Intended for healthcare professionals


Neglected causes of post-traumatic stress disorder

BMJ 2019; 365 doi: (Published 10 June 2019) Cite this as: BMJ 2019;365:l2372
  1. Chris R Brewin, emeritus professor in clinical psychology1,
  2. Freya Rumball, clinical psychologist2,
  3. Francesca Happé, professor of cognitive neuroscience2
  1. 1Clinical, Educational and Health Psychology, University College London, Gower Street, London WC1E 6BT, UK
  2. 2Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, UK
  1. Correspondence to: c.brewin{at}

Patients with psychosis, other delusional states, or autism are also at risk

Post-traumatic stress disorder (PTSD) has been defined by successive editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (most recently DSM-5). The diagnosis requires an objectively traumatic event that involves exposure to “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence.” This focus on objective event characteristics maintains PTSD as a response to extreme rather than everyday stress, but it overlooks mounting evidence that subjective responses to traumatic events predict PTSD just as or more strongly.1 Groups of patients who are at risk of developing PTSD might be overlooked because the triggering event is subjectively rather than objectively traumatic. We describe three such groups here, but there are undoubtedly others.

Traumatic events, both objective and subjective, are common in the lives of patients with psychosis. Experiences, such as being forcibly sedated or admitted to hospital during an acute episode, can be terrifying to someone who cannot understand fully what is happening or appreciate the motives of those involved. …

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