Re-evaluating PTSD Classification: Neurobiological and Therapeutic Perspectives on its Psychological and Psychotic Dimensions - A Systematic Review

Introduction Post-Traumatic Stress Disorder presents heterogeneous symptoms, prompting debate over whether it is best understood as a psychological disorder or a condition with psychotic-like features. Clarifying its diagnostic position remains important for treatment planning. This review synthesized neurobiological, clinical, and therapeutic evidence, with attention to trauma complexity. Methods Following PRISMA 2020 guidelines, a systematic search of PubMed, PsycINFO, Scopus, Web of Science, and ScienceDirect identified studies published between 2000 and 2024 on classification, psychotic features, neurobiology, and treatment outcomes. Empirical studies meeting eligibility criteria were included, and quality was assessed using the Cochrane Risk of Bias Tool. Results Forty-one studies were included. Neuroimaging findings frequently showed hippocampal volume reduction (78%) and amygdala hyperactivity (65%). Up to 40% of chronic cases reported psychotic-like symptoms, particularly after prolonged or early-life trauma. Greater trauma complexity was associated with more severe and dissociative presentations. Psychological therapies, especially Cognitive Behavioral Therapy and Eye Movement Desensitization and Reprocessing, showed stronger long-term outcomes than pharmacological interventions. Discussion The overlap between PTSD and psychotic disorders appeared partial and largely trauma-related rather than indicative of primary psychosis. Findings pointed to prefrontal-limbic dysregulation, especially in chronic or complex trauma, while symptom variability appeared closely linked to trauma severity and dissociative processes. These patterns may reflect trauma-associated dysregulation within a stress-related framework rather than a distinct psychotic condition. Conclusion The evidence supports a trauma-spectrum model that recognizes limited overlap with psychosis while preserving PTSD’s core psychological basis. Trauma-informed frameworks may improve classification and individualized care. Registration This review was not registered.