Posttraumatic Stress Disorder (PTSD) Criteria and Phenomenology

DSM-5-TR PTSD. DSM-5-TR defines PTSD after exposure to a traumatic event (Criterion A). Core symptoms are grouped into intrusion (Criterion B), avoidance (C), negative cognition/mood (D), and hyperarousal (E). Intrusive re-experiencing takes the form of distressing memories, nightmares, or dissociative flashbacks in which the trauma seems to recur. Avoidance includes conscious efforts to avoid trauma reminders. Negative alterations in mood/cognition include amnesia for trauma aspects, persistent negative beliefs, exaggerated blame, anhedonia, isolation, or dysphoria. Arousal/reactivity symptoms include irritability, aggression, reckless behavior, hypervigilance, exaggerated startle, and sleep/concentration problems. Symptoms must persist >1 month, cause impairment, and not be due to substances/illness. DSM-5-TR introduced no changes to these adult criteria. DSM-5 also allows a dissociative specifier (Depersonalization/Derealization) for those with prominent trauma-linked dissociation.

ICD-11 PTSD. The WHO’s ICD-11 narrows core PTSD to three clusters: re-experiencing, avoidance, and a sense of current threat. Re-experiencing is defined as either trauma-related nightmares or dissociative flashbacks (reliving the trauma “here and now”). Avoidance requires at least one symptom of avoiding trauma memories or reminders (internal or external). A sense of threat manifests as persistent hypervigilance or exaggerated startle. Functional impairment is also required. In ICD-11, hypervigilance is explicitly listed as the ongoing alertness for danger. Notably, ICD-11’s PTSD criteria do not include delusions or hallucinations as core features; however, the ICD-11 text acknowledges that “psychotic reactions” (hallucinations or delusions) can accompany PTSD when they are related to the trauma. In both systems, intrusive re-experiencing, avoidance of reminders, and heightened threat perception (hyperarousal) are hallmark features of PTSD.

PTSD Symptom Profile: Hypervigilance, Intrusions, Dissociation, and Mistrust

Hypervigilance and threat perception. PTSD often involves chronic hyperarousal, especially hypervigilance – a constant scanning of the environment for threat. People with PTSD may be on “constant alert,” over-interpreting benign cues as dangerous. This can lead to exaggerated threat perception (“everyone is out to get me”) and mistrust. The excessive vigilance is a learned response from life-threatening trauma, not true paranoia, but it can resemble paranoid thinking. For example, DSM-5’s Criterion E specifically lists hypervigilance and an exaggerated startle reflex as trauma-linked arousal symptoms.

Intrusive memories and nightmares. Intrusive re-experiencing (Criterion B) can be severe. Survivors report sudden, vivid memories or nightmares in which they relive the event. Unlike ordinary flashbacks, these can involve dissociation. ICD-11 emphasizes that flashbacks lie on a continuum: one end is complete absorption (as if the event is actually happening again), and the other a distressing “memory as if” moment. This re-experiencing is unmistakably trauma-linked (e.g. hearing voices of a former abuser only when reminded of that abuse).

Avoidance and numbing. Individuals with PTSD actively avoid thoughts, places, or situations that remind them of the trauma. Emotional numbing (detachment, loss of interest) and negative beliefs about self/others/world often follow. Over time, mistrust of others is common, especially if the trauma was interpersonal (e.g. abuse by a trusted person). However, this mistrust is generally mood- or trauma-related, not a fixed false belief.

Dissociation. PTSD frequently involves dissociation. The DSM-5 dissociative specifier notes that some patients experience depersonalization (“this is not happening to me”) or derealization (“things are not real”) during trauma recall. More broadly, ICD-11 acknowledges that PTSD can be accompanied by pseudohallucinations (e.g. hearing one’s own thoughts as voices) and dissociative amnesia. These can blur the line between memory and perception, making some PTSD experiences appear hallucinatory even though they are internally generated memories.

Flashbacks, Dissociation, Overvalued Ideas and Delusions

A key challenge is distinguishing true psychosis from trauma-related phenomena. Flashbacks (Criterion B) are involuntary re-experiencing of the actual trauma, often with the survivor fully recognizing it as memory (sometimes even noting “This is another flashback”). In contrast, a psychotic hallucination is a sensory experience with no external stimulus. PTSD-related “hallucinations” tend to be more accurately called pseudohallucinations – for instance, hearing a voice of an abuser speaking from one’s own memories. For example, in one case study a veteran “heard [a] flashback saying: ‘hide’… he also hears men from the torture”. Here the auditory “voices” are clearly linked to remembered trauma, even if experienced as if external.

Dissociative experiences are similar to flashbacks but broader. A patient might momentarily feel the trauma “taking over” or lose awareness of the present environment during a flashback, a transient dissociative episode. Such experiences are part of PTSD’s criteria (e.g. flashbacks where one feels the event is recurring) or its dissociative specifier.

Overvalued ideas vs fixed delusions. Trauma can give rise to strong beliefs (e.g. “I will never be safe”) that are understandable given the person’s history. These may border on overvalued ideas – beliefs held with excessive importance but still somewhat flexible. In contrast, a delusion is a fixed false belief that resists all evidence. For example, believing “My ex-abuser is definitely watching me through hidden cameras in every room” is a concrete delusional claim if held with certainty despite no evidence. Overvalued ideas often admit doubt or rationale, whereas delusions do not. Clinically, one asks: can the person recognize a kernel of doubt? Are these beliefs culturally or subculturally shared? By definition, in a bona fide delusion the person cannot be reasoned out of it.

PTSD with Psychotic Features: Subtype or Comorbidity?

“PTSD with secondary psychotic features” (sometimes called PTSD-SP) is not an official DSM or ICD diagnosis. Neither DSM-5/-5-TR nor ICD-11 include a “PTSD-SP” category. Experts have proposed PTSD-SP as a proposed subtype of PTSD (with hallucinations/delusions emerging after PTSD onset), but this remains controversial. Frias Ibáñez et al. (2014) note that some studies “postulate a subtype of PTSD with psychotic features (PTSD-SP)”, but emphasize that “nosological status of PTSD-SP … requires more research”. Similarly, a recent refugee study stressed that PTSD-SP is not recognized in current diagnostic manuals: “PTSD-SP is a rather new concept, which is not included in the diagnostic nomenclature (the DSM-5/ICD-10/ICD-11)”.

Some clinicians use PTSD-SP descriptively for trauma survivors who develop persistent hallucinations or delusions (especially persecutory ones) after PTSD onset, without other psychotic disorder criteria. For example, Rathke et al. report that, in refugee samples, PTSD-SP patients often have chronic auditory hallucinations and persecutory delusions with trauma-related content. Compean & Hamner (2019) review evidence and describe PTSD-SP as an “emerging diagnostic entity,” noting some genetic/biological distinctions. But they caution research is in its infancy and uniform criteria are lacking. In sum, PTSD-SP remains a theorized subtype, not a settled category.

Surveillance and Persecutory Beliefs in Trauma

Many individuals with PTSD harbor hypervigilant beliefs about being watched or targeted. When trauma involves interpersonal violations (abuse, war atrocities, torture), the survivor may develop persecutory ideas – for example, believing their abuser continues to conspire with police or intelligence services to monitor or harm them, or that hidden cameras and phone taps are everywhere. Clinicians describe this as a paranoid/surveillance-themed delusional system when it becomes fixed. Studies show that when hallucinations or delusions occur in PTSD, they are often trauma-themed – e.g. hearing voices of perpetrators or believing former captors are watching them. Rathke et al. found that trauma-affected refugees with psychotic symptoms typically have “hallucinations and persecutory delusions, often reflecting trauma-related themes”. Such beliefs can seem very real to the person. For instance, one patient insisted “they watch me all night through the lamp camera”; another believed “my neighbors spy for the agency that tortured me.” Without evidence (no actual cameras, etc.), these fixed beliefs qualify as delusions. However, one must tread carefully: some real-world stalking or surveillance can and does occur. Assessment must carefully discriminate unfounded delusion from genuine threat, using collateral data (police reports, witness statements) when possible.

Psychotic Symptoms Outside Trauma Reminders

A critical assessment point is temporal context of psychotic symptoms. In pure PTSD re-experiencing, hallucinations or suspiciousness occur during trauma flashbacks or in response to reminders, and are clearly tied to the memory. For example, hearing a voice of an abuser only when seeing a related trigger. In contrast, true psychotic symptoms (e.g. in schizophrenia) would occur independently of trauma cues, in waking reality. If a person only “sees persecutors” while in flashback trance, that suggests dissociation rather than chronic psychosis. But if hallucinations/delusions persist even in neutral, day-to-day contexts, a comorbid psychotic disorder is more likely.

Compean & Hamner note that by definition PTSD-SP involves PTSD symptoms first, followed by chronic psychosis (“PTSD symptoms precede the emergence of chronic psychotic symptoms, such as hallucinations and delusions”). They also emphasize PTSD-SP patients “should not have a formal thought disorder” (i.e. disorganized thinking). Clinically, one looks for intact reality testing aside from the delusional content. If the patient acknowledges some doubt or can be reality-tested when not in trauma recall, that supports PTSD-SP rather than schizophrenia. In practice, diagnosticians may treat them as separate until proven linked: one asks, “Do you ever doubt this belief? Can you explain why this might happen?” The appearance of visual hallucinations, bizarre delusions, or formal thought disorder leans toward a primary psychotic disorder.

Differential Diagnosis

Schizophrenia spectrum: Schizophrenia or schizoaffective disorder can mimic PTSD-SP, but key differences exist. Schizophrenia typically begins in younger adulthood without a clear trauma trigger, often includes formal thought disorder (disorganized speech) and negative symptoms (flat affect, social withdrawal) which are not features of PTSD. Schizoaffective disorder has concurrent major mood episodes. By contrast, in PTSD-SP the psychotic content is thematically linked to known trauma and the emotional tone is often fear rather than flat/blunted mood.

Psychotic depression: Severe depression can involve psychosis (often mood-congruent delusions). Here mood is low and psychosis is mood-linked (e.g. self-blame delusions). If the patient has prominent depressive symptoms, consider major depressive disorder with psychotic features. High comorbidity of PTSD-SP with depression has been reported (79% of PTSD-SP patients also had major depression in one study), so concurrent depression should be treated but does not in itself explain all psychotic symptoms.

Delusional disorder: This involves one or more persistent delusions for ≥1 month, without other psychosis. If a patient has a single isolated fixed delusion (e.g. of being spied on) but no PTSD re-experiencing or flashbacks, delusional disorder is more likely. However, when delusions co-occur with full PTSD criteria, a PTSD-based formulation is favored.

Dissociative disorders: Dissociative Identity Disorder or severe dissociative amnesia can cause unexpected behaviors or voice-like inner experiences, but not true hallucinations or persecutory delusions in the same way. Body-altering dissociation (e.g. feeling detached from body) is common in PTSD but is different from a sensory hallucination.

Medical/substance causes: Traumatic brain injury (TBI) can cause memory problems and hallucinations, so always inquire about head injury history. Drugs (stimulants, hallucinogens) or withdrawal (alcohol, benzos) can produce psychosis; toxicology screening is prudent. Endocrine or neurological conditions (e.g. delirium) should be ruled out in older patients.

Factual stalking/coercive control: Critically, if the patient claims surveillance, check its factual basis. Are there credible reports that they are being followed? True coercive control or harassment (e.g. domestic abuse with technology abuse) should not be dismissed; it may warrant safety measures. Assess whether other people notice suspicious behavior (e.g. family saying “there’s been someone behind you”) or if only the patient reports it. In absence of objective evidence, but presence of PTSD, one may conclude the surveillance belief is likely a delusion stemming from trauma-induced paranoia. Thus, an objective fact-check is needed before labeling a belief delusional.

Trauma History and Interviewing

A trauma-informed approach is essential throughout assessment. Clinicians should ask about past victimization with neutral but empathetic openness, avoiding any implication that the patient is making it up or that their fear is unreasonable. One should neither uncritically accept every reported abuse as literally true (to preserve objectivity) nor reflexively dismiss it (which can retraumatize the person). Instead, gather the trauma history sensitively: use validated screeners (e.g. Life Events Checklist), allow the person to speak in their own words, and build trust. Never say “that’s impossible” to a persecutory belief; that undermines rapport. But also don’t reinforce a delusional claim (e.g. avoid saying “Yes, the CIA really is watching you”). Instead, one might say: “I’m hearing how frightened you are. It must feel terrifying to believe people are plotting against you. Let’s work together to figure out what we can do to keep you safe.”

Trauma-informed interviewing principles emphasize safety, trust, choice, collaboration and empowerment. For example, Stern et al. describe how they engaged a terrified patient by involving her in decisions (letting her disrobe herself, choose her care providers) to maximize her sense of control. Similarly, the clinician should validate the patient’s feelings (“You went through a lot; you have every right to be cautious”) even if clarifying that some beliefs are likely misperceptions. Gentle grounding techniques (brief breathers, breaks, focusing on the present environment) can prevent flashbacks during the interview. The goal is to avoid retraumatization and to collaborate on a plan, not to reinforce delusions or provoke shut-down.

Treatment Approaches

Psychotherapy. First-line interventions for PTSD are trauma-focused psychotherapies. These include prolonged exposure (PE), cognitive processing therapy (CPT), trauma-focused CBT, or EMDR. All major guidelines (WHO, ISTSS, APA) strongly endorse these modalities for PTSD, even in complex cases. Importantly, recent evidence indicates that trauma-focused therapy can be delivered safely to those with psychotic symptoms. For instance, EMDR is recognized by WHO as a first-line treatment for PTSD. A randomized trial in patients with chronic psychosis and PTSD found that EMDR significantly reduced PTSD symptoms (with gains maintained at 6-month follow-up) and even improved psychotic and affective symptoms without harm. Compean & Hamner note that “individuals with PTSD and comorbid psychosis can benefit from evidence-based psychotherapy”. Therefore, PTSD-SP patients should be offered integrated trauma therapy (for example, beginning with stabilization/coping skills and then trauma processing) while carefully monitoring psychotic stress. Cognitive restructuring can also address overvalued beliefs (e.g. testing alternative explanations for perceived surveillance).

Medication. Pharmacotherapy follows general PTSD guidelines. First-line drugs for PTSD are SSRIs or SNRIs (e.g. sertraline, paroxetine). These can also help comorbid depression/anxiety. Prazosin is often used for trauma nightmares (though recent large trials have had mixed results). Sleep aids (mirtazapine, trazodone) or short-term clonazepam may be needed for insomnia, but benzodiazepines should be used with caution.

There is very limited evidence on antipsychotic medications specifically for PTSD-SP. A review concludes that only two atypical antipsychotics (risperidone, quetiapine) have been trialed, and overall “not enough evidence to recommend SGAs” for PTSD-SP. In practice, a low-dose second-generation antipsychotic might be tried if the patient’s hallucinations or delusions are severe and disabling. However, clinicians must weigh this against side effects and the possibility that trauma therapy alone may reduce those symptoms. The high rate of co-occurring major depression (e.g. 79% in one study) means antidepressants (and possibly adjunctive therapy for depression) are often indicated. For substance abuse, integrated treatment (motivational interviewing, CBT for SUD) is essential. When comorbid disorders are present, evidence-based treatments for each should be provided concurrently (e.g. Mood stabilizer or SSRI for bipolar/depression, detox/rehab for substance use).

Safety and stabilization. Before processing trauma, the clinician may need to focus on safety/stabilization (Phase 1 of treatment). This can include teaching coping skills (grounding, relaxation), ensuring the patient has a safe living situation, and collaboratively creating a crisis plan. A trauma-informed safety plan might involve identifying warning signs of a flashback or psychotic break, rehearsing soothing strategies, and establishing contacts (trusted friend, crisis line) to call if alarmed by perceived surveillance. The idea is to empower the patient – for example, agreeing that “if you ever feel unsafe at home because you think someone’s there, let’s make a plan like checking locks together or going to a safe friend’s house” – and to reinforce the person’s own agency over their environment.

Clinical Vignette

Ms. A is a 35-year-old survivor of intimate partner violence (IPV) who presents with severe anxiety. She reports a history of repeated physical abuse by her ex-partner years ago, and was diagnosed with PTSD. Lately she has begun to believe former abuser is still watching her through hidden cameras, and that he bribed local police to monitor her movements. She mentions hearing occasional whispers (“kill her”) and sees fleeting shadows in her apartment corners at night. These symptoms cause intense fear: she rarely leaves home and checks windows constantly.

Assessment: The clinician acknowledges Ms. A’s trauma (“I’m so sorry you went through that abuse; no wonder you feel unsafe”) and gathers history. Ms. A describes standard PTSD symptoms: nightmares of the abuse, flashbacks when alarms go off, avoidance of reminders (she switched jobs to avoid her old neighborhood), hypervigilance (jumps at sudden sounds), and mistrust of strangers. These align with DSM-5 PTSD criteria. The new symptoms – hearing voices and believing in surveillance – raise the question of a psychotic process.

Rather than immediately labeling her delusional, the clinician carefully probes context: “Do these voices say the same things as your nightmares, or different?” Ms. A explains she sometimes hears her ex-husband’s voice from the past. On examination, she reports the voices when alone at night, and feels terrified. The clinician notes she remains oriented to reality (she doesn’t believe the voices come from the lamp), and she retains insight that “maybe it’s my mind playing tricks.” There is no formal thought disorder or bizarre affect.

Differential considerations: The clinician considers schizophrenia or mood disorder, but Ms. A’s primary complaints still revolve around trauma reminders. She denies pervasive delusions outside that context. There is a history of depression treated with SSRIs. No evidence of substance use or medical issues is found. The idea of surveillance is idiosyncratic (cameras in every room), but the clinician gently explores possible factual basis (checking her apartment for devices, contacting a local abuse support worker). Finding no evidence of actual devices, this belief appears to be a fixed paranoid idea likely stemming from her trauma-induced suspicion rather than reality. At the same time, the clinician validates Ms. A’s fear: “It must be terrifying to feel so watched. Whether or not the cameras are real, let’s find ways to help you feel safe.”

Diagnostic uncertainty and collaboration: The psychiatrist explains the diagnosis is uncertain: “Some people with PTSD have trauma-linked psychotic symptoms, but we can’t be sure if this is just PTSD or an additional problem. What we do know is that what you experienced was real and it left you very vulnerable.” Instead of a firm label, the plan is framed in partnership.

Plan (collaborative safety and treatment): They develop a safety plan: Ms. A will ask a trusted neighbor or counselor to check in regularly by phone. The clinician teaches grounding techniques for when she feels a flashback coming. They agree to keep windows locked but also to schedule short daily walks with a friend (addressing avoidance). Medication is reviewed: they maintain her SSRI (helpful for PTSD/depression) and consider a low-dose antipsychotic only if the voices become uncontrollable. The main focus is on trauma therapy: the clinician explains that trauma-focused therapy (e.g. EMDR or CPT) can help process the abuse memories, which may in turn reduce these intrusive perceptions.

Over the following weeks, Ms. A engages in therapy. She slowly builds trust again. When she still feels “spied on,” her therapist gently asks, “What do you notice about the evidence for that?” without arguing. Little by little, Ms. A learns coping skills to soothe her anxiety. Eventually, she reports that the paranoia has decreased in intensity; she still sometimes feels uneasy, but she now has coping strategies (deep breathing, calling a friend, looking out the window with a flashlight to reassure herself there is no one).

Outcome: Through this trauma-informed, collaborative approach, the clinician neither dismisses Ms. A’s fears nor confirms them outright. Diagnostic labels remain provisional. The plan balances safety (“Let’s make sure you have a phone close and someone to call if you’re panicking”) with empowerment (involving her in decisions, reinforcing that “you got through the abuse, and we’re going to get through this together”). This vignette illustrates careful verification of facts, respect for the patient’s perspective, and collaborative safety planning in a case of PTSD complicated by paranoid fears.

References

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5); DSM-5 Text Revision (DSM-5-TR) – criteria summary.
• World Health Organization, ICD-11 for Mortality and Morbidity Statistics, 2019 – PTSD description (re-experiencing, avoidance, threat).
• Frias Ibáñez A, Palma Sevillano C, et al. Trauma, PTSD and psychosis: etiopathogenic and nosological implications. Eur J Psychiat. 2014;28(1):57–73.
• Compean E, Hamner MB. Posttraumatic Stress Disorder with Secondary Psychotic Features: Diagnostic and treatment challenges. Prog Neuropsychopharmacol Biol Psychiatry. 2019;93:132–143.
• Rathke HA, Poulsen S, Carlsson J, Palic S. PTSD with secondary psychotic features among trauma-affected refugees: The role of torture and depression. Psychiatry Res. 2020;287:112898.
• Kronborg L, et al. Secondary psychotic features in refugees diagnosed with PTSD: a retrospective cohort study. BMC Psychiatry 2016;16:268.
• Stern TA, Vyas CM, et al. Caring for traumatized elders: Lessons from trauma-informed care. Prim Care Companion CNS Disord. 2024;26(2):23f03643.
• Bäuml J, Voderholzer U, et al. EMDR therapy in psychosis: A pilot study. Front Psychiatry 2018;9:179.
• National Center for PTSD (US Dept. of Veterans Affairs). PTSD Diagnostic Criteria. (DSM-5-TR).