Learning Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians

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PTSD from a PE View: The Fear Structure, Trauma, and Recovery

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.


  • Fear and anxiety are a normal response to trauma.
  • Due to avoidance, sometimes fear does not extinguish.
  • PTSD can be conceptualized as a disorder of extinction.
  • Fear structures contain information about the feared stimuli, the fear responses, and the meaning.



Our third video is on PTSD: A View from the PE Perspective.
And I want to start with a theoretical idea that we refer to as a fear structure. A fear structure is a program in our memories for escaping danger. It includes information about the feared stimuli, the fear responses, and the meaning of the stimuli and responses.
So an example unrelated to PTSD, say you’re hiking in the woods and you see a bear, that’s going to be the feared stimulus. You’re going to have fear responses. Your heart rate is going to increase. You may start sweating. You may feel a tightness in your stomach. You may feel like you want to freeze, flee, or fight. And usually, the fear responses include one of these three F’s: to fight, flee, or freeze. And the meaning of the stimuli and responses. So in this case, if you see a bear in the woods, you’re going to think, “Oh my gosh, I’m in danger. This bear could hurt me.”

What happens with the trauma memory is that it’s a specific fear structure that includes representations of stimuli that were present during the trauma, physiological and behavioral responses that occur during the trauma, and meanings associated with these stimuli and the responses. The associations among the stimulus, response, and meaning representations may be realistic or they may be unrealistic.

The characteristics of an early trauma structure, in which case they might be unrealistic, there is going to be a large number of stimuli. So everything will trigger this memory. There will be excessive responses, and that becomes the form of PTSD symptoms. There will be erroneous associations between the stimuli and danger. And I’ll give you an example of a young woman I saw years ago who was sexually assaulted and she had been wearing a yellow sweater. And afterwards, she became scared of wearing yellow sweaters. And again, there’s nothing dangerous about a yellow sweater. It’s only through its association with the assault.

The characteristics of the early trauma structure also include erroneous associations between responses and incompetence. For example, a number of people who have frozen during an assault or didn’t fight back, they feel like that’s an indication that they were incompetent.
The early trauma structure is often fragmented and poorly organized.

The early PTSD symptoms, the trauma reminders in the daily life of the trauma memory, and associated perception of danger and incompetence. So when people experience these symptoms, they feel that if I’m scared, there must be danger. Or if I’m scared and there’s not danger, it means I’m incompetent; I’m weak. Activation of the trauma memory is reflected very often in the re-experiencing symptoms and arousal. So when I think of it and I have flashbacks and then my body responds, I don’t like that. I don’t like these re-experiencing symptoms. I don’t like this arousal, this distress I feel in my body. And so then for a lot of people, that motivates avoidance behavior. If I don’t like it, I want to stop doing it.

In chronic PTSD, we see that the persistent cognitive and behavioral avoidance prevents the change in the trauma memory because it limits activation of the trauma memory. Remember earlier we said that when something important happens to us with emotional processing, we need to process it. One of the best ways we process it is by thinking about it. And for example, with the grief process, we think about the person we lost. We cry about the person. We talk with other people and cry about them. And then eventually, it becomes less distressing. It’ll always be sad that we lost them, but maybe 6 months down the road, we can think of them without crying. But if we avoid any activation of the trauma memory, then it prevents this process.
It also limits exposure to corrective information if I have had a motor vehicle crash and I’m now scared to drive my car. Most of us have had some sort of incident in the car. The first time we get behind the wheel, we’re scared. The more we drive, the more we get our confidence back. If we avoid driving, then we don’t have that corrective information. It also limits the articulation of the trauma memory and so it prevents the organization of the trauma memory. It also prevents changing it in any way. So for example, an Iraq or Afghanistan veteran who has been driving down the road hits an IED; the Humvee blows up and his friend dies. If he can’t even think about it, if he can’t even go there, then he can’t possibly think about it differently. And so that’s how it just festers and haunts him.

Some of the erroneous cognitions that underline PTSD include that the world is extremely dangerous. People are untrustworthy. No place is safe. I’m extremely incompetent. And very often, people will use their PTSD symptoms as a sign of their weakness. They might think that other people would have prevented the trauma or other people would have done more or other people would have fought back.

Part of the recovery process includes the repeated activation of the trauma memory. We want to emotionally engage when we’re going through the trauma memory. We want to incorporate corrective information about the world and the self. And we’re going to talk a lot more about this as we go through the specifics of the therapy. The activation and disconfirmation occur via confronting the trauma reminders, so thinking about it and contact with the trauma reminders. And the corrective information consists of the absence of the anticipated harm. They talk about it and nothing bad happens.

In general, when we’re doing exposure therapy with someone, we want them to learn, one, that what they’re scared of doesn’t happen. Two, that when they stay with the reminders, the trauma memory or real-life reminders, that the distress will go down while they’re still with it. They don’t need to avoid it or escape. And three, that they can handle the distress. So many people come in and they hate their anxiety; they hate the distress. They’re scared that if they let themselves feel these emotions that they might never stop crying. And so they learn that yes, you can cry and that you do stop crying.

So the key points from this video are that fear and anxiety are a normal response to trauma. For most people, this fear will extinguish over time. For some, usually due to avoidance, the fear does not extinguish. PTSD can be conceptualized as a disorder of extinction. Fear structures contain information about the feared stimuli, the fear responses, and the meaning.

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