When people hear “PTSD,” they often picture combat veterans or first responders — those who’ve faced life-threatening situations and come home with invisible scars. But as Dr. Tyler Ralston and I explored in our recent Mind Tricks Radio conversation, Post-Traumatic Stress Disorder is both broader and more misunderstood than most realize. It’s one of the few mental health conditions that requires an event to qualify — a true trauma, something that shatters one’s sense of safety through threat, injury, or violation. That makes PTSD unique among psychiatric diagnoses, yet also one of the most frequently misused terms in popular culture. These days, people joke about being “traumatized” by a bad day at work or a crowded parking lot, but that’s not PTSD — that’s life being life.
At its core, PTSD is defined by a specific pattern of symptoms following real trauma: intrusive memories or nightmares, avoidance of reminders, negative changes in thinking and mood, and hyperarousal — that constant sense of being “on guard.” These clusters, taken together, separate PTSD from ordinary stress reactions or anxiety. And the symptoms have to last more than a month and cause genuine distress or impairment. As Tyler put it, “If it’s bothering them enough that they don’t like it being there, that’s clinically significant.”
We also unpacked the many conditions that can look like PTSD but aren’t. Acute Stress Disorder is the short-term cousin, lasting less than a month after a traumatic event. Adjustment Disorder can resemble PTSD but follows major life stressors that aren’t life-threatening — like divorce, job loss, or relocation. Other disorders such as Generalized Anxiety, Panic Disorder, and OCD share pieces of the picture — worry, avoidance, intrusive thoughts — but without the defining link to a Criterion A trauma. Even depression overlaps with PTSD’s fatigue, guilt, and hopelessness, but lacks the re-experiencing and hypervigilance that make trauma-based symptoms so distinct.
Why does all this matter? Because diagnosis drives treatment. PTSD calls for trauma-focused therapies — Cognitive Processing Therapy, Prolonged Exposure, EMDR — approaches designed to help the brain process and reintegrate the traumatic memory. Mislabeling PTSD as simple anxiety or depression can send someone down the wrong treatment path entirely. Getting the diagnosis right isn’t about semantics; it’s about healing.
Our hope in recording this episode was to cut through the noise and bring clarity to one of psychology’s most complex and emotionally charged topics. PTSD isn’t a label to be thrown around lightly — it represents real suffering, but also real pathways to recovery when properly understood. If anything in our conversation resonates with you, take it as a cue not to self-diagnose, but to reach out to a professional who can help sort through the details with you. Understanding trauma is the first step toward overcoming it.
FULL TRANSCRIPT
Dr. Aaron: Hey, Tyler, welcome back.
Dr. Tyler: Hi, thank you. Glad to be back.
Dr. Aaron: It wasn’t too long ago that I saw you and we recorded our last episode about emotional reasoning. That was a ton of fun and has been really well received. So I’m super excited to have you again to talk about today’s subject, which is PTSD or Post Traumatic Stress Disorder and Differential Diagnoses. So I hope you’re pumped up for this one because I am.
Dr. Tyler: I am.
Dr. Aaron: Let’s start off. The whole idea about this is to try to understand better what PTSD is and what some of the common differential diagnoses are—in other words, other diagnoses that look similar to PTSD in some ways, but are not PTSD. And I also want to start by saying that whatever Tyler and I talk about today is not meant to be used for you to diagnose yourself with PTSD or anything else. This is for informational purposes only. If anything here resonates with you, please see a clinician and have these properly diagnosed. But hopefully from our conversation today, you’ll get some ideas about these various different disorders that we find and understand some of the differences between them.
So PTSD: this is an interesting disorder. We find it in the Diagnostic and Statistical Manual of Mental Disorders. This is where we go to look at the symptom criteria for all sorts of different disorders that people are diagnosed with. PTSD is kind of an interesting one, especially with the historical context in combat-related trauma. Going back to World War I, soldiers were labeled with things like “shell shock,” and in World War II “combat fatigue.” Then, after the Vietnam War, the Department of Veterans Affairs started doing a very good job looking at this condition and the vets that came back, and a lot more research was being done about PTSD and trauma. It was formally included in the DSM-III in 1980. After that, clinicians really started seeing that it’s not just combat veterans that suffer from PTSD, but survivors of many other kinds of traumas as well. Research on PTSD started exploding after that to all sorts of different kinds of trauma. That’s a little background. Do you have any thoughts on that, Tyler, on the historical background?
Dr. Tyler: That was a nice summary. There’s even written information of symptom presentations going back to Roman times—documentation of that—though they didn’t call it PTSD back then.
An interesting thing about PTSD is it’s one of the few disorders in the DSM that actually requires an event to make the diagnosis. A traumatic event has to occur in order for you to have PTSD. A lot of other disorders—anxiety, mood, even psychotic disorders—don’t have that; there doesn’t have to be a known antecedent event related to the cause. The differences might be substance use disorder—obviously you have to be abusing substances—or some kind of organic brain disorder that leads to cognitive dysfunction. Aside from those, there are very few that have an event associated with developing PTSD.
Dr. Aaron: Tell us a little bit about this concept of the event that needs to be there in order to develop PTSD.
Dr. Tyler: It’s referred to as Criterion A in the diagnostic system: exposure to something pretty serious—usually death-related, serious injury, or sexual violence. It can be one time or repeated times; it just depends on the event. That’s Criterion A for PTSD. Serious stuff.
Dr. Aaron: It’s worth mentioning that people throw the word “trauma” around pretty liberally these days. They could be talking about an argument with their boss. For Criterion A, it really has to have created intense feelings of fear, helplessness, or horror where your life or well-being was at stake—several levels above bad day-to-day experiences. Sexual violence, actual violence, combat—those clearly fall into that category.
Dr. Tyler: You bring up a good point about the casual use of “trauma” or “PTSD.” People say things not aligned with Criterion A. “I went to the mall during the holidays, couldn’t find parking, I’m traumatized, I have PTSD.” It’s a corny example, but people talk like this more and more, which weakens the usefulness of those terms when we really need them for people facing serious injury or death.
Dr. Aaron: Assuming a legitimate traumatic event has occurred—single or multiple events—PTSD can result from either. We then have main criteria of symptoms that need to be present to diagnose PTSD. The event is there, then Criterion B: intrusive symptoms. You only need one of these. Examples?
Dr. Tyler: You could be sitting at home and an unwanted memory pops in related to the trauma. It shows up at any time and is very upsetting. It intrudes into the present moment.
Dr. Aaron: So unwanted thoughts that pop into your head. Another example is nightmares—waking you up, unsettling, anxiety-provoking. People can wake up in cold sweats or with a racing heart. People can have nightmares without PTSD, but it’s common in PTSD. Then there are intrusions triggered by reminders of the event. Examples?
Dr. Tyler: Let’s say the trauma involved a guy wearing a red shirt and a mustache. Years later you see a different guy with a similar red shirt and mustache. The brain picks up on that association and it becomes very distressing. The person may think the trauma is happening again or that they’re in danger. That leads to a host of behaviors that get in the way of the current moment.
Dr. Aaron: It could be a person, place, thing, situation, song, type of food—something that triggers the memory and brings up uncomfortable feelings. As a side note, flashbacks also fall into intrusions: the reminder is so strong you feel like you’re back inside the traumatic event as if it were happening now. True flashbacks are not as common as people think. The word gets used a lot when it’s not truly a flashback; a true flashback involves loss of touch with current reality and believing you’re back in that moment.
Dr. Tyler: Exactly. A flashback is more than a memory; it’s re-experiencing sensations as if you’re really there. It’s uncommon—I’ve mostly seen it with combat veterans—and much less with other trauma types.
Dr. Aaron: Then we’ve got avoidance symptoms—Criterion C. Thoughts on avoidance?
Dr. Tyler: If intrusive reminders trigger increased heart rate, blood pressure, muscle tension, anxiety—unpleasant memories—it’s natural to want to avoid. People avoid people, places, things, reminders. We often call them harmless reminders because in many cases they are. Avoiding an actual perpetrator isn’t “avoidance” in the pathological sense—that’s prudence. But avoiding certain memories is very common: don’t think about it, don’t talk about it, distract, avoid places or beaches, avoid saying certain names. Common in my practice: avoiding smells (often alcohol), sounds (often a song), places, photos.
Dr. Aaron: So if someone goes out of their way to not be around or think about reminders—altering behavior—that’s avoidance. The avoidance is geared toward relief from unpleasant experiences.
Then we have negative cognitions and mood: guilt, detachment, distorted self-blame. Thoughts?
Dr. Tyler: Guilt wasn’t as recognized in earlier DSM editions; I’m glad it’s more prominent now. Clients often have guilt about what they did or didn’t do related to the trauma—thoughts they think they shouldn’t have thought, feelings they think they shouldn’t have felt. The guilt feeds detachment and emotional numbing and can become a big problem over months and years—shame and related issues.
Dr. Aaron: Guilt is huge in trauma. You co-wrote a book on guilt with Dr. Edward Cubaney, and we talked about related guilt and hindsight bias on earlier shows. On detachment: emotional numbing or pulling back because emotions are so painful. The problem is you can’t selectively turn off emotions; it’s all or nothing. If you turn down guilt, pain, anger, shame, you also turn down love, happiness, contentment. That becomes a problem.
Let’s talk about arousal and reactivity symptoms—Criterion D/E: hypervigilance, irritability, increased anger, difficulty sleeping—ramped up presentation. Sometimes like a car in neutral with a brick on the accelerator: you’re idling too high. It wears people out physically and causes relationship problems. Depending on the trauma and the person, it presents differently. In male veterans, more outward aggression; in formerly battered women, hypervigilance is easy to see, irritability shows as a cynically hostile worldview. Sleep issues are common.
Dr. Tyler: That elevated internal thermostat leads to concentration problems, sleep problems, irritability. Hypervigilance is walking through life scanning constantly so you can’t be taken by surprise—very draining. Veterans often describe scanning a restaurant, choosing a seat to see everything. With battered women: checking doors and windows, scanning parking lots before getting out.
Dr. Aaron: Those are the main clusters. You need a certain number within each to meet PTSD criteria. A couple other important points for diagnosing PTSD: symptoms must persist more than one month after the trauma, and they must cause significant distress or impairment. Just having symptoms isn’t enough—they must be clinically significant or impairing.
How do you look at “significant distress” in your practice?
Dr. Tyler: I determine whether it’s bothering them enough that it’s worth mentioning and they want it to bother them less. It’s subjective: if they say it’s bothering them to the point they don’t like it being there, that’s clinically significant. If someone says, “I have these memories now and then, but it doesn’t really bother me,” that’s different. Similarly for impairment—if they don’t like the impact on their life, I consider that clinically significant impairment.
Dr. Aaron: Distress and impairment usually go hand in hand. There are instruments to measure things—we can talk about those later—but there’s gray area. It’s important to talk to a professional and, if needed, get a second opinion.
The last thing: symptoms should not be due to substances or a medical condition. Substances and medical conditions can alter physiological and emotional states. In PTSD, symptoms are caused by the traumatic event(s), not other factors.
Let’s get into differential diagnosis. First: Acute Stress Disorder. Similarities to PTSD?
Dr. Tyler: Acute Stress Disorder comes up commonly. Symptoms are similar to PTSD, but the main difference is duration: within one month of the trauma. Once we go beyond that, we’re looking at PTSD. If ASD doesn’t go away or get treated within that month, it can be a precursor to PTSD.
Dr. Aaron: Having symptoms that meet ASD criteria is very common following a traumatic event. A high percentage may meet criteria right after; symptoms often abate within a month and don’t progress to PTSD. Still, it’s helpful to reach out for help immediately to reduce the chance it turns into PTSD.
Next: Adjustment Disorder. I’d guess it’s the most commonly diagnosed across the board—clinicians often need a diagnosis for insurance billing, and it’s probably this one most often. Adjustment Disorder has to do with adjusting to life events causing distress. Take it from there?
Dr. Tyler: It’s common and related to all kinds of life events. Differentially, someone might experience a Criterion A trauma but not have enough other PTSD symptoms; we might diagnose Adjustment Disorder. Conversely, someone might have PTSD-like symptoms but no Criterion A event; again, Adjustment Disorder. Examples: divorce, job loss—very upsetting, but not Criterion A. It can be a bit of a catch-all.
Dr. Aaron: Often a person is having a hard time—ongoing divorce, problems with a child, toxic boss. They may experience anxiety or depressed mood. You can have Adjustment Disorder with anxiety, depressed mood, or both. It’s a lower level of anxiety compared to PTSD. It’s also commonly confused with PTSD: people experience some symptoms or a Criterion A event but don’t meet full PTSD criteria—it’s probably Adjustment Disorder.
Next: Generalized Anxiety Disorder. With GAD, we see chronic, free-floating worry across multiple domains, not tied to a traumatic cue. Physiological tension, restlessness, sleep problems—often related to worry. I see chronic worriers—worrying across many domains to an impairing degree. Thoughts?
Dr. Tyler: I agree. I think of GAD as broader: anxiety and worry about a variety of things. PTSD tends to be narrower and deeper—tied to a traumatic event, with strong symptoms linked to that. Sometimes patients had GAD before a trauma, then develop PTSD—teasing apart what’s PTSD versus preexisting worry can be tricky.
Dr. Aaron: These disorders can be comorbid, though I think comorbidity is overdiagnosed; usually one supersedes. Also, GAD can be overdiagnosed for people who worry a lot. To reach GAD, worry must be irrational, across multiple domains, and significantly impairing.
Next: Panic Disorder and Agoraphobia—often together. Panic first?
Dr. Tyler: In panic, the focus is fear of the panic experience and its symptoms—anxiety and physiological sensations—not necessarily about a traumatic event.
Dr. Aaron: People with PTSD can have panic attacks, but usually they’re triggered by trauma cues, not the panic itself.
Dr. Tyler: Right. In panic disorder, the fear is of having the panic attack, not of trauma reminders.
Dr. Aaron: Agoraphobia can be with or without panic attacks. People think of it as not leaving the house, but it’s broader: fear of being unable to escape situations that feel uncomfortable, so people avoid them. Crowds, shopping malls, airplanes, buses, being far from help—all can qualify.
Dr. Tyler: Exactly—going out of town into the desert or mountains and fearing you won’t get help if needed.
Dr. Aaron: Differentially, PTSD avoidance is about avoiding trauma reminders—things that were dangerous or felt dangerous—whereas in agoraphobia, avoidance is to prevent panic, embarrassment, or those sensations, even in objectively safe places like Costco. Add panic disorder to agoraphobia and it compounds the avoidance: fear of passing out, being embarrassed, getting hurt—though passing out is rare.
Next: OCD. With OCD we also have intrusive thoughts and sometimes avoidance. OCD is common; I’ve done a few episodes on it. How is OCD different from PTSD?
Dr. Tyler: The big difference: no Criterion A traumatic event in OCD. Intrusions in OCD aren’t trauma-related. People with OCD often have compulsions; PTSD usually doesn’t. Many other PTSD symptoms aren’t present in OCD.
Dr. Aaron: Intrusive thoughts in OCD are often extremely irrational and ego-dystonic: e.g., “I’ll reach over and choke this person,” “I’ll start singing loudly,” “I might have run over a dog”—then checking repeatedly. Compulsions try to undo the thought, like knocking three times. It doesn’t make sense, but that’s the pattern. It’s a separate animal from PTSD.
Getting away from anxiety disorders: mood components in PTSD can look like Major Depressive Disorder. How do you differentiate PTSD from depression?
Dr. Tyler: In mood disorders, we often don’t see prominent re-experiencing or hyperarousal tied to trauma cues. There isn’t a trigger-based pattern. In PTSD, symptoms are tied to specific trauma-related triggers.
Dr. Aaron: People with depression can have hopelessness, anhedonia, fatigue, guilt—overlap with PTSD—but without re-experiencing or trauma-linked hyperarousal. There’s high comorbidity between PTSD and MDD—makes sense. Medications and treatments often overlap.
Dr. Tyler: Studies show comorbidity in some populations around 75%—so they go hand in hand prominently.
Dr. Aaron: When you diagnose PTSD and consider differentials, how do you sort it out? Tools?
Dr. Tyler: I’ve used the CAPS (Clinician-Administered PTSD Scale)—the gold standard. These days I rely more on meeting the person, observing behavior and affect, listening to their words, plus screening tools like the PCL-5 and trauma surveys (e.g., Potentially Traumatic Events Questionnaire). Put it together in the first session or two and we’re usually clear. Differential diagnosis is like a Venn diagram—where do PTSD and, say, OCD overlap and not overlap? The non-overlaps often tell you the diagnosis.
Dr. Aaron: Same approach: good interview, look at differentials, see the source of anxiety. The PCL is a nice screening tool. I like the CAPS when the stakes are higher—e.g., forensic evaluations—I won’t diagnose PTSD without CAPS there. For routine clinical work, interview + PCL usually suffices.
Dr. Tyler: Earlier in my career I used manuals more; after treating and formally diagnosing so much PTSD with CAPS, you get better at reading subtleties in the room. Not that there can’t be error—studies show there can—but experience helps. If I use a formal instrument, it’s often confirmation.
Dr. Aaron: Why does getting the diagnosis right matter?
Dr. Tyler: It guides treatment. We don’t want to apply the wrong treatment. There might be overlap, but we want accuracy so the person gets proper care—by us or others reviewing charts. There are different treatments; common ones share active ingredients, but we need to know if it’s PTSD, panic/agoraphobia, depression, etc., so we target correctly.
Dr. Aaron: I agree. Cognitive-behavioral techniques aren’t magic or wildly different, but how we target and orient them varies by disorder. At the core, mechanisms overlap; further out, differences emerge—where accurate diagnosis becomes critical.
Dr. Tyler: Exactly.
Dr. Aaron: Hey, Tyler, this has been really fun talking all things PTSD and differential diagnosis. Thanks so much for coming on. Hopefully we’ll reconvene soon with another exciting and interesting topic.
Dr. Tyler: Thanks for having me. It’s always a pleasure.