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going or intermittent exposure) where there is the threat to oneself or others of death, serious injury
or violence. It is accompanied by intense fear and feelings of helplessness, with distressing recollec-
tions, dreams or flashbacks along with hyper-vigilance and avoidance of anything that reminds one
of the stressor. These symptoms usually occur within one month of experiencing the traumatic event,
although ‘delayed expression’ of symptoms can also occur. PTSD is most often associated with at least
one other major mental health conditions such as depression, anxiety, panic disorder, and alcohol or
substance abuse.

Post-Traumatic Stress Disorder in the International Classification of Diseases-11 (ICD-11, 2018), “is
a disorder that may develop following exposure to an extremely threatening or horrific event or series
of events. It is characterized by all of the following:

1. re-experiencing the traumatic event or events in the present in the form of vivid intrusive me-
mories, flashbacks, or nightmares. These are typically accompanied by strong or overwhelming
emotions, particularly fear or horror, and strong physical sensations;
2. avoidance of thoughts and memories of the event or events, or avoidance of activities, situations,
or people reminiscent of the event or events; and
3. persistent perceptions of heightened current threat, for example as indicated by hypervigilance
or an enhanced startle reaction to stimuli such as unexpected noises. The symptoms persist for
at least several weeks and cause significant impairment in personal, family, social, educational,
occupational or other important areas of functioning.”

Uncomplicated PTSD is sometimes used to describe PTSD that involves the above three symptom cri-
teria. Co-morbid PTSD is a term used when PTSD is associated with at least one other major mental
health conditions such as depression, anxiety, panic disorder, and alcohol or substance abuse.

Vicarious or Secondary Trauma
Humanitarian workers can predict to a certain degree that their role has inherent risks. However, the
cumulative exposure to stories of unbearable pain and tragedy can have a profound impact on cop-
ing mechanisms. Vicarious trauma is caused by exposure to often large numbers of traumatized and
vulnerable populations. Even when humanitarian personnel have had no direct exposure to traumatic
events, there is a risk of vicarious trauma. Hearing detailed, and at times harrowing, stories can some-
times cause severe distress and disturbance that can impact daily functioning.

The humanitarian worker’s sense of overwhelming helplessness can be compounded by moral injury
when working with victims of war, torture, abuse and rape (for more information on moral injury see
this presentation by Sonya Norman, US National Center for PTSD). Vicarious trauma is often linked
with compassion fatigue and burnout. The latter is related to an accumulation of chronic, unresolved
stress over time, from overwork, too high expectations/disappointments, exposure to problems, poor
self-care and social support, etc. leading to incapacitating emotional distress and behavioral dysfunc-
tion.

Complex Post-Traumatic Stress Disorder, according to ICD-11, “is a disorder that may develop fol-
lowing exposure to an event or series of events of an extreme and prolonged or repetitive nature that
is experienced as extremely threatening or horrific and from which escape is difficult or impossible
(e.g., torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual
or physical abuse). The disorder is characterized by the core symptoms of PTSD; that is, all diagnostic
requirements for PTSD have been met at some point during the course of the disorder. In addition,
complex PTSD is characterized by:

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