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. 2026 Apr 8;17(1):2649110. doi: 10.1080/20008066.2026.2649110

The overlooked trauma: psychological violence and its impact on PTSD symptoms

El trauma desapercibido: la violencia psicológica y su impacto en los síntomas del TEPT

Raquel M Gonçalves a, Camila MF Gama a, Sérgio De Souza Junior a, Mariana Xavier b, Eliane Volchan c, Letícia De Oliveira a, Fátima S Erthal c, William Berger d, Izabela Mocaiber b, Mirtes G Pereira a,CONTACT
PMCID: PMC13063330  PMID: 41949330

ABSTRACT

Background: Psychological violence, defined as interpersonal acts intended to humiliate or diminish others without physical force, has been linked to significant psychological suffering. Despite its prevalence and association with mental health disorders, it is not classified as a potentially traumatic event under the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) criteria for post-traumatic stress disorder (PTSD) diagnosis.

Objective: This study examines whether psychological violence, when identified as the index trauma, is associated with PTSD symptoms at levels comparable to those elicited by DSM-5-recognized traumas.

Method: In this cross-sectional study, 530 Brazilian undergraduate students completed the Trauma History Questionnaire (THQ) and the PTSD Checklist for DSM-5 (PCL-5). Negative binomial regression and logistic regression models were used to examine associations between trauma type and PTSD symptom severity and probable diagnosis.

Results: Compared to crime- and disaster-related trauma, psychological violence was associated with greater PTSD symptom severity and higher odds of probable PTSD diagnosis. Its impact was comparable to that of physical and sexual violence.

Conclusions: These findings emphasize the importance of raising awareness about the emotional consequences of psychological violence and highlight the need for greater recognition of psychological violence as part of the spectrum of experiences associated with PTSD. Recognizing psychological trauma as a threat to the fundamental human need for social connection has critical implications for diagnostic refinement and treatment protocols.

KEYWORDS: Psychological violence, post-traumatic stress disorder, trauma, DSM-5, mental health

HIGHLIGHTS

  • Psychological violence is associated with PTSD symptoms and probable diagnoses at higher levels than traumas related to crime or disasters.

  • Psychological violence was reported as the worst event experienced in life even among some participants who had also experienced DSM-5–defined traumas.

  • Recognizing psychological violence as a form of trauma can improve treatment, inform diagnostic criteria, and guide prevention and social justice initiatives by addressing the event itself rather than only its consequences.

1. Introduction

The World Health Organization (WHO) defines violence as the intentional use of physical force or power, whether real or threatened, against oneself, another person, or a group or community. Psychological violence, which can occur in various contexts, such as caregiver–child relationships, intimate partnerships, and workplaces, includes acts of belittling, humiliation, defamation, ridicule, threats, intimidation, discrimination, and rejection (Krug et al., 2002). Its prevalence varies significantly depending on the context, ranging from 35% to 49% in intimate partner relationships (Dokkedahl et al., 2022), 10.6% in workplace settings (Bunce et al., 2024), and from 25.3% to 40.1% when public humiliation is considered (Li et al., 2024)., psychological violence can inflict profound emotional suffering and result in a constant sense of fear, embarrassment, shame, and guilt. Additionally, psychological violence has been associated with reduced task performance; decreased creativity, flexibility, and altruism (Porath & Erez, 2009); and mental disorders such as depression and anxiety (Gama et al., 2021; Lagdon et al., 2014; Li et al., 2024; Rasool et al., 2020).

Although the literature consistently demonstrates that psychological violence is a highly detrimental event linked to significant mental health impairments, its potential association with the development of post-traumatic stress disorder (PTSD) is underexplored. PTSD is a mental disorder that significantly interferes with an individual’s daily functioning, with symptoms such as re-experiencing, avoidance, negative changes in mood and cognitions, and hyperexcitability (APA, 2013). According to the DSM-5, the diagnosis of PTSD requires exposure to a potentially traumatic eventinvolving actual or threatened death, serious injury, or sexual violence (APA, 2013). Under this framework, despite being extremely harmful, psychological violence is not currently classified as a Criterion A event (i.e. life-threatening or serious injury) and therefore is not considered a qualifying traumatic stressor for PTSD diagnosis (APA, 2013). However, since its introduction in the Statistical and Diagnostic Manual of Mental Disorders (DSM), the adequacy of the definition of trauma (‘traumatic stressor,’ Criterion A of the PTSD diagnosis) has been highly controversial and has undergone many revisions throughout the editions of the DSM (Brewin et al., 2009; Rosen & Lilienfeld, 2008; Weathers & Keane, 2007). In contrast, the ICD-11 (WHO, 2018) adopts a more streamlined definition of PTSD, placing greater emphasis on core symptom clusters and less formal weight on the detailed operationalization of a Criterion A–like stressor while still requiring exposure to an extremely threatening or horrific event. These conceptual differences are central to ongoing debates about what should qualify as a traumatic event.

Although, at first glance, psychological violence is not explicitly associated with an imminent threat to physical integrity, have historically relied on social groups for sustenance, mating partners, and security (Burkart et al., 2014; Gilbert, 2002; Hare, 2017; Slavich, 2020; Tomasello, 2020). Consequently, situations that signal a possible exclusion of the group, such as humiliation or rejection, are experienced as highly salient and threatening. Moreover, humans are fundamentally motivated to be socially connected to other people. This need to belong constitutes a ‘pervasive drive to form and maintain at least a minimum amount of lasting, positive and meaningful interpersonal relationships’ (Baumeister & Leary, 1995, p. 497). From newborns to elderly individuals, the feeling of social isolation is alarming, distressing and painful. Indeed, authors have proposed that social pain (derived from isolation, rejection and loss) and physical pain share the same neural circuits (Bzdok & Dunbar, 2020; Eisenberger & Lieberman, 2004; Kross et al., 2011). Humans react to cues of social rejection or exclusion by triggering the autonomic, endocrine, and immune systems similarly to when confronting physical attacks or life-threatening events (see Eisenberger, 2012). Thus, based on the understanding that the emotional processing of social information is linked to threat perception, it is critical to conduct studies that investigate whether psychological violence is associated with trauma-related symptomatology in ways comparable to events widely recognized as traumatic.

Therefore, the present study aims to compare the severity of PTSD symptoms reported in relation to a psychological violence event with those evoked by events involving a threat of death, serious injury, or sexual violence. The rationale is to assess whether the severity of symptoms observed in association with psychological violence might be equivalent to that associated with traumatic events that are in accordance with the DSM-5 criteria. Here, we focus on humiliation/ridicule, a form of psychological violence that typically precedes more complex and multidimensional abusive dynamics, such as dominance and coercive control (Dokkedahl et al., 2022; Stark, 2013). We hope that our findings contribute to a deeper understanding of the potentially distressing and trauma-related nature of psychological violence and highlight its importance in developing new mental health treatments and interventions.

2. Methods

This cross-sectional study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional observational studies (von Elm et al., 2008).

2.1. Participants and recruitment procedures

The participants were undergraduates from two Brazilian public universities (Universidade Federal do Rio de Janeiro and Universidade Federal Fluminense). In total, 678 students agreed to participate in the research. Student recruitment was carried out at the universities through a brief announcement in classrooms. The students who agreed to participate completed an informed consent form, a sociodemographic survey and a booklet containing self-report questionnaires assessing trauma history and PTSD symptoms according to the DSM-5, and they were identified exclusively by numbers to ensure respondent anonymity. As an inclusion criterion, the volunteers had to be over 18 years old. The exclusion criteria were incomplete questionnaire responses (n = 30) or failure to report an index trauma in accordance with DSM-5 criterion A or an event of psychological violence (n = 118). Thus, the final sample consisted of 530 participants. The flowchart with sample exclusion criteria is shown in Figure 1.

Figure 1.

A flow chart showing university student sampling from 678 initial participants to 530 final participants after 3 exclusion steps. The figure shows a flow chart summarizing recruitment and exclusions in a university student study. At the top, a header labeled Sample appears above a large box containing the text Initial Sample, 678 participants. A vertical arrow leads downward through 3 sequential boxes on the left, ending in Final Sample, 530 participants, with a side bar labeled Included. To the right, a second header labeled Exclusion Criteria sits above 3 boxes aligned with the left sequence. From the Initial Sample box, a horizontal arrow points to a box labeled No trauma index reported on the Trauma History Questionnaire, 12 exclusions. From the second left box, labeled N equals 666, a horizontal arrow points to a box labeled Incomplete Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition, 18 exclusions. From the third left box, labeled N equals 648, a horizontal arrow points to a box labeled Events that are not Diagnostic and Statistical Manual of Mental Disorders, fifth edition, criterion A or not a psychological violence event, 118 exclusions. All boxes are rectangular and connected by arrows to indicate the stepwise reduction of the sample from 678 to 530 participants.

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Flow chart representing the steps taken to select the final sample.

This study was approved by the Ethics Review Board of the Federal University of Rio de Janeiro (CAAE 56431116.5.0000.5263) and by the Ethics Review Board of the Federal Fluminense University (CAAE 19104519.3.0000.8160). All methods were carried out following relevant guidelines and national regulations. A psychologist was present in the room to guarantee emotional support if any participant was emotionally destabilized during the procedure. The participants received no compensation for their participation in the study.

2.2. Measures

2.2.1. Trauma history questionnaire (THQ) and the additional psychological violence item

This questionnaire investigates a broad range of potentially traumatic events, which are distributed into three categories: crime-related events, disasters (natural or man-made), and sexual and physical experiences (Green, 1996). We used the Brazilian version of the questionnaire translated and adapted by Fiszman et al. (2005). The participants were instructed to indicate whether they had experienced each event. Additionally, we added one item to investigate events of psychological violence. This additional item was ‘Has anyone in your family or among your social connections persistently ridiculed, humiliated, or ignored you, causing intense suffering?’. Furthermore, an open-ended question allowed the participants to report events that happened to them but were not on the questionnaire list. Among all events reported (including those in the open-ended question), the participants were asked to identify the most distressing event, which was referred to as their index trauma. The assessment of PTSD symptoms was conducted with reference to this index trauma.

2.2.2. Posttraumatic stress disorder checklist for the DSM-5 (PCL-5)

The PCL-5 is a widely used instrument for assessing PTSD symptoms, developed in accordance with DSM-5 criteria (Weathers et al., 2013) comprising 20 items corresponding to the four symptom clusters: re-experiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. The participant rated each of the PTSD symptoms on a Likert scale (from 0 = ‘not at all’ to 4 = ‘extremely’). The score ranges from zero to 80. The PCL-5 was completed based on the worst trauma identified by the participant, which could be an event that fell into one of the three THQ trauma categories described above or the included psychological violence item.

The psychometric properties of the PCL-5 have been assessed in different cultural contexts and samples, presenting satisfactory to high internal consistency, very good to high test-retest reliability, and strong convergent and discriminant validity (Ashbaugh et al., 2016; Blevins et al., 2015; Sveen et al., 2016). The Brazilian Portuguese version of the PCL-5 translated and adapted by Lima et al. (2016) was used. The cultural adaptation study revealed good internal consistency, adequate temporal stability, and correlation patterns supporting convergent and discriminant validity, with all the items showing a content validity coefficient ≥ 0.80 across the criteria (Lima et al., 2016). In the present study, internal consistency, as measured by Cronbach’s alpha, was high for the overall scale (α = 0.92) and for the theoretical dimensions outlined in the DSM-5: Criterion B (α = 0.86), Criterion C (α = 0.74), Criterion D (α = 0.85), and Criterion E (α = 0.78).

Probable PTSD was defined using a cut-off score of 36, as supported by diagnostic utility analyses in a Brazilian validation study using the SCID-5-CV as the reference standard (overall efficiency = 0.80) (Pereira-Lima et al., 2019). In addition, probable PTSD was defined using the DSM-5 diagnostic rule, which requires the endorsement of at least one re-experiencing symptom (Criterion B), one avoidance symptom (Criterion C), two negative alterations in cognition and mood symptoms (Criterion D), and two hyperarousal symptoms (Criterion E) (Apa, 2013). These DSM-5 symptom-cluster diagnostic criteria complement the cut-off approach by incorporating symptom endorsement across PTSD-specific clusters.

Because both the THQ trauma categories and the PCL-5 are aligned with the DSM-5 definitions of potentially traumatic events and PTSD symptoms, the present assessment is grounded in a DSM-5 conceptual framework. Accordingly, all analyses and prevalence estimates reported in this study refer to the DSM-5 criteria.

2.3. Statistical analysis

Descriptive statistics are reported in Table 1. Normality tests were conducted to investigate the distribution profile of the dependent variable. The results of the Shapiro–Wilk test indicated that the PCL-5 scores and residuals did not follow a normal distribution (PCL-5: W = 0.96, p < .000). Overdispersion of the data was inferred considering that the variance of the dependent variable (310.71) was much larger than the mean (24.97). To compare the severity of PTSD symptoms associated with a psychological violence event with those evoked by DSM-5 Criterion A events, we constructed negative binomial regression models. First, the participants were divided into four groups based on their index trauma: (1) psychological violence; (2) crime; (3) general disaster; and (4) physical or sexual violence. Then, we ran negative binomial regression models with the type of index trauma as the independent variable and the severity of PTSD symptoms (PCL-5 score) as the outcome. Negative binomial regression was chosen to address the problem of overdispersed data and nonnormality conditions. We checked whether the negative binomial model would provide a better fit than the Poisson model by examining the overdispersion parameter alpha calculated using the ‘nbreg’ command in Stata. The alpha value was substantially different from zero (p = .922), suggesting that the negative binomial model was more appropriate for the data. The exponentiated regression coefficients of the negative binomial regression models provide the incidence ratio rate (IRR). For categorical independent variables, the IRR might be interpreted as an increase or decrease in the dependent variable in terms of the change in the category of the independent variable (relative to the reference group). Thus, the IRR may be interpreted as an increase (IRR > 1) or decrease (IRR < 1) in the severity of PTSD symptoms for each group of participants who reported an index trauma meeting DSM-5 Criterion A relative to those who reported psychological violence as their index trauma. Additionally, we ran an adjusted model in which gender, age, and a number of other types of traumas from each THQ cluster (crime, general disaster, physical/sexual violence) to which the participants were exposed were included as control variables. Including this variable in the adjusted model accounted for the possibility that other DSM-5 Criterion A traumas could fully explain the association between psychological violence and PTSD symptoms.

Table 1.

Sociodemographic information, PTSD symptoms and trauma exposure for the total sample and for each index trauma group.

    Type of index trauma
  Total Sample (n = 530) Psychological Violence (n = 61) Crime (n = 70) General Disaster (n = 283) Sexual and Physical Assault (n = 116)
Age-years (M) 21.3 20.4 21.9 21.0 22.1
Gender (n/%)          
Female 418 (78.9) 45 (73.8) 48 (68.6) 220 (77.7) 105 (90.5)
Male 112 (21.1) 16 (26.2) 22 (31.4) 63 (22.3) 11 (9.5)
PTSD Symptoms – PCL-5 Mean (SE) 25.0 (0.77) 27.4 (2.0) 19.4 (1.85) 22.1 (0.98) 34.2 (1.76)
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Finally, we used logistic regression to test whether psychological violence as the index trauma was associated with higher or lower odds of probable PTSD (PCL-5 > 36; Pereira-Lima et al., 2019) compared to DSM-5 Criterion A traumas, adjusting for gender, age, and number of trauma types. Analyses were performed in Stata 12.0 with p < .05.

3. Results

3.1. Sample characteristics

The mean age of the sample was 21.3 years. Approximately 79% of the participants were women (n = 418), and 21% were men (n = 112). The sample was divided into four groups according to the index trauma: crime-related events, disasters (natural or man-made), sexual and physical experiences, and psychological violence events. Psychological violence was reported as the worst trauma experienced by 11.5% of the sample (n = 61), while 13.2% reported crime (n = 70), 53.4% reported general disaster (n = 283), and 21.8% reported physical or sexual abuse (n = 116) as their index trauma. Information regarding age, gender, trauma type, and the average PCL-5 score among the groups is available in Table 1. The average PCL-5 score for the whole sample was 25. When individuals were grouped based on their index trauma, the mean PCL-5 score was 27.4 (SD = 13.44) for psychological violence, 19.4 (SD = 23.33) for crime, 22.1 (SD = 37.48) for disaster, and 34.2 (SD = 9.19) for physical or sexual violence. Among the total sample, 26% had scores consistent with a probable PTSD diagnosis (i.e. a PCL score above the cut-off point of 36). With respect to each group individually, 29.5% of individuals who identified psychological violence as their index trauma had a probable PTSD diagnosis. Among those who reported a general disaster event as their worst trauma, 19.8% had a probable PTSD diagnosis, followed by 14.3% in the group of participants who reported a crime event as their worst trauma. The highest proportion of individuals with a probable PTSD diagnosis, 46.6%, was in the group of individuals who reported an event of physical or sexual violence as their index trauma. The differences between trauma types in relation to PCL-5 scores and the percentage of probable PTSD diagnoses for each trauma group are illustrated in Figure 2.

Figure 2.

Two bar charts comparing index trauma groups; sexual or physical assault shows the highest PCL 5 scores and PTSD probable diagnosis percent. The figure shows two bar charts summarizing post traumatic stress across four index trauma groups from the same sample. The left bar chart plots Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition total score on the vertical axis from 0 to 40 in steps of 10, against trauma group on the horizontal axis. Groups are Psychological Violence, Crime, General Disaster, and Sexual or Physical Assault. Bars for Psychological Violence and Sexual or Physical Assault are higher than bars for Crime and General Disaster, with Sexual or Physical Assault visibly highest; short error bars sit on top of each bar. The right bar chart plots probable post traumatic stress disorder diagnosis percentage on the vertical axis from 0 to 50 in steps of 10, against the same four trauma groups on the horizontal axis. The Sexual or Physical Assault bar is tallest, the Psychological Violence bar is intermediate, and Crime is lowest, with General Disaster between Crime and Psychological Violence. All data are approximate.

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Association between each type of index trauma and PTSD. A: PCL-5 mean score and standard error. B: Percentage of participants presenting a probable PTSD diagnosis (above the cut-off point of 36).

3.2. Association between the type of index trauma and PTSD severity

To investigate the impact of each type of index trauma on PTSD symptomatology, we used negative binomial regression models. The psychological violence group was set as the reference group, allowing a comparison of this group with all others. The results of the bivariate and multivariate models are reported in Table 2. Participants reporting an index trauma of psychological violence (reference group) presented higher PTSD symptomatology compared to those in the crime group [IRR = 0.708 (CI .534–.939); p = .017]. In other words, participants who experienced crime as their worst trauma had a mean PCL-5 score that was 29.2% lower than that of those who experienced psychological violence as their index trauma. The comparison of psychological violence with other types of index trauma did not reach statistical significance (general disaster [IRR = .805 (CI .642–1.010); p = .06]; physical or sexual violence [IRR = 1.25 (CI .969–1.608); p = .086]).

Table 2.

Negative binomial regression: association between each type of index trauma and PTSD symptom severity (total PCL-5 score and re-experiencing cluster score).

  Bivariate Model (raw) Multivariate Model (adjusted*)
Type of Trauma Index IRR 95% CI p value IRR 95% CI p value
Total PCL-5 score
Psychological Violence Ref.     Ref.    
Crime .708 [.534–.939] .017 .700 [.533–.920] .010
General Disaster .805 [.648–1.608] .060 .742 [.596–.923] .007
Sexual or Physical Assault 1.25 [.969–1.608] .086 .953 [.733–1.240] .721
Re-experiencing Cluster score
Psychological Violence Ref.     Ref.    
Crime 1.12 [.689–1.821] .646 1.17 [.717–1.895] .537
General Disaster 1.38 [.935–2.045] .105 1.41 [.952–2.081] .086
Sexual or Physical Assault 2.29 [1.488–3.528] .000 2.31 [1.498–3.566] .000
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Note: Abbreviations: IRR – incidence ratio rate; CI – confidence interval; *adjusted by gender, age, and the number of types of trauma.

In the multivariate model, we included gender, age, and the number of types of trauma (crime, general disaster, physical/sexual violence) as control variables. The results show that participants who reported psychological violence (reference group) as their index trauma presented higher PTSD symptoms than those reporting a crime event [IRR = 0.700 (CI .533–.920); p = .010] or a general disaster event [IRR = 0.742 (CI .596–.923); p = .007] in the adjusted model. Thus, after adjusting for the impact of gender, age, and exposure to other DSM-5 Criterion A-related trauma, the severity of PTSD symptoms among participants who experienced crime as their worst trauma was estimated to be approximately 30% lower than that of those who experienced psychological violence, whereas those who experienced a general disaster showed symptom severity that was 25.8% lower than that associated with psychological violence. The severity of PTSD symptoms among participants reporting an event of physical or sexual violence as their index trauma did not differ significantly from that among those reporting an index trauma of psychological violence [IRR = .953 (CI .733–1.240); p = .086] in the adjusted model.

In addition, we conducted a complementary negative binomial regression focusing on re-experiencing symptoms, modelling this PTSD symptom cluster as the outcome rather than the total PCL-5 score, to assess whether the pattern observed for overall symptom severity was maintained when analyses were restricted to PTSD-specific symptoms. No statistically significant differences were observed between psychological violence, crime-related trauma, and disaster-related trauma, whereas physical or sexual violence was associated with higher levels of re-experiencing symptoms (Table 2). Through boxplots, Figure 3 illustrates this pattern, showing largely overlapping distributions in the re-experiencing cluster among psychological violence, crime-related trauma, and disaster-related trauma, with an upward shift in symptom severity observed only for physical or sexual violence. Taken together, these findings indicate that when analyses are restricted to a PTSD-specific symptom cluster, psychological violence shows a symptom profile closely aligned with that observed for crime-related and disaster-related trauma. Comparable distributions are observed across the remaining PTSD symptom clusters, as presented in Figure 3.

Figure 3.

Four box and whisker charts comparing PTSD symptom scores across psychological violence, crime, disaster, and physical or sexual violence. The figure shows four box and whisker charts arranged in a grid, each displaying posttraumatic stress disorder symptom scores by index trauma type. The top left chart is titled Re experiencing Cluster. The horizontal axis is labeled Re experiencing symptoms score and ranges from 0 to 30 with ticks every 5 units. Four horizontal box plots represent psychological violence, crime, disaster, and physical or sexual violence. All trauma types show overlapping score ranges centered between about 3 and 15, with physical or sexual violence shifted slightly toward higher scores. The top right chart is titled Avoidance Cluster. The horizontal axis is labeled Avoidance symptoms score and ranges from 0 to 30 with ticks every 5 units. Box plots for psychological violence, crime, disaster, and physical or sexual violence cluster between about 1 and 10 with similar medians and whiskers. The bottom left chart is titled Negative alterations in cognitions and mood cluster. The horizontal axis is labeled Cognition and mood symptoms score and ranges from 0 to 30 with ticks every 5 units. All four trauma types again show broadly similar box lengths and whiskers, extending roughly from 3 to 20. The bottom right chart is titled Hyperarousal Cluster. The horizontal axis is labeled Hyperarousal symptoms score and ranges from 0 to 30 with ticks every 5 units. Each trauma type has a box plot spanning approximately 2 to 18, with overlapping distributions. Individual participant scores appear as dots overlaid on each box plot. All data are approximate.

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PTSD symptom cluster severity by index trauma type. Box-and-whisker plots show the distribution of DSM-5 PTSD symptom cluster scores (Re-experiencing, Avoidance, Negative alterations in cognitions and mood, and Hyperarousal) stratified by index trauma type (psychological violence, crime, disaster, and physical/sexual violence). Boxes represent the interquartile range (IQR), centre lines indicate the median, and whiskers indicate the full range. Dots represent individual participants’ scores.

3.3. Association between the type of trauma and probable PTSD diagnosis

We performed logistic regression analyses to explore how each type of trauma affects the likelihood of having a PCL-5 score that is compatible with a probable diagnosis. A cut-off point of 36 on the PCL was used to classify participants in the presence or absence of a probable PTSD diagnosis group. Additionally, participants were grouped according to their type of index trauma, as in the previous analysis. Table 3 shows the results of the logistic regression. The psychological violence group was again set as the reference group, allowing comparison with all the other groups. Compared with those who reported psychological violence as their index trauma, participants who reported crime had 60.2% lower odds of having a probable PTSD diagnosis [OR = 0.398 (CI = 0.167–0.947); p = .037] There was also no difference between the psychological violence group and the general disaster group [OR = .589 (CI .316–1.099); p = .096]. Furthermore, compared with those in the psychological violence group, individuals in the physical or sexual violence group were more likely to have a probable PTSD diagnosis [OR = 2.081 (CI 1.075–4.026); p = .03].

Table 3.

Logistic regression: Association between each type of index trauma and the probability of presenting a probable PTSD diagnosis.

  Bivariate Model Multivariate Model (adjusted*)
Type of Trauma Index OR 95% CI p-value OR 95% CI p-value
Cut-off score (PCL-5 > 36)
Psychological Violence Ref.     Ref.    
Crime .398 [.167–.947] .037 .406 [.166–.992] .048
General Disaster .589 [.316–1.099] .096 .494 [.259–.942] .032
Sexual or Physical Assault 2.081 [1.075–4.026] .030 .929 [.438–1.97] .848
DSM-5 symptom-cluster diagnostic criteria
Psychological Violence Ref.     Ref.    
Crime .536 [.258–1.117] .096 .539 [.258–1.125] .100
General Disaster .943 [.537–1.656] .839 .939 [.534–1.650] .827
Sexual or Physical Assault 2.191 [1.165–4.120] .015 2.152 [1.136–4.076] .019
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Note: Abbreviations: IRR – incidence ratio rate; CI – confidence interval; *gender, age, the number of types of trauma.

Finally, in the adjusted model, when the numbers of exposures to DSM-5 Criterion A events (crime, general disaster, and physical/sexual violence) are included as control variables together with gender and age, we observe a greater likelihood of having a probable PTSD diagnosis among participants who reported psychological violence as their index trauma than among those who reported crime [OR = 0.406 (CI .166–.992); p = .048]. Compared with psychological violence, a general disaster also produces a lower likelihood of a probable PTSD diagnosis [OR = .494 (CI .259–.942); p = .032]. In other words, participants who reported a general disaster as their index trauma had 50.6% lower odds of having a probable PTSD diagnosis compared to those who reported psychological violence as their index trauma.. Additionally, after controlling for gender, age, and exposure to other traumatic events, individuals who identified psychological violence as their worst trauma have similar chances of having a probable PTSD diagnosis compared to those indicating sexual or physical violence as their index trauma [OR = .929 (CI .438–1.97); p = .848].

In addition, we conducted a complementary logistic regression analysis using the DSM-5 diagnostic rules applied to the PCL-5 to define probable PTSD (Apa, 2013), which requires the presence of symptoms across multiple clusters, including PTSD-specific symptoms. Under the DSM-5 symptom-cluster diagnostic criteria, the odds of psychological violence did not differ statistically from those of crime-related or disaster-related trauma in terms of the likelihood of a probable PTSD diagnosis, whereas the odds of physical or sexual violence were greater than those of psychological violence (Table 3). This pattern is consistent with the overlapping symptom distributions observed for psychological violence, crime-related trauma, and disaster-related trauma depicted in Figure 3.

4. Discussion

The present study explored whether psychological violence might also be associated PTSD symptomatology at equivalent to those associated with DSM-5 Criterion A trauma, i.e. involving a threat of death, serious injury, or sexual violence. The events of psychological violence addressed here consisted of humiliation or ridicule without physical harm. We focused on humiliation and ridicule, a foundational and early-expressed form of psychological violence that directly targets the victim’s sense of self, social status, and belonging and often precedes more complex abusive dynamics such as dominance and coercive control (Dokkedahl et al., 2022). The results indicate that, compared with crime-related and disaster-related trauma, psychological violence is associated with greater PTSD symptom severity and higher odds of a probable PTSD diagnosis. The results indicate that, compared with crime-related and disaster-related trauma, psychological violence is associated with increased overall PTSD symptomatology and increased odds of a probable PTSD diagnosis on the basis of global symptom scores. Notably, re-experiencing symptom levels among individuals who reported psychological violence as their index trauma were similar to those observed following crime-related or disaster-related trauma, with higher levels observed for physical or sexual violence. This cluster is widely regarded as a hallmark feature of traumatic stress responses and is less likely to reflect nonspecific emotional distress alone (Brewin et al., 2009).

These findings are in line with those of previous studies that have already highlighted the association between psychological violence and PTSD symptomatology. For example, Bjornsson et al. (2020) demonstrated that when experiencing humiliation and rejection, one-third (32.7%) of a sample with social anxiety disorder met the diagnostic criteria for PTSD or suffered from clinically significant PTSD symptoms. Hyland et al. (2021) reported high odds of PTSD or complex PTSD among participants who were exposed to psychologically threatening events such as stalking, bullying, emotional abuse, and neglect. A meta-analysis exploring the associations between intimate partner psychological violence and depression, anxiety, and PTSD reported that psychological violence was associated with all outcomes (Dokkedahl et al., 2022). More recently, Hardarson et al. (2025) demonstrated that perceived social threats, such as humiliation and rejection, are significantly associated with increased PTSD symptom severity, even in the absence of direct life-threatening exposure. The current study contributes to the literature by showing that the severity of PTSD symptoms linked to an index trauma of psychological violence is similar to or greater than the severity of those associated with an index trauma in accordance with DSM-5 Criterion A.

The fact that a highly detrimental event linked to significant mental health impairments, such as psychological violence, has received less attention in relation to PTSD is most likely due to the DSM's requirement that PTSD diagnosis depends on the exposure to an event involving life-threatening situations. However, psychological violence functions as a destructive force that undermines the very fabric of relational and emotional well-being. In this sense, disruptions to the satisfaction of fundamental social and emotional needs can trigger profound physiological and psychological stress responses (Eisenberger & Lieberman, 2004; Williams, 2007). The observed pattern of PTSD-related symptoms associated with psychological violence may be understood in light of converging neurobiological and cognitive models of traumatic stress. Evidence from affective neuroscience indicates a functional overlap in the neural substrates underlying physical and social pain (Eisenberger & Lieberman, 2004). Such overlap suggests that acute threats to the integrity of the self and to social belonging may activate neuroendocrine stress responses that are also implicated in traumatic stress reactions. Consistent with the cognitive model of PTSD proposed by Ehlers and Clark (2000), psychological violence can therefore be conceptualized as a violation of fundamental internal standards that are central to self-integrity, Consequently, a fragmented self-concept is accompanied by persistent, vivid recollection of traumatic memories (Lanius et al., 2020). Accordingly, the persistence of intrusive recollections and heightened physiological reactivity may reflect disruptions in memory integration processes consistent with dual representation theory, resulting in involuntary, sensor-bound representations that remain weakly integrated with their contextual framework (Brewin et al., 2010).

The prevalence rates of probable PTSD observed in the present study are high and align with some prior findings from Brazilian samples. Previous research has reported elevated PTSD rates across diverse trauma-exposed populations, including survivors of sexual violence (44.1%; Luz et al., 2016), military personnel injured by firearms (36.7%; Monteiro et al., 2023), and health care workers during the COVID-19 pandemic (23.8% to 37.9%; Machado et al., 2023; Gama et al., 2022; de Souza Junior et al., 2024). Increased PTSD prevalence in Brazil has been linked not only to discrete traumatic events but also to broader contextual exposures, such as chronic urban violence and repeated threats. Epidemiological studies of urban Brazilian populations indicate high background exposure to traumatic events – particularly those involving violence – with many individuals experiencing multiple types of trauma across the lifespan (Ribeiro et al., 2013; Luz et al., 2016). This cumulative exposure may increase vulnerability to posttraumatic stress symptoms across different trauma types, contributing to elevated prevalence rates in nonclinical samples.

4.1. Implications

Recognizing psychological violence as a form of trauma and, consequently, an event associated with the development of PTSD can have significant effects on the treatment of victims. Trauma-focused therapies – widely regarded as the gold standard in PTSD treatment (Lee et al., 2016) – emphasize the index event as a central component of psychotherapy. Therapies such as cognitive-behavior therapy use imaginal exposure to directly process the traumatic event (Ehlers & Clark, 2000). When experiences of psychological violence are not conceptualized as potentially traumatic, therapeutic interventions may disproportionately prioritize these downstream cognitive and affective consequences over the event itself. Recognizing psychological violence as a potentially traumatic experience does not diminish the utility of consequence-focused models; rather, it broadens the therapeutic framework by allowing clinicians to flexibly integrate both event-focused and cognition-focused strategies. This integrated perspective may improve treatment outcomes by ensuring that interventions directly target the mechanisms most relevant to each individual’s distress.

From a clinical perspective, these findings highlight the need for careful assessment of PTSD-related symptoms in individuals exposed to psychological violence, as symptom severity may resemble that observed following events commonly associated with PTSD. In this sense, the present results may also inform ongoing discussions about the conceptual boundaries of traumatic events and the potential traumatic nature of psychological violence.

Moreover, prevention strategies could be proactively implemented by institutions such as corporations, religious organizations, and universities, given that psychological violence permeates various forms of relationships. Finally, these insights could have significant implications for social justice, potentially driving the development of laws and policies aimed at protecting survivors and holding perpetrators accountable.

4.2. Limitations and future directions

The cross-sectional nature of the study precludes conclusions about causality between the variables examined. Our data were collected via self-report questionnaires, which may limit the reliability and validity of the responses because of potential recall bias and varying levels of participant comprehension. In the absence of clinician-administered diagnostic interviews, these measures may capture general distress in addition to PTSD-specific symptomatology. We focused on one type of psychological violence even though the literature highlights a broader definition of this construct. We adopted this approach because psychological violence often begins with humiliation or ridicule before it progresses to more complex and systematized forms, such as dominance or coercion (Dokkedahl et al., 2022). Participants were exposed to multiple traumas, which could influence the results. This limitation is partly contextual, as 87% of the Brazilian population has been exposed to trauma (Ribeiro et al., 2013). Despite high levels of trauma exposure, we addressed this limitation by controlling for the effects of other trauma types, and psychological violence still produced symptoms as severe as those associated with DSM-5-defined traumatic events. A further limitation is the absence of data about race/ethnicity, which limits the analysis of potential disparities or variations in the outcomes associated with this factor. Another limitation concerns the exclusive use of DSM-5–based trauma categories and symptom measures. Because PTSD conceptualization differs across the ICD-11, the generalizability of the present findings across diagnostic frameworks warrants cautious interpretation. Finally, the sample was limited to university students, which may restrict the generalizability of the findings to other populations. Future research should aim to expand the investigation of psychological violence by employing broader questionnaires to investigate different typifications of the phenomenon, exploring its effects across diverse populations, including comparisons with trauma-free groups, and evaluating the efficacy of therapeutic interventions specifically designed to address psychological violence.

5. Conclusion

Our results indicate that individuals who experienced psychological violence as the worst event in their lives had comparable levels of PTSD symptom severity and a similar chance of presenting a probable PTSD diagnosis as those who reported traumas meeting the DSM-5 Criterion A for trauma. This finding underscores that psychological violence, while underrecognized, can have profound psychological consequences and should not be underestimated in the context of PTSD. Additionally, recognizing psychological violence as a form of trauma has critical implications for refining treatment protocols to better meet the needs of survivors.

Supplementary Material

Supplementary Material anon ..docx
ZEPT_A_2649110_SM9509.docx (96.1KB, docx)

Funding Statement

This work was supported by the following federal and state Brazilian research agencies: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) (Grant No. 001), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), and FINEP (Financing Agency for Studies and Projects).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The ethics committee did not authorize making the data publicly available; however, the data can be requested from the authors for scientific research purposes.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2026.2649110.

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Supplementary Materials

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Data Availability Statement

The ethics committee did not authorize making the data publicly available; however, the data can be requested from the authors for scientific research purposes.

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