Emotional pain, not fear, weighs more heavily on individuals with PTSD
A study in Biological Psychiatry identifies two distinct biological post-traumatic stress disorder profiles, paving the way for more precise and compassionate treatment
Elsevier
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A new study in Biological Psychiatry, published by Elsevier, challenges the long-held view of post-traumatic stress disorder (PTSD) as a fear-based disorder. In the study, 68% of trauma-exposed individuals reported that emotional pain impaired their daily functioning more than fear. This network illustrates the relationships between fear (red), emotional pain (orange), and specific PTSD symptoms (light blue) based on the 20 items of the PCL-5 (checklist for DSM-5) questionnaire. Blue lines represent positive associations, while red lines indicate negative associations, with the thickness of the lines corresponding to the magnitude of the partial correlations.
view moreCredit: Biological Psychiatry / Ben-Zion et al.
February 4, 2026 – New research is challenging the long-held view of post-traumatic stress disorder (PTSD) as a fear-based disorder. In a new study, 68% of trauma-exposed individuals reported that emotional pain (guilt, shame, sadness, loss of joy) impaired their daily functioning more than fear. The findings from this research in Biological Psychiatry, published by Elsevier, underscore the need to broaden PTSD models beyond fear and re-evaluate treatment pathways accordingly.
PTSD affects approximately 8% of individuals and often co-occurs with depression and anxiety. The DSM-5 defines PTSD based on 20 symptoms spanning intrusion, avoidance, negative mood and cognition, and hyper-arousal. In this study across two independent samples, researchers identified two distinct PTSD profiles—one centered on fear (flashbacks and hyper-arousal symptoms), and another on emotional pain (symptoms of guilt, shame, anhedonia).
“For some, trauma inflicts not just fear, but a moral or existential wound, shattering beliefs about oneself, others, or the world; For others, it deepens pre-existing negative schemas, reinforcing guilt, shame, or worthlessness. These internalized and meaning-laden responses often give rise to persistent emotional pain,” says first author Ziv Ben-Zion, PhD, Yale School of Medicine, VA Connecticut Healthcare System, and University of Haifa.
Senior investigator Ilan Harpaz-Rotem, PhD, Yale School of Medicine, Yale University, and VA Connecticut Healthcare System, adds, “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 Study 1, using a large online sample of 838 trauma-exposed individuals, researchers mapped how fear and emotional pain relate to specific PTSD symptoms through network analysis. Study 2, a unique longitudinal neuroimaging study of 162 recent trauma survivors, used whole-brain connectivity at one-month post-trauma to predict symptom severity 14 months later for the two profiles identified in Study 1 (Fear and Emotional Pain). Connectivity patterns robustly predicted chronic fear-based symptoms but not emotional pain, suggesting mechanistic differences between these profiles.
This is one of the first studies to integrate subjective emotional experience, symptom network structure, and neurobiological prediction to differentiate PTSD profiles.
John Krystal, MD, Editor of Biological Psychiatry, comments, “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 continues, “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.”
“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,” notes Dr. Harpaz-Rotem.
Identifying whether a patient’s distress is primarily driven by fear or by emotional pain could guide more personalized and mechanism-based treatment planning. Fear-driven profiles may respond best to exposure-based therapies, whereas emotional pain may be better addressed through approaches targeting guilt, shame, and negative self-beliefs. This distinction may also help clarify which symptoms are likely to persist chronically.
Dr. Ben-Zion concludes, “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.”
Research in Biological Psychiatry, published by Elsevier, has identified two distinct post-traumatic stress disorder (PTSD) profiles—one centered on emotional pain and another on fear. This figure shows the strength of the associations (edge weight) of both profiles, detailing specific PCL-5 (DSM-5 symptoms) items. Legend: PCL1=Memories, PCL2=Nightmares, PCL3=Flashbacks, PCL4=Emotional Reactivity, PCL5=Physical Reactivity, PCL6=Internal Avoidance, PCL7=External Avoidance, PCL8=Amnesia, PCL9=Negative Beliefs, PCL10=Blame, PCL11=Negative Emotions, PCL12=Anhedonia, PCL13=Disconnection, PCL14=Trouble Positive Emotions, PCL15=Irritability, PCL16=Risk Behavior, PCL17=Hypervigilance, PCL18=Startle, PCL19=Concentration, PCL20=Sleep.
Credit
Biological Psychiatry / Ben-Zion et al.
Journal
Biological Psychiatry
Method of Research
Experimental study
Subject of Research
People
Article Title
Dissecting Fear and Emotional Pain in PTSD: From Symptom Networks to Neural Signatures
COI Statement
The authors’ affiliations and disclosures of financial relationships and conflicts of interests are available in the article. John H. Krystal, MD, is Chairman of the Department of Psychiatry at the Yale University School of Medicine, Chief of Psychiatry at Yale-New Haven Hospital, and a research psychiatrist at the VA Connecticut Healthcare System. His disclosures of financial relationships and conflicts of interests are available at https://www.biologicalpsychiatryjournal.com/content/bps-editorial-disclosures.
Noninvasive brain treatment reduces traumatic memories
Preliminary results in individuals with PTSD
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Illustration of the experimental setup.
view moreCredit: Tel Aviv University
In the study, participants’ traumatic memories were first reactivated, and only then was brain stimulation applied — precisely at the stage when the memory is in a “flexible” state and amenable to change. The researchers’ goal was to influence the way memory is reconsolidated in the brain, thereby alleviating post-traumatic symptoms.
A new study conducted at Tel Aviv University introduces an innovative approach to treating post-traumatic stress disorder (PTSD), generating particular interest in light of the sharp rise in the number of individuals coping with the condition following the events of October 7 and the Iron Swords War. According to the study’s preliminary findings, treatment using noninvasive brain stimulation succeeded in significantly reducing intrusive memories, such as flashbacks and intrusive thoughts, which are considered among the most severe and treatment-resistant symptoms of PTSD.
The study was conducted in the laboratories of Prof. Nitzan Censor and Yair Bar-Haim from the School of Psychological Sciences and the Sagol School of Neuroscience at Tel Aviv University. It was led by doctoral students Or Dezachyo and Noga Yair, in collaboration with the laboratory of Prof. Ido Tavor. The research team included Noga Mendelovitch, Dr. Niv Tik, Dr. Haggai Sharon of Tel Aviv Sourasky Medical Center (Ichilov), and Prof. Daniel Pine of the National Institute of Mental Health (NIMH) in the United States. The study was published in the scientific journal Brain Stimulation.
PTSD affects millions of people worldwide, including soldiers and survivors of terrorist attacks, traffic accidents, and violence. Despite advances in psychological and pharmacological treatments, only about 50% of patients respond well to existing therapies, and intrusive memories continue to burden many of them years after the traumatic event. These memories are not just distressing thoughts; they are vivid, tangible experiences that reactivate the body and emotions as though the trauma were happening all over again.
The researchers focused on the hippocampus — a deep brain structure responsible for the processing, storage, and retrieval of memories. Because direct stimulation of deep brain regions requires invasive intervention, the team employed an indirect and sophisticated method: they identified superficial brain regions that are functionally connected to the hippocampus and stimulated them using transcranial magnetic stimulation (TMS). The precise stimulation site was determined individually for each participant based on fMRI scans, allowing for a personalized treatment approach.
Ten adults with PTSD participated in the initial study, undergoing five weekly treatment sessions. During each session, the traumatic memory was first deliberately reactivated, after which brain stimulation was applied — precisely at the stage when the memory is in a “flexible” state and more open to change, within a process known as reconsolidation. The researchers’ aim was to influence the way the memory is re-stored in the brain, thereby alleviating post-traumatic symptoms.
The results showed a sharp reduction in the severity of post-traumatic symptoms, particularly in the frequency and intensity of intrusive memories, with participants demonstrating consistent improvement. At the same time, brain imaging revealed reduced connectivity between the hippocampus and the stimulation regions — evidence that the effects were not merely subjective but reflected a real change in brain activity.
Special significance in the aftermath of October 7
These findings carry particular importance for IDF soldiers, members of the security forces, civilians exposed to the terror attacks of October 7, survivors of the massacre, and victims of shootings and abductions — Israeli populations in which the prevalence of PTSD is expected to be especially high. Many of them report experiencing intense intrusive memories months after the events. The potential development of a short, noninvasive treatment that directly targets the mechanisms underlying traumatic memories could become a valuable component of the national rehabilitation effort.
According to the researchers, although this was a preliminary study conducted in a small group and did not include a control group, it provides clear proof of feasibility. Larger, controlled clinical trial is already underway at Tel Aviv University, and is required to assess the method’s effectiveness and long-term impact. If the findings are confirmed, this may represent a fundamental shift in the way traumatic memories are treated — addressing not only its emotional consequences, but the underlying neural root itself.
Prof. Nitzan Censor concludes: “These preliminary findings point to a conceptual shift in how we can approach the treatment of PTSD. We are attempting to intervene, in a targeted manner, in the brain mechanism of memory itself — at the moment when it ‘reopens’ and becomes amenable to change. The fact that we observed a consistent reduction in intrusive memories, alongside a measurable change in brain activity, is encouraging. It is important to emphasize that these are still very early results. Nevertheless, especially in light of the current reality in Israel, we hope that continued, comprehensive clinical research will eventually make it possible to develop a noninvasive and accessible treatment that will help many soldiers and civilians return to functional lives, free from the constant intrusion of traumatic memories.”
Link to the article:
https://www.sciencedirect.com/science/article/pii/S1935861X25003651?via%3Dihub
Journal
Brain Stimulation
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