Recognizing Hyperarousal Symptoms in PTSD

A Heightened State of Anxiety After Extreme Trauma

A model poses as an anxious person
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Hyperarousal is a specific cluster of symptoms associated with post-traumatic stress disorder (PTSD). As the name implies, hyperarousal is the abnormally heightened state of anxiety that occurs whenever you think about a traumatic event. Even though the threat may no longer be present, your body will respond as if it were.

PTSD can develop after a recent or past trauma, such as warfare, acts of violence, a life-threatening illness, emotional abuse, or the death of a loved one. Hyperarousal can persist long after the trauma has passed, leaving you hyper-responsive to anything that reminds you of the event (including sights, smells, sounds, or even specific words of passages of music).


PTSD does not occur in isolation but rather in response to a trauma, either sustained over a long period of time or as a single event. PTSD symptoms like hyperarousal ultimately develop as a result of the overreaction of the body's stress response.

Epinephrine (adrenaline) is one of two stress hormones that play a role in the body's flight-or-fight response. Epinephrine works in the short term and produces acute stress symptoms, including pupil dilation, increased blood pressure, and a rapid heart rate. The other hormone, cortisol, works over the long term to regulate the body's response to stress.

PTSD causes biological changes in the brain that differ from depression or bipolar disorder. Rather than affecting the "feel-good" hormones (including serotonin and dopamine), PTSD triggers the hyperproduction of epinephrine simply by remembering a traumatic event.

However, unlike chronic stress in which cortisol levels will invariably rise, cortisol levels in people with PTSD tend to be low. Because cortisol is meant to restore balance to the body after a stressful event, the lack of cortisol can prolong and worsen a PTSD episode. Even during a panic attack, epinephrine levels will shoot up in people with PTSD; cortisol levels will not.

Hyperarousal is believed to be caused when the neurological pathways to the hypothalamus-pituitary-adrenal (HPA) axis—which regulates the stress response—become overly sensitized. When confronted with certain sensory stimuli, the HPA axis will overreact, secreting excessive amounts of epinephrine which, in turn, stimulate the fear center of the brain, known as the amygdala.

Among some of the more common events that trigger PTSD:

  • Wartime trauma
  • Childhood abuse
  • Sexual assault or abuse
  • Physical violence
  • Threats with a weapon
  • Vehicle collision
  • Airplane crash
  • Fire
  • Life-threatening illness
  • Traumatic injury
  • Natural disaster
  • Terrorist attack
  • Kidnapping

People who lack a strong support system, endured long-term emotional trauma, or have an alcohol or substance abuse problem are more vulnerable to PTSD.


Hyperarousal in PTSD can affect children and adults equally. Symptoms include:

  • Chronic anxiety
  • Difficulty falling or staying asleep
  • Frightening dreams
  • Difficulty concentrating
  • Irritability
  • Anger and angry outbursts
  • Panic attacks
  • Being constantly on guard for threats (hypervigilance)
  • Being easily startled (excessive startle reflex)

Sleep problems are especially prevalent in children, war veterans, and victims of extreme violence. These individuals will often experience nightmares or flashbacks about past traumas. Children will often re-enact their experiences during play or in drawings or stories.


Many people with PTSD will internalize feelings of shame and guilt and bear an inappropriate sense of responsibility for the trauma they incurred. This can lead to severe bouts of depression and may manifest with self-destructive behaviors like excessive drinking, risky sex, or reckless driving. Eating disorders are not uncommon in people with untreated PTSD.

In extreme cases, PTSD may lead to suicidal thoughts and behaviors. A 2010 study from Denmark, which examined 9,612 suicide cases from 1994 to 2006, reported a 9.8-fold increase in the risk of completed suicide in people diagnosed with PTSD compared to the general population.

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our National Helpline Database.


As with all symptoms of PTSD, hyperarousal can be difficult to manage. It not only involves managing the underlying anxiety but effectively dealing with sleep problems, panic attacks, impulsive behaviors, self-harm, anger, and substance abuse issues.

Treatment is typically multidisciplinary and may include psychotherapy, medication, and stress management training. Examples include:

  • Cognitive behavioral therapy. The aim of cognitive behavioral therapy (CBT), a form of talk therapy, is to change patterns of thinking or behavior that fuel PTSD symptoms.
  • Exposure therapy. The aim of exposure therapy is to expose you to the triggers that stimulate stress in order to help you recognize them and alter your response.
  • Eye movement desensitization and reprocessing. The goal of eye movement desensitization and reprocessing (EMDR) is to use eye movement to redirect you from traumatic memories of the past to current sensations of the present.
  • Mindfulness training. Mindfulness aims to focus your thoughts on immediate sensations rather than following erratic and stressful thoughts. This may involve techniques such as meditation, controlled breathing, guided imagery, or biofeedback.
  • Medications. PTSD may be treated with one or several medications, including antidepressants, beta blockers, and anti-anxiety drugs. The antidepressants Zoloft (sertraline), Prozac (fluoxetine), Paxil (paroxetine), and Effexor (venlafaxine) are considered the first-line drugs of choice.

Some doctors will also prescribe medical marijuana, where legal, to help alleviate anxiety and aid in sleep (although there is no clinical evidence of its benefit in improving PTSD over the long term).

Benzodiazepines, otherwise effective in treating anxiety, and avoided in people with PTSD as they can cause dissociation (the detachment from feelings, identity, and even reality) which only serves to amplify PTSD symptoms.


Hyperarousal symptoms are part and parcel of the PTSD experience. There is rarely a straight road to recovery, and there may be setbacks and complications along the route. But, even when faced with these challenges, it is important to remember that you are as much a factor in your recovery as are your doctors and medications.

To this end, there are things you can do better cope as you take the steps to recognize and overcome PTSD. Among them:

  • Improve your sleep hygiene. People with PTSD often fear sleep and will do anything to avoid it. This can lead to sleep deprivation and the worsening of your symptoms. While your doctor may recommend a sleep aid, you can do your part by improving your sleep hygiene, including keeping to the same sleep schedule every night.
  • Avoid alcohol and caffeine. Alcohol is depressant that can amplify feelings of depression and the side effects of your drugs. Caffeine is a stimulant that can increase feelings of edginess and anxiety.
  • Exercise regularly. Exercise stimulates the production of endorphins, the hormone of which can elevate moods and potentially temper the epinephrine response. Exercise also makes you feel stronger and more in control.
  • Take time to relax. People with PTSD often avoid silence because they fear it will bring up negative thoughts. But without taking the time to relax, you cannot effectively manage stress. To this end, it helps to set aside time for relaxing mind-body therapies, such as yoga, tai chi, or progressive muscle relaxation (PMR).
  • Improve your eating habits. Stress-related eating is a common problem in people with PTSD. To avoid this, remove junk food from your pantry and stock your fridge with healthy fruits, nuts, and vegetables. Always eat your meals at a table with a plate and utensils rather than eating out of a bag or fast food container. Use cooking as a means to decompress after a long day.
  • Build a support network. Don't suffer in silence. Find friends and family in whom you can confide, ideally people who don't panic or try to "make things right." You can also speak to your therapist about PTSD support groups to share your thoughts with others who understand what you are going through.

To find a PTSD support group in your area, call the National Alliance on Mental Illness (NAMI) hotline at 800-950-NAMI (6264) from Monday through Friday, 10:00 a.m. to 6:00 p.m. ET, or contact your local NAMI chapter.

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