminders are called ‘triggers’.

Avoiding triggers is a natural way to lessen the memories. You might feel the need to sacrifice parts of your usual lifestyle, like watching the news or going out in large crowds.

Thoughts, beliefs, mood and feelings may change or become more negative following a traumatic event. You might have trouble remembering important aspects of the traumatic event, develop ‘tunnel vision’ (specific parts get ‘stuck’), or develop negative or distorted ideas and beliefs about yourself (guilt, shame, indignation, hurt) or others (blame, anger, mistrust). Like avoidance, these can worsen over time unless addressed.

Feeling ‘keyed up’ (hyperarousal, hyperreactivity, hypervigilance). You may startle easily or feel a high level of physical tension and alertness (being ‘on guard’), have trouble falling or staying asleep, be irritable, suspicious, angry, destructive or impulsive more, have trouble with attention or concentration span, or perhaps just always feel ‘ungrounded’.

A brief note on CPTSD

Perhaps falling short of negligence through omission, it certainly behoves any discussion of PTSD in women to adumbrate, early on, complex PTSD, a relatively new category in one of the two most widely used ‘manuals’ (the ICD-11) for diagnosing mental health disorders.

Arguably (the research is yet to be assimilated by mainstream healthcare), this epithet must first be diagnostically excluded in cases where individuals have experienced prolonged, repeated or multiple forms of traumatic exposure such as childhood or institutionalised abuse (more on this below).

The additional symptoms that characterise a diagnosis of CPTSD are referred to as “disturbances in self-organisation” and include a predominance of problems in affect (feelings, mood) regulation, difficulties in sustaining relationships and feeling close to others, and beliefs about oneself as diminished, defeated, or worthless.

Sex differences in general mental health

Sex differences are prevalent worldwide in many mental health issues^(4.). Internalising disorders, where people keep their problems to themselves (includes anxiety, depression, and trauma-related DSM-5 diagnoses) are more commonly diagnosed in women, whereas externalising disorders, where maladaptive thoughts and feelings are ‘acted out’ (includes substance use and impulsive/aggressive behavioural disorders) and, neurodevelopmental disorders, where impairments of brain function which develop over time and affect emotion, learning ability, self-control and/or memory (includes autism spectrum and learning disorders), are more often diagnosed in men.

Sex differences in PTSD

The Royal College of General Practitioners reports that Australian prevalence rates for PTSD are 4.4% (12 month) and 7.2% (lifetime). In most studies, approximately twice as many women as men are diagnosed with PTSD, and this ratio is consistent across diagnostic systems, measurement methods, ethnicities, cultural backgrounds, and study populations.

Indeed the disparity has been heralded globally:

Women are more than twice as likely as men to suffer from PTSD. Studies are underway to find out why.

Marlene Cimons, Washington Post, October 19, 2019

It is not just the prevalence of PTSD that differs between women and men^(5.), but also their PTSD subcluster scores (i.e. symptoms- see below). For instance, women report re-experiencing the event and anxious arousal more often, manifest symptoms sooner post-trauma, and consistently display more robust recovery trajectories, than men.

Additional significant sex/gender differences are reported in symptom profile, age of onset, comorbidities (i.e. ‘secondary’ or co-existing disorders), functional impairment, prognosis, as well as in responses to various treatments.

Furthermore, the literature is replete with studies that demonstrate that PTSD is not only more prevalent but also more disabling in women than in men^(6.).

In a nutshell, it turns out that there are 3 co-related differences: 1. how men and women respond to trauma, 2. which traumas they are likely to be exposed to, and 3. the timing/frequency of trauma exposure^(7.).

In general, high-impact events, such as sexual abuse or interpersonal violence, are associated with a higher probability of developing PTSD than are lower-impact events, such as car accidents or disasters. Although men experience high-impact events, women have a much higher chance of being exposed to these types of events than men. This difference in exposure is partly responsible for the increased risk of PTSD in women^(8.).

These interrelated factors are further described (in a necessarily meandering fashion) below:

The stress response is regulated primarily through the hypothalamic-pituitary-adrenal (HPA) axis and neurocircuitry involving the medial prefrontal cortex (mPFC), amygdala, hippocampus, hypothalamus, insula, anterior cingulate cortex, and brainstem (see diagram- Appendix).

Studies have shown that activation of these regions is also sexually dimorphic (different in men and women). Therefore, when it comes to a mental health condition like PTSD, men and women may display different signs and symptoms.

The HPA, involved in fear-threat response and conditioning, has been shown^(5.) to become more easily dysregulated in women due to a heightening of sensitivity of glucocorticoid receptor sensitivity and an increase in the negative feedback inhibition of cortisol in the pituitary, leading to poorer acute stress adaptation, and thus a greater vulnerability to PTSD.

Notably, but beyond the scope of this article, recent studies^(9.,10.) have found dysregulation of other dimorphic neurocircuits and biological sex-linked systems as well (down to the molecular level), to be implicated in the pathophysiology of PTSD.

A better understanding of how PTSD manifests molecularly in sexually dimorphic psycho-neurobiology is key to improving our understanding and treatment of the disorder. Increasingly wider application of genomic technologies has revealed that neuropsychiatric disorders such as major depressive disorder and PTSD are molecularly distinct in males versus females^(11.).

Sex-specific neuroendocrine influences impact the stress response chain and are associated with a higher PTSD risk. Female gonadal hormones (oestrogen/oestradiol and progesterone), and perhaps especially the constant fluctuations in these occurring naturally as part of the menstrual cycle, are believed to contribute to both the risk of developing PTSD, and its temporally fluid symptomatology:

Fluctuations in these steroid hormones are very likely to co-influence the neurocircuitry supporting acute threat reactivity and extinction learning^(12.).

Heritability is also at play, with sex-specific effects of several transcriptomes, differentially expressed genes, and other genetic pathways of PTSD now elucidated. Additionally, epigenetic transmission of sexually dimorphic disordered expression of several key stress response modulators and mediators has been identified.

Immune and inflammatory responses: Growing evidence^(13.) in the past two decades points to mechanisms related to the innate (i.e. ‘first line’) and adaptive (i.e., antigen-specific) immune systems in the pathophysiology of PTSD.

Moreover, hypothesis-free genome-wide, epigenome-wide, and transcriptomic studies of PTSD have identified multiple genes related to the immune system.

Recent evidence has also revealed biological mechanisms by which psychological stress is converted into inflammatory signalling in the brain and periphery, and inflammation impacts neurotransmitters and neurocircuits that contribute to behavioural symptoms associated with PTSD:

Results suggest that inflammation contributes to compromised reward circuitry and symptoms of anhedonia and PTSD in trauma-exposed women^(33.).

Developmental determinants of experiential differences within the female PTSD cohort have also been enumerated: recent data from the UK^(14.) , for example, suggests young women are particularly at risk. An Adult Psychiatric Morbidity Survey found 12.6 per cent of women aged 16-24 years old screened positive for PTSD, compared with 3.6 per cent of men of the same age.

Women and men experience different types of trauma and at different times in their lives. Women, for example, are typically exposed to more interpersonal and high-impact trauma, such as sexual assault, than men, and at a younger age^(15.).

Indeed, women experience some traumatic events more often and at a younger age. Thus, they may be more likely to develop PTSD. Traumatic stress affects different areas of the brains of boys and girls at different ages, and can interfere with neurobiological development and personality(7.,8.). Such neurodevelopmental disruptions are amplified in cases involving repetitive exposure to trauma, such as in domestic violence or repeated perpetration of sexual abuse by a caregiver.

Individuals in these scenarios, especially where emotional neglect co-occurs, also record a higher risk for various personality and dissociative disorders. For such individuals in pursuit of a diagnostic resonance to best guide their treatment and recovery, CPTSD (see above) may prove worthy of consideration. Mental health professionals often use a variety of techniques, including talk therapy, to treat PTSD symptoms.

Psychosocial gender/sex-based differences in multiple PTSD risk factors (e.g., negative thoughts (feelings/mood), rumination, low self-esteem, depression) flag women as more likely to develop PTSD.

For example, several peer-reviewed papers support the (arguably intuitive) notion that women and girls are socially conditioned (through mimicry, mirroring, and ritual) to respond to stress with excessive fear and anxiety (which may include horror, helplessness, dissociation, negative appraisals, and trauma-related guilt and shame), making them more vulnerable to PTSD than men.

Women are indirectly exposed to more traumatic events than men, as others prove more likely to share their trauma with them.

Immediate post-trauma coping strategies have also been found^(7.) to predict the subsequent onset of PTSD. For example, female paramedics were found more likely than their male counterparts to report using the coping strategies of wishful thinking, mental disengagement, and suppression of trauma memories.

Society and culture:

Previous studies (21.) have argued that women are more frequently exposed than men to traumatic experiences involving a betrayal of trust (such as experiencing trauma like childhood abuse perpetrated by someone close to the victim), which may lead to a set of outcomes that differ in kind from traumas that do not involve betrayal. Life threat predicts symptoms of anxiety and hyper-arousal, while social betrayal predicts symptoms of dissociation, emotional numbness and depression, and future constricted or abusive relationships(21.).

Gender norms are explicatory in many evidence-based hypotheses explaining sex-linked differential expression of PTSD. For example, boys are encouraged to confront their fears more than girls, which has been speculated to reduce avoidance behaviour in boys but induce learned helplessness in girls.

Added to these is the fact that many cultures shame women for being victims, or doubt their stories entirely. Since stigma and shame contributes to developing and maintaining PTSD, it creates the perfect storm for women to develop a social avoidance symptom and continue to suffer from the condition longer.

Numerous researchers have postulated that because women generally respond to stressors using ‘tend-and-befriend’ strategies (whereas men commonly utilise fight/flight arousal strategies), they experience more negative outcomes following trauma if social support is unavailable.

Indeed, although women often receive more social support, they are also exposed to more negative social responses (e.g., victim blaming) than men.

It is asserted furthermore that if, due to the circumstances of the trauma, women are unable to reach out and connect to others, symptoms of dissociation (an extreme form of psychological withdrawal)- e.g. memory loss and experiencing events as if they were unreal- tend to dominate their PTSD symptom ‘profile’ as ‘shutdown’ is the only source of relief from distress consequently available to them.

Other confounding variables & co-morbidities:

Many more interrelated factors and co-occurring conditions have been cited including:

• In low socioeconomic status communities (with a disproportionately high female population), trauma exposure and PTSD can be as high as 88%. This over-representation^(16.) has been found to correlate to wage/income level/stability disparities and reflect multivariate homelessness^(22.) trends.
• Health professionals’ biases in the clinical treatment and diagnosis of women’s mental health issues.
• While women with PTSD are less likely than men to develop post-trauma addictions, researchers have reported that women predominantly use alcohol (as opposed to other substances, or behavioural coping strategies) to self-medicate the mood symptoms and physical symptoms of PTSD. The National Eating Disorders Association reports that PTSD is a prevalent co-occurring condition with eating disorders in women.
• Researchers found a significant association between PTSD symptoms and female hypersexual behaviours^(17.). The authors hypothesise that repeated sexual behaviours may be used as a coping mechanism for women with PTSD.

Gender-based violence^(18.) (GBV) is a widespread and serious societal problem. Nearly one in three women around the world is affected by GBV, regardless of their social circumstances or ethnicity. The experience of gender-based violence is also linked to PTSD.

Rape is one of the most severe types of traumatic events, with a high prevalence of PTSD (up to 50% of victims) as a direct consequence of the trauma^(5.), and women are three times more likely to experience sexual violence than men.

As a subset of GBV, intimate partner violence^(18.) (IPV) is one of the most common forms of violence against women. IPV is any behaviour in an intimate relationship that causes physical, psychological, or sexual harm to the victim of the violence.

IPV also applies to controlling behaviours such as isolating the partner from other people, monitoring their doings, and controlling and restricting finances, employment, education, and medical care.

Research findings suggest that structural brain alterations among women with IPV-related PTSD may be driven by symptom severity within specific symptom clusters and that PTSD symptoms in this cohort may have a differential (increased or decreased) association with brain structures^(19.).

The complex psychiatric sequelae of IPV (e.g., PTSD and depression) along with its neurological effects may contribute to a poor prognosis for recovery and increased risk of exacerbation due to re-victimisation.

There are also specific limitations and barriers to treatment engagement and completion for women with PTSD following IPV, including childcare, housing and financial instability, ongoing safety concerns, and difficulties attending regular therapy sessions.

Postnatal PTSD, or Childbirth PTSD (CB-PTSD)

Research^(20.) in Australia suggests that almost half (45.5 %) of women describe their childbirth experience as traumatic, while one in three women will display at least three trauma symptoms in the early postpartum period. This is consistent with data from the United States and other high-income countries where the prevalence of birth trauma is estimated at around 34 %. Reported rates of childbirth-related post-traumatic stress disorder (PTSD) in Australia range from 1 % to 6 %, believed to be an underestimate.

Despite how common the condition is, many women – and even healthcare practitioners – are unaware of it. In fact, signs and symptoms of birth trauma are sometimes mistaken for postnatal depression.

Avoiding reminders of birth has been impossible. I’ve had to revisit the hospital where I gave birth for ongoing care. My newborn’s crying was a trigger – as was physical touch I hadn’t initiated. These caused me to have physical and emotional reactions and flashbacks. The negative emotions I experienced in the year after my son’s birth were like nothing I’d experienced before.

While birth trauma can occur as a result of a significant physical injury or threat to the life of the woman giving birth or baby, it can equally arise as a response to threats to psychological safety via interactions with healthcare providers and the maternity care system:

Women speak out about birth trauma ahead of NSW parliamentary inquiry.

ABC Illawarra / By Penny Burfitt 21 Jul 2023

In Australia, routine antenatal health care and screening around mental health is quite narrow. It really only looks at antenatal and postnatal depression, with some mentions of anxiety. No one is screening for birth-related PTSD; it’s strangely overlooked.^(21.).

Menstrual cycle phase influences on PTSD and fear response symptoms

Natural fluctuations in oestradiol, progesterone and its metabolite allopregnanolone, the primary endogenous female steroid hormones, over the ovarian cycle of women are associated with changes in PTSD symptoms which are in turn co-related with how these hormones influence neural substrates (including HPA axis, serotonergic, gamma-aminobutyric acid (GABA) ergic, and noradrenergic stress response systems) critical for the regulation and conditioning of fear responses^(12.).

Limited available data on menstrual cycle phase and PTSD symptoms suggest that different aspects of PTSD symptomology change over the varying phases of the menstrual cycle, including an increase in memory-related symptoms such as flashbacks and intrusive recall during the early/mid luteal phase, increased behavioural avoidance symptoms (e.g., “feeling afraid to travel on buses, or trains”) during the late luteal and early follicular phases, and a spiking of anxiety symptoms during the early follicular phase.

There may also be cultural beliefs or stereotypes about symptoms during specific phases of the menstrual cycle that contribute to symptom fluctuations^(22.).

Findings also raise potential considerations regarding the delivery of exposure-based treatments for PTSD (see below) within specific phases of the menstrual cycle. For example, better encoding of trauma memories appears to occur in the midluteal phase^(22.), with an increased glucocorticoid release associated with the luteal phase of the menstrual cycle found to facilitate consolidation of trauma memories^(23.).

Editor’s note: It must be emphasised that there are no standard male or female response types to traumatic stress, but some features are more common in women and others in men.

Generally, symptoms of PTSD are more severe, chronic, and recurrent in women than they are in men. Associated symptom/behaviour types also differ. Women with PTSD report, in addition to the core symptoms listed above, dissociative phenomena, somatisation (bodily ailments), disordered eating, low self-esteem, and extreme levels of guilt and shame, whereas men commonly present with problems relating to aggression, thrill-seeking, risk-taking, and impulse-control.

Females are also more likely than males to experience symptoms for a longer period before seeking diagnosis and treatment. On average, females wait 4 years, compared with 1 year for males, before seeking help for their symptoms.

Notable ‘red-flag’ issues for women and PTSD are summarily listed below:

Re-experiencing: traumatic events are more often re-lived in the minds of women than men, with intrusive, vivid memories (sometimes called ‘flashbacks’) commonly described, and often experience higher levels of anxious arousal as a consequence of these events. Importantly, a recent study showed that genetic alterations of dopamine D1-receptor-expressing neurons can exaggerate remote contextual fear, which corresponds to the ‘re-experiencing’ symptom of PTSD^(24.).

Avoidance behaviour: women may experience themselves more frequently avoiding things, people, places, activities etc that trigger memories of the trauma than men. In particular, women often avoid their trauma by pouring themselves into their career or parenting so that they are busy 100% of the time and have no ‘downtime’ for their mind to ‘wander where they don’t want it to go’. Thus, although counterintuitive, avoidance behaviour in women may be masked by a hyper-focused or high functioning outward appearance.

Self-blame and guilt: women are more likely than men to form negative views of themselves following a trauma, and experience more feelings of guilt or shame, especially in relation to sexual assault. This may be worsened by cultural issues (such as stigma against assault survivors).

Anxiety and depression: women may experience more internal symptoms, such as feeling down and anxious, compared to men who sometimes have more struggles with anger or substance abuse.

Panic attacks: these are more commonly experienced by women and can bring on physical symptoms like a racing heart and shallow breathing. A medical practitioner should be consulted in these instances.

Stronger startle response: women with PTSD may feel more frequently ‘on edge’ or ‘jumpy’, startle more easily, or find themselves reacting more strongly than usual upon being startled.

Numbness: women in particular may have more trouble feeling emotions and self-assess as ‘detached’ or ‘numb’ when going through PTSD. They may lose interest in hobbies, feel flat or disinterested, and have trouble forming attachments with others or continuing relationships they had maintained before the trauma.

Feeling ‘frozen’: another manifestation of numbness, women commonly describe a ‘freeze response’ (readers may find polyvagal theory useful in better understanding this autonomic nervous system phenomenon) when reminded of their traumas, feeling paralysed and unable to react.

Distrust:. women who experience trauma at the hands of someone they know (eg an intimate partner or family member) frequently develop a lasting sense of general distrust (especially of men, who are disproportionately represented in positions of power).

Physical aches and pains: women experience somatic (bodily) symptoms more than men. These can include fatigue, muscle and joint pain, headache or other physical ailments, and disorders related to altered immune or inflammatory responses.

Co-morbidities: entangled more in women with PTSD than men are eating disorders and hormonal-related mood swings. Women with a history of PTSD are 2.5 times more likely to experience alcohol abuse or dependency compared to those who have never had PTSD.

Excessive rumination: characterised by repetitive, negative self-focused thoughts and mood, several studies^(25.) report alterations in the neural substrates of ruminative thought in women with PTSD.

Peritraumatic dissociation: i.e. experiencing dissociative states during a traumatic experience such as depersonalisation, derealisation, amnesia, and/or detachment is more prevalent in women than in men.

Reduced self-kindness including: less meaning in life, reduced self-growth and personal development, less positive reframing of other distressing experiences, and the development of a pattern of being involved in constricted or abusive relationships^(21.) characterise the PTSD experiences of many women, particularly the victims of IPV^(18.).

Negative financial consequences, housing instability, and social stigma are additionally more likely to be felt by women with PTSD.

Coping style traits: research examining sex/gender differences in the relationship between PTSD symptoms and personality traits^(26.) has found that although women use a ‘broader and more flexible repertoire of stress-response strategies’ (i.e. have an emotion-focused coping style), women who develop more severe PTSD symptoms score higher for emotional reactivity and perseveration (going to extremes) and lower for endurance than men exposed to similar traumas.

The diagnosis of PTSD in women

To receive such a diagnosis, a person must 1. have experienced (or been intimately involved with, in the case of first responders and some medical professionals) one or more traumatic events, 2. continue to experience a significant proportion of the symptoms above over time (at least a month, although the symptoms may not emerge immediately after the trauma), and 3. be negatively impacted by 1. and 2. in their capacity to lead an ‘ordinary life’ (eg employment, relationships, interests, life goals etc).

Amongst several available screening ‘tests’ for PTSD, the ‘PCL-5’ is currently the most widely utilised assessment tool in Australia. The infographic below includes a list of the 20 symptoms screened for in the PCL-5, based on, and named after, the DSM-5:

It should be noted that self-assessment against the items above doesn’t predict a mental health diagnosis, although it may provide a good starting point for discussion of the topic with a qualified mental health professional, who will most likely ask for additional information, including some details related to the trauma/s you have experienced, so that the best treatment approach may be agreed upon. Before diving into the various treatment approaches, it’s crucial to have a comprehensive understanding of PTSD symptoms in women, as this will guide the therapeutic process.

Interestingly, women with PTSD may benefit more from treatment than men with PTSD do. As one researcher puts it “a handful of studies have shown that men may drop out of therapy prematurely more so than women, and that women may improve a bit more than men”.

Numerous randomised control trials have identified the psychotherapeutic approaches that effectively treat PTSD and which may be tailored or combined to fit each patient’s differing needs.

These ‘evidence-based’ therapies include different kinds of cognitive approaches (e.g. CBT/CPT-see below), which help change a patient’s thought processes around the negative event, and exposure therapies (e.g. prolonged exposure therapy, EMDR-see below), which guide patients through the process of re-experiencing trauma in a safe and controlled manner such that may be ‘re-consolidated’ in a holistically healthy way.

When perusing the list below, it is important to note that each treatment type is associated with particular risks, contraindications, and levels of demonstrated efficacy, depending on each sufferer’s individual circumstances: the expert advice of a qualified mental health practitioner should be sought when choosing an approach.

EMDR

Based on the Adaptive Information Processing (AIP) theory of PTSD, eye movement desensitisation and reprocessing involves recalling trauma-related memories while focusing on an external bilateral (side-to-side) stimulus (such as a moving light/object, sound, or skin tap/sensation). For more information regarding EMDR, please navigate to this page. The history of, and science behind, the approach is explained here.

Prolonged Exposure Therapy (PET)

PET, which incorporates Emotional Processing Theory as well as AIP, and generally requires a greater number of sessions than EMDR, utilises ‘in-vivo’ (i.e. ‘out-of-rooms’ controlled, brief, activity-based) exposure in addition to the type of (imaginal) exposure facilitated during EMDR.

Cognitive Processing Therapy (CPT)

A form of cognitive behavioural therapy (CBT) and based on Cognitive Processing Theory, users of this cognitive restructuring approach learn how to think about things in a new way. Mental imagery of the traumatic event may help them work through their trauma to gain control of their fear and distress.

(Socratic) dialogue with the therapist examines problematic beliefs, emotions, and negative appraisals stemming from a traumatic event, such as self-blame or mistrust.

By strengthening connectivity within the brain’s Executive Control Network, CPT addresses the ‘top-down’ cognitive control of affective (thought/mood) processes, which are disrupted in PTSD, to improve the processing of trauma-related stimuli, resulting in moderated expression of emotion in response to trauma-related cues.

Overall, findings^(27.) indicate that CPT is effective in reducing psychological symptoms of PTSD in women (particularly IPV survivors^(28.)), and is also available in various specialised and ‘condensed’ protocols tailored for optimal feasibility and treatment palates.

Schema Therapy

Schema therapy was originally developed as an expansion of traditional cognitive-behavioural treatments and integrates elements of cognitive therapy, behaviour therapy, attachment theory, and emotion-focused therapies.

Derived from, and sharing the same toolbox of strategies as CBT/CPT, schema therapy additionally integrates a number of novel behavioural/affect change techniques, such as imagery rescripting, Chair Work, and Limited Reparenting, to create change and promote post-traumatic growth.

Conceptually, Schema therapy is based on addressing the following constructs:

Early Maladaptive Schemas: Self-defeating, core themes or patterns that are repeated throughout one’s lifetime, and which develop in response to basic emotional needs not being adequately met during the developmentally sensitive years of childhood and adolescence.

Schema Modes: Emotional states which are also often associated with habitual behavioural responses which are triggered by life situations that we are sensitive to (our “emotional buttons”).  Schema modes can shift from minute-to-minute and may lead people to act or react in ways that actually result in increased longer-term distress.

Maladaptive Coping Styles: Environmentally driven ways in which, as a child, we adapted ways of managing distressing experiences in order to survive and continue with daily life. For example, blocking out pain, fighting back, or people-pleasing.

For those whose curiosity is piqued by (the relatively recent) ‘social safety theory’ PTSD treatment model, further research into this modality may prove fruitful.

Other therapies to investigate

With the jury still out on whether they may be officially classed as ‘evidence-based’ PTSD treatments at this time (some are certified treatments for various other disorders), the following are referenced for completeness:

Psychedelic (MDMA)- assisted therapy

Clearly a field fraught with controversy, the therapist-guided use of psychedelics in the (often co-) treatment of several psychological disorders has garnered recent support. Indeed, where all other treatments have failed:

In Australia, from July 1, 2023, authorised psychiatrists will be allowed to prescribe MDMA — the active ingredient in party drugs such as “ecstasy” or “molly” — to treat post-traumatic stress disorder (PTSD).

“The mind field” Four Corners, Published 25 Jul 2022 By Elise Worthington, Kyle Taylor, and Tynan King

Relevant excepts from a February 2023 ABC News report (‘TGA approves psilocybin and MDMA for use in treating depression and PTSD’ by Leonie Thorne) are worthy of inclusion here:

The TGA said the decision addressed the “lack of options” for people with some mental illnesses that did not respond to other treatments, and stressed that the drugs had only been approved for use under controlled medical settings by authorised psychiatrists.

Richard Bryant from the School of Psychology at the University of NSW urged caution, saying scientists did not know how MDMA compared to existing, evidence-based treatments for PTSD that were “cheaper and simpler”. He adds “The science is at a point where we can say it is too early to be prescribing MDMA for PTSD patients”.

The most advanced trials to date come out of the US, where the not-for-profit Multidisciplinary Association for Psychedelic Studies is currently awaiting results from phase three trials using MDMA to treat PTSD.

The association’s claim that phase two research showed 67 per cent of participants no longer had PTSD two months post treatment was unable to be verified by the time this article was published.

Narrative Exposure Therapy (NET)

NET, like PET, is grounded in emotional processing theory and may utilise similar strategies, nuancing the therapeutic pathway with an emphasis on ‘the experiencing self which participates in every part of a (trauma) story^(29.)’; one’s autobiography is central to the structure of therapy this approach informs.

Notably, it is recognised in the UK as an evidence-based treatment for PTSD.

Psychodynamic Psychotherapy & Brief Eclectic Psychotherapy (BEP)

Both of these incorporate imaginal exposure, written narrative processes, cognitive restructuring through attention to meaning and integration of the experience, relaxation techniques, and may utilise metaphors and ‘ritual’ in achieving trauma ‘closure’/growth.

Finally, there is weaker support for several individual, manualised non-trauma-focused therapies for patients diagnosed with PTSD, such as Stress Inoculation Training (SIT), Present-Centred Therapy (PCT), and Interpersonal Psychotherapy (IPT). While these treatments are not strongly recommended, there is some data to be found indicating these approaches produce an outcome superior to that achieved by receiving no treatment at all. Similarly, though limited data shows group therapy for PTSD is less effective than individual manualised therapy, it is still suggested if the alternative is no treatment.

In conclusion

If you or a loved one is or may likely be suffering from PTSD, or you are looking for a therapist who is trained and experienced in trauma and/or PTSD and CPTSD treatment, please feel free to contact us.

If you require immediate help, please call a 24/7 help-line such as :

• Lifeline on 13 11 14
• Kids Helpline on 1800 551 800
• Suicide Call Back Service on 1300 659 467
• Beyond Blue on 1300 224 636 or its
• Headspace on 1800 650 890

If you believe yourself or others to be at risk of immanent harm, you must call ‘000’.

Appendix: A framework for understanding PTSD

From research for this article illuminating many theoretical frameworks^(5.) purporting to best represent the expression of PTSD in relation to numerous variables including trauma type & timing, age, predisposition, early life stress, genetics, neurobiology, immunology, co-morbidity and various ‘-omics’, Social Safety Theory arguably achieves the multifoliate gestalt of current biopsychosocial and diathesis-stress PTSD modelling most useful for explaining why men and women experience PTSD differently.

Indeed much of this exposition (and subsequent articles tracking new research into the PTSD-immune system link) references the diagram^(30.) below:

Abbreviations: ACTH, adrenocorticotropin hormone; ADRB2, b2-adrenergic receptor; CNS, central nervous system; CRH, corticotropin releasing hormone; CSF, cerebrospinal fluid; DAMPs, damage-associated molecular patterns; HPA, hypothalamic–pituitary–adrenal; PRR, pattern recognition receptor; SNS, sympathetic nervous system.

Key: (a) Social Safety Theory is grounded in the understanding that the primary purpose of the human brain and immune system is to keep the body biologically and physically safe.

Accordingly, the brain continually monitors the (1) social environment, interprets social signals and behaviours, and judges the extent to which its surroundings are socially safe versus threatening. These appraisals are subserved by the (2) amygdala network, mentalising network, empathy network, and mirror neuron system (i.e., the social brain).

When a potential social threat is perceived, the brain activates a multilevel response that is mediated by several social signal transduction pathways- namely, the (3) SNS, (4) HPA axis, (5) vagal (parasympathetic) neuro-pathways, and (6) meningeal lymphatic vessels.

These pathways enable the brain to communicate with the peripheral immune system and vice versa. Whereas the main end products of the SNS (i.e., adrenaline and noradrenaline) suppress transcription of antiviral type I interferon genes and upregulate transcription of proinflammatory immune response genes, the product of the HPA axis (i.e., cortisol) generally reduces both antiviral and inflammatory gene expression, although it can lead to increased inflammatory gene expression under certain physiological circumstances (e.g., glucocorticoid insensitivity/resistance).

The vagus nerve in turn plays a putative role in suppressing inflammatory activity, whereas meningeal lymphatic vessels enable immune mediators originating in the CNS to traffic to the periphery, where they can exert systemic effects.

(b) This multilevel “Biobehavioural Response to Social Threat” is critical for promoting well-being and survival. However, it can also increase risk for negative health and behavioural outcomes when it is sustained by internal physiological or external social recursion. Several factors can also moderate these effects, including birth cohort, childhood microbial environment, sleep, genetics, air pollution, diet, and self-harm behaviour.

Editor’s note: The text and images comprising this article are for educational purposes only, are not intended to be a substitute for professional advice, and do not necessarily reflect the views of Brisbane Counselling Centre.

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