Recognizing Hyperarousal Symptoms in PTSD

A Heightened State of Anxiety After Extreme Trauma

A model poses as an anxious person

Claudia Burlotti / Getty Images

Table of Contents
View All
Table of Contents

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, or abuse. 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 including dysregulation of the stress response system. This can then be triggered even by simply remembering a traumatic event.

Stress Response System

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 potentially prolong and worsen PTSD. 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, triggering the secretion of excessive amounts of epinephrine which, in turn, stimulate the fear centers of the brain.

Common Triggering Events

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, endure long-term emotional trauma, or have an alcohol or substance use problem are more vulnerable to PTSD.


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

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


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 988 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 gradually and safely 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 attention, in a non-judgmental way, on immediate sensations rather than following erratic and stressful thoughts.
  • Medications: PTSD may be treated with one or several medications, including antidepressants, beta-blockers, and anti-anxiety drugs. The antidepressants such as 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 clear clinical evidence of its benefit in improving PTSD over the long term).

Benzodiazepines tend not to be used in PTSD, as their risks (such as dependency) tend to outweigh their potential short-term benefits.


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 to 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.

11 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 3, Understanding the Impact of Trauma.

  2. National Institutes of Health. Post-traumatic stress disorder.

  3. KidsHealth from Nemours. Posttraumatic Stress Disorder.

  4. El-solh AA. Management of nightmares in patients with posttraumatic stress disorder: current perspectives. Nat Sci Sleep. 2018;(10):409-420.  doi:10.2147/NSS.S166089

  5. Kimble MO, Fleming K, Bennion KA. Contributors to hypervigilance in a military and civilian sample. J Interpers Violence. 2013;(28)8:1672-92.  doi:10.1177/0886260512468319

  6. Gradus JL, Qin P, Lincoln AK, et al. Posttraumatic stress disorder and completed suicide. Am J Epidemiol. 2010;(171)6:721-7.  doi:10.1093/aje/kwp456

  7. Zoellner LA, Feeny NC, Bittinger JN, et al. Teaching trauma-focused exposure therapy for PTSD: Critical clinical lessons for novice exposure therapists. Psychol Trauma. 2011;(3)3:300-308. doi:10.1037/a0024642

  8. American Psychological Association. Medications for PTSD.

  9. Weston CS. Posttraumatic stress disorder: A theoretical model of the hyperarousal subtype. Front Psychiatry. 2014;(5):37. doi:10.3389/fpsyt.2014.00037

  10. National Sleep Foundation. Caffeine and sleep.

  11. Tagay S, Schlottbohm E, Reyes-rodriguez ML, Repic N, Senf W. Eating disorders, trauma, PTSD, and psychosocial resources. Eat Disord. 2014;(22)1:33-49.  doi:10.1080/10640266.2014.857517

Additional Reading

By Matthew Tull, PhD
Matthew Tull, PhD is a professor of psychology at the University of Toledo, specializing in post-traumatic stress disorder.