PTSD Clinical Formulation in PE: Fear Structures


Associate Vice-Chair of Clinical Research, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
Director, Emory Healthcare Veterans Program
Director, Emory Trauma and Anxiety Recovery Program
Paul A. Janssen Chair in Neuropsychopharmacology

Key Points

  1. Sarah’s PTSD and potential depression originate from a traumatic childhood experience involving a violent home invasion, leading to unprocessed emotional trauma.
  2. Her condition is characterized by an interplay of specific stimuli (triggers), her responses to these stimuli, and the meanings she attaches to them, leading to avoidance and fear.
  3. The lack of emotional processing and discussion about her traumatic experiences post-immigration has played a crucial role in the persistence and severity of her symptoms.
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Sarah was diagnosed with Post-Traumatic Stress Disorder (PTSD) and possibly depression. Her traumatic experience occurred at age eight in Somalia, involving a violent home invasion by soldiers. This event, marked by threats to her family and exposure to violence, is central to her current psychological condition.

Emotional Processing and Immigration

Sarah’s inability to process this trauma emotionally at the time, compounded by a lack of discussion about these events after immigrating to the United States, has significantly impacted her mental health.

Presenting Symptoms

Stimuli, Responses, and Meaning

Sarah’s case involves a complex interplay of stimuli, responses, and their associated meanings which, in PE, are conceptualized as being the elements of the fear structure:

  1. Stimuli: Various triggers, such as loud noises, crowds, and discussions about the traumatic event, evoke fear responses in Sarah. She actively avoids situations reminiscent of her trauma, including rush-hour travel and large gatherings.
  2. Responses: Her psychological responses include exaggerated startle reactions, hypervigilance, decreased concentration, nausea, lightheadedness, and avoidance of trauma-related topics. Sleep disturbances are notable, stemming from the traumatic nighttime invasion.
  3. Meaning: Sarah associates certain situations with danger and vulnerability. She perceives crowds, public transportation, and even her family’s safety as potential threats, reflective of her traumatic memories. Her fear of police is influenced by her past trauma with soldiers and societal issues of police brutality towards African Americans in the U.S.


Impact of Trauma

The home invasion disrupted Sarah’s sense of safety permanently. Her father’s subsequent alcohol use and her parents’ avoidance of discussing the trauma deprived her of the opportunity to process her experiences.

Influence of Perpetrators

The actions of the Somalian soldiers and a corrupt regime not only caused the initial trauma but also shaped her current fears and distrust.

Looking for practical everyday tools? This print-friendly handout is just what you need. Click on the following link to download the PDF:

Addressing PTSD Through Fear Structure Analysis

This handout summarizes important aspects of prolonged exposure (PE) therapy for post-traumatic stress disorder (PTSD). It focuses on the concept of ‘fear structure’ in a patient’s memory, which is key to understanding and treating PTSD with PE. The handout mentions that PE therapy targets reducing avoidance behaviors and enhancing the emotional processing of traumatic events. It references a case study to illustrate these points, highlighting how PTSD symptoms and their underlying causes, such as the impact of traumatic events and cultural adjustments post-immigration, can affect a patient’s mental health.


When using this handout in your practice, focus on identifying and understanding the ‘fear structure’ in your PTSD patients’ memories as outlined in prolonged exposure (PE) therapy. Use the case study as a reference to recognize how specific stimuli trigger fear responses and the meanings patients assign to these. Engage in discussions about the impact of trauma and how factors like immigration and cultural adjustments may compound the patient’s experience and processing of traumatic events. This handout summarizes important aspects of PE therapy and its application in real-world clinical settings, helping you address the complex dynamics of PTSD in your patients.

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PTSD Clinical Formulation in PE: Fear Structures