When most people think of post-traumatic stress disorder (PTSD), they imagine symptoms like flashbacks, nightmares, and feeling constantly on edge.
These are the fear-based symptoms that are often shown in movies and talked about in the news. But new research from Yale School of Medicine shows that PTSD is more complex than just fear.
According to scientists at Yale, PTSD actually comes in two main forms: one focused on fear, and another focused on emotional pain. This discovery could change how we think about PTSD and how it’s treated.
The research was led by Dr. Ziv Ben-Zion, Dr. Ilan Harpaz-Rotem, and their colleagues. They found that current ways of diagnosing and treating PTSD mostly focus on fear. But this new study shows that emotional pain—such as sadness, guilt, and a sense of loss—can be just as important.
In their first study, the team looked at more than 800 people who had experienced trauma. They used a questionnaire to understand which symptoms people had. They found two clear patterns.
One group had symptoms linked to fear: being startled easily, avoiding reminders of trauma, having nightmares, and distressing flashbacks. The other group had symptoms tied to emotional pain: feeling emotionally numb, having negative thoughts, trouble sleeping, and feeling withdrawn.
Surprisingly, almost 70% of the participants said emotional pain caused more problems in their daily lives than fear did.
To go a step further, the researchers used brain scans to study the brains of 162 people who had recently experienced trauma. They wanted to see if brain activity patterns could predict whether someone would later develop fear-based or emotional pain-based PTSD.
Using a method called functional MRI (fMRI), the team looked at how different parts of the brain talked to each other. They found that these patterns could predict how bad a person’s fear-based symptoms would be 14 months later—but not their emotional pain symptoms.
This finding is important because it suggests that the fear and emotional pain types of PTSD might come from different brain mechanisms. That could explain why treatments focused only on reducing fear don’t work for everyone.
Dr. Ben-Zion says that understanding whether a person’s PTSD is driven by fear or emotional pain could lead to better, more personalized care.
“A simple but powerful clinical question is whether fear or emotional pain is driving a patient’s distress,” he explains. “Centering treatment on that dominant emotional experience may lead to more precise and effective care.”
This new research may help explain why many PTSD medications fail or only work for some people. Dr. Harpaz-Rotem, one of the senior scientists in the study, says that the team is focused on “precision psychiatry”—developing treatments that are customized to the individual based on their unique symptoms.
For years, PTSD has been treated as if it was just about fear. But this study shows that emotional pain plays a major role too, and for many people, it might even be the bigger problem.
The study was published in the journal Biological Psychiatry and points to a future where PTSD treatment is more tailored, effective, and compassionate.
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