1. Traumatic events

1.1. Defining trauma

The experience of traumatic events is ubiquitous both in general populations around the world (Kessler et al., 2017; Koenen et al., 2017; Olff et al., 2021) and in (at risk) subpopulations (e.g. Boelen & Adamkovič, 2024; Cao et al., 2020; Hoeboer et al., 2025; Hoppen & Morina, 2019; Kuester et al., 2017; Lin et al., 2024; Nissen et al., 2021; Yehuda et al., 2014; Yousef et al., 2021). Operationalization and assessment of trauma are the bedrock upon which studies of trauma outcomes are based and are the basis of important global discourse. For example, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Text revised (DSM-5-TR) defines traumatic events as exposure to actual or threatened death, serious injury, or sexual violence in several ways, including direct experience, witnessing, and/or learning about violent or accidental trauma events that occurred to close family members of friends (American Psychiatric Association, 2022). The DSM-5-TR definition of trauma also includes the experience of chronic or extreme exposure to details of traumatic events, such as in the case of first responders or police officers who may be exposed to details of others’ trauma or traumatic scenes of death, injury or abuse. The International Classification of Diseases-11th Revision (ICD-11) defines trauma broadly as ‘an extremely threatening or horrific event or series of events’ (World Health Organization, 2022), but neither the DSM-5 nor ICD-11 provides a comprehensive list of potentially traumatic events. Furthermore, the term ‘trauma’ is now used more broadly by both laypersons and researchers than it was previously, including less ‘severe’ adverse events (Haslam et al., 2020). On the one hand, this may be positive and contribute to the recognition of harmful practices (e.g. labelling emotional abuse as potentially traumatizing). On the other hand, overuse of the term may lead to pathologizing stressful, but not necessarily traumatic, experiences, expectations of negative health outcomes, and a victim mindset. It can, therefore, be challenging for health and other professionals (e.g. working in the legal system) to arrive at a mutual understanding of what constitutes a traumatic event and consequent traumatic reactions that meet a threshold for access to treatment and/or compensation (Olff et al., 2019). Of note, a recent content analysis of commonly used measures of potentially traumatizing events concluded that there is not a great deal of concordance between events and the description of events that are queried in both research and practice (Karstoft & Armour, 2023).Criterion A for PTSD refers to the characteristics of the traumatic event that must occur to potentially trigger the development of PTSD. Debate on the definition and utility of the Criterion A is not new. Indeed, Marx et al. (2024) recently divided this debate into four positions: (1) expanding Criterion A to include more events (e.g. indirect exposure through social media, experience of racial discrimination), (2) narrowing Criterion A to include fewer events (e.g. exclude all forms of indirect exposure), (3) eliminating Criterion A completely, and (4) keeping the definition of Criterion A as presently written. In accordance with Marx et al. (2024), we recommend future research to determine how best to define Criterion A – considering different geographical and cultural contexts – to ultimately facilitate harmonization of research and optimization of healthcare (Haslam et al., 2020).Types of potentially traumatic events faced by large segments of the population also change over time. For example, the recent COVID-19 pandemic has led to a surge of papers showing that COVID-19-related events may also fulfil the PTSD A Criterion and give rise to a wide range of mental health symptoms (e.g. Greene et al., Citation2021; Olff et al., Citation2021). Even young children have been shown to be affected (Vasileva et al., Citation2021). Two special issues of this journal have addressed the impact of COVID-19 (Ford & Seedat, Citation2023; O’Donnell & Greene, Citation2021). Climate change is another emerging global context that is associated with increasingly frequent traumatic experiences such as disaster exposure, violence, and migration due to extreme weather (Berry et al., Citation2010; Massazza et al., Citation2022; Olff, Citation2023; Pardon et al., Citation2024; Vergunst et al., Citation2024, see also https://www.global-psychotrauma.net/climate). Globally, climate change impacts populations unequally with vulnerable populations being more affected. The impact on mental health as well as potential protective factors have been addressed in a recent special issue in the journal (O’Donnell & Palinkas, Citation2024).In sum, defining trauma is complex and multifaceted. Survivors’ subjective interpretation of an experience may be more important than the objective characteristics of an event or experience. Text mining offers interesting options to screen for posttraumatic stress reactions (e.g. Marengo et al., Citation2022). Future research needs to address how assessment of exposure to traumatic events can be refined to reduce the variability across common standardized trauma tools.

1.2. Trauma exposure: sex/gender aspects

Sex and gender effects have been increasingly studied in psychotraumatology. While sex is a biological variable (e.g. sex assigned at birth; female, male), gender is a social and cultural variable (e.g. woman, non-binary) (Langeland & Olff, Citation2024).Both sex and gender have a bearing on the rates of specific types of traumatic events (and on their consequences, see Section 2.10). For example, men are more likely to experience certain types of violence and combat. Women on the other hand are more likely to experience physical and sexual assault (Langeland & Olff, Citation2024; Norris et al., Citation2002; Olff, Citation2017; Olff et al., Citation2007; Tolin & Foa, Citation2008) and to be exposed at a younger age, all of which are associated with a higher conditional risk of PTSD (e.g. Olff et al., Citation2007). Also, members of sexual of gender diverse (SOGD) communities are at disproportionately higher risk for sexual violence compared to cisgender heterosexual people (Blackburn et al., Citation2024).Unfortunately, although we see improvement since the introduction of the gender policy in this journal (Langeland & Olff, Citation2024), overall many prior studies lacked clarity around whether sex or gender was being tested and the vast majority defined both as binary constructs. To better clarify the role of sex and gender on the impact of traumatic events future research should move beyond the binary conceptualization. Langeland and Olff (Citation2024) provide concrete suggestions on methods for the assessment of sex and gender.

1.3. Trauma exposure: lifespan perspectives

Children and adolescents are reporting increasingly high levels of exposure to traumatic events. Interestingly, in epidemiological studies and representative population samples, younger individuals report higher levels of lifetime trauma exposure compared to older individuals (de Vries & Olff, Citation2009; Havermans, van Alphen, et al., Citation2023; Hoeboer et al., Citation2025). Whether younger people are actually being more exposed to potentially traumatic events, or are more likely to recognize more events as traumatic, or whether this is a recall effect requires more research. Vice versa, older adults report lower levels of exposure than younger individuals, which is surprising considering these are life time measures (Havermans, Hoeboer, et al., Citation2023; Hoeboer et al., Citation2025). It thus remains unclear if this is due to ‘forgetting’, related to cognitive decline, or whether it reflects reporting bias due to stigma or shame, or due to not attributing more events as traumatic.Exposure to any form of traumatic stressor(s) in childhood increases the risk of later adverse social and/or psychological outcomes (Armour, Citation2021; Charak et al., Citation2023; Dunn et al., Citation2019). Exposure to interpersonal traumas (i.e. intentional acts by other persons, e.g. maltreatment, family or community violence) in childhood is particularly strongly associated with psychological, relational, and physical health problems later in childhood and adolescence (Briggs-Gowan et al., Citation2019) with lasting effects that extend into adulthood (Cloitre et al., Citation2020; Ford et al., Citation2020; Van Assche et al., Citation2020). Exposure to multiple types of severe danger, harm, or victimization in childhood increases the likelihood and severity of PTSD symptoms and other trauma-related disorders across the lifespan with a dose–response relationship. This has been described as cumulative trauma exposure (Charak et al., Citation2023; Wilker et al., Citation2015), poly-traumatization (Contractor et al., Citation2018), poly-victimization (Gilbar & Ford, Citation2020; Lee et al., Citation2022), or adverse childhood experiences (ACEs; Karatzias et al., Citation2020; Knipschild, Hein, et al., Citation2024).However, caution is necessary in interpretating studies on childhood trauma due to inherent methodological limitations. Research assessment of childhood trauma often involves adult participants giving retrospective reports of childhood experiences. Likewise, many standardized measures of trauma, including childhood trauma, do not assess the frequency, intensity, and/or duration of events. Rather, the individual is asked whether they had experienced a particular traumatic event with an expected yes or no response. The adverse childhood experiences (ACEs) literature has been criticized for only including 10 types of childhood adversities (Finkelhor et al., Citation2015) and for simply summing the number of adversity types to produce a score that weights the impact of each adversity equally (Briggs et al., Citation2021).Given that childhood is characterized by elevated neural plasticity and developing neurobiological systems, it is not surprising that stressful events during childhood seem to strongly affect the regulation of emotions and the mediation of stress responses later in life, inducing alterations in neural circuits, biochemical neuroendocrine and immune systems, enhancing the risk for psychiatric disorders (Agorastos, Citation2017; Meier et al., Citation2024; Nkrumah et al., Citation2024). However, most studies broadly summarize ‘childhood’ to extend across early life (sometimes summarizing ‘under 16’) and thereby may miss the key critical developmental, ‘critical periods.’ For example, some research has shown that exposures in early childhood (before 3 years of age) may be especially salient (Dunn et al., Citation2019). Further, children who were poly-victims (i.e. experienced multiple forms of traumatic victimization) in early childhood (from birth to 6 years of age) were more likely to be poly-victimized in middle childhood and adolescence as well though the types of victimization tended to differ across developmental epoch (Grasso et al., Citation2016) and to have different types of psychosocial and posttraumatic symptoms if they had been poly-victimized in only one developmental epoch (i.e. primacy and recency effects) (Dierkhising et al., Citation2019). Moving forward, given the multitude of neurobiological changes that occur during specific critical periods, it will be important for future research investigations to take a more nuanced approach to understanding the impacts of traumatic stress during early childhood, mid-childhood, peri-puberty, and beyond.In addition to paying attention to specific critical periods, future research on childhood trauma should include instruments that assess frequency, intensity, and duration of events. Moreover, along with the assessment of traumatic events, in order to understand and therapeutically address their impact it also is important to identify benevolent events – especially in childhood, but also with a lifetime perspective – that support resilience and recovery from traumatic adversity (Karatzias et al., Citation2020).While abuse of older adults is prevalent (Acierno et al., Citation2010) research to better understand the long-term lifespan impact of early trauma and how trauma experienced later in life may impact older adults. PTSD has been associated with accelerated biological ageing (e.g. Wolf & Morrison, Citation2017). Of note, cognitive decline may also result from traumatic brain injury (TBI) (Akhanemhe et al., Citation2024). Interestingly, while ACE instruments exist, as far as we know there is not yet an instrument capturing specific ‘Adverse Older adults Experiences’ (AOE). Traumatic experiences towards the end of the life cycle, for example in dementia, need further investigation. Identifying traumatic exposure and potential PTSD in patients with cognitive decline or dementia may require specialized diagnostic tools and interviews tailored to this population (Havermans, van Alphen, et al., Citation2023; Trauma & Ageing, Citationn.d.).

1.4. Trauma exposure: global and contextual perspectives

Over the past 15 years, research has confirmed that trauma exposure is common worldwide, but there are substantial variations in prevalence across countries (Benjet et al., Citation2016; Kessler et al., Citation2017). Discrepancies in prevalence might arise from a combination of historical, geopolitical, economic, and cultural factors that influence rates of intentional and unintentional injury and other adverse events (Atwoli et al., Citation2017). It is increasingly clear that residents of countries affected by war and conflict are at substantially higher risk of experiencing or witnessing potentially traumatic events (for example, Pavlova & Rogowska, Citation2023; Yousef et al., Citation2021). There is also growing recognition that, in lower-resource and conflict-affected regions where violence is chronic and continuous, trauma exposure may not be best conceptualized as a discrete event but rather as an ongoing condition of living with no clear ‘pre’- and ‘post’-trauma period (Hecker et al., Citation2017; Kaminer et al., Citation2018). In addition, it is likely that notions of what constitutes a ‘traumatic’ event vary across contexts and cultures, so that what is perceived as extremely shocking or adverse in one setting may be accepted as a normal part of life in another. Most of the terminology in psychotraumatology has been developed in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. Ascertainment bias is a factor as traumatic event screens that are widely used largely capture Westernized conceptions of trauma. Cross-cultural research comparing the social meanings of different events (see also the discussion above on the concept creep of Criterion A) could enhance our understanding of the widely varying prevalence rates of PTSD across cultural settings. In non-Western settings, there is a lack of screening tools that are inclusive of the range of potential trauma events experienced in these settings. A large global collaboration on traumatic stress (GCTS) project has been designed to map traumatic experiences in a cultural context (MaTRix, Citationn.d.). In sum, with regard to definitions and prevalence of trauma exposure, more research is needed by researchers from the global south.

2. Mental and physical health consequences of trauma exposure

Traumatic events may have a wide range of transdiagnostic mental and physical health consequences, not limited to PTSD. Symptom presentation, prevalence, and course, in response to traumatic experiences, differ depending on individuals’ age and developmental phase, sex/gender, sociocultural contexts, and systemic societal forces (e.g. health disparities, systemic discrimination). Research on the most common outcomes following trauma is discussed below, and we will end this section with a focus on sex/gender aspects, the lifetime perspective and global and contextual perspectives on the consequences of trauma.

2.1. Resilience

The most common response to trauma (approximately two-thirds) is resilience as demonstrated by Galatzer-Levy et al. (Citation2018) in a meta-analysis of 54 studies. In assessing the moderating factors that may be able to differentiate between trajectories of risk and resilience, aspects of emotional functioning, such as coping flexibility, coping strategies and style, perceived self-efficacy, optimism, neuroticism and resilience beliefs play potentially significant roles. Likewise, it has been reported that the most consistent predictors of resilience are personality, financial security and educational attainment, social support, coping, meaning making, and experience of positive emotions (e.g. Bonanno et al., Citation2015). Bonanno (Bonanno, Citation2021) critiques this body of literature by stating that the quality of the evidence varies and even when a factor is statistically related to a resilient outcome, the predictive power is modest at best. One potentially fruitful line of inquiry may be to focus on a person's flexible self-regulation abilities during and after the traumatic experience. Theoretically, those who are more adept at emotion regulation might have a greater likelihood of more resilient outcomes post-trauma. Flexible self-regulation or the ‘Flexibility Sequence,’ involves three sequential components: (1) context sensitivity, (2) repertoire, and (3) feedback (Bonanno, Citation2021). It is important to note, however, that despite the many psychosocial advantages that may be provided by post-traumatic resilience, these benefits come at a potentially severe cost to overall health due to the allostatic load that results from mobilizing the body’s physiological resources to adapt to the adverse impacts of trauma (Brody et al., Citation2016). Resilience may decline towards the end of the life when protective factors like loss of the support structure, or risk factors including reduced health come in play.

2.2. PTSD, dissociative-PTSD (D-PTSD) and complex PTSD (CPTSD)

Trauma exposure is associated with a range of negative outcomes for survivors, their loved ones, and the wider community. The most extensively studied negative outcome is PTSD, which is described differently across diagnostic systems. In the DSM-5-TR PTSD is characterized by 20 symptoms belonging to four symptom clusters of intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity (APA, Citation2022). In addition, the DSM-5-TR includes Dissociative-PTSD (D-PTSD), which is characterized by the presence of PTSD with added dissociative symptoms of derealization and/or depersonalization. This subtype has been confirmed via a systematic review of 11 empirical studies, although investigating covariates across the studies produced mixed results (Hansen, Ross, et al., Citation2017).In the ICD-11 (WHO, Citation2022), PTSD is characterized by three symptom clusters of re-experiencing, avoidance, and perceptions of heightened current threat and includes the sibling disorder Complex PTSD (CPTSD). CPTSD is characterized by the presence of PTSD and additional symptoms of three domains of Disturbances in Self Organization (i.e. Affect Dysregulation, Negative Self Concept, and Disturbance in Relationships (WHO, Citation2022). The conceptual differences between the diagnostic descriptions of PTSD, D-PTSD, and CPTSD in the DSM-5 and the ICD-11 have led to multiple studies on how these differences may impact estimated prevalence rates (e.g. Cao et al., Citation2020; Hansen et al., Citation2015; Hansen, Hyland, et al., Citation2017) Interestingly, the differences in relation to PTSD are found to be quantitative (i.e. result in different rates of PTSD) as well as qualitative (i.e. kappa values varying between .60-.68) in studies using both the PTSD Checklist for DSM-5 (PCL-5) and the International Trauma Questionnaire (ITQ) (Hansen, Ross, et al., Citation2017; Robinson et al., Citation2024). Similarly, Robinson et al. (Citation2024) investigated the impact on estimated prevalence rates of D-PTSD and CPTSD and found only moderate agreement between these classifications (Kappa = .70; Robinson et al., Citation2024). In areas of the world where treatment is dependent on diagnostic status, these discrepancies may mean that people may be offered or denied treatment depending on the classification system used. Similarly, a recent study suggests that the estimated effect of treatment may also be influenced by the specific choice of diagnostic system (Elmose Andersen et al., Citation2022).

2.3. Moral injury

Traumatic events may also result in moral injury, defined as ‘the profound psychological distress that can arise from being exposed to various situations involving acting, failing to act, or witnessing events that go against personal or collective core beliefs or expectations’ (Maguen & Norman, Citation2024; see www.global-psychotrauma.net/moral-injury). Moral injury involves both the exposure component to a potentially morally injurious event, as well as the resulting symptoms of moral distress or moral injury that often include shame, guilt, despair, and loss of morale. A wide range of mental health disorders including PTSD may also result from exposure to morally injurious events.In the past 15 years, we have seen an exponential growth of research on moral injury. A recent special issue dedicated to this topic in the journal showed that the research started mainly with military personnel but now includes other populations (Ter Heide & Olff, Citation2023) such as healthcare workers (Coimbra et al., Citation2024; Hegarty et al., Citation2022) and refugees (Hoffman et al., Citation2019). Notably, research on the treatment of moral injury is progressing (Williamson et al., Citation2022; Ter Heide & Olff, Citation2023).Future research might explore the need for a formal diagnosis in our diagnostic systems. Also, the conceptualization of moral injury in a global context deserves attention. Furthermore, we still know very little on how these types of events impact physical health (Schnyder, Citation2024). Finally, with regard to assessment, since moral injury involves both the exposure component as well as the consequences future research might include instruments that tap both, such as the Moral Injury and Distress Scale (MIDS) (freely available from Maguen & Norman, Citation2024; Norman et al., Citation2024).

2.4. Prolonged grief

After decades of research establishing pathological grief reactions as a condition related to and yet distinct from PTSD, Prolonged Grief Disorder (PGD) was recently introduced in the ICD-11 (WHO, Citation2022), and in the DSM-5-TR as a stressor-related disorder alongside PTSD (APA, Citation2022). However, the criteria are different across diagnostic classification systems. The DSM-5-TR requires PGD symptoms to last at least 12 months (6 months in children), while the ICD-11 only requires a symptom duration of 6 months. A recent systematic review of 48 studies identified several characteristics that differentiate between the development of pathological grief and PTSD, but the included studies were very heterogeneous and mainly cross-sectional (Jann et al., Citation2024). Recent empirical data suggest that the two classifications might not capture the same clinical entity (Eisma et al., Citation2022). Regardless, the recognition of PGD as a condition in international classifications has accelerated research on its phenomenology (e.g. Eisma & Lenferink, Citation2023; Hennemann et al., Citation2023) and treatment (Tang et al., Citation2024), in particular, in the context of the global death toll of the COVID-19 pandemic (Djelantik et al., Citation2021).

2.5. Other (comorbid) mental health outcomes

After trauma, major depressive disorder (MDD), anxiety disorders, substance use disorders, and sleep disorders are common outcomes. Comorbidity between PTSD and major depressive disorder (MDD) is particularly high, with a meta-analysis reporting rates as high as 52% (Rytwinski et al., Citation2013). Not surprisingly, the DSM-5 PTSD symptom cluster ‘negative alterations in cognition and mood’ increases the overlap with depressive symptoms (Hurlocker et al., Citation2018). Notably, over 90% of individuals with PTSD report either insomnia, nightmares, or both (Milanak et al., Citation2019), which are increasingly recognized for their role in undermining emotional learning necessary for PTSD recovery and treatment response (Colvonen et al., Citation2019; de Boer et al., Citation2020; van der Heijden et al., Citation2022).Epidemiologic research suggests that substance use disorders (SUD) affect 2.2% of the world population (Castaldelli-Maia & Bhugra, Citation2022), with higher prevalence rates in higher income countries. Alcohol use disorder (AUD) is the most prevalent SUD world-wide (Glantz et al., Citation2020). PTSD and SUD, including AUD, co-occur at high rates, with estimates suggesting that approximately one in two individuals with PTSD have met criteria for a SUD in their lifetime (e.g. Gielen et al., Citation2012; Roberts et al., Citation2022; Van den Brink, Citation2015). The co-occurrence of PTSD and SUD is well-established across populations and is characterized by a more complex, severe, and functionally impairing course with poorer treatment outcomes compared to either disorder alone (Roberts et al., Citation2022). Recent work published in this journal supports a bidirectional relationship between PTSD and SUD, with higher effect sizes for PTSD’s relationship with future SUD than the reverse (Amstadter et al., Citation2023). Despite tremendous gains in developing our understanding of the PTSD/SUD comorbidity over the years, more work is needed, using rigorous methodologies, to understand the biopsychosocial mechanisms underlying risk and maintenance processes for PTSD/SUD.Around a quarter of persons diagnosed with PTSD also have a borderline personality disorder (BPD), and vice versa. Because of overlapping symptoms, in particular with Complex PTSD, there is even controversy about the validity of BPD as a separate diagnosis (Snoek et al., Citation2024). A comorbid personality disorder is sometimes perceived as a barrier for treatment of PTSD. In a recent meta-analysis, patients with comorbid personality disorders were not at higher risk for dropout from PTSD treatment, although they might benefit less from the PTSD treatment (Snoek et al., Citation2021).

2.6. Transdiagnostic perspectives and survivor-centred approaches

Given the multiple, often comorbid, outcomes of trauma, researchers have called for transdiagnostic screening of trauma survivors (e.g. Grace et al., Citation2023; Haering et al., Citation2024). Although recent work on transdiagnostic perspectives and treatment targets indicates that all disorders reflect associated phenomena and hence may share some treatment targets (e.g. the HiTOP, Kotov et al., Citation2017), it is important to include the comprehensive nature and complex interactions and aftermath of the impact of traumatic exposure.The nature of the negative impact caused by trauma on the individual may also vary between and within the same type of traumatic exposure as there is no specific universal experience hereof and hence no universal reaction to traumatic exposure. For instance, PTSD is highly prevalent following sexual assault. Estimated prevalence rates of PTSD are found to vary between 17 and 74% depending on the time of measurement (Dworkin et al., Citation2023; Koss et al., Citation2020), but it is too simplistic to examine only PTSD as a potential psychological outcome (Koss et al., Citation2020). It is thus important to adapt a broader perspective and include other psychological reactions (e.g. depression, anxiety, sleep, and suicidal thoughts and behaviour), and physical reactions (e.g. fractures and pain), social reactions (e.g. social isolation, stigma, racial discrimination) as well as the ensuing interactions between the survivors and their surrounding network (European Union Agency for Fundamental Rights, Citation2014; Hoeboer et al., Citation2024; Koss et al., Citation2020; Mekawi et al., Citation2020; Olff et al., Citation2019). This is especially relevant in considering cultures that are more collectivistic versus individualistic. It can therefore be helpful to include a broader socio-ecological informed perspective (Campbell et al., Citation2009). Furthermore, there is a need for more survivor-centred, culturally appropriate, and trauma-informed services following sexual assault or trauma, more general. Specifically, a recent review identified seven main categories of characteristics of underserved survivors of sexual assault: ethnic and cultural minorities, disabilities, financial vulnerability, sexual and gender minorities, mental health conditions, problematic substance use, and older age (Bach et al., Citation2021).A study in young people in Georgia showed that a transdiagnostic approach has potential to provide an effective service for those at risk of mental health problems (Makhashvili et al., Citation2022). Future research should address screening for transdiagnostic outcomes after trauma and whether transdiagnostic screening may improve identification of a wide range of trauma-related outcomes and improved access to care.

2.7. Impact of trauma on physical health

The acute stress response after trauma involves a cascade of Central Nervous System (CNS) and neuroendocrine reactions that help people contend with the experience, and chronic activation of these systems (as in PTSD) can lead to physical health problems. It has been hypothesized that biological dysregulation might mediate the effects of trauma on psychological health, consequently increasing the risk for developing psychiatric disorders as well as physical illnesses (Akiki et al., Citation2018; Binder, Citation2017; Bussières et al., Citation2023; Clemens et al., Citation2018; Engel et al., Citation2020, Citation2023; Lüönd et al., Citation2025; Nugent et al., Citation2014, Citation2016).PTSD is associated with increased rates of obesity and metabolic disorders (e.g. type 2 diabetes mellitus; (Michopoulos et al., Citation2016), autoimmune disorders (e.g. rheumatoid arthritis, lupus; (Boscarino, Citation2004; Goldschen et al., Citation2023; Spitzer et al., Citation2020), thyroid disease, asthma, and obstructive sleep apnea (OSA) (Colvonen et al., Citation2015), the latter of which has been shown to impair inhibitory and extinction learning (Reist et al., Citation2021). Clemens et al. (Clemens et al., Citation2018) found childhood trauma to be associated with obesity, diabetes, cancer, hypertension, chronic obstructive pulmonary disease, history of myocardial infarction and stroke, and odds for all conditions increased with increasing number of maltreatment subtypes that were experienced. How subtypes of child maltreatment are related to somatic symptoms, as well as the mechanisms connecting them, calls for more research (Lüönd et al., Citation2025).It is often difficult to distinguish symptoms and consequences of physical health problems such as pain (e.g. social withdrawal, sleep problems, or concentration) from difficulties related to PTSD (e.g. avoidance, arousal, or re-experiencing) and vice versa (Hansen et al., Citation2021, Citation2023). PTSD is common in chronic pain patients (Siqveland et al., Citation2017), possibly due in part to differences in neural processing (Miedl et al., Citation2024). Some of the coping behaviours and changes in the daily routine that people show after trauma can also affect their health negatively e.g. weight gain, smoking, self-medication with alcohol or drugs, fear of sleep, and social isolation (Budenz et al., Citation2021; Meeker et al., Citation2021; Werner et al., Citation2021).Trauma exposure and PTSD are associated with increased rates of cardiovascular disease, including stroke, myocardial infarction, hypertension, and heart failure (Edmondson et al., Citation2013; O’Donnell et al., Citation2021; O’Donnell & Greene, Citation2021), as well as risk factors such as increased carotid intima-media thickness (Spitzer et al., Citation2020; Vulic et al., Citation2019) and arterial plaque burden (Gharios et al., Citation2024). While some of these risk factors may result from behavioural changes related to PTSD (e.g. smoking, low physical activity, poor diet and sleep; Michopoulos et al., Citation2016), PTSD has demonstrated an independent effect on cardiovascular risk after accounting for these factors (Seligowski et al., Citation2024). Mechanistically, chronic elevation of the stress response in PTSD (e.g. heightened sympathetic arousal, inflammation) may lead to hypertension and vascular damage that ultimately increase cardiovascular risk. Inflammatory responses related to the stress response in PTSD are also thought to increase risk for several other physical health sequelae.

2.8. Neurobiological consequences of trauma

Trauma exposure and PTSD are associated with variability in neural reactivity, brain morphology, and neurotransmitter systems (Harnett et al., Citation2020). There are alterations in brain function, structure, and neurotransmitter systems that overlap with a core neurocircuit involved in threat processing (Fragkaki et al., Citation2016; Lanius & Olff, Citation2017). Meta-analyses suggest trauma and PTSD are often related to heightened amygdala and dorsomedial prefrontal cortex (PFC) reactivity to emotional stimuli, as well as reduced ventromedial PFC reactivity (Hayes et al., Citation2012; Stark et al., Citation2015). Mega-analyses of brain morphology data further suggest that PTSD is associated with reduced hippocampal volume (Logue et al., Citation2018). The amygdala, PFC, and hippocampus form a neural network that is critical for healthy emotional functioning and regulation of responses to threat. Importantly, neural circuitry findings in PTSD may vary by several important factors. Neuroimaging meta-analyses suggest that PTSD-related neural reactivity differences may be modulated by the type of trauma experienced (Boccia et al., Citation2016). Further, subtypes of PTSD (e.g. the dissociative subtype) may show varying neurobiological signatures compared to classical patterns in PTSD (Lebois et al., Citation2021). More recent work also suggests that specific neurobiological biotypes may underlie specific symptom trajectories following trauma exposure (Stevens et al., Citation2021). There are likely a multitude of biopsychosocial predictors involved in post-trauma responding; more research is needed to build biopsychosocial predictive risk models.A systematic review reported high heterogeneity in experiences, exposures, and contextual factors among groups across the globe (Nicholson et al., Citation2022). Consideration of unique stressors (e.g. discrimination, refugee/migrant-related stress) is critical for understanding unique neural signatures for PTSD (Nicholson et al., Citation2022). In addition, prior stress, trauma, and environmental influences can affect ‘neurophenotypes’ and contribute to different imaging profiles (Lanius, Citation2015; Marinova & Maercker, Citation2015).

2.9. Genetic risk for trauma-related conditions

Twin studies from civilian and veteran populations have documented moderate heritability for PTSD, ranging from 30 to 72% (Sartor et al., Citation2012; Stein et al., Citation2002). In children, notably, parent-offspring transmission of Acute Stress Reactions (ASRs) or PTSD was correlated with both rearing and genes. Even after accounting for potential shared index traumas, correlations were similar for both rearing and genes (Amstadter et al., Citation2024). The landscape of molecular genetic studies on PTSD has changed dramatically in the past decade, driven by the influences of large-scale consortia science and the lowering cost of genotyping. The Psychiatric Genomics Consortia workgroup for PTSD (PGC-PTSD), formed in 2013, has united researchers from across the globe who are working together to discover the genetic architecture of PTSD, a disorder that is characterized by fewer genetic discoveries compared to similarly heritable phenotypes. The most recent multi-ancestry meta-analysis from the PGC-PTSD workgroup included over 1.2 million individuals and identified nearly 100 genome-wide significant loci, 85% of which were novel (Nievergelt et al., Citation2024). Aggregate genetic risk for PTSD is moderately to highly correlated with other psychiatric disorders, with the genetic correlation between PTSD and major depressive disorder (MDD) being the highest (Nievergelt et al., Citation2024) which is also consistent with bivariate twin work on PTSD and MDD (Sartor et al., Citation2012).Recent work has also included molecular genetic investigations of resilience (Cusack et al., Citation2023), although limitations of sample size render this work preliminary. In addition to the increase in available molecular genetic data on PTSD, novel statistical genetic techniques such as genomic structural equation modelling, mendelian randomization, and polygenic risk scoring are being applied to PTSD and related phenotypes. These techniques have great promise for further understanding the underlying genetic risk for trauma-related conditions. Finally, a meta-analysis of epigenome-wide association studies including 23 military and civilian cohorts identifies 11 DNA methylation sites associated with PTSD that may represent the susceptibility to PTSD, the impact of trauma, or the sequelae of PTSD itself (Katrinli et al., Citation2024).

2.10. Trauma consequences: sex/gender aspects

PTSD prevalence rates are twice as high in women compared to men (Hoeboer et al., Citation2025; Kilpatrick et al., Citation2013; Langevin et al., Citation2024; Olff, Citation2017; Olff et al., Citation2007; Tolin & Foa, Citation2008), higher rates for women are also found for comorbid disorders (e.g. major depression, anxiety, insomnia, nightmares) following trauma. Sex differences also exist in PTSD symptom trajectories within one-year post-trauma. Although the same trajectories were observed for men and women, i.e. resilient, recovery, chronic symptoms and delayed onset, the recovering trajectory was more prevalent in women, while the delayed onset trajectory was more prevalent in men (van Zuiden et al., Citation2022).In women, biological sex hormones appear to influence the higher risk for PTSD, such that women with low levels of oestradiol (either through saliva, plasma, or menstrual phase estimation) experience worse PTSD symptoms and impaired fear inhibition (Glover et al., Citation2012, Citation2013; Nillni et al., Citation2015; Pineles et al., Citation2016; Seligowski et al., Citation2020). In contrast, high progesterone levels appear to confer worse extinction retention in women with but not without PTSD (Pineles et al., Citation2016). Sex differences in PTSD prevalence appear to emerge in adolescence (Hiscox et al., Citation2023).A meta-analysis in a large multi-ethnic cohort identified sex-specific genetic risk loci, thus demonstrating Single Nucleotide Polymorphism (SNP)-based heritability estimates varying by sex (Nievergelt et al., Citation2019). However, with increased sample sizes this is no longer significant (Nievergelt et al., Citation2024). Findings from neuroimaging studies indicate that women may have stronger activation of the locus coeruleus in response to fearful faces (Felmingham et al., Citation2010) and lower activation of the dorsal anterior cingulate during extinction recall (Shvil et al., Citation2014). Additionally, elevated heart rate and cytokine levels may be more salient indicators of PTSD risk in women than men (Kleim et al., Citation2010; Michopoulos et al., Citation2015; Seligowski et al., Citation2021). Cognitive and behavioural responses during and after trauma have been shown to fully mediate both the effect of sex differences and accidental versus interpersonal trauma on PTSD symptom severity at 6 months after the trauma (Beierl et al., Citation2020).There are important sex differences in cardiometabolic risk after trauma. For example, inflammatory cytokines have been associated with worse PTSD symptoms and psychophysiological hyperarousal in trauma-exposed women but not men (Michopoulos et al., Citation2015), and sympathetic arousal measured via heart rate appears to be higher in women versus men with PTSD (Fonkoue et al., Citation2023; Seligowski et al., Citation2021). Further, low oestradiol levels are associated with worse sympathetic arousal and vascular function (Regitz-Zagrosek & Kararigas, Citation2017; Seligowski et al., Citation2020) in women with and without PTSD. More neurobiological and psychosocial research on gender diverse populations with PTSD is needed.

2.11. Trauma consequences: lifespan perspectives

Children/adolescents – While it is evident that not all trauma-exposed children and adolescents develop PTSD, prevalence estimates vary considerably, depending on the study sample, the assessment methods, and the type of events evaluated. A meta-analysis by Alisic et al. (Citation2014) with more than 70 studies published estimated that approximately 16% of children and adolescents develop PTSD after exposure to a potentially traumatic event, almost twice the proportion seen in adult populations.Given climate change, children (as well as adults) are likely to be exposed to more and more natural disasters (Olff, Citation2023; O’Donnell & Palinkas, Citation2024). A special issue in this journal highlighted how children can be prepared for natural disasters and the mental health aspects of such events (Dyregrov et al., Citation2018). A recent systematic review identified a number of PTSD risk factors from children to elderly earthquake survivors that could help the identification of at-risk families (Sirotich & Camisasca, Citation2024).Child abuse and neglect in early childhood may lead to symptoms beyond PTSD and internalizing symptoms to include attachment as well as emotional and behaviour problems. Youth exposed to traumatic events across multiple settings and by multiple perpetrators tend to have more severe trauma-related symptoms than children who experience multiple incidents or chronic exposure to a single type of adversity. Adverse cumulative effects of trauma exposure can occur following a combination of two types of traumatic adversity; some types of traumatic stressors (i.e. sexual and physical abuse, neglect, domestic violence) have synergistic adverse effects (Briggs et al., Citation2021). Cumulative trauma or poly-traumatization at any point in childhood places youth at risk for a wide variety of posttraumatic and psychosocial problems, but its adverse impact differs depending upon the specific developmental epoch(s) in which it occurs (Dierkhising et al., Citation2019).Developmental Trauma Disorder (DTD) has been formulated and empirically validated as an integrative theoretical and clinical framework to describe the range of trauma-related problems that poly-victimized children and adolescents may experience in developing the fundamental psychosocial competencies for self-regulation, including dysregulation of bodily functions, emotion, attention and cognition, behavioural self-control, engagement in relationships, and identity formation (Ford et al., Citation2021, Citation2022). Although not a formally codified diagnosis in the DSM or ICD, a developmentally-attuned posttraumatic syndrome in children exposed to traumatic victimization and disruption in attachment bonding has been shown to be distinct from and to occur separately as well as together with PTSD (Ford et al., Citation2022) with a distinct profile of comorbidity from PTSD (Ford et al., Citation2022; van Der Kolk et al., Citation2019). DTD also has been shown to account for psychosocial impairment over and above that attributable to PTSD in both an initial field trial and an independent replication study (Ford et al., Citation2021). DTD thus may provide clinicians and researchers with a clinical framework to identify victimized youth who could benefit from trauma-focused treatment but who otherwise would only be considered as candidates for treatment related to other psychiatric disorders.Older adults – There has been relatively little work examining the prevalence of PTSD in older adults compared to other age groups. Many individuals exhibit sub-threshold symptoms, which do not meet the full diagnostic criteria for PTSD. The available evidence suggests that the prevalence of PTSD diminishes with older age (Creamer & Parslow, Citation2008; Havermans, Hoeboer, et al., Citation2023; Moye et al., Citation2022). The prevalence of PTSD among those aged 60 and older ranges from 1.9% to 9.5% (Fox et al., Citation2020; Pietrzak et al., Citation2011). The mechanisms that result in a decrease in PTSD among older individuals remain unclear. Several possible explanations have been suggested include a survivor’s bias among the general population. That is, those with PTSD are more vulnerable to serious illness, endure chronic stress, and are prone to engaging in risky and maladaptive behaviours (Lohr et al., Citation2015). Other theorists have suggested that PTSD may present differently in older individuals such that the current diagnostic criteria may not capture the disorder in older adults (van Dongen et al., Citation2022). Examples of such differences include limited contact with external cues due to physical impairments that limit mobility or hearing loss that may mitigate hypervigilant behaviour (Fox et al., Citation2020). Additional explanations for the lower prevalence of PTSD among older adults include interpreting mental health concerns as somatic as well as higher mental health-related stigma among older individuals. It also remains largely unclear why traumatized individuals who are initially able to successfully cope with the events, present in later life with delayed-onset PTSD (Andrews et al., Citation2007). Despite the lower prevalence of PTSD among older individuals, there are a substantial number of older adults who have PTSD and thus additional work in this area is warranted. Furthermore, advances in medical care and increased awareness of mental health disorders are likely to result in increased rates of PTSD in older individuals in the near future.

2.12. Trauma consequences: global and contextual perspectives

Symptoms of PTSD and CPTSD are endorsed across a range of cultures, indicating that both diagnoses have some cross-cultural validity (Charak et al., Citation2022; Ho et al., Citation2020; Ng et al., Citation2020; Nielsen et al., Citation2023). However, there is mounting evidence that responses to trauma vary considerably across cultural contexts, and Western diagnostic nosologies are not sufficient to capture the full breadth of these responses. For example, somatic responses, social isolation, and ‘thinking a lot’ are commonly reported amongst survivors of traumatic events in Low- or Middle-Income Countries (LMICs) (Martínez-Radl et al., Citation2023; Michalopoulos et al., Citation2020). This highlights that culturally informed assessment tools are vital adjuncts to DSM- and ICD-based measures if trauma survivors in need of support are to be accurately identified across different cultural settings. Trauma symptom screening measures have been developed for some specific cultural settings in collaboration with local stakeholders (for example, Jalal et al., Citation2017). In addition, the Global Psychotrauma Screen (GPS, www.global-psychotrauma.net/gps), which assesses a broad array of transdiagnostic traumatic stress symptoms common across different cultural settings, has been validated in various non-Western settings (Brunnet et al., Citation2024; Oe et al., Citation2020; Primasari, Hoeboer, Bakker, et al., Citation2024; Salimi et al., Citation2023).Further consideration of within culture/context heterogeneity is also needed to improve our understanding of the impacts of trauma and PTSD. For example, there is considerable ethnoracial variability in the prevalence and impact of trauma exposure that reveals potentially important moderators to consider. Specifically, Black individuals in the United States are exposed to a greater number of risk factors for trauma-related disorder development but often report similar or lower experiences of trauma and PTSD symptoms compared to groups with less risk factors (Harnett et al., Citation2023; Maguire-Jack et al., Citation2020; Roberts et al., Citation2011; Slopen et al., Citation2016). The incongruence may be due in part to the adoption of adaptive neurophysiological mechanisms to counteract the impacts of stressors (Webb et al., Citation2024) which may however lead to more severe symptoms for those susceptible (Williams, Citation2018). Similar mechanisms may be in play with regard to the finding that lower levels of PTSD have been reported in countries with higher vulnerability rating, the so called vulnerability paradox (Dückers et al., Citation2016; Dückers & Olff, Citation2017). Inclusivity of ethnoracially and culturally diverse participants is not always considered which can contribute to bias in research findings (Harnett et al., Citation2023).

3. Preventive interventions

3.1. Preventive pharmacological interventions

To date, there is still no ‘morning after pill’ to prevent PTSD in the aftermath of a traumatic exposure. Research has failed to demonstrate the efficacy of several psychopharmacological compounds to prevent the development of PTSD, including the beta blocker propranolol, gabapentin and antidepressants (selective serotonin reuptake inhibitors [SSRIs]) (Bertolini et al., Citation2022). Some data suggest that hydrocortisone might be efficacious, although more rigorous research is needed (Bertolini et al., Citation2022). Oxytocin holds some promise in the prevention of PTSD (Engel et al., Citation2019, Citation2020; Frijling, Citation2017; Olff, Citation2012) but only – as shown in posthoc analyses – for those with high levels of initial symptoms (van Zuiden et al., Citation2017). To prevent the transition from ASD to PTSD, prazozin was found effective in a small pilot open-label study (Magnin et al., Citation2023). In sum, we need much more research before being able to pharmacologically prevent PTSD shortly after trauma.

3.2. Preventive psychological interventions

Preventive interventions after an adverse event can be used in different phases of care (Magruder et al., Citation2016, Citation2017). Delivering early interventions has the potential to prevent posttraumatic stress reactions from escalating to a PTSD diagnosis whether delivered at the golden hour or in the weeks after trauma (Bisson & Olff, Citation2021). Such interventions are tolerable and effective (Bragesjö et al., Citation2021). Traumatic events may have long term (>10 years) adverse outcomes including PTSD (Karchoud et al., Citation2024), emphasizing the importance of preventive interventions.Psychoeducation as part of psychotherapy is common (Schnyder et al., Citation2015). However psycheducational stand-alone interventions have been controversial since the ‘debriefing’ debate (see e.g. Olff et al., Citation2019), but have garnered interest again (Knipschild, Klip, et al., Citation2024; Primasari, Hoeboer, Sijbrandij, et al., Citation2024). A systematic review including 10 studies found some evidence for psychoeducation improving attitudes towards and knowledge of mental health, and was generally considered acceptable and useful, but no support for routine use of brief psychoeducation as a stand-alone intervention to prevent PTSD (Brooks et al., Citation2021). In LMICs with limited access to mental health care, easy-to-administer psychoeducational interventions can be a first step in stepped care strategy (Primasari, Hoeboer, Sijbrandij, et al., Citation2024). A psychological first-aid intervention was shown to decrease early PTSD symptoms but did not prevent it (Figueroa et al., Citation2022).A systematic review and meta-analysis showed effectiveness of several early psychological interventions for individuals with traumatic stress symptoms following trauma exposure, especially for those meeting the diagnostic threshold for ASD or PTSD (Roberts et al., Citation2019). However, there is no evidence supporting universal psychological interventions for all trauma-exposed individuals irrespective of their symptoms (Roberts et al., Citation2019). Bisson et al. (Bisson et al., Citation2021; Bisson & Olff, Citation2021) concluded the strongest evidence was found for trauma-focused cognitive behaviour therapy applied as an indicated intervention to trauma survivors who show symptoms within the first months after the trauma to prevent further deterioration and the development of PTSD. A smaller review of seven studies of efficacy of early interventions after sexual assault showed durable effects on PTSD severity (Oosterbaan et al., Citation2019).After mass trauma and disasters we can assume that there will be a need for interventions targeting both adults (Eisma et al., Citation2019) and children (Dyregrov et al., Citation2018). First responders (Cogan et al., Citation2024), medical personnel (Greene et al., Citation2021), and military service members (Blais et al., Citation2021) may be at risk of developing PTSD or other symptoms due to the frequent exposure to potentially traumatizing experiences inherent in their professions. For traumatic loss, we know little about specific implications for prevention (Boelen et al., Citation2019).We do not yet know enough about which interventions to offer and for whom. For example, a study of early intervention with Eye Movement Desensitization and Reprocessing (EMDR) therapy in rape survivors did not demonstrate greater effectiveness, as compared to ‘watchful waiting,’ in reducing symptoms of posttraumatic stress and other psychopathology (Covers et al., Citation2021). Similarly, a review of early interventions offered to individuals experiencing workplace trauma did not establish clear benefits of any specific intervention, nor suggest which was superior, although only generic debriefing was associated with negative outcomes (Billings et al., Citation2023). In addition, despite cumulative evidence on the impact of sleep disturbance on subsequent PTSD risk (e.g. Agorastos & Olff, Citation2021), early interventions targeting sleep within the acute aftermath of trauma to prevent PTSD remain a nascent area of research (Reffi, Kalmbach, et al., Citation2023; Swift et al., Citation2022). Although exciting new studies that seek to promote healthy sleep after trauma are underway (e.g. Sayk et al., Citation2024), there is also evidence suggesting sleep deprivation may be protective (e.g. Repantis et al., Citation2020).In sum, for early or preventive interventions there is a need for high-quality evidence, which may be challenging considering the context of this type of research. Kassam-Adams (Citation2014) suggested a (still-relevant) framework. Interventions must be theoretically grounded, practical for delivery in peri-trauma and early post-trauma context, and ready for evaluation. Ethical issues around early intervention need to be considered, e.g. with regard to iatrogenic damage (Rose et al., Citation2002) as well as the screening versus capacity to treat (Greene et al., Citation2022). Artificial intelligence (AI) mediated early interventions, for instance, using large language models to either screen or provide support to trauma-exposed individuals, are exciting new avenues currently being explored (e.g. Figueroa et al., Citation2025).

3.3. Complementary/integrative preventive interventions

To date, there are few well-controlled studies and limited evidence to support mind–body interventions such as mindfulness and yoga for the prevention of PTSD (Niles et al., Citation2018; Citation2023; Tan et al., Citation2023). However, given the low rates of adverse events associated with these interventions and the potential for improved health and wellness, they may be considered as safe palliative or adjunctive therapies (Tan et al., Citation2023).

3.4. Sex/gender aspects in preventive interventions

Although sex differences in PTSD symptom trajectories within one-year post-trauma (van Zuiden et al., Citation2022) may call for sex or gender-specific preventive interventions there is a paucity of literature on this topic. Only one study to date has examined sex or gender differences in early interventions post-trauma. Among a sample of US Army soldiers who received a version of psychological first-aid, men attended fewer sessions than women, and lower attendance was associated with worse symptom severity (Biggs et al., Citation2016). As these study findings may not generalize to other populations, additional research is warranted to better understand how men versus women respond to early post-trauma interventions. Not surprisingly, few prevention strategies specifically aim to reduce sexual violence among sexual and gender diverse (SOGD) communities and Blackburn and colleagues (Blackburn et al., Citation2024) call for action.

3.5. Lifespan perspectives in preventive interventions

A framework for the design, delivery, and evaluation of early interventions for children has been proposed by Kassam-Adams (Citation2014). Suggested targets for early intervention mentioned were maladaptive trauma-related appraisals, excessive early avoidance, and social/interpersonal processes. Effective early interventions for children may also include preventive programs to support parenthood for very vulnerable women during pregnancy and the first two years of the child's life (Mejdoubi et al., Citation2015). Mental health problems of parents increase the risk for young people to develop trauma-related problems, whereby guidelines and initiatives for Children of Parents with Mental Illness (COPMI) for youth care and youth protection both offer tools for possible interventions. For parents who cannot provide sufficient emotional security in the attachment relationship with their children, Video Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD; Juffer & Bakermans-Kranenburg, Citation2018) has been shown to be effective. In this intervention, parents receive feedback based on video recordings of interactions between them and their children. The aim of the intervention is to improve the parenting skills of the parent, thereby preventing or reducing behavioural problems. Also, Parent Child Interaction Therapy (PCIT: Abrahamse et al., Citation2016) and Child–Parent Psychotherapy (CPP: Guild et al., Citation2021) are potentially effective interventions in promoting attachment relationships.For children who recently experienced a stressful life event, the Watchful Waiting protocol has been developed (Covers et al., Citation2021). This protocol stipulates screening for post-traumatic stress symptoms at least two times during the first month post-event and, if indicated, subsequent referral for evidence-based treatment.For older adults, preventive interventions are a much-needed terrain of research with the growth of this population worldwide.

3.6. Cross-cultural/global perspectives in preventive interventions

Task-shifting interventions for PTSD and other stress-related disorders in LMIC have overwhelmingly focused on treatment interventions (Akhtar et al., Citation2022; Purgato et al., Citation2018; Singla et al., Citation2017), with a dearth of randomized clinical trials (RCTs) on prevention and promotion. Universal, selected and indicated preventive interventions can arguably be delivered in community settings at scale through task-shifting to primary care workers (including primary care health workers) and community workers. A synthesis of 113 RCTs of primary-level and/or community health worker interventions, compared to any control conditions, for promoting mental health and/or preventing mental disorders in adults and children in LMICs was recently published (Purgato et al., Citation2023). Thirty RCTs of PTSD prevention in adults and 5 in children were included. The systematic review found that promotion/universal prevention interventions compared to usual care may slightly reduce distress or PTSD symptoms in adults (without risk factors for mental disorders) compared to usual care. However, it is uncertain whether selective prevention (in adults with risk factors for mental disorders/lack of protective factors) or indicated preventive interventions (in adults with a high vulnerability to develop mental disorders) compared to usual care have any effect on distress/PTSD symptoms. In children, promotion/universal prevention interventions compared to usual care may slightly reduce distress/ PTSD symptoms; selective interventions compared to usual care probably slightly reduce distress/PTSD symptoms; whilst indicated prevention compared to usual care may slightly reduce distress/PTSD symptoms. Considering that social determinants and cultural factors may be contributing to the wide variability in outcomes in prevention and promotion of PTSD, these and other moderating effects will need to be parsed out in future RCTs. For instance, interpersonal violence exposure may be a social determinant of sleep health among racially diverse and socioeconomically disadvantaged communities that might in turn contribute to the prevalence of PTSD in these populations (Reffi et al., Citation2024).People in LMICs are also disproportionately affected by humanitarian crises. With regards to psychological interventions (focusing on practical support, instilling hope, strengthening coping, and building resilience) and social interventions (focusing on strengthening social support and connections), a Cochrane review (Purgato et al., Citation2018) found that, for children, psychosocial interventions were no more effective than control conditions (waitlist, no treatment, treatment as usual) in reducing PTSD symptoms, depression, and anxiety symptoms at the study end-point or at the 3-month follow-up. Acceptability was also similar for intervention and control groups, but information on tolerability (side effects) was not reported, which is a pervasive limitation across RCTs of psychological interventions. Notably, no RCT data on PTSD promotion/prevention were available for adults impacted by humanitarian crises living in LMIC.In sum, variability in the quality of studies calls for RCTs that are more methodologically robust. Studies that are intentionally designed to evaluate the effectiveness of prevention interventions in reducing the incidence of PTSD across the lifespan among people living in LMIC are needed.

4. Treatment of trauma-related disorders

4.1. Pharmacological interventions

For the past couple of decades, the medications for PTSD approved by regulatory authorities in most countries are sertraline, and paroxetine, two selective serotonin reuptake inhibitor antidepressants. As part of a special issue on prevention and treatment of PTSD in this journal (Bisson & Olff, Citation2021), a systematic review and meta-analysis including 115 studies found evidence of a small positive effect of selective serotonin reuptake inhibitors (SSRIs) in reduction of PTSD symptoms: fluoxetine, paroxetine, sertraline, venlafaxine and the antipsychotic quetiapine when used as monotherapy, prazosin and risperidone for augmentation (Hoskins, Bridges, et al., Citation2021). Although efficacious in large trials, these medications yield relatively small effects on PTSD symptom severity compared to that of trauma-focused therapies, leading recent VA/DOD guidelines (VA/DoD, Citation2023) to only recommend them when trauma-focused therapies are not available. A recent systematic review showed that clonidine looked promising in improving sleep, nightmares, and PTSD symptoms but the evidence is based on few and low-quality studies. Another review systematically reviewed and meta-analysed ketamine intervention for PTSD and concluded that a placebo is the likely mechanism behind reported effects (Borgogna et al., Citation2024).A systematic review and meta-analysis on pharmacological-assisted psychotherapies using conventional and novel drug agents in reducing PTSD symptom severity showed that the only promising interventions was methylenedioxymethamphetamine (MDMA)-assisted therapy but based on a small numbers of participants (Hoskins, Sinnerton, et al., Citation2021). A recent phase III trial found MDMA-assisted psychotherapy for individuals with severe PTSD to be highly efficacious (Mitchell et al., Citation2021), suggesting that this approach may have significant potential for those with severe PTSD and associated comorbidities. The Australian Therapeutic Goods Administration approved MDMA in conjunction with psychotherapy in the treatment of PTSD in 2023, under strict prescribing rules. On the other hand, despite the current available data including two large trials (Mitchell, Bogenschutz, et al., Citation2023; Mitchell, Ot’alora, et al., Citation2023), the US Food and Drug Administration recently reviewed MDMA in combination with psychotherapy in the treatment of PTSD but did not grant approval requesting more (rigorous) data.Furthermore, identifying patients with specific molecular biomarkers can aid in developing treatment strategies targeting specific biological processes, improving clinical care by matching individuals to the most appropriate intervention. Future research can explore the reversibility of biological consequences of early life stress, prevention of its effects through early therapeutic interventions (Carvalho Silva et al., Citation2024), and identification of biological mediators of early life stress and other medical conditions (Thomaes et al., Citation2016).

4.2. Psychological interventions

There are a number of well-established, evidence-based psychological treatment approaches for PTSD, including EMDR, Prolonged Exposure, Cognitive Processing Therapy and Cognitive Therapy for PTSD (e.g. Australian PTSD Guidelines – Phoenix Australia, Citationn.d.; Bisson et al., Citation2019; Bisson & Olff, Citation2021) that lead, on average, to large reductions in PTSD symptoms. There is less research on treatments for CPTSD; however, there is emerging evidence that the well-established approaches may be helpful also for both adults and young people with CPTSD (Hoeboer et al., Citation2021; Jensen et al., Citation2022; Oprel et al., Citation2021). Whilst these interventions are effective for many people with PTSD, they are not helpful for all; some individuals drop out of treatment prematurely (Lewis, Roberts, Gibson, et al., Citation2020; van der Hoeven, Assink, et al., Citation2023), and many continue to experience significant symptoms once treatment is complete (Lewis, Roberts, Andrew, et al., Citation2020). The specific setting may determine outcomes. A review of 87 studies on patients in a medical setting showed beneficial effects of EMDR on reducing psychological and physical symptoms although the high heterogeneity of studies and high risk of bias should be noted (Driessen et al., Citation2024). Another systematic review in refugee populations showed positive effects, but only in the short term (Daniel et al., Citation2024). Thus, it is important to build upon the extant literature base with attention to factors that might influence the effectiveness of specific treatments for the individual across sociocultural contexts.In general, it is vital for studies to focus on populations that are currently underserved or understudied in trauma research, for example those that do not respond to current evidence-based trauma treatment or those that never receive treatment due to treatment barriers (Hoeboer et al., Citation2025), or due to circumstances around for instance intimate partner violence that make help seeking potentially unsafe or impossible (Hoeboer et al., Citation2024; Nshimyumukiza et al., Citation2024; Sprague et al., Citation2017; Sprague & Olff, Citation2014). Understanding the mechanisms behind treatment resistance and developing tailored interventions for these groups will be essential to ensure that advances in the field benefit all individuals affected by trauma.Evidence-based psychological therapies for PTSD share common emphases on psychoeducation; emotion regulation and coping skills; cognitive processing, restructuring, and/or meaning making; emotional processing; and in turn, trauma memory processing (Schnyder et al., Citation2015). Evidence suggests that similar psychological processes drive changes in PTSD symptoms across evidence-based therapies; in particular, changes in beliefs about the causes or consequences of the trauma, changes in memory processing, and decreases in unhelpful coping strategies, including avoidance, safety behaviours and rumination (Bisson et al., Citation2022; Brown et al., Citation2019; Ehlers et al., Citation2023; Wiedemann et al., Citation2023).A systematic review on treatment for PTSD showed that trauma-focused interventions were cost-effective, while further research regarding pharmacotherapy and other treatments was needed (von der Warth et al., Citation2020). Another study showed no differences in cost-effectiveness between different forms of prolonged exposure for PTSD (Kullberg et al., Citation2023). Trauma-focused cognitive therapy for PTSD was more cost-effective than general CBT focusing on teaching coping techniques including exposure (Penington et al., Citation2024).Large-scale dissemination efforts have been made in several countries to disseminate evidence-based treatments for PTSD into routine clinical services. These have several difficulties and obstacles to overcome, and some decreases in overall effectiveness have been observed under some conditions. Foa et al. (Citation2013) highlight the importance of the quality of training (which requires case supervision besides a manual and workshop), and high-level organizational support and an appropriate infrastructure for the maintenance of dissemination efforts. Clark (Citation2018) emphasized the role of outcome monitoring in helping services and therapists develop the best practice models. Therapist attitudes such as skepticism towards evidence-based interventions and overestimation of the risks of exposure to trauma memories can impede the implementation trauma-focused treatments (Schumacher et al., Citation2018). Systematic studies of factors that facilitate and impede the implementation of effective interventions are needed.

4.2.1. Treating comorbidities

The treatment of comorbid PTSD/ SUD provides a particular challenge for many clinicians (Roberts et al., Citation2023). Trauma-focused integrative interventions (Back et al., Citation2014; Hien et al., Citation2022) for PTSD/SUD show the most promise in treating individuals with PTSD/SUD (Roberts et al., Citation2022). The integration of leading treatments for PTSD, such as Prolonged Exposure therapy, with cognitive–behavioural therapy for SUD, such as Relapse Prevention, are particularly promising (e.g. Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure [COPE]; Back et al., Citation2014). Simpson et al. (Citation2021) found that trauma-focused, non-trauma-focused, and manualized SUD interventions were sound options for individuals with comorbid PTSD/SUD. However, recent meta-analytic findings suggest high rates of attrition and modest treatment effects even among the most effective evidence-based interventions, including trauma-focused integrative interventions (Roberts et al., Citation2022). While we have made tremendous gains in treating the complex comorbidity of PTSD/SUD, more work is needed to enhance extant treatments and develop novel intervention avenues. In the absence of robust evidence-based literature, expert recommendations for the assessment and treatment of this comorbidity have recently been developed (Roberts et al., Citation2023).Another challenging clinical presentation is the co-occurrence of PTSD and sleep disorders, namely insomnia, nightmares, or obstructive sleep apnea (OSA). Unfortunately, trauma-focused interventions do not reliably improve sleep to a clinically meaningful degree (Kline et al., Citation2025), with more than 50% of patients whose PTSD remitted following trauma-focused therapy continuing to report insomnia at follow-up (e.g. Schnurr & Lunney, Citation2019). Importantly, residual symptoms of insomnia, nightmares, or OSA hinder patients’ response to PTSD treatment (e.g. Taylor et al., Citation2020) and may increase risk for future relapse (Kartal et al., Citation2021). The refractoriness of sleep disorders has therefore galvanized efforts to better target them among individuals with PTSD using novel approaches (Colvonen et al., Citation2018), such as delivering cognitive behavioural therapy for insomnia (CBT-I) prior to initiating PE (Colvonen et al., Citation2019) Indeed, CBT-I, the first-line treatment for insomnia (Edinger et al., Citation2021), exerts very large effects on PTSD symptom reduction (g = 1.3) (Hertenstein et al., Citation2022), and emerging evidence supports the efficacy and rationale of integrating it with PE to facilitate fear extinction learning (Hunt et al., Citation2023). Similar effects on fear extinction have been observed following other sleep-focused interventions such as continuous positive airway pressure (CPAP) for OSA (Reist et al., Citation2021) and morning blue light treatment for circadian rhythm stabilization (Vanuk et al., Citation2022).Current evidence-based treatments for prolonged grief include cognitive behavioural therapy (e.g. Haneveld et al., Citation2022), as well as a 16-session manualized loss-focused psychotherapy (Shear et al., Citation2016), that has also shown efficacy on PTSD symptoms associated with bereavement (Na et al. Citation2021). Finally, pharmacological treatments typically efficacious for PTSD including selective serotonin reuptake inhibitors (SSRIs) have not demonstrated efficacy in decreasing the core symptoms of PGD (Shear et al., Citation2016). Future psychopharmacotherapy research should focus on compounds targeting biological pathways implicated in PGD, including the oxytocin (Bui et al., Citation2019; Gang et al., Citation2021; O’Connor et al., Citation2008), reward (O’Connor et al., Citation2008), and pain (Gang et al., Citation2021) pathways.

4.2.2. Digital technologies

A significant challenge for health care providers is to create evidence-based therapies for PTSD and related conditions available at scale, and in a way that is sufficiently accessible to individuals requiring treatment. As a wide range of technologies have become a pervasive part of everyday life for individuals around the globe, research has moved to leverage technology to improve access to evidence-based treatments (Javanbakht et al., Citation2024; Kaltenbach et al., Citation2021; Kasparik et al., Citation2022; Kothgassner et al., Citation2019; Olff, Citation2015; Strelchuk et al., Citation2023).Technologies ranging from smartphones, to smartwatches, to video games, and beyond, provide us information about our behaviours (e.g. app usage, ‘step counts,’ heart rate, sleep, and so much more) and offer to connect us with others in our network to share health goals or music preferences and so much more. Interventions have increasingly leveraged these technologies, increasing the ease and validity of between-session in vivo ‘tracking’ and reviewing data with patients in session and even permitting between session automated (Nugent et al., Citation2023). For example, during the pandemic, many providers and patients moved to remote delivery of traditional therapies, with evidence increasingly supporting comparable outcomes observed in both in person and remote delivery (McClellan et al., Citation2022). Guidance on how to adapt trauma-focused treatments remotely was published (Fisher, Citation2021; Wild et al., Citation2020). Research has also explored ways that virtual reality may have a key role in delivery of PTSD interventions, especially exposure to trauma reminders and feared situations (Eshuis et al., Citation2021; Kothgassner et al., Citation2019; Rizzo & Shilling, Citation2017).A number of therapist-assisted digital interventions have been developed, mostly to deliver the content of trauma-focused CBT. Digital approaches usually require less therapist input and can be accessed by users remotely and in a more flexible way. There is now increasing evidence that such approaches can be helpful for adults with mild to moderate symptom severity, with large effect sizes (Bisson et al., Citation2022; Ehlers et al., Citation2023; Simon et al., Citation2019; van der Meer et al., Citation2020).Future research needs to determine the optimal levels of therapist guidance required for such interventions (Simon et al., Citation2023), whether such interventions can also be helpful for children and young people, and whether the concept of digital therapy can be extended to those with more complicated presentations, such as individuals with CPTSD, PTSD/SUD, or comorbid sleep disorders. For instance, Ehlers et al. (Citation2023) found greater advantages in outcomes for internet-delivered cognitive therapy compared to a comprehensive non-trauma focused CBT program (focusing on coping skills including mindfulness) for patients who met CPTSD criteria than those who did not. Moreover, recent studies found digital CBT-I delivered 3–4 years prior to the COVID-19 pandemic was protective against traumatic stress reactions in April 2020, during the initial weeks of stay-at-home orders in the United States (Cheng et al., Citation2021; Reffi, Drake, et al., Citation2023).Given increasing recognition of the benefits of integrating digital technologies into intervention efforts, it will be necessary to continue to innovate in this realm, extending treatment and assessment possibilities further into the in vivo and experiential worlds outside of the therapy office.

4.2.3. Positive and negative effects of social media

Online social networking (OSN), ranging from public facing posts on platforms like X, Facebook, Whatsapp, and Instagram to private messaging /texting, increasingly augments face-to-face interactions. A number of studies have underscored the negative impact of OSN. For example, cyberbullying has been associated with increased likelihood of clinically significant levels of distress (Ranney et al., Citation2016). Importantly, interactions that occur through OSN may also facilitate positive social support. During the pandemic, private messaging strategies, but not use of public posting, were observed to be comparable to in person interactions (Hoefer et al., Citation2022). Public posting has also been a way for trauma survivors to give voice to their shared trauma. For example, social media users leveraged hashtags such as #whyIdidntreport to describe barriers to reporting sexual assault (Orchowski et al., Citation2022), and #PuertoRicoSeLavanta to describe resilience after natural disasters (Rodríguez-Guzmán et al., Citation2021), and #DomesticViolence to comment on intimate partner violence during the pandemic (López et al., Citation2022).An important distinction between those who find social media use helpful and those who experience secondary traumatization may explain the ways that they are engaging with the technologies available. Following Typhoon Hato, social media use involving trauma viewing was associated with increased PTSD whereas social media exposure focused on information gathering or viewing heroic acts decreased PTSD (B. J. Hall et al., Citation2019). A similar pattern was observed following an aircraft accident in China, with vicarious trauma observed among individuals who report high levels of exposure to peer communication and recommendation systems use (use of the algorithms that push exposure to particular content) associated (Li et al., Citation2024). Individuals who are being intentional and using social media for knowledge and positive connections may benefit greatly from social media tools whereas more passive strategies of engagement may translate to increased exposure to distressing content pushed through algorithms.More research is needed to characterize the ways that public and private OSN may facilitate individual and community level coping with trauma.

4.3. Innovations in treatment

An interesting development in the field in the past few years has been the accumulation of studies evaluating intensive or massed trauma-focused psychological therapies (Bongaerts et al., Citation2022; Ehlers et al., Citation2014; Hendriks et al., Citation2010; van Pelt et al., Citation2021; Wagenmans et al., Citation2018; Zepeda Méndez et al., Citation2018). One approach which has received significant attention is a model, developed in the Netherlands, combining adapted forms of EMDR and Prolonged Exposure and delivered over an 8-day period. Whilst this model has not yet been subject to evaluation via RCT, several non-controlled studies have been published over the last 6 years, suggesting high levels of retention in treatment and very encouraging improvements in symptoms and loss of diagnostic status for both adults (e.g. Bongaerts et al., Citation2022; Voorendonk et al, Citation2020; Wagenmans et al., Citation2018) and adolescents (van Pelt et al., Citation2021). Further recent work has also explored the feasibility of adapting this model further to people with mild intellectual disabilities and their families (Mevissen et al., Citation2020).For helping those with severe and treatment resistant PTSD an approach which has received increased attention over the past few years, with emerging evidence of effectiveness is multi-modal motion-assisted memory desensitization and reconsolidation (3MDR) 3MDR is a novel therapy including exposure to trauma related reminders via a large screen, and taxing of working memory, through a dual task involving bilateral stimulation. This intervention is delivered whilst the patient walks on a treadmill. Several small trials have shown evidence of effectiveness of 3MDR in veteran samples (Bisson et al., Citation2020; van Gelderen et al., Citation2020), including veterans with mild traumatic brain injury (Roy et al., Citation2022). Further work is being undertaken to consider how this approach might be adapted for children and adolescents (Hoekstra et al., Citation2023).Other interesting developments – although requiring further research in the treatment of PTSD – include neuroscientifically guided treatments such as deep brain stimulation (DBS), and transcranial magnetic stimulation (TMS) (Novakovic et al., Citation2011; Rosson et al., Citation2022) or Deep Brain Reorienting (DBR) targeting the brainstem-level neurophysiological sequence that transpired during a traumatic event (Kearney et al., Citation2023), or Targeted memory reactivation (TMR) which enhances memory consolidation by presenting reminder cues during sleep (van der Heijden et al., Citation2024).

4.4. Complementary/integrative interventions

The complementary and integrative health (CIH) group of interventions is comprised of varied treatments ranging from meditative mind–body (e.g. yoga, mindfulness) to music to animal-assisted therapies (Niles et al., Citation2023). Although evidence is accruing for many of these non-pharmacological and non-psychological treatments, empirical support for their efficacy to address PTSD symptoms does not yet support use as first-line therapies (Bisson et al., Citation2020; VA/DoD, Citation2023). Evidence for CIH therapies that can augment current evidence-based treatments is similarly promising, but not yet established (Michael et al., Citation2019). However, since CIH therapies are primarily focused on enhancement of health and wellbeing rather than symptom reduction, they have the potential to improve quality of life even when symptoms do not fully abate. Furthermore, for the substantial proportion of individuals who cannot tolerate or choose not to engage in recommended trauma-focused treatments (Lewis, Roberts, Gibson, et al., Citation2020), CIH alternatives that do not require direct confrontation of traumatic events can be offered. In recent reviews and clinical guidelines, mindfulness and yoga have emerged as recommended second-line treatments (Bisson et al., Citation2020; VA/DoD, Citation2023).A recent systematic review and meta-analysis of 10 clinical trials on neurofeedback for PTSD showed beneficial effects across diverse populations, including those with different types of trauma (military and civilians) and from different ethnic backgrounds (Askovic et al., Citation2023). Although more research is needed a recent review on dance therapy found some indication for it improving both psychological and physiological symptoms associated with trauma exposure (Tomaszewski et al., Citation2023).In sum, CIH interventions may provide a ‘foot in the door’ to promote engagement in other treatments, but high-quality research is needed. For future research a holistic approach is recommended, i.e. addresses other symptoms than PTSD, including quality of life and wellness and physical health. Identifying mechanisms of action as well as scalability and remote delivery potential may need to be the focus of new research.

4.5. Sex/gender aspects in treatment

Women were found more likely to seek psychotherapy and make stronger treatment gains compared to men although differences were generally small (Békés et al., Citation2016; Olff, Citation2017; Roberts et al., Citation2011; Wade et al., Citation2016). The sex differentiation in treatment effects seems to emerge in adolescence (Hiscox et al., Citation2023). In a recent review of studies in the past five years in the journal Langeland and Olff (Citation2024) showed that there was little impact of sex and gender on treatment outcomes. Also for dropout in psychological therapies, there was no indication of sex or gender differences (Lewis, Roberts, Gibson, et al., Citation2020).Similarly, no clear sex or gender differences have been found for pharmacological interventions. However, women were found to be slightly more likely than men to receive medication including antidepressants recommended for PTSD, but also medications that should not be prescribed for PTSD, such as benzodiazepines (Hiscox et al., Citation2023).Future research should focus on civilian samples as most research on sex and gender treatment differences has been done in veterans.

4.6. Lifespan perspectives in treatment

Treatment research with child and adolescent populations has shown strong support for cognitive–behavioural treatment strategies (Alisic et al., Citation2020; Forbes et al., Citation2020; Martin et al., Citation2021; Mavranezouli et al., Citation2020), including for children as young as 3–8 years (Hitchcock et al., Citation2022), and with a growing base of evidence supporting treatments such as EMDR and Narrative Exposure Therapy. Numerous trauma therapies for children and adolescents have been developed, showing a substantial commonality of techniques and mechanisms across five evidence-based trauma therapies (TF-CBT; EMDR; KIDNET = narrative exposure therapy for children; PE-A = prolonged exposure therapy for adolescents; TRT = teaching recovery techniques). Common techniques include psychoeducation, relaxation, recording the critical experiences, traumatic recollection, exposure, homework, cognitive shifting, sharing the trauma story with others, future perspectives, and termination; and the common mechanisms cover consolidation, trauma processing, therapeutic relationship, motivation, affect modulation, reciprocal integration, and sharing. Notably, almost all of the identified therapeutic mechanisms – namely, consolidation, motivation, affect modulation, reciprocal integration, and therapeutic relationship – were considered present in all five therapies (Kooij et al., Citation2022).Social functioning is critical to mental health, and identifying these social aspect important for relationships in individuals exposed to child maltreatment is growing rapidly (see also www.global-psychotrauma.net/child-maltreatment) (Fares-Otero et al., Citation2024; Haim-Nachum et al., Citation2024; Pfaltz et al., Citation2022; Wadji et al., Citation2023). Additionally, therapies may address parent child relationship enhancement. An example of an approach that involves parents is the Stepped Care Trauma-Focused Cognitive behavioural Therapy (Fagermoen et al., Citation2023; Salloum et al., Citation2014) where parents are trained to deliver trauma-focused components to their children at home, with minimal therapist support. Furthermore, there are initial indications for evidence for Integrative Attachment Trauma Protocol for Children (IATP-C): an integrative treatment model, combining family therapy and EMDR therapy, for improving behaviours, attachments, and symptoms of traumatic stress in children impacted by early abuse, neglect, and placement outside of the biological home (van der Hoeven et al., Citation2024; van der Hoeven, Plukaard, et al., Citation2023).However, much more research is needed as research in child and adolescent treatments continues to lag behind adult interventions. Moreover, it will be important to ensure that ongoing treatment research incorporates considerations of inclusion and equity (Alisic et al., Citation2020).Interventions for older individuals with PTSD is a comparably understudied topic. In a systematic review of narrative exposure therapy (NET) older age predicted better treatment results for PTSD and depression symptoms (Lely et al., Citation2019). A review of interventions among older combat veterans indicated mixed results for evidence-based interventions including exposure-based therapies (Owens et al., Citation2005). Treatment outcomes were complicated by the range of complex medical and mental health-related comorbidities among such older adults, which highlights the potential need for more comprehensive treatment strategies with this population. The review by Ruisch et al. (Citation2023) showed that people with PTSD and dementia can benefit from PTSD treatment including EMDR, prolonged exposure, acceptance and commitment therapy and pharmacological treatment. Pilot work has suggested that exercise training coupled with cognitive behavioural strategies may be an example of one such approach (Hall et al., Citation2020). Additional work in this area is needed, especially as the world’s population ages and there is a greater need for PTSD treatments for older adults.

4.7. Global and contextual perspectives in treatment

There are no global recommendations for evidence-based treatment. For example, the American Psychiatric Association’s Clinical Practice Guideline lists four strongly recommended treatments for PTSD: Cognitive Behavioural Therapy, Cognitive Processing Therapy, Cognitive Therapy, and Prolonged Exposure (Association, A. P., Citation2020). Cultural differences may necessitate a broader scope of available treatments and adaptations to these approaches.Over the past 15 years, robust evidence has emerged to support the effectiveness and safety of empirically supported psychotherapies for PTSD in a variety of cultural contexts, in many instances delivered by non-specialist health providers through task-sharing models (Morina et al., Citation2017; Singla et al., Citation2017). There is also growing evidence of the effectiveness of transdiagnostic interventions for trauma survivors in LMICs, addressing a range of mental and behavioural health difficulties simultaneously (Bonilla-Escobar et al., Citation2018; Murray et al., Citation2020; Rahman et al., Citation2016). While there is now a substantial RCT evidence base for the effectiveness of trauma interventions across different cultural settings, there is as yet very limited research demonstrating that these interventions can be successfully scaled up in resource-constrained contexts. Implementing task-sharing delivery models in LMICs requires prioritizing long-term training models centred on continuous supervision by local trainers and supervisors (Singla et al., Citation2020).Research increasingly indicates that adapting evidence-based treatments for local cultural contexts, leveraging inputs from local insiders, can enhance the acceptability and effectiveness of trauma interventions (for example, Jalal et al., Citation2017). However, there is debate about whether surface-level adaptations (such as changes to language and terminology) are sufficient, or whether there is a need for deeper cultural adaptation (such as including culturally based explanatory models of illness or local healing rituals) that may alter the core components of the intervention (Ennis et al., Citation2020). Schnyder et al. (Citation2015) argue that a culturally sensitive psychotraumatology is critical when implementing treatments across different contexts, but untested stereotypes about culture should not be used as an excuse for failing to provide these treatments.

5. Methodological developments

A final note on methodological developments in the field of psychotrauma over the last 15 years and where we anticipate going. There have been countless advances in methodological practices, as evidenced by the studies published in EJPT since its launch. These include critical innovations in data collection, such as brain imaging, genetics research, and smartphone technology, to name but a few. In parallel, we have seen unprecedented progress in our ability to analyse data, including the development of advanced statistical software and models, the application of machine learning, and vastly improved capacity to process big data. Recently, there has also been a push to use computational models to refine theories related to the impact of trauma (Birkeland & Sundnes, Citation2024).These kinds of advanced methods are showing great promise in improving our ability to predict mental health outcomes following trauma (Held, Splaine, et al., Citation2023), and in guiding treatment selection and personalizing interventions (Held, Patton, et al., Citation2023). Crucially, it is clear that artificial intelligence is going to play a pivotal role in substantially advancing all of these (Olff, Citation2024). Yet the full range of possibilities as well as potential pitfalls (for example related to the replicability of models) of integrating AI into the traumatic stress field have not yet been understood. We will welcome studies that explore the use of AI in a thoughtful and nuanced way.Moving forwards, EJPT aims to continue to publish studies that advance our understanding of psychological trauma, its impact, and its treatment. We do not simply seek papers that apply novel methods for the sake of it. Rather, we are looking for studies that use the best methods available to answer specific research questions. This includes traditional tried-and-tested methods, however we anticipate that as the science of trauma continues to evolve at an unprecedented pace, we will increasingly publish studies based on more robust data (i.e. larger samples, longitudinal studies, combining multiple data types), and with more sophisticated analyses. Needless to add that in line with our Open Science principles we hope to find research increasingly based on Findable, Accessible, Interoperable, and Re-usable (FAIR) research data, to make the enormous number of rich potentially re-usable datasets available to all around the world (Kassam-Adams & Olff, Citation2020) (see also call for papers for a special issue on Data FAIRification in this journal). Consider publishing Data Notes, short, peer-reviewed articles that describe a dataset stored in a repository, to make the data set even more visible. Sharing data will enhance global collaboration and accelerate solid research output, at least for the next 15 years.

Traumatic Events and Their Impact: A Comprehensive Overview

This document explores the nature of traumatic events, their effects on mental and physical health across different populations, and current approaches to prevention and treatment.

Defining Trauma

Experiencing traumatic events is common worldwide, affecting both the general public and specific groups at higher risk. The definitions of trauma are crucial for studying its effects and for discussions globally. For example, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revised (DSM-5-TR) defines trauma as exposure to actual or threatened death, serious injury, or sexual violence. This includes direct experiences, witnessing such events, or learning about them if they involve close family or friends. The DSM-5-TR also includes ongoing or extreme exposure to traumatic details, such as that experienced by first responders. The International Classification of Diseases-11th Revision (ICD-11) offers a broader definition: "an extremely threatening or horrific event or series of events." However, neither manual provides a complete list of possible traumatic events.

The term "trauma" is now used more broadly by both the public and researchers, sometimes including less severe adverse events. This wider use can be positive by recognizing harmful practices like emotional abuse as potentially traumatic. However, it can also lead to labeling stressful, but not necessarily traumatic, experiences as pathological, creating expectations of negative health outcomes, and fostering a victim mentality. This can complicate the ability of health and legal professionals to agree on what constitutes a traumatic event and its resulting reactions, which is important for accessing treatment or compensation. A recent analysis of common trauma measures showed a lack of agreement in how events are described and questioned in research and practice.

Criterion A for Post-Traumatic Stress Disorder (PTSD) describes the specific characteristics a traumatic event must have to potentially cause PTSD. The discussion around this definition is ongoing, with various viewpoints on whether to expand it (e.g., to include indirect exposure through social media or racial discrimination), narrow it (e.g., exclude all indirect exposure), eliminate it entirely, or keep it as it is. Further research is needed to determine the best definition for Criterion A, considering different geographical and cultural contexts, to improve research consistency and healthcare.

The types of potentially traumatic events affecting large populations also change over time. The recent COVID-19 pandemic, for instance, has led to many studies showing that COVID-19-related events can meet the PTSD Criterion A and cause a range of mental health symptoms, affecting even young children. Climate change is another growing global issue, linked to more frequent traumatic experiences like disaster exposure, violence, and forced migration due to extreme weather. Climate change affects vulnerable populations disproportionately.

Overall, defining trauma is complex. A person's individual interpretation of an experience may be more significant than the objective facts of the event. New methods like text mining can help identify post-traumatic stress reactions. Future research should focus on improving how exposure to traumatic events is assessed to reduce differences across common standardized trauma tools.

Trauma Exposure: Sex/Gender Aspects

The influence of sex and gender on psychological trauma has been increasingly studied. Sex refers to biological traits (e.g., assigned at birth as female or male), while gender relates to social and cultural roles (e.g., woman, non-binary). Both sex and gender affect the rates of specific types of traumatic events and their outcomes. For instance, men are more likely to experience certain types of violence and combat, whereas women are more likely to experience physical and sexual assault, often at a younger age. These factors are linked to a higher risk of developing PTSD. Additionally, members of sexual and gender diverse (SOGD) communities face a higher risk of sexual violence compared to cisgender heterosexual individuals.

Although progress is being made in research, many past studies have not clearly distinguished between sex and gender, and most have defined both as only male or female. To better understand how sex and gender influence the impact of traumatic events, future research needs to move beyond these simple definitions. Guidance is available on how to assess sex and gender more accurately in studies.

Trauma Exposure: Lifespan Perspectives

Children and adolescents are reporting increasingly high levels of exposure to traumatic events. Studies of large populations show that younger individuals report more lifetime trauma exposure than older individuals. It is unclear if this is because younger people actually face more traumatic events, are more likely to label events as traumatic, or if it is an effect of memory recall. Conversely, older adults report lower levels of exposure, which is surprising for lifetime measures. This might be due to forgetting, cognitive decline, reporting biases (like stigma or shame), or not seeing certain events as traumatic.

Exposure to any form of traumatic stress in childhood increases the risk of negative social and psychological outcomes later in life. Interpersonal traumas (intentional acts by others, like abuse or violence) during childhood are especially linked to mental, relationship, and physical health problems in later childhood and adolescence, with lasting effects into adulthood. Experiencing multiple types of severe danger, harm, or victimization in childhood increases the likelihood and severity of PTSD and other trauma-related disorders throughout life, with a "dose-response" relationship (meaning more trauma leads to worse outcomes). This is known by various terms, including cumulative trauma exposure, poly-traumatization, poly-victimization, or adverse childhood experiences (ACEs).

However, studies on childhood trauma must be interpreted carefully due to research limitations. Often, adults report past childhood experiences, and many standardized trauma measures do not assess how often, how intense, or how long events lasted, simply asking for a yes or no answer. The ACEs literature has also been criticized for focusing on only 10 types of childhood adversities and for giving equal weight to each by simply summing them up.

Given that childhood is a period of high brain adaptability and developing neurological systems, it is not surprising that stressful events during this time strongly affect emotional regulation and stress responses later in life. This can lead to changes in brain circuits, hormone systems, and immune systems, increasing the risk for psychiatric disorders. Most studies broadly define "childhood" as early life (sometimes up to age 16), potentially missing important specific developmental periods. For example, some research suggests that exposures in very early childhood (before age 3) may be particularly significant. Children who experienced multiple forms of victimization in early childhood (birth to 6 years) were also more likely to be victimized in middle childhood and adolescence, though the types of victimization changed. They also showed different psychological and post-traumatic symptoms if they were victimized in only one developmental period. Moving forward, given the many neurobiological changes during specific developmental periods, future research needs a more detailed approach to understanding the effects of traumatic stress during early, mid-childhood, puberty, and beyond.

In addition to focusing on specific developmental periods, future research on childhood trauma should use tools that measure the frequency, intensity, and duration of events. Furthermore, alongside assessing traumatic events, it is important to identify positive events that promote resilience and recovery from adversity, especially in childhood but also throughout life. While abuse of older adults is common, more research is needed to understand the long-term impact of early trauma and how trauma experienced later in life affects them. PTSD has been linked to faster biological aging. Additionally, cognitive decline can result from traumatic brain injury. While tools for childhood adversities exist, there isn't yet a specific tool for "Adverse Older Adult Experiences." Traumatic experiences at the end of life, such as in dementia, require further study. Identifying trauma exposure and potential PTSD in patients with cognitive decline or dementia may require specialized diagnostic tools and interviews designed for this population.

Trauma Exposure: Global and Contextual Perspectives

Over the past 15 years, research has confirmed that trauma exposure is common globally, but its frequency varies significantly across countries. These differences in prevalence may stem from historical, geopolitical, economic, and cultural factors that influence the rates of intentional and unintentional injuries and other adverse events. It is increasingly clear that people living in countries affected by war and conflict face a much higher risk of experiencing or witnessing potentially traumatic events. There is also growing recognition that in regions with fewer resources and ongoing conflict, where violence is constant, trauma exposure may be better understood not as a single event but as an ongoing part of life, without clear "before" and "after" periods.

Additionally, what is considered "traumatic" likely varies across cultures. An event perceived as extremely shocking in one setting might be accepted as a normal part of life in another. Much of the language used in the study of psychological trauma comes from Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. This can lead to bias because widely used trauma screening tools often reflect Western ideas of trauma. Cross-cultural research comparing the social meanings of different events could improve our understanding of the widely differing rates of PTSD in various cultural settings. In non-Western contexts, there is a need for screening tools that include the range of potential traumatic events experienced in those regions. A large global research project is underway to map traumatic experiences within their cultural contexts. In summary, more research on the definitions and prevalence of trauma exposure is needed from researchers in the global South.

Mental and Physical Health Consequences of Trauma Exposure

Traumatic events can lead to a wide range of mental and physical health problems, not just PTSD. How these symptoms appear, how common they are, and how they progress depend on a person's age, developmental stage, sex/gender, social and cultural background, and societal factors (like health disparities and systemic discrimination). The most common outcomes after trauma are discussed below, focusing on sex/gender, lifespan, and global/contextual perspectives on these consequences.

Resilience

Resilience, defined as successfully adapting to adverse situations, is the most common response to trauma, occurring in about two-thirds of individuals. Factors that help determine who shows resilience include emotional functioning aspects like coping flexibility, various coping strategies, perceived self-efficacy, optimism, and beliefs in one's ability to recover. Consistent predictors of resilience also include personality, financial stability, educational background, social support, finding meaning in experiences, and experiencing positive emotions. However, some researchers note that the evidence quality varies, and even when a factor is statistically linked to resilience, its predictive power is often modest.

A promising area of study focuses on a person's ability to flexibly manage their emotions during and after a traumatic experience. Those who are better at emotional regulation may have a higher chance of resilient outcomes. This "flexibility sequence" involves three steps: being aware of the situation, having a range of responses, and learning from experience. It is important to remember that while post-traumatic resilience offers many psychological benefits, these can come at a significant cost to overall health due to the physiological strain of adapting to trauma's adverse effects. Resilience may also decrease later in life when protective factors, such as social support, are lost, or when risk factors, like declining health, become more prominent.

PTSD, Dissociative-PTSD (D-PTSD), and Complex PTSD (CPTSD)

Trauma exposure is linked to various negative outcomes for survivors, their families, and communities. Post-Traumatic Stress Disorder (PTSD) is the most studied negative outcome, described differently across diagnostic systems. The DSM-5-TR identifies 20 PTSD symptoms grouped into four clusters: intrusion, avoidance, negative changes in thoughts and mood, and changes in arousal and reactivity. It also includes Dissociative-PTSD (D-PTSD), where PTSD is present along with dissociative symptoms like derealization (feeling detached from reality) or depersonalization (feeling detached from oneself). A review of studies has confirmed this subtype, though research on related factors has shown mixed results.

The ICD-11 defines PTSD by three symptom clusters: re-experiencing, avoidance, and heightened perception of current threat. It also includes Complex PTSD (CPTSD), characterized by PTSD symptoms plus additional difficulties in three areas: affect dysregulation (difficulty managing emotions), negative self-concept (negative view of oneself), and disturbances in relationships. The differences in how DSM-5 and ICD-11 describe PTSD, D-PTSD, and CPTSD have led to many studies on how these differences affect estimated prevalence rates. These differences are both quantitative (resulting in different rates) and qualitative (showing moderate agreement between classifications). In places where treatment depends on a formal diagnosis, these discrepancies can mean that individuals may or may not receive treatment based on the classification system used. One study also suggests that the estimated effect of treatment may be influenced by the diagnostic system chosen.

Moral Injury

Traumatic events can also lead to moral injury, which is defined as deep psychological distress that results from experiencing, witnessing, or failing to prevent actions that violate one's deeply held personal or group beliefs. Moral injury includes both the exposure to a potentially morally injurious event and the resulting symptoms, which often involve shame, guilt, despair, and a loss of morale. Various mental health disorders, including PTSD, can also arise from exposure to morally injurious events.

Research on moral injury has grown significantly in the past 15 years. Initially focused on military personnel, studies now include other groups such as healthcare workers and refugees. Progress is also being made in developing treatments for moral injury.

Future research could explore whether moral injury needs to be a formal diagnosis in our diagnostic systems and how it is understood in different global contexts. Additionally, little is currently known about how these events affect physical health. Regarding assessment, since moral injury involves both the event and its consequences, future research should use tools that measure both, such as the Moral Injury and Distress Scale (MIDS).

Prolonged Grief

After decades of research establishing pathological grief reactions as a distinct condition from PTSD, Prolonged Grief Disorder (PGD) was recently included in the ICD-11 and the DSM-5-TR as a stress-related disorder alongside PTSD. However, the diagnostic criteria differ between these classification systems. The DSM-5-TR requires PGD symptoms to last at least 12 months (6 months in children), while the ICD-11 only requires a symptom duration of 6 months. A recent review of 48 studies identified several characteristics that distinguish between pathological grief and PTSD, but the studies were diverse and mostly cross-sectional. Recent data suggest that the two classifications may not describe the same clinical condition. Regardless, the recognition of PGD in international classifications has boosted research into its symptoms and treatment, especially given the global death toll of the COVID-19 pandemic.

Other (Comorbid) Mental Health Outcomes

After trauma, major depressive disorder (MDD), anxiety disorders, substance use disorders, and sleep disorders are common outcomes. The co-occurrence of PTSD and MDD is especially high, with studies reporting rates as high as 52%. The DSM-5 PTSD symptom cluster related to "negative alterations in cognition and mood" increases the overlap with depressive symptoms. Notably, over 90% of individuals with PTSD report insomnia, nightmares, or both. These sleep problems are increasingly recognized for hindering emotional learning needed for PTSD recovery and treatment response.

Epidemiological research indicates that substance use disorders (SUD) affect 2.2% of the world's population, with higher rates in high-income countries. Alcohol use disorder (AUD) is the most common SUD globally. PTSD and SUD, including AUD, frequently co-occur, with estimates suggesting that about half of individuals with PTSD have met criteria for a SUD in their lifetime. The co-occurrence of PTSD and SUD is well-established across populations and is linked to a more complex, severe, and disabling course, with poorer treatment outcomes compared to either disorder alone. Recent research supports a two-way relationship between PTSD and SUD, with PTSD having a stronger link to future SUD. Despite significant progress in understanding PTSD/SUD comorbidity, more rigorous research is needed to understand the biological, psychological, and social mechanisms that contribute to its risk and maintenance.

Approximately one-quarter of people diagnosed with PTSD also have borderline personality disorder (BPD), and vice versa. Due to overlapping symptoms, particularly with Complex PTSD, the validity of BPD as a separate diagnosis is sometimes debated. A comorbid personality disorder is sometimes seen as a barrier to PTSD treatment. However, a recent meta-analysis found that patients with comorbid personality disorders were not at a higher risk of dropping out of PTSD treatment, although they might benefit less from it.

Transdiagnostic Perspectives and Survivor-Centered Approaches

Given the many, often co-occurring, outcomes of trauma, researchers have called for a comprehensive screening of trauma survivors that looks across different diagnoses. While recent work on transdiagnostic approaches suggests that various disorders may share common treatment targets, it is important to consider the full and complex impact of traumatic exposure.

The negative impact of trauma can vary among individuals, even after the same type of exposure, as there is no single universal experience or reaction to trauma. For example, PTSD is highly prevalent after sexual assault, with estimated rates varying widely depending on when symptoms are measured. However, focusing solely on PTSD as a psychological outcome is too simplistic. It is important to adopt a broader perspective that includes other psychological reactions (e.g., depression, anxiety, sleep problems, suicidal thoughts), physical reactions (e.g., fractures, pain), and social reactions (e.g., social isolation, stigma, racial discrimination), as well as the interactions between survivors and their social networks. This is especially relevant when considering collectivistic versus individualistic cultures. Therefore, a broader socio-ecological perspective can be helpful. Additionally, there is a need for more survivor-centered, culturally appropriate, and trauma-informed services following sexual assault or trauma in general. A recent review identified seven main groups of underserved sexual assault survivors: ethnic and cultural minorities, individuals with disabilities, those facing financial vulnerability, sexual and gender minorities, people with mental health conditions, individuals with problematic substance use, and older adults.

A study with young people in Georgia showed that a transdiagnostic approach has the potential to provide effective support for those at risk of mental health problems. Future research should investigate screening for various trauma-related outcomes and whether such screening can improve the identification of a wide range of issues and access to care.

Impact of Trauma on Physical Health

The body's immediate response to trauma involves a rush of central nervous system and hormone reactions that help a person cope. However, the continuous activation of these systems (as seen in PTSD) can lead to physical health problems. It is believed that biological imbalances may link trauma to psychological health, increasing the risk for both psychiatric disorders and physical illnesses.

PTSD is linked to higher rates of obesity and metabolic disorders (like type 2 diabetes), autoimmune disorders (like rheumatoid arthritis, lupus), thyroid disease, asthma, and obstructive sleep apnea (OSA). OSA has been shown to impair learning that helps reduce fear. Childhood trauma has been linked to obesity, diabetes, cancer, high blood pressure, chronic obstructive pulmonary disease, heart attacks, and strokes, with the risk for all these conditions increasing with the number of types of child maltreatment experienced. More research is needed to understand how different types of child maltreatment are linked to physical symptoms and the underlying mechanisms.

It is often hard to tell the difference between symptoms of physical health problems like pain (e.g., social withdrawal, sleep problems, or concentration issues) and difficulties related to PTSD (e.g., avoidance, heightened arousal, or re-experiencing), and vice versa. PTSD is common in patients with chronic pain, possibly partly due to differences in how their brains process pain. Some coping behaviors and daily routine changes after trauma can also negatively affect health, such as weight gain, smoking, self-medicating with alcohol or drugs, fear of sleep, and social isolation.

Trauma exposure and PTSD are associated with increased rates of cardiovascular disease, including stroke, heart attack, high blood pressure, and heart failure, as well as risk factors like increased arterial wall thickness and plaque buildup. While some of these risk factors may result from behavioral changes related to PTSD (e.g., smoking, low physical activity, poor diet, and sleep), PTSD has an independent effect on cardiovascular risk even after accounting for these factors. The chronic elevation of the stress response in PTSD (e.g., heightened sympathetic arousal, inflammation) may lead to high blood pressure and blood vessel damage, ultimately increasing cardiovascular risk. Inflammatory responses linked to the stress response in PTSD are also thought to increase the risk for several other physical health problems.

Neurobiological Consequences of Trauma

Trauma exposure and PTSD are linked to changes in brain activity, brain structure, and neurotransmitter systems. There are alterations in how the brain functions, its physical structure, and chemical systems that overlap with a core brain circuit involved in processing threats. Studies suggest that trauma and PTSD are often related to increased activity in the amygdala (involved in emotion) and dorsomedial prefrontal cortex (PFC, involved in decision-making) when exposed to emotional stimuli, as well as reduced activity in the ventromedial PFC (involved in emotional regulation). Large-scale analyses of brain structure data also suggest that PTSD is associated with reduced volume in the hippocampus (involved in memory). The amygdala, PFC, and hippocampus form a neural network crucial for healthy emotional functioning and regulating responses to threat.

Importantly, findings about brain circuits in PTSD can vary based on several factors. Brain imaging studies suggest that differences in brain activity related to PTSD may be affected by the type of trauma experienced. Additionally, different subtypes of PTSD (e.g., the dissociative subtype) may show different neurobiological patterns compared to typical PTSD. More recent work also suggests that specific biological brain types may underlie different symptom patterns following trauma exposure. It is likely that many biological, psychological, and social factors predict how individuals respond after trauma; more research is needed to build comprehensive predictive risk models.

A review highlighted that there is much variation in experiences, exposures, and contextual factors among different groups globally. Considering unique stressors (e.g., discrimination, refugee/migrant-related stress) is essential for understanding distinct brain patterns in PTSD. Furthermore, previous stress, trauma, and environmental influences can impact "neurophenotypes" and contribute to different brain imaging profiles.

Genetic Risk for Trauma-Related Conditions

Twin studies in both civilian and military populations have shown that PTSD has a moderate heritability, ranging from 30% to 72%. In children, the transmission of acute stress reactions (ASRs) or PTSD from parents to children was linked to both upbringing and genes. Even when accounting for shared traumatic events, the correlations for upbringing and genes were similar. The field of molecular genetic studies on PTSD has changed significantly in the last decade, driven by large-scale collaborative science and reduced costs of genetic testing. The Psychiatric Genomics Consortia workgroup for PTSD (PGC-PTSD), formed in 2013, has brought together researchers globally to uncover the genetic basis of PTSD, a disorder that has seen fewer genetic discoveries compared to other conditions with similar heritability. The most recent large-scale genetic analysis from the PGC-PTSD workgroup included over 1.2 million individuals and identified nearly 100 genetic locations linked to PTSD, with 85% being new discoveries. The overall genetic risk for PTSD is moderately to highly correlated with other psychiatric disorders, with the strongest genetic link found between PTSD and major depressive disorder (MDD), consistent with twin studies.

Recent work has also included genetic studies of resilience, although these are still preliminary due to sample size limitations. In addition to more genetic data on PTSD, new statistical genetic techniques, such as genomic structural equation modeling, Mendelian randomization, and polygenic risk scoring, are being applied to PTSD and related conditions. These techniques hold great promise for further understanding the underlying genetic risk for trauma-related conditions. Finally, a meta-analysis of epigenome-wide association studies, including 23 military and civilian groups, identified 11 DNA methylation sites associated with PTSD. These sites may indicate susceptibility to PTSD, the impact of trauma, or the long-term effects of PTSD itself.

Trauma Consequences: Sex/Gender Aspects

PTSD prevalence rates are twice as high in women compared to men, and women also show higher rates of co-occurring disorders like major depression, anxiety, insomnia, and nightmares after trauma. Sex differences also exist in how PTSD symptoms change in the year after trauma. Although men and women experience the same symptom patterns (resilient, recovery, chronic symptoms, and delayed onset), the recovery pattern was more common in women, while delayed onset was more common in men.

In women, biological sex hormones seem to influence the higher risk for PTSD. Women with low levels of estrogen (measured through saliva, plasma, or menstrual cycle phase) experience worse PTSD symptoms and impaired fear inhibition. In contrast, high progesterone levels appear to worsen extinction retention (the ability to unlearn fear) in women with PTSD but not in those without it. Sex differences in PTSD prevalence seem to emerge in adolescence.

A meta-analysis in a large multi-ethnic group identified genetic risk locations specific to each sex, showing that genetic heritability estimates vary by sex. However, with larger sample sizes, this finding is no longer statistically significant. Brain imaging studies suggest that women may have stronger activation in a specific brain region (locus coeruleus) when seeing fearful faces and lower activation in another area (dorsal anterior cingulate) during fear extinction recall. Additionally, higher heart rate and cytokine levels (markers of inflammation) may be more significant indicators of PTSD risk in women than men. Cognitive and behavioral responses during and after trauma have been shown to fully explain the effects of sex differences and accidental versus interpersonal trauma on PTSD symptom severity six months after the event.

There are also important sex differences in heart and metabolic risk after trauma. For example, inflammatory cytokines have been linked to worse PTSD symptoms and physiological hyperarousal in trauma-exposed women but not men. Heart rate, a measure of sympathetic arousal, appears higher in women with PTSD compared to men with PTSD. Furthermore, low estrogen levels are associated with worse sympathetic arousal and blood vessel function in women, with and without PTSD. More research focusing on the neurobiological and psychosocial aspects of PTSD in gender-diverse populations is needed.

Trauma Consequences: Lifespan Perspectives

Children/adolescents – While it is clear that not all trauma-exposed children and adolescents develop PTSD, prevalence estimates vary considerably depending on the study group, assessment methods, and types of events evaluated. A meta-analysis of over 70 studies estimated that about 16% of children and adolescents develop PTSD after a potentially traumatic event, almost double the rate seen in adults.

Given climate change, children (like adults) are likely to face more natural disasters. A special issue in this journal highlighted how children can be prepared for natural disasters and the mental health aspects of such events. A recent review identified several PTSD risk factors in earthquake survivors, from children to the elderly, which could help identify at-risk families.

Child abuse and neglect in early childhood can lead to symptoms beyond PTSD and internalizing issues, including problems with attachment, emotions, and behavior. Youth exposed to traumatic events across multiple settings and by multiple perpetrators tend to have more severe trauma-related symptoms than children who experience repeated incidents or chronic exposure to a single type of adversity. The negative effects of cumulative trauma exposure can occur after a combination of two types of adversity; some types of traumatic stressors (e.g., sexual and physical abuse, neglect, domestic violence) have combined adverse effects that are greater than the sum of their individual effects. Cumulative trauma or poly-traumatization at any point in childhood puts youth at risk for a wide variety of post-traumatic and psychological problems, but its negative impact differs depending on the specific developmental period(s) in which it occurs.

Developmental Trauma Disorder (DTD) has been proposed and supported by evidence as a comprehensive framework to describe the range of trauma-related problems experienced by poly-victimized children and adolescents. These problems affect the development of fundamental self-regulation skills, including the regulation of bodily functions, emotions, attention and cognition, behavioral self-control, engagement in relationships, and identity formation. Although not formally recognized in the DSM or ICD, this developmentally-attuned post-traumatic syndrome in children exposed to traumatic victimization and disrupted attachment has been shown to be distinct from PTSD, occurring both separately and alongside it. It also has a unique pattern of co-occurring disorders compared to PTSD. DTD has also been shown to explain psychological impairment beyond what can be attributed to PTSD in both an initial study and an independent replication. Thus, DTD may provide clinicians and researchers with a framework to identify victimized youth who could benefit from trauma-focused treatment but who might otherwise only be considered for treatment related to other psychiatric disorders.

Older adults – Relatively little research has examined PTSD prevalence in older adults compared to other age groups. Many individuals show some symptoms that do not meet the full diagnostic criteria for PTSD. The available evidence suggests that PTSD prevalence decreases with older age. The prevalence of PTSD among those aged 60 and older ranges from 1.9% to 9.5%. The reasons for this decrease in PTSD among older individuals are unclear. Several explanations have been suggested, including a "survivor's bias" in the general population, meaning those with PTSD may be more vulnerable to serious illness, chronic stress, and risky behaviors. Other theories propose that PTSD may present differently in older individuals, and current diagnostic criteria might not fully capture the disorder in this age group. Examples of such differences include reduced exposure to external triggers due to physical impairments that limit mobility or hearing loss, which may lessen hypervigilant behavior. Additional explanations for lower PTSD prevalence in older adults include interpreting mental health concerns as physical problems, and higher stigma related to mental health among older individuals. It also remains largely unclear why traumatized individuals who initially cope successfully with events may develop delayed-onset PTSD later in life. Despite lower prevalence, a significant number of older adults have PTSD, so more research in this area is warranted. Furthermore, advances in medical care and increased awareness of mental health disorders are likely to lead to increased rates of PTSD in older individuals in the near future.

Trauma Consequences: Global and Contextual Perspectives

PTSD and CPTSD symptoms are reported across various cultures, suggesting that both diagnoses have some cross-cultural validity. However, there is growing evidence that responses to trauma vary significantly across cultural contexts, and Western diagnostic categories may not fully capture the range of these responses. For example, physical symptoms, social isolation, and "thinking a lot" are commonly reported among trauma survivors in Low- or Middle-Income Countries (LMICs). This highlights the importance of culturally informed assessment tools, alongside DSM- and ICD-based measures, to accurately identify trauma survivors needing support in different cultural settings. Trauma symptom screening measures have been developed for some specific cultural contexts in collaboration with local experts. Additionally, the Global Psychotrauma Screen (GPS), which assesses a broad range of trauma-related symptoms common across different cultural settings, has been validated in various non-Western environments.

Further consideration of differences within cultures and contexts is also needed to improve our understanding of trauma and PTSD. For instance, there is significant ethnic and racial variation in the prevalence and impact of trauma exposure, revealing important factors to consider. Specifically, Black individuals in the United States are exposed to more risk factors for developing trauma-related disorders but often report similar or lower experiences of trauma and PTSD symptoms compared to groups with fewer risk factors. This discrepancy may partly be due to the adoption of adaptive brain mechanisms to counteract the effects of stressors, which may, however, lead to more severe symptoms for those who are susceptible. Similar mechanisms may explain the "vulnerability paradox," where lower levels of PTSD have been reported in countries with higher vulnerability ratings. The lack of inclusion of ethnically and culturally diverse participants in research can lead to biased findings.

Preventive Interventions

Preventive Pharmacological Interventions

Currently, there is no "morning after pill" to prevent PTSD after a traumatic event. Research has not shown that several medications, including the beta blocker propranolol, gabapentin, and antidepressants (SSRIs), can prevent PTSD. Some data suggest that hydrocortisone might be effective, but more rigorous research is needed. Oxytocin shows some promise in preventing PTSD, but only for those with high initial symptoms, as shown in later analyses. Prazosin was found effective in a small pilot study for preventing the transition from acute stress disorder (ASD) to PTSD. In summary, much more research is needed before we can prevent PTSD with medication shortly after trauma.

Preventive Psychological Interventions

Preventive interventions after an adverse event can be used at different stages of care. Delivering early interventions has the potential to stop post-traumatic stress reactions from worsening into a PTSD diagnosis, whether given immediately after trauma or in the weeks following. Such interventions are tolerable and effective. Traumatic events can have negative outcomes, including PTSD, lasting over 10 years, which highlights the importance of prevention.

Psychoeducation, as part of psychotherapy, is common. However, stand-alone psychoeducational interventions have been controversial since the "debriefing" debate, though interest has revived. A systematic review of 10 studies found some evidence that psychoeducation improved attitudes toward and knowledge of mental health and was generally considered acceptable and useful. However, it did not support the routine use of brief psychoeducation alone to prevent PTSD. In Low- and Middle-Income Countries (LMICs) with limited access to mental healthcare, easy-to-administer psychoeducational interventions can be a first step in a stepped-care strategy. A psychological first-aid intervention was shown to reduce early PTSD symptoms but did not prevent PTSD.

A systematic review and meta-analysis demonstrated the effectiveness of several early psychological interventions for individuals with traumatic stress symptoms after trauma exposure, especially for those meeting the diagnostic criteria for ASD or PTSD. However, there is no evidence to support universal psychological interventions for all trauma-exposed individuals, regardless of their symptoms. The strongest evidence was found for trauma-focused cognitive behavioral therapy used as an indicated intervention for trauma survivors who show symptoms within the first few months after trauma, to prevent further worsening and the development of PTSD. A smaller review of seven studies on early interventions after sexual assault showed lasting effects on PTSD severity.

After widespread trauma and disasters, interventions targeting both adults and children will likely be needed. First responders, medical personnel, and military service members may be at risk of developing PTSD or other symptoms due to frequent exposure to potentially traumatizing experiences in their professions. For traumatic loss, little is known about specific prevention strategies.

There is still insufficient knowledge about which interventions to offer and to whom. For example, a study of early Eye Movement Desensitization and Reprocessing (EMDR) therapy in rape survivors did not show greater effectiveness compared to "watchful waiting" in reducing symptoms of post-traumatic stress and other mental health issues. Similarly, a review of early interventions for workplace trauma did not establish clear benefits of any specific intervention or suggest which was superior, although only generic debriefing was linked to negative outcomes. Additionally, despite growing evidence on how sleep disturbance impacts future PTSD risk, early interventions targeting sleep immediately after trauma to prevent PTSD are a new area of research. Although promising new studies aimed at promoting healthy sleep after trauma are underway, there is also some evidence suggesting that sleep deprivation might be protective.

In summary, high-quality evidence is needed for early or preventive interventions, which can be challenging to obtain in this type of research. A proposed framework for these interventions suggests they must be based on theory, practical for delivery during and immediately after trauma, and ready for evaluation. Ethical considerations for early intervention must be addressed, such as the risk of harm and the balance between screening and the capacity to provide treatment. Artificial intelligence (AI)-driven early interventions, such as using large language models for screening or support, are exciting new avenues currently being explored.

Complementary/Integrative Preventive Interventions

Currently, there are few well-controlled studies and limited evidence to support mind-body interventions like mindfulness and yoga for preventing PTSD. However, given the low rates of negative side effects associated with these interventions and their potential for improving overall health and wellness, they can be considered safe supportive or additional therapies.

Sex/Gender Aspects in Preventive Interventions

While sex differences exist in how PTSD symptoms progress within a year after trauma, which might suggest the need for sex or gender-specific preventive interventions, there is little research on this topic. Only one study to date has examined sex or gender differences in early interventions after trauma. Among US Army soldiers who received a form of psychological first aid, men attended fewer sessions than women, and lower attendance was linked to worse symptom severity. Since these findings may not apply to other populations, more research is needed to better understand how men and women respond to early post-trauma interventions. Unsurprisingly, few prevention strategies specifically aim to reduce sexual violence among sexual and gender diverse (SOGD) communities, and calls have been made for action in this area.

Lifespan Perspectives in Preventive Interventions

A framework has been proposed for designing, delivering, and evaluating early interventions for children. Suggested targets for early intervention included maladaptive trauma-related thoughts, excessive early avoidance, and social/interpersonal issues. Effective early interventions for children may also include preventive programs to support vulnerable pregnant women and new mothers during their child's first two years. Parents' mental health problems increase the risk for young people to develop trauma-related issues, and guidelines and initiatives for Children of Parents with Mental Illness (COPMI) offer tools for potential interventions. For parents who struggle to provide emotional security in their attachment relationships with their children, the Video Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) has been shown to be effective. In this intervention, parents receive feedback based on video recordings of their interactions with their children, aiming to improve parenting skills and prevent or reduce behavioral problems. Additionally, Parent Child Interaction Therapy (PCIT) and Child-Parent Psychotherapy (CPP) are potentially effective interventions for promoting attachment relationships.

For children who have recently experienced a stressful life event, the Watchful Waiting protocol has been developed. This protocol involves screening for post-traumatic stress symptoms at least twice during the first month after the event and, if indicated, referring for evidence-based treatment. For older adults, preventive interventions are a much-needed area of research, especially with the global growth of this population.

Cross-Cultural/Global Perspectives in Preventive Interventions

Interventions that involve shifting tasks (e.g., to non-specialist health workers) for PTSD and other stress-related disorders in Low- and Middle-Income Countries (LMICs) have largely focused on treatment, with a scarcity of randomized clinical trials (RCTs) on prevention and promotion. Universal, selective, and indicated preventive interventions can arguably be delivered widely in community settings through task-shifting to primary care workers (including health and community workers). A recent review of 113 RCTs on interventions delivered by primary-level and/or community health workers in LMICs, aimed at promoting mental health or preventing mental disorders in adults and children, was published. This review included 30 RCTs on PTSD prevention in adults and 5 in children.

The systematic review found that promotion/universal prevention interventions, when compared to usual care, may slightly reduce distress or PTSD symptoms in adults without mental disorder risk factors. However, it is uncertain whether selective prevention (for adults with mental disorder risk factors/lack of protective factors) or indicated preventive interventions (for adults highly vulnerable to developing mental disorders), compared to usual care, have any effect on distress/PTSD symptoms. In children, promotion/universal prevention interventions, compared to usual care, may slightly reduce distress/PTSD symptoms; selective interventions probably slightly reduce distress/PTSD symptoms; while indicated prevention may slightly reduce distress/PTSD symptoms. Considering that social determinants and cultural factors may contribute to the wide variability in PTSD prevention and promotion outcomes, these and other influencing effects will need to be analyzed in future RCTs. For example, exposure to interpersonal violence may be a social determinant of sleep health among racially diverse and socioeconomically disadvantaged communities, which could in turn contribute to PTSD prevalence in these populations.

People in LMICs are also disproportionately affected by humanitarian crises. Regarding psychological interventions (focused on practical support, fostering hope, strengthening coping, and building resilience) and social interventions (focused on strengthening social support and connections), a Cochrane review found that, for children, psychosocial interventions were no more effective than control conditions (waitlist, no treatment, usual care) in reducing PTSD, depression, and anxiety symptoms at the study's end or at 3-month follow-up. Acceptability was similar for intervention and control groups, but information on tolerability (side effects) was not reported, which is a common limitation in RCTs of psychological interventions. Notably, no RCT data on PTSD promotion/prevention were available for adults affected by humanitarian crises living in LMICs.

In summary, the varying quality of studies calls for more methodologically robust RCTs. Studies specifically designed to evaluate the effectiveness of prevention interventions in reducing PTSD incidence across the lifespan among people in LMICs are needed.

Treatment of Trauma-Related Disorders

Pharmacological Interventions

For the past couple of decades, the medications approved by regulatory authorities in most countries for PTSD are sertraline and paroxetine, both selective serotonin reuptake inhibitor (SSRI) antidepressants. A systematic review and meta-analysis of 115 studies, part of a special issue on PTSD prevention and treatment in this journal, found small positive effects of SSRIs (fluoxetine, paroxetine, sertraline, venlafaxine) and the antipsychotic quetiapine when used alone in reducing PTSD symptoms. Prazosin and risperidone showed promise for augmenting other treatments. Although effective in large trials, these medications have relatively small effects on PTSD symptom severity compared to trauma-focused therapies. This has led recent guidelines to recommend them only when trauma-focused therapies are unavailable. A recent systematic review showed that clonidine appeared promising for improving sleep, nightmares, and PTSD symptoms, but this evidence is based on a few low-quality studies. Another review systematically analyzed ketamine interventions for PTSD and concluded that a placebo effect is the likely mechanism behind reported improvements.

A systematic review and meta-analysis on medication-assisted psychotherapies using conventional and new drugs to reduce PTSD symptom severity showed that the only promising intervention was methylenedioxymethamphetamine (MDMA)-assisted therapy, but this was based on a small number of participants. A recent Phase III trial found MDMA-assisted psychotherapy to be highly effective for individuals with severe PTSD, suggesting significant potential for those with severe PTSD and related co-occurring conditions. In 2023, the Australian Therapeutic Goods Administration approved MDMA combined with psychotherapy for PTSD treatment, under strict prescribing rules. Conversely, despite available data including two large trials, the US Food and Drug Administration recently reviewed MDMA combined with psychotherapy for PTSD but did not grant approval, requesting more rigorous data.

Furthermore, identifying patients with specific biological markers can help develop treatment strategies targeting specific biological processes, improving clinical care by matching individuals to the most appropriate intervention. Future research can explore whether the biological consequences of early life stress are reversible, how to prevent these effects through early therapeutic interventions, and how to identify biological factors linking early life stress and other medical conditions.

Psychological Interventions

There are several well-established, evidence-based psychological treatment approaches for PTSD, including EMDR (Eye Movement Desensitization and Reprocessing), Prolonged Exposure, Cognitive Processing Therapy, and Cognitive Therapy for PTSD. These treatments generally lead to significant reductions in PTSD symptoms. Less research exists on treatments for Complex PTSD (CPTSD); however, there is emerging evidence that these established approaches may also be helpful for both adults and young people with CPTSD. While these interventions are effective for many individuals with PTSD, they are not universally helpful; some individuals drop out of treatment early, and many continue to experience significant symptoms after treatment is completed. The specific treatment setting can influence outcomes. A review of 87 studies on patients in medical settings showed beneficial effects of EMDR on reducing psychological and physical symptoms, though the high variability and risk of bias in these studies should be noted. Another systematic review in refugee populations showed positive effects, but only in the short term. Therefore, it is important for studies to expand on the existing literature by considering factors that might influence the effectiveness of specific treatments for individuals across different social and cultural contexts.

In general, it is crucial for studies to focus on populations that are currently underserved or understudied in trauma research, such as those who do not respond to current evidence-based trauma treatment or those who never receive treatment due to barriers. Understanding the reasons for treatment resistance and developing tailored interventions for these groups will be essential to ensure that advances in the field benefit all individuals affected by trauma.

Evidence-based psychological therapies for PTSD share common focuses: psychoeducation, emotion regulation and coping skills, cognitive processing (rethinking thoughts), emotional processing, and trauma memory processing. Evidence suggests that similar psychological processes drive changes in PTSD symptoms across these therapies. Specifically, changes in beliefs about the trauma's causes or consequences, changes in how memories are processed, and decreases in unhelpful coping strategies (like avoidance, safety behaviors, and rumination) are important.

A systematic review on PTSD treatment showed that trauma-focused interventions were cost-effective, while more research was needed for medication and other treatments. Another study found no differences in cost-effectiveness between different forms of prolonged exposure for PTSD. Trauma-focused cognitive therapy for PTSD was more cost-effective than general cognitive behavioral therapy focusing on coping techniques, including exposure.

Large-scale efforts have been made in several countries to spread evidence-based PTSD treatments into regular clinical services. These efforts face difficulties and obstacles, and sometimes lead to a decrease in overall effectiveness. The quality of training (requiring supervision beyond manuals and workshops), strong organizational support, and proper infrastructure are important for maintaining these dissemination efforts. Therapist attitudes, such as skepticism toward evidence-based interventions and overestimating the risks of exposure to trauma memories, can hinder the use of trauma-focused treatments. Systematic studies are needed to identify factors that help or hinder the implementation of effective interventions.

Treating Comorbidities

The treatment of co-occurring PTSD and Substance Use Disorder (SUD) presents a particular challenge for many clinicians. Trauma-focused integrated interventions for PTSD/SUD show the most promise in treating individuals with both conditions. The combination of leading PTSD treatments, such as Prolonged Exposure therapy, with cognitive-behavioral therapy for SUD, like Relapse Prevention (e.g., Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure [COPE]), is particularly promising. One study found that trauma-focused, non-trauma-focused, and manualized SUD interventions were valid options for individuals with co-occurring PTSD/SUD. However, recent meta-analytic findings suggest high rates of treatment dropout and only modest effects, even among the most effective evidence-based interventions, including trauma-focused integrated interventions. While significant progress has been made in treating the complex comorbidity of PTSD/SUD, more work is needed to improve existing treatments and develop new intervention approaches. In the absence of robust evidence-based literature, expert recommendations for assessing and treating this co-occurrence have recently been developed.

Another challenging clinical presentation is the co-occurrence of PTSD and sleep disorders, specifically insomnia, nightmares, or obstructive sleep apnea (OSA). Unfortunately, trauma-focused interventions do not reliably improve sleep to a clinically meaningful extent; more than 50% of patients whose PTSD improved after trauma-focused therapy still reported insomnia at follow-up. Importantly, remaining symptoms of insomnia, nightmares, or OSA hinder patients' response to PTSD treatment and may increase the risk of future relapse. The persistence of sleep disorders has led to efforts to better target them in individuals with PTSD using new approaches, such as delivering cognitive behavioral therapy for insomnia (CBT-I) before starting Prolonged Exposure (PE). Indeed, CBT-I, the first-line treatment for insomnia, has very large effects on reducing PTSD symptoms, and emerging evidence supports its effectiveness and the logic of integrating it with PE to aid in fear extinction learning. Similar effects on fear extinction have been observed after other sleep-focused interventions like continuous positive airway pressure (CPAP) for OSA and morning blue light treatment for stabilizing circadian rhythms.

Current evidence-based treatments for prolonged grief include cognitive behavioral therapy, as well as a 16-session structured psychotherapy focused on loss, which has also shown effectiveness for PTSD symptoms related to bereavement. Finally, medications typically effective for PTSD, such as selective serotonin reuptake inhibitors (SSRIs), have not shown effectiveness in reducing the core symptoms of PGD. Future psychopharmacotherapy research should focus on compounds that target biological pathways involved in PGD, including those related to oxytocin, reward, and pain.

Digital Technologies

A significant challenge for healthcare providers is to make evidence-based therapies for PTSD and related conditions widely available and accessible to individuals who need them. As various technologies have become a common part of everyday life globally, research has focused on using technology to improve access to evidence-based treatments.

Technologies like smartphones, smartwatches, and video games provide information about our behaviors (e.g., app usage, step counts, heart rate, sleep) and allow us to connect with others to share health goals, music preferences, and more. Interventions have increasingly used these technologies, making it easier and more reliable to track patient data between sessions and even allowing automated communication between sessions. For example, during the pandemic, many providers and patients switched to remote delivery of traditional therapies, with growing evidence supporting similar outcomes for both in-person and remote delivery. Guidance on how to adapt trauma-focused treatments for remote delivery has been published. Research has also explored how virtual reality can play a key role in delivering PTSD interventions, especially exposure to trauma reminders and feared situations.

A number of therapist-assisted digital interventions have been developed, mostly to deliver the content of trauma-focused Cognitive Behavioral Therapy (CBT). Digital approaches usually require less therapist involvement and can be accessed remotely and flexibly by users. There is now increasing evidence that such approaches can be helpful for adults with mild to moderate symptom severity, showing large positive effects.

Future research needs to determine the optimal level of therapist guidance required for such interventions, whether they can also help children and young people, and whether digital therapy can be extended to those with more complex presentations, such as individuals with CPTSD, PTSD/SUD, or co-occurring sleep disorders. For example, one study found greater benefits for internet-delivered cognitive therapy compared to a comprehensive non-trauma-focused CBT program (focusing on coping skills including mindfulness) for patients who met CPTSD criteria. Moreover, recent studies found that digital CBT-I delivered 3–4 years before the COVID-19 pandemic protected against traumatic stress reactions in April 2020, during the initial weeks of stay-at-home orders in the United States.

Given the increasing recognition of the benefits of integrating digital technologies into intervention efforts, it will be necessary to continue innovating in this area, extending treatment and assessment possibilities further into real-world and experiential settings outside of the therapy office.

Positive and Negative Effects of Social Media

Online social networking (OSN), encompassing public platforms like X, Facebook, Whatsapp, and Instagram, as well as private messaging/texting, increasingly supplements face-to-face interactions. Several studies have highlighted the negative impact of OSN. For example, cyberbullying has been linked to an increased likelihood of clinically significant levels of distress. Importantly, interactions through OSN can also facilitate positive social support. During the pandemic, private messaging strategies, but not public posting, were observed to be comparable to in-person interactions. Public posting has also served as a way for trauma survivors to express their shared experiences. For instance, social media users employed hashtags like #whyIdidntreport to describe barriers to reporting sexual assault, #PuertoRicoSeLavanta to describe resilience after natural disasters, and #DomesticViolence to comment on intimate partner violence during the pandemic.

An important distinction between those who find social media helpful and those who experience secondary traumatization may explain how individuals engage with available technologies. Following Typhoon Hato, social media use involving trauma viewing was associated with increased PTSD, whereas social media exposure focused on information gathering or viewing heroic acts decreased PTSD. A similar pattern was observed after an aircraft accident in China, with vicarious trauma noted among individuals who reported high levels of exposure to peer communication and recommendation systems (algorithms that push specific content). Individuals who intentionally use social media for knowledge and positive connections may benefit greatly, while more passive engagement strategies may lead to increased exposure to distressing content pushed by algorithms.

More research is needed to understand how public and private OSN can support individual and community coping with trauma.

Innovations in Treatment

An interesting development in the field over the past few years has been the growing number of studies evaluating intensive or massed trauma-focused psychological therapies. One approach that has received significant attention is a model, developed in the Netherlands, combining adapted forms of EMDR and Prolonged Exposure delivered over an 8-day period. While this model has not yet been evaluated by randomized controlled trials (RCTs), several non-controlled studies published over the last 6 years suggest high rates of treatment completion and very encouraging improvements in symptoms and recovery from a PTSD diagnosis for both adults and adolescents. Further recent work has also explored the feasibility of adapting this model for people with mild intellectual disabilities and their families.

For individuals with severe and treatment-resistant PTSD, an approach that has gained increased attention and shows emerging evidence of effectiveness is multi-modal motion-assisted memory desensitization and reconsolidation (3MDR). 3MDR is a new therapy that involves exposure to trauma-related reminders on a large screen and taxing working memory through a dual task involving bilateral stimulation, all while the patient walks on a treadmill. Several small trials have shown the effectiveness of 3MDR in veteran populations, including veterans with mild traumatic brain injury. Further work is underway to adapt this approach for children and adolescents.

Other interesting developments in PTSD treatment, though requiring more research, include neuroscientifically guided treatments like deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS), or Deep Brain Reorienting (DBR) which targets the brainstem-level neurophysiological sequence that occurred during a traumatic event, or Targeted Memory Reactivation (TMR) which enhances memory consolidation by presenting reminder cues during sleep.

Complementary/Integrative Interventions

The group of complementary and integrative health (CIH) interventions includes various treatments, from meditative mind-body practices (e.g., yoga, mindfulness) to music and animal-assisted therapies. Although evidence is accumulating for many of these non-pharmacological and non-psychological treatments, empirical support for their effectiveness in addressing PTSD symptoms does not yet support their use as first-line therapies. Evidence for CIH therapies that can enhance current evidence-based treatments is similarly promising but not yet fully established. However, since CIH therapies primarily focus on improving health and well-being rather than just reducing symptoms, they have the potential to enhance quality of life even when symptoms do not completely disappear. Furthermore, for the significant number of individuals who cannot tolerate or choose not to engage in recommended trauma-focused treatments, CIH alternatives that do not require direct confrontation of traumatic events can be offered. In recent reviews and clinical guidelines, mindfulness and yoga have emerged as recommended second-line treatments.

A recent systematic review and meta-analysis of 10 clinical trials on neurofeedback for PTSD showed beneficial effects across diverse populations, including those with different types of trauma (military and civilians) and from different ethnic backgrounds. Although more research is needed, a recent review on dance therapy found some indication that it improves both psychological and physiological symptoms associated with trauma exposure.

In summary, CIH interventions may provide an entry point to encourage engagement in other treatments, but high-quality research is needed. For future research, a holistic approach is recommended, addressing symptoms beyond PTSD, including quality of life, wellness, and physical health. Identifying mechanisms of action, as well as potential for scalability and remote delivery, may need to be the focus of new research.

Sex/Gender Aspects in Treatment

Women were found to be more likely to seek psychotherapy and achieve greater treatment gains compared to men, though these differences were generally small. Sex differences in treatment effects appear to emerge in adolescence. A recent review of studies in this journal over the past five years showed little impact of sex and gender on treatment outcomes. There was also no indication of sex or gender differences in dropout rates for psychological therapies.

Similarly, no clear sex or gender differences have been found for pharmacological interventions. However, women were found to be slightly more likely than men to receive medications, including antidepressants recommended for PTSD, but also medications that should not be prescribed for PTSD, such as benzodiazepines. Future research should focus on civilian populations, as most research on sex and gender differences in treatment has been conducted in veterans.

Lifespan Perspectives in Treatment

Treatment research with child and adolescent populations has shown strong support for cognitive-behavioral treatment strategies, including for children as young as 3-8 years, and a growing base of evidence supporting treatments like EMDR and Narrative Exposure Therapy. Numerous trauma therapies for children and adolescents have been developed, showing significant commonalities in techniques and mechanisms across five evidence-based trauma therapies (Trauma-Focused Cognitive Behavioral Therapy [TF-CBT]; EMDR; KIDNET = narrative exposure therapy for children; PE-A = prolonged exposure therapy for adolescents; TRT = teaching recovery techniques). Common techniques include psychoeducation, relaxation, documenting critical experiences, traumatic recollection, exposure, homework, cognitive shifting, sharing the trauma story with others, future perspectives, and termination. The common mechanisms cover consolidation, trauma processing, therapeutic relationship, motivation, affect modulation, reciprocal integration, and sharing. Notably, almost all identified therapeutic mechanisms – consolidation, motivation, affect modulation, reciprocal integration, and therapeutic relationship – were considered present in all five therapies.

Social functioning is critical to mental health, and identifying these important social aspects for relationships in individuals exposed to child maltreatment is a rapidly growing area of research. Additionally, therapies may focus on improving parent-child relationships. An example of an approach involving parents is the Stepped Care Trauma-Focused Cognitive Behavioral Therapy, where parents are trained to deliver trauma-focused components to their children at home with minimal therapist support. Furthermore, there are initial indications of evidence for the Integrative Attachment Trauma Protocol for Children (IATP-C): an integrated treatment model combining family therapy and EMDR therapy to improve behaviors, attachments, and symptoms of traumatic stress in children affected by early abuse, neglect, and placement outside the biological home.

However, much more research is needed as research into child and adolescent treatments continues to lag behind adult interventions. Moreover, it will be important to ensure that ongoing treatment research includes considerations of inclusivity and equity.

Interventions for older individuals with PTSD is a comparatively understudied topic. In a systematic review of narrative exposure therapy (NET), older age predicted better treatment results for PTSD and depression symptoms. A review of interventions among older combat veterans showed mixed results for evidence-based interventions, including exposure-based therapies. Treatment outcomes were complicated by the range of complex medical and mental health comorbidities among such older adults, which highlights the potential need for more comprehensive treatment strategies for this population. A review showed that people with PTSD and dementia can benefit from PTSD treatment, including EMDR, prolonged exposure, acceptance and commitment therapy, and pharmacological treatment. Pilot work has suggested that exercise training combined with cognitive behavioral strategies may be one such approach. Additional work in this area is needed, especially as the world's population ages and there is a greater need for PTSD treatments for older adults.

Global and Contextual Perspectives in Treatment

There are no global recommendations for evidence-based treatment. For example, the American Psychiatric Association's Clinical Practice Guideline lists four strongly recommended treatments for PTSD: Cognitive Behavioral Therapy, Cognitive Processing Therapy, Cognitive Therapy, and Prolonged Exposure. Cultural differences may require a broader range of available treatments and adaptations to these approaches.

Over the past 15 years, strong evidence has emerged supporting the effectiveness and safety of empirically supported psychotherapies for PTSD in various cultural contexts, often delivered by non-specialist health providers through task-sharing models. There is also growing evidence for the effectiveness of transdiagnostic interventions for trauma survivors in Low- and Middle-Income Countries (LMICs), addressing a range of mental and behavioral health difficulties simultaneously. While there is now a substantial body of randomized controlled trial (RCT) evidence for the effectiveness of trauma interventions across different cultural settings, there is still very limited research demonstrating that these interventions can be successfully scaled up in resource-limited contexts. Implementing task-sharing delivery models in LMICs requires prioritizing long-term training models focused on continuous supervision by local trainers and supervisors.

Research increasingly indicates that adapting evidence-based treatments for local cultural contexts, using input from local experts, can improve the acceptability and effectiveness of trauma interventions. However, there is debate about whether superficial adaptations (like changes to language and terminology) are enough, or whether deeper cultural adaptations (like including culturally based explanations of illness or local healing rituals) that might change the core components of the intervention are needed. Researchers argue that a culturally sensitive approach to psychological trauma is critical when implementing treatments across different contexts, but untested stereotypes about culture should not be used as an excuse for failing to provide these treatments.

Methodological Developments

This section concludes with a final note on methodological developments in the field of psychological trauma over the last 15 years and future directions. There have been countless advances in research practices, as shown by studies published in the European Journal of Psychotraumatology (EJPT) since its launch. These include important innovations in data collection, such as brain imaging, genetic research, and smartphone technology, among others. At the same time, there has been unprecedented progress in our ability to analyze data, including the development of advanced statistical software and models, the application of machine learning, and vastly improved capacity to process large datasets. Recently, there has also been a push to use computational models to refine theories related to the impact of trauma.

These advanced methods show great promise in improving our ability to predict mental health outcomes after trauma and in guiding treatment selection and personalizing interventions. Crucially, it is clear that artificial intelligence (AI) will play a pivotal role in significantly advancing all these areas. However, the full range of possibilities, as well as potential pitfalls (for example, related to the replicability of models), of integrating AI into the traumatic stress field have not yet been fully understood. Studies that thoughtfully and subtly explore the use of AI are welcome.

Moving forward, EJPT aims to continue publishing studies that advance our understanding of psychological trauma, its impact, and its treatment. The goal is not simply to publish papers that apply novel methods for their own sake. Instead, the focus is on studies that use the best available methods to answer specific research questions. This includes traditional, proven methods, but as the science of trauma continues to evolve rapidly, it is anticipated that the journal will increasingly publish studies based on more robust data (i.e., larger samples, longitudinal studies, combining multiple data types) and with more sophisticated analyses. In line with open science principles, research is hoped to be increasingly based on Findable, Accessible, Interoperable, and Re-usable (FAIR) research data, to make the enormous number of rich, potentially reusable datasets available globally. Consider publishing "Data Notes," which are short, peer-reviewed articles describing a dataset stored in a repository, to make the dataset even more visible. Sharing data will enhance global collaboration and accelerate solid research output, at least for the next 15 years.

Traumatic Events

Defining Trauma

Experiencing traumatic events is common worldwide, both in general populations and in groups at higher risk. How trauma is defined and measured is important for studying its effects and for global discussions. For example, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Text Revised (DSM-5-TR) defines traumatic events as exposure to actual or threatened death, serious injury, or sexual violence. This includes direct experience, witnessing such events, or learning about them if they happened to close family or friends. The DSM-5-TR also includes ongoing or extreme exposure to traumatic details, such as that experienced by first responders. The International Classification of Diseases-11th Revision (ICD-11) broadly defines trauma as an “extremely threatening or horrific event or series of events.” However, neither manual provides a complete list of all possible traumatic events.

The term "trauma" is now used more broadly by both the public and researchers, sometimes including less severe negative experiences. This wider use can be helpful by recognizing harmful situations, like emotional abuse, as potentially traumatic. However, it can also lead to classifying stressful but not necessarily traumatic experiences as disorders, which might cause expectations of negative health outcomes or a "victim" mindset. This can make it hard for professionals, such as those in healthcare or the legal system, to agree on what constitutes a traumatic event and the reactions that qualify for treatment or compensation. A recent study found that common tools used to measure potentially traumatizing events do not consistently define or describe these events.

Criterion A for Post-Traumatic Stress Disorder (PTSD) describes the specific characteristics of a traumatic event that might lead to PTSD. The discussion about how to define and use Criterion A is ongoing. This debate can be divided into four main viewpoints: expanding Criterion A to include more events (like indirect exposure through social media or racial discrimination), narrowing it to include fewer events (like excluding all indirect exposure), removing it entirely, or keeping it as it is. Future research should aim to define Criterion A in a way that considers different global and cultural contexts, to help standardize research and improve healthcare.

The types of potentially traumatic events that large groups of people face also change over time. For example, the COVID-19 pandemic led to many studies showing that COVID-19 related events can meet the PTSD A Criterion and cause various mental health symptoms. Even young children were affected. Climate change is another global issue leading to more frequent traumatic experiences, such as disasters, violence, and forced migration due to extreme weather. Climate change affects vulnerable populations more severely, and its mental health impact and protective factors have been explored in recent studies.

Overall, defining trauma is complex. A person's individual interpretation of an experience may be more important than the event's objective features. New data analysis methods, such as text mining, offer promising ways to identify post-traumatic stress reactions. Future research should focus on improving how exposure to traumatic events is assessed to reduce differences across common trauma measurement tools.

Trauma Exposure: Sex/Gender Aspects

Research in psychotraumatology has increasingly focused on the effects of sex and gender. Sex refers to biological factors (such as sex assigned at birth), while gender relates to social and cultural aspects (such as woman or non-binary). Both sex and gender affect the rates of specific types of traumatic events and their outcomes. For instance, men are more likely to experience certain types of violence and combat. Women are more likely to experience physical and sexual assault, often at a younger age, which is linked to a higher risk of PTSD. Additionally, members of sexual and gender diverse (SOGD) communities face a higher risk of sexual violence compared to cisgender heterosexual people.

Historically, many studies have not clearly distinguished between sex and gender, often defining both as binary (male/female) constructs. While improvements are being made, more research is needed to better understand the distinct roles of sex and gender in the impact of traumatic events, moving beyond a simple binary view. Specific suggestions for measuring sex and gender have been provided to guide future studies.

Trauma Exposure: Lifespan Perspectives

Children and adolescents are reporting increasingly high levels of traumatic event exposure. Surprisingly, studies of general populations show that younger individuals report more lifetime trauma exposure than older individuals. It is unclear if this means younger people are genuinely exposed to more trauma, are more likely to identify events as traumatic, or if it is related to how memories are recalled. Conversely, older adults report lower levels of exposure, which is unexpected given that these are lifetime measures. This could be due to forgetting, cognitive decline, stigma, shame, or not considering certain events as traumatic.

Exposure to any form of traumatic stress during childhood increases the risk of negative social and psychological outcomes later in life. Interpersonal traumas (intentional acts by others, like maltreatment or violence) in childhood are particularly linked to psychological, relationship, and physical health issues in childhood and adolescence, with lasting effects into adulthood. Experiencing multiple severe dangers, harms, or victimizations in childhood increases the likelihood and severity of PTSD symptoms and other trauma-related disorders throughout life, showing a dose-response relationship. This phenomenon has been described as cumulative trauma exposure, poly-traumatization, poly-victimization, or adverse childhood experiences (ACEs).

However, caution is needed when interpreting studies on childhood trauma due to research limitations. Often, adults provide retrospective reports of childhood experiences, and many standard trauma measures, including those for childhood trauma, do not assess the frequency, intensity, or duration of events, typically asking for a simple yes or no response. The ACEs framework has been criticized for only including 10 types of childhood adversities and for simply adding up the number of adversity types, treating each as having equal impact.

Given the heightened brain plasticity and developing nervous systems in childhood, it is not surprising that stressful events during this period can strongly influence emotional regulation and stress responses later in life. This can cause changes in brain circuits, biochemical systems, and immune systems, increasing the risk for psychiatric disorders. Most studies broadly define "childhood" as extending across early life (sometimes up to age 16), which may overlook critical developmental periods. For example, some research suggests that exposures in early childhood (before age 3) may be especially impactful. Children who experienced multiple forms of victimization in early childhood (birth to 6 years) were more likely to be re-victimized in middle childhood and adolescence, although the types of victimization changed over time. These children also showed different patterns of psychosocial and post-traumatic symptoms depending on when the victimization occurred. Going forward, due to the many neurobiological changes during specific developmental stages, future research should adopt a more detailed approach to understanding the effects of traumatic stress during different childhood periods.

In addition to focusing on specific critical periods, future research on childhood trauma should use tools that measure the frequency, intensity, and duration of events. It is also important to identify positive, supportive events, especially in childhood but also throughout life, that help build resilience and recovery from trauma. While abuse of older adults is common, more research is needed to understand the long-term effects of early trauma and how later-life trauma affects older adults. PTSD has been linked to accelerated biological aging. Cognitive decline can also result from traumatic brain injury. Although tools exist for adverse childhood experiences (ACEs), there is currently no specific tool for "Adverse Older Adult Experiences" (AOE). Traumatic experiences later in life, such as during dementia, need more investigation. Identifying trauma exposure and potential PTSD in individuals with cognitive decline or dementia may require specialized diagnostic tools and interviews designed for this population.

Trauma Exposure: Global and Contextual Perspectives

Over the past 15 years, research has confirmed that trauma exposure is common globally, but its frequency varies significantly across countries. These differences in prevalence may stem from historical, geopolitical, economic, and cultural factors that influence the rates of intentional and unintentional injuries and other adverse events. It is clear that people living in countries affected by war and conflict face a much higher risk of experiencing or witnessing potentially traumatic events. There is also a growing understanding that in low-resource and conflict-affected regions where violence is constant, trauma exposure may not be a single event but an ongoing condition of life, without clear "pre-" and "post-" trauma periods.

Furthermore, what is considered a "traumatic" event likely varies across cultures. An event perceived as extremely shocking or adverse in one setting might be accepted as a normal part of life in another. Much of the language used in psychotraumatology has originated in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. This can lead to measurement bias, as commonly used trauma screens largely reflect Western ideas of trauma. Cross-cultural research comparing the social meanings of different events could improve our understanding of the wide variations in PTSD rates across cultures. In non-Western settings, there is a lack of screening tools that cover the range of potential traumatic events experienced in those regions. A large global project called MaTRix is designed to map traumatic experiences within their cultural contexts. In summary, regarding the definitions and prevalence of trauma exposure, more research is needed from researchers in the global South.

Mental and Physical Health Consequences of Trauma Exposure

Traumatic events can lead to a wide range of mental and physical health problems, not just PTSD. The way symptoms appear, how common they are, and how they progress after trauma can differ based on an individual's age, developmental stage, sex, gender, sociocultural background, and societal factors (such as health inequalities and systemic discrimination). The most common outcomes after trauma are discussed below, focusing on sex/gender, lifespan, and global perspectives on the consequences of trauma.

Resilience

The most common response to trauma (about two-thirds of cases) is resilience, as shown in a meta-analysis of 54 studies. Factors that may help explain who becomes resilient versus who develops problems include aspects of emotional functioning, such as coping flexibility, coping strategies, self-efficacy, optimism, neuroticism, and beliefs about resilience. The most consistent predictors of resilience have been personality, financial security, education, social support, ability to cope, finding meaning, and experiencing positive emotions. However, some researchers argue that the quality of this evidence varies, and even when a factor is statistically linked to resilience, its predictive power is often small. A promising area of research may be to focus on a person's flexible self-regulation skills during and after a traumatic experience. People who are better at managing their emotions might be more likely to show resilient outcomes after trauma. Flexible self-regulation involves three steps: being aware of the situation, having a range of responses, and using feedback. Despite the psychological benefits of post-traumatic resilience, these benefits can come at a significant cost to overall health due to the physiological strain (allostatic load) of adapting to trauma's adverse effects. Resilience may decrease later in life as protective factors, like a strong support system, lessen, and risk factors, such as declining health, increase.

PTSD, Dissociative-PTSD (D-PTSD), and Complex PTSD (CPTSD)

Exposure to trauma is linked to various negative outcomes for individuals, their families, and communities. The most studied negative outcome is Post-Traumatic Stress Disorder (PTSD), which is described differently across diagnostic systems. In the DSM-5-TR, PTSD has 20 symptoms grouped into four categories: intrusion, avoidance, negative changes in thoughts and mood, and changes in arousal and reactivity. The DSM-5-TR also includes Dissociative-PTSD (D-PTSD), where PTSD symptoms are accompanied by dissociative symptoms like derealization (feeling detached from reality) or depersonalization (feeling detached from oneself). A systematic review confirmed this subtype, though specific factors related to it showed mixed results across studies.

The ICD-11 defines PTSD with three symptom clusters: re-experiencing, avoidance, and feelings of heightened current threat. It also includes Complex PTSD (CPTSD), which features PTSD symptoms along with additional problems in three areas: emotional dysregulation, negative self-concept, and difficulties in relationships. The differences in how PTSD, D-PTSD, and CPTSD are defined in the DSM-5 and ICD-11 have led to many studies examining how these distinctions affect estimated prevalence rates. These studies suggest that the differences are both quantitative (leading to different rates of PTSD) and qualitative (with moderate agreement between classifications). In regions where treatment availability depends on a diagnosis, these inconsistencies might mean that people receive or are denied treatment based on which classification system is used. One recent study also suggests that the estimated effectiveness of a treatment can be influenced by the diagnostic system chosen.

Moral Injury

Traumatic events can also lead to moral injury, which is deep psychological distress caused by experiencing, failing to prevent, or witnessing actions that go against one's core beliefs or values. Moral injury involves both exposure to a potentially morally harmful event and the resulting symptoms, often including shame, guilt, despair, and a loss of morale. Many mental health disorders, including PTSD, can also result from morally injurious events.

Research on moral injury has grown significantly in the past 15 years. Initially focused on military personnel, it now includes other populations, such as healthcare workers and refugees. Studies on treating moral injury are also progressing. Future research could explore whether moral injury needs a formal diagnosis in our diagnostic systems and how it is understood in different global contexts. There is also limited knowledge about how moral injury affects physical health. For assessment, future research should use tools that measure both the exposure to morally injurious events and the resulting symptoms, such as the Moral Injury and Distress Scale (MIDS).

Prolonged Grief

After decades of research showing that pathological grief reactions are distinct from PTSD but related to it, Prolonged Grief Disorder (PGD) was recently included in the ICD-11 and as a stressor-related disorder alongside PTSD in the DSM-5-TR. However, the diagnostic criteria differ between these systems. The DSM-5-TR requires PGD symptoms to last at least 12 months (6 months for children), while the ICD-11 only requires 6 months. A recent systematic review identified several factors that distinguish between pathological grief and PTSD, but the studies were diverse and mostly cross-sectional. Current research suggests that the two classifications might not describe the same clinical condition. Regardless, the recognition of PGD in international classifications has spurred more research into its symptoms and treatment, especially given the global death toll of the COVID-19 pandemic.

Other (Comorbid) Mental Health Outcomes

After trauma, major depressive disorder (MDD), anxiety disorders, substance use disorders, and sleep disorders are common. PTSD and MDD often occur together, with a meta-analysis reporting rates as high as 52%. The DSM-5 PTSD symptom cluster related to "negative alterations in cognition and mood" increases the overlap with depressive symptoms. More than 90% of individuals with PTSD report insomnia, nightmares, or both. These sleep problems are increasingly recognized for hindering the emotional learning needed for PTSD recovery and treatment.

Substance use disorders (SUD) affect about 2.2% of the world's population, with higher rates in wealthier countries. Alcohol use disorder (AUD) is the most common SUD globally. PTSD and SUDs, including AUD, often occur together, with about half of individuals with PTSD meeting criteria for a SUD at some point in their lives. The co-occurrence of PTSD and SUD leads to a more complex, severe, and impairing course, with worse treatment outcomes than either disorder alone. Recent research supports a bidirectional relationship between PTSD and SUD, meaning each can influence the other, with PTSD having a stronger effect on future SUD. Despite significant progress in understanding this comorbidity, more rigorous research is needed to understand the biological, psychological, and social mechanisms that contribute to the risk and persistence of PTSD/SUD.

About a quarter of people diagnosed with PTSD also have Borderline Personality Disorder (BPD), and vice versa. Due to overlapping symptoms, especially with Complex PTSD, there is ongoing debate about whether BPD should be considered a separate diagnosis. While a co-occurring personality disorder is sometimes seen as a barrier to PTSD treatment, a recent meta-analysis found that patients with comorbid personality disorders were not at higher risk for dropping out of PTSD treatment, although they might benefit less from it.

Transdiagnostic Perspectives and Survivor-Centred Approaches

Given the many, often co-occurring, outcomes of trauma, researchers have called for a comprehensive screening of trauma survivors that looks beyond a single diagnosis. Although recent work on transdiagnostic approaches suggests that various disorders share some treatment targets, it is important to consider the broad and complex interactions that follow traumatic exposure. The negative impact of trauma can vary even within the same type of exposure, as there is no single universal experience or reaction to trauma. For example, PTSD is very common after sexual assault, with prevalence rates ranging from 17% to 74% depending on when it is measured. However, focusing only on PTSD as a potential psychological outcome is too simple.

It is important to adopt a broader perspective that includes other psychological reactions (such as depression, anxiety, sleep problems, and suicidal thoughts), physical reactions (such as fractures and pain), and social reactions (such as social isolation, stigma, and racial discrimination). This also includes the interactions between survivors and their social networks. This comprehensive view is especially relevant when considering collectivist versus individualistic cultures. Therefore, it can be helpful to include a wider socio-ecological perspective. Additionally, there is a need for more survivor-centered, culturally appropriate, and trauma-informed services after sexual assault or trauma in general. A recent review identified seven categories of underserved sexual assault survivors: ethnic and cultural minorities, individuals with disabilities, those who are financially vulnerable, sexual and gender minorities, people with mental health conditions, those with problematic substance use, and older adults. A study in Georgia found that a transdiagnostic approach could effectively help young people at risk of mental health problems. Future research should explore whether transdiagnostic screening can improve the identification of various trauma-related outcomes and increase access to care.

Impact of Trauma on Physical Health

The body's acute stress response after trauma involves a series of central nervous system and hormone reactions that help people cope. However, chronic activation of these systems (as seen in PTSD) can lead to physical health problems. It is believed that biological dysregulation might explain how trauma affects mental health, increasing the risk for both psychiatric disorders and physical illnesses.

PTSD is linked to higher rates of obesity and metabolic disorders (like type 2 diabetes), autoimmune disorders (like rheumatoid arthritis, lupus), thyroid disease, asthma, and obstructive sleep apnea (OSA). OSA has been shown to impair learning processes important for overcoming fear. One study found that childhood trauma was linked to obesity, diabetes, cancer, high blood pressure, chronic obstructive pulmonary disease, and a history of heart attack and stroke, with the risk for all these conditions increasing with more types of child maltreatment experienced. More research is needed to understand how different types of child maltreatment relate to physical symptoms and the mechanisms connecting them.

It can be hard to tell the difference between symptoms and effects of physical health problems like pain (e.g., social withdrawal, sleep problems, or difficulty concentrating) and difficulties related to PTSD (e.g., avoidance, arousal, or re-experiencing). PTSD is common in patients with chronic pain, possibly due to differences in how their brains process pain. Some coping behaviors and daily routine changes people adopt after trauma, such as weight gain, smoking, self-medicating with alcohol or drugs, fear of sleep, and social isolation, can also negatively affect their health.

Trauma exposure and PTSD are linked to increased rates of cardiovascular disease, including stroke, heart attack, high blood pressure, and heart failure, as well as risk factors like increased arterial plaque. While some of these risk factors may come from behavioral changes related to PTSD (e.g., smoking, low physical activity, poor diet and sleep), PTSD has shown an independent effect on cardiovascular risk even after accounting for these factors. Mechanistically, the chronic elevation of the stress response in PTSD (e.g., heightened sympathetic arousal, inflammation) may lead to high blood pressure and damage to blood vessels, ultimately increasing cardiovascular risk. Inflammatory responses related to the stress response in PTSD are also thought to increase the risk for several other physical health problems.

Neurobiological Consequences of Trauma

Trauma exposure and Post-Traumatic Stress Disorder (PTSD) are linked to changes in neural activity, brain structure, and neurotransmitter systems. There are alterations in brain function, structure, and neurotransmitter systems that overlap with a core brain circuit involved in processing threats. Meta-analyses suggest that trauma and PTSD are often associated with increased activity in the amygdala and dorsomedial prefrontal cortex (PFC) when responding to emotional stimuli, as well as reduced activity in the ventromedial PFC. Large-scale analyses of brain structure data also indicate that PTSD is linked to reduced hippocampal volume. The amygdala, PFC, and hippocampus form a neural network crucial for healthy emotional functioning and regulating responses to threat.

It is important to note that neural circuit findings in PTSD can vary based on several factors. Neuroimaging meta-analyses suggest that PTSD-related differences in neural activity may be influenced by the type of trauma experienced. Additionally, subtypes of PTSD (such as the dissociative subtype) may show different neurobiological patterns compared to typical PTSD presentations. More recent work also indicates that specific neurobiological profiles (biotypes) may underlie different symptom pathways after trauma exposure. Many biological, psychological, and social factors are likely involved in how people respond to trauma; more research is needed to build predictive risk models that incorporate these factors.

A systematic review reported significant variability in experiences, exposures, and contextual factors among groups worldwide. Considering unique stressors (such as discrimination, or stress related to being a refugee or migrant) is crucial for understanding specific neural patterns in PTSD. Furthermore, previous stress, trauma, and environmental influences can affect "neurophenotypes" and contribute to different brain imaging profiles.

Genetic Risk for Trauma-Related Conditions

Studies of twins in civilian and veteran populations have shown that PTSD has a moderate heritability, ranging from 30% to 72%. In children, the transmission of Acute Stress Reactions (ASRs) or PTSD from parent to child was linked to both rearing factors and genes. Even when considering shared traumatic experiences, the correlations for rearing and genes were similar. Molecular genetic studies on PTSD have advanced significantly in the past decade, largely due to large-scale collaborative research and reduced genotyping costs. The Psychiatric Genomics Consortia workgroup for PTSD (PGC-PTSD), established in 2013, has brought together researchers globally to uncover the genetic basis of PTSD, a disorder with fewer genetic discoveries compared to other conditions with similar heritability. The most recent meta-analysis from the PGC-PTSD workgroup included over 1.2 million individuals and identified nearly 100 significant genetic locations (loci), 85% of which were new discoveries.

The overall genetic risk for PTSD is moderately to highly correlated with other psychiatric disorders, with the highest genetic correlation observed between PTSD and major depressive disorder (MDD). This finding aligns with twin studies on PTSD and MDD. Recent work has also explored the molecular genetics of resilience, though these studies are preliminary due to limited sample sizes. In addition to more molecular genetic data on PTSD, new statistical genetic techniques—such as genomic structural equation modeling, Mendelian randomization, and polygenic risk scoring—are being applied to PTSD and related conditions. These techniques hold great promise for further understanding the underlying genetic risk for trauma-related conditions. Finally, a meta-analysis of epigenome-wide association studies across 23 military and civilian groups identified 11 DNA methylation sites associated with PTSD. These sites may indicate susceptibility to PTSD, the impact of trauma, or the consequences of PTSD itself.

Trauma Consequences: Sex/Gender Aspects

PTSD prevalence rates are twice as high in women compared to men, and women also show higher rates of co-occurring disorders like major depression, anxiety, insomnia, and nightmares after trauma. Sex differences also exist in how PTSD symptoms develop within the first year after trauma. While similar symptom patterns (resilient, recovery, chronic symptoms, and delayed onset) were observed for both men and women, the recovery pattern was more common in women, and delayed onset was more prevalent in men.

In women, biological sex hormones appear to contribute to the higher risk for PTSD. Women with lower levels of estradiol (measured through saliva, plasma, or menstrual cycle phase) tend to experience worse PTSD symptoms and impaired fear inhibition. Conversely, high progesterone levels seem to worsen the ability to suppress fear memories in women with PTSD, but not in those without it. Sex differences in PTSD prevalence typically emerge during adolescence.

A meta-analysis of a large multi-ethnic group identified sex-specific genetic risk locations, showing that heritability estimates based on genetic variations can differ by sex. However, with larger sample sizes, this difference is no longer statistically significant. Neuroimaging studies suggest that women may have stronger activation in a brain region called the locus coeruleus when seeing fearful faces and less activation in the dorsal anterior cingulate during the recall of fear extinction. Additionally, elevated heart rate and cytokine levels may be more significant indicators of PTSD risk in women than in men. Cognitive and behavioral responses during and after trauma have been shown to fully explain the effects of both sex differences and the type of trauma (accidental versus interpersonal) on PTSD symptom severity six months after the trauma.

Important sex differences exist in cardiometabolic risk after trauma. For example, inflammatory cytokines have been linked to worse PTSD symptoms and physiological hyperarousal in trauma-exposed women, but not men. Also, sympathetic arousal, measured by heart rate, appears higher in women with PTSD compared to men with PTSD. Furthermore, low estradiol levels are associated with worse sympathetic arousal and poorer blood vessel function in women with and without PTSD. More neurobiological and psychosocial research on gender-diverse populations with PTSD is needed.

Trauma Consequences: Lifespan Perspectives

Children/Adolescents

While it is clear that not all children and adolescents exposed to trauma develop PTSD, prevalence estimates vary greatly depending on the study population, assessment methods, and the types of events evaluated. A meta-analysis of over 70 studies estimated that about 16% of children and adolescents develop PTSD after experiencing a potentially traumatic event, which is nearly double the rate seen in adults. Given climate change, children (and adults) are likely to face more natural disasters. A special issue of this journal highlighted ways to prepare children for natural disasters and addressed the mental health aspects of such events. A recent review identified PTSD risk factors for earthquake survivors, from children to the elderly, which could help identify families at risk.

Child abuse and neglect in early childhood can lead to symptoms beyond PTSD, including internalizing symptoms, attachment problems, and emotional and behavioral issues. Young people exposed to traumatic events across multiple settings and by multiple perpetrators tend to have more severe trauma-related symptoms than children who experience repeated or chronic exposure to a single type of adversity. The negative effects of trauma exposure can accumulate, especially after a combination of two types of traumatic adversity; some traumas (such as sexual and physical abuse, neglect, and domestic violence) have combined, intensified negative effects. Cumulative trauma or poly-traumatization at any point in childhood puts youth at risk for a wide range of post-traumatic and psychosocial problems, but its negative impact differs depending on the specific developmental period(s) in which it occurs.

Developmental Trauma Disorder (DTD) has been developed and proven empirically as an integrated theoretical and clinical framework. It describes the range of trauma-related problems that children and adolescents who have experienced multiple victimizations may face in developing essential self-regulation skills, including dysregulation of bodily functions, emotions, attention, cognition, behavioral self-control, relationship engagement, and identity formation. Although DTD is not a formal diagnosis in the DSM or ICD, this post-traumatic syndrome in children exposed to traumatic victimization and disruptions in attachment has been shown to be distinct from, and can occur alongside, PTSD, with its own unique pattern of co-occurring conditions. DTD has also been shown to explain psychosocial impairment beyond what is attributed to PTSD in both initial and independent replication studies. Thus, DTD may offer clinicians and researchers a clinical framework to identify victimized youth who could benefit from trauma-focused treatment but who might otherwise only be considered for treatment related to other psychiatric disorders.

Older Adults

Relatively little research has focused on the prevalence of PTSD in older adults compared to other age groups. Many older individuals show some symptoms that do not meet the full diagnostic criteria for PTSD. Available evidence suggests that the prevalence of PTSD decreases with older age. The prevalence of PTSD among those aged 60 and older ranges from 1.9% to 9.5%. The reasons for this decrease in PTSD among older individuals are not fully understood. Several explanations have been proposed, including a "survivor's bias" in the general population, meaning those with PTSD may be more vulnerable to serious illness, chronic stress, and risky behaviors. Other theories suggest that PTSD might appear differently in older individuals, so current diagnostic criteria may not fully capture the disorder in this age group. For example, reduced contact with external cues due to physical limitations or hearing loss might lessen hypervigilant behavior. Additional explanations for the lower prevalence of PTSD among older adults include interpreting mental health issues as physical problems and greater mental health-related stigma in this age group. It also remains largely unclear why traumatized individuals who initially cope successfully might develop delayed-onset PTSD later in life. Despite the lower prevalence, a significant number of older adults do have PTSD, so more research in this area is justified. Furthermore, advancements in medical care and increased awareness of mental health disorders are likely to lead to higher rates of PTSD in older individuals in the future.

Trauma Consequences: Global and Contextual Perspectives

Symptoms of PTSD and Complex PTSD (CPTSD) are reported across various cultures, indicating that both diagnoses have some validity worldwide. However, there is growing evidence that responses to trauma vary significantly across cultural contexts, and Western diagnostic systems may not fully capture the breadth of these responses. For example, physical symptoms, social isolation, and "thinking a lot" are commonly reported among trauma survivors in low- and middle-income countries (LMICs). This highlights the need for culturally informed assessment tools, in addition to DSM- and ICD-based measures, to accurately identify trauma survivors needing support in different cultural settings. Trauma symptom screening tools have been developed for specific cultural contexts in collaboration with local experts. Additionally, the Global Psychotrauma Screen (GPS), which assesses a wide range of common traumatic stress symptoms across cultures, has been validated in various non-Western settings.

Further examination of differences within cultures and contexts is also needed to improve our understanding of trauma's impacts. For example, there are significant ethnoracial variations in the prevalence and impact of trauma exposure, revealing potentially important factors to consider. Specifically, Black individuals in the United States are exposed to more risk factors for developing trauma-related disorders but often report similar or lower experiences of trauma and PTSD symptoms compared to groups with fewer risk factors. This discrepancy might be partly due to the adoption of adaptive neurophysiological mechanisms to counter stressors, which could, however, lead to more severe symptoms for those susceptible. Similar mechanisms might explain the "vulnerability paradox," where lower levels of PTSD are reported in countries with higher vulnerability ratings. The lack of inclusion of ethnoracially and culturally diverse participants can contribute to bias in research findings.

Preventive Interventions

Preventive Pharmacological Interventions

Currently, there is no "morning after pill" to prevent PTSD immediately following a traumatic event. Research has not shown that several medications, including the beta blocker propranolol, gabapentin, and antidepressants (SSRIs), are effective in preventing PTSD. Some data suggest that hydrocortisone might be effective, but more rigorous research is needed. Oxytocin shows some promise for PTSD prevention, but only in individuals with high initial symptoms. Prazosin was found effective in a small pilot study for preventing the progression from Acute Stress Disorder (ASD) to PTSD. In summary, much more research is required before PTSD can be pharmacologically prevented soon after trauma.

Preventive Psychological Interventions

Preventive interventions after a negative event can be used at various stages of care. Providing early interventions can prevent post-traumatic stress reactions from worsening into a PTSD diagnosis, whether delivered immediately after trauma or in the weeks that follow. Such interventions are generally well-tolerated and effective. Traumatic events can have negative outcomes, including PTSD, for more than 10 years, highlighting the importance of preventive measures.

Psychoeducation, which involves teaching people about mental health, is a common part of psychotherapy. However, stand-alone psychoeducational interventions have been controversial since the "debriefing" debate, though they have recently regained interest. A systematic review of 10 studies found some evidence that psychoeducation improves attitudes and knowledge about mental health and was generally seen as acceptable and useful. However, it did not support the routine use of brief psychoeducation alone to prevent PTSD. In low- and middle-income countries (LMICs) with limited access to mental healthcare, easily administered psychoeducational interventions can be a first step in a stepped care strategy. A psychological first-aid intervention was shown to reduce early PTSD symptoms but did not prevent PTSD entirely.

A systematic review and meta-analysis demonstrated the effectiveness of several early psychological interventions for individuals with traumatic stress symptoms after trauma exposure, especially for those meeting the diagnostic criteria for Acute Stress Disorder (ASD) or PTSD. However, there is no evidence supporting universal psychological interventions for all trauma-exposed individuals, regardless of their symptoms. The strongest evidence supports trauma-focused cognitive behavioral therapy used as an indicated intervention for trauma survivors who show symptoms within the first few months after trauma, to prevent further worsening and the development of PTSD. A smaller review of seven studies on early interventions after sexual assault showed lasting effects on PTSD severity.

After large-scale traumas and disasters, interventions are likely needed for both adults and children. First responders, medical personnel, and military service members may be at risk of developing PTSD or other symptoms due to frequent exposure to potentially traumatizing experiences in their professions. For traumatic loss, little is known about specific prevention strategies. We still need more information about which interventions to offer and for whom. For example, a study of early Eye Movement Desensitization and Reprocessing (EMDR) therapy in rape survivors did not show greater effectiveness compared to "watchful waiting" in reducing PTSD symptoms or other psychological problems. Similarly, a review of early interventions for workplace trauma did not identify clear benefits for any specific intervention, nor suggest which was superior, although generic debriefing was linked to negative outcomes. Additionally, despite strong evidence that sleep disturbance increases the risk of PTSD, early interventions targeting sleep immediately after trauma to prevent PTSD are a new area of research. Although promising new studies aimed at promoting healthy sleep after trauma are underway, there is also some evidence suggesting that sleep deprivation might be protective.

In summary, high-quality evidence is needed for early or preventive interventions, which can be challenging to gather in this research context. A suggested framework emphasizes that interventions must be theoretically sound, practical for delivery during and immediately after trauma, and ready for evaluation. Ethical considerations for early intervention, such as the risk of causing harm or the challenge of screening for trauma without the capacity to treat, also need attention. Artificial intelligence (AI)-mediated early interventions, such as using large language models to screen or provide support to trauma-exposed individuals, are exciting new avenues currently being explored.

Complementary/Integrative Preventive Interventions

Currently, there are few well-controlled studies and limited evidence to support mind-body practices like mindfulness and yoga for preventing PTSD. However, given the low risk of negative effects associated with these interventions and their potential to improve overall health and wellness, they can be considered safe supportive or additional therapies.

Sex/Gender Aspects in Preventive Interventions

While sex differences in how PTSD symptoms develop within the first year after trauma might suggest the need for sex- or gender-specific preventive interventions, there is little research on this topic. Only one study to date has examined sex or gender differences in early interventions after trauma. Among U.S. Army soldiers who received a type of psychological first aid, men attended fewer sessions than women, and lower attendance was linked to more severe symptoms. Since these findings may not apply to other populations, more research is needed to understand how men and women respond to early post-trauma interventions. Unsurprisingly, few prevention strategies specifically aim to reduce sexual violence among sexual and gender diverse (SOGD) communities, leading to calls for action in this area.

Lifespan Perspectives in Preventive Interventions

A framework has been proposed for designing, delivering, and evaluating early interventions for children. Suggested targets for early intervention included unhealthy trauma-related thoughts, excessive early avoidance, and social/interpersonal processes. Effective early interventions for children may also include preventive programs to support parenting for very vulnerable women during pregnancy and the first two years of the child's life. Parental mental health problems increase the risk for young people to develop trauma-related issues, and guidelines and initiatives for Children of Parents with Mental Illness (COPMI) offer tools for possible interventions in youth care and protection. For parents who struggle to provide emotional security in their attachment relationships with their children, the Video Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) has proven effective. In this intervention, parents receive feedback based on video recordings of their interactions with their children, aiming to improve parenting skills and prevent or reduce behavioral problems. Other potentially effective interventions for promoting attachment relationships include Parent Child Interaction Therapy (PCIT) and Child–Parent Psychotherapy (CPP).

For children who have recently experienced a stressful life event, the Watchful Waiting protocol has been developed. This protocol involves screening for post-traumatic stress symptoms at least twice during the first month after the event and, if indicated, referring the child for evidence-based treatment. For older adults, preventive interventions are a much-needed area of research, especially given the global growth of this population.

Cross-Cultural/Global Perspectives in Preventive Interventions

Task-shifting interventions for PTSD and other stress-related disorders in low- and middle-income countries (LMICs) have primarily focused on treatment, with a scarcity of randomized clinical trials (RCTs) on prevention and promotion. Universal, selective, and indicated preventive interventions could likely be delivered in community settings on a large scale by shifting tasks to primary care and community workers. A review of 113 RCTs of primary-level and/or community health worker interventions for promoting mental health or preventing mental disorders in adults and children in LMICs was recently published. This review included 30 RCTs on PTSD prevention in adults and 5 in children. It found that promotion/universal prevention interventions compared to usual care may slightly reduce distress or PTSD symptoms in adults (without risk factors for mental disorders). However, it is uncertain whether selective prevention (in adults with risk factors) or indicated preventive interventions (in adults with high vulnerability) have any effect on distress/PTSD symptoms compared to usual care. In children, promotion/universal prevention interventions may slightly reduce distress/PTSD symptoms; selective interventions probably slightly reduce distress/PTSD symptoms; while indicated prevention may slightly reduce distress/PTSD symptoms. Considering that social factors and cultural influences may contribute to the wide variability in PTSD prevention and promotion outcomes, these and other moderating effects need to be further examined in future RCTs. For example, exposure to interpersonal violence could be a social factor affecting sleep health in racially diverse and socioeconomically disadvantaged communities, which might, in turn, contribute to PTSD prevalence in these groups.

People in LMICs are also disproportionately affected by humanitarian crises. A Cochrane review on psychological interventions (focused on practical support, instilling hope, strengthening coping, and building resilience) and social interventions (focused on strengthening social support and connections) found that for children, psychosocial interventions were no more effective than control conditions (waitlist, no treatment, usual care) in reducing PTSD, depression, and anxiety symptoms at the end of the study or at the 3-month follow-up. Acceptability was similar for intervention and control groups, but information on side effects was not reported, which is a common limitation in RCTs of psychological interventions. Notably, no RCT data on PTSD promotion/prevention were available for adults affected by humanitarian crises living in LMICs. In summary, the varied quality of studies calls for more methodologically robust RCTs. Studies specifically designed to evaluate the effectiveness of prevention interventions in reducing PTSD incidence across the lifespan among people in LMICs are needed.

Treatment of Trauma-Related Disorders

Pharmacological Interventions

For the past couple of decades, the only medications approved by regulatory authorities in most countries for PTSD have been sertraline and paroxetine, both selective serotonin reuptake inhibitor (SSRI) antidepressants. A systematic review and meta-analysis of 115 studies found that SSRIs (fluoxetine, paroxetine, sertraline, venlafaxine) and the antipsychotic quetiapine, when used alone, had a small positive effect on reducing PTSD symptoms. Prazosin and risperidone showed benefits when used as additional treatments. Although effective in large trials, these medications have relatively small effects on PTSD symptom severity compared to trauma-focused therapies. This has led recent VA/DoD guidelines to recommend them only when trauma-focused therapies are unavailable. A recent systematic review indicated that clonidine looked promising for improving sleep, nightmares, and PTSD symptoms, but this evidence is based on a few low-quality studies. Another review on ketamine interventions for PTSD concluded that a placebo effect likely explains the reported benefits.

A systematic review and meta-analysis on drug-assisted psychotherapies using both traditional and new drugs to reduce PTSD symptom severity showed that methylenedioxymethamphetamine (MDMA)-assisted therapy was the only promising intervention, though based on a small number of participants. A recent Phase III trial found MDMA-assisted psychotherapy to be highly effective for individuals with severe PTSD, suggesting significant potential for those with severe PTSD and related co-occurring conditions. The Australian Therapeutic Goods Administration approved MDMA, in conjunction with psychotherapy, for PTSD treatment in 2023, under strict prescribing rules. Conversely, despite available data from two large trials, the U.S. Food and Drug Administration recently reviewed MDMA combined with psychotherapy for PTSD but did not grant approval, requesting more rigorous data.

Furthermore, identifying patients with specific molecular biomarkers can help develop treatment strategies targeting particular biological processes, thereby improving clinical care by matching individuals to the most appropriate intervention. Future research can explore whether the biological consequences of early life stress are reversible, how to prevent their effects through early therapeutic interventions, and how to identify biological factors that link early life stress with other medical conditions.

Psychological Interventions

Several established, evidence-based psychological treatments for PTSD exist, including EMDR (Eye Movement Desensitization and Reprocessing), Prolonged Exposure, Cognitive Processing Therapy, and Cognitive Therapy for PTSD. These therapies generally lead to significant reductions in PTSD symptoms. Less research is available on treatments for Complex PTSD (CPTSD), but emerging evidence suggests that established approaches may also be helpful for both adults and young people with CPTSD. While these interventions are effective for many individuals with PTSD, they do not help everyone; some people drop out of treatment early, and many continue to experience significant symptoms after treatment ends. The specific setting can influence outcomes. A review of 87 studies on patients in medical settings showed that EMDR had beneficial effects on reducing psychological and physical symptoms, though studies varied greatly in quality and had a high risk of bias. Another systematic review in refugee populations showed positive, but only short-term, effects. Therefore, it is important for future studies to focus on factors that might influence the effectiveness of specific treatments for individuals across different social and cultural contexts.

Generally, studies need to focus on populations that are currently underserved or understudied in trauma research. This includes individuals who do not respond to current evidence-based trauma treatments, or those who never receive treatment due to barriers, such as circumstances surrounding intimate partner violence that make seeking help unsafe or impossible. Understanding the reasons for treatment resistance and developing tailored interventions for these groups will be essential to ensure that advances in the field benefit all individuals affected by trauma.

Evidence-based psychological therapies for PTSD share common elements: psychoeducation, emotion regulation and coping skills, cognitive processing (restructuring thoughts and finding meaning), emotional processing, and processing trauma memories. Research suggests that similar psychological processes drive changes in PTSD symptoms across these effective therapies. Key changes include shifts in beliefs about the trauma's causes or consequences, changes in how memories are processed, and a decrease in unhelpful coping strategies like avoidance, safety behaviors, and rumination. A systematic review on PTSD treatment found that trauma-focused interventions were cost-effective, but more research was needed for medication and other treatments. Another study showed no differences in cost-effectiveness between different forms of prolonged exposure for PTSD. Trauma-focused cognitive therapy for PTSD was more cost-effective than general CBT focused on coping techniques, including exposure.

Large-scale efforts have been made in several countries to spread evidence-based PTSD treatments into regular clinical services. These efforts face various difficulties and obstacles, and sometimes lead to a decrease in overall effectiveness. Researchers emphasize the importance of high-quality training (including case supervision, not just manuals and workshops), strong organizational support, and appropriate infrastructure to sustain these dissemination efforts. The role of tracking patient outcomes in helping services and therapists develop best practice models has also been highlighted. Therapist attitudes, such as skepticism toward evidence-based interventions and overestimating the risks of exposure to trauma memories, can hinder the implementation of trauma-focused treatments. Systematic studies of factors that help or hinder the use of effective interventions are needed.

Treating Comorbidities

Treating co-occurring PTSD and Substance Use Disorder (SUD) presents a particular challenge for many clinicians. Trauma-focused integrative interventions, which combine treatments for both conditions, show the most promise for individuals with PTSD/SUD. The integration of leading PTSD treatments, such as Prolonged Exposure therapy, with cognitive-behavioral therapy for SUD, like Relapse Prevention, is especially promising. While some studies suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are viable options for individuals with comorbid PTSD/SUD, recent meta-analytic findings indicate high rates of dropout and only modest treatment effects even among the most effective evidence-based interventions. Despite significant progress in treating the complex comorbidity of PTSD/SUD, more work is needed to improve existing treatments and develop new intervention approaches. In the absence of strong evidence-based literature, expert recommendations for assessing and treating this comorbidity have recently been developed.

Another challenging clinical presentation is the co-occurrence of PTSD and sleep disorders, specifically insomnia, nightmares, or obstructive sleep apnea (OSA). Unfortunately, trauma-focused interventions do not consistently improve sleep to a clinically significant extent. More than 50% of patients whose PTSD improved after trauma-focused therapy still reported insomnia at follow-up. Importantly, lingering symptoms of insomnia, nightmares, or OSA hinder patients' response to PTSD treatment and may increase the risk of future relapse. The persistence of sleep disorders has therefore driven efforts to better target them among individuals with PTSD using new approaches, such as delivering cognitive behavioral therapy for insomnia (CBT-I) before starting Prolonged Exposure. Indeed, CBT-I, the primary treatment for insomnia, has a very large effect on reducing PTSD symptoms, and emerging evidence supports its effectiveness and the logic of integrating it with Prolonged Exposure to improve fear extinction learning. Similar effects on fear extinction have been observed after other sleep-focused interventions, such as continuous positive airway pressure (CPAP) for OSA and morning blue light treatment for stabilizing circadian rhythm.

Current evidence-based treatments for prolonged grief include cognitive behavioral therapy, as well as a manualized 16-session psychotherapy focused on loss, which has also shown effectiveness in reducing PTSD symptoms associated with bereavement. Finally, pharmacological treatments typically effective for PTSD, such as selective serotonin reuptake inhibitors (SSRIs), have not proven effective in reducing the core symptoms of Prolonged Grief Disorder (PGD). Future research on drug therapies should focus on compounds that target biological pathways involved in PGD, including pathways related to oxytocin, reward, and pain.

Digital Technologies

A major challenge for healthcare providers is to make evidence-based therapies for PTSD and related conditions widely available and accessible to those who need treatment. As various technologies have become common in daily life worldwide, research has moved towards using technology to improve access to evidence-based treatments. Technologies such as smartphones, smartwatches, and video games provide information about our behaviors (e.g., app usage, step counts, heart rate, sleep) and connect us with others to share health goals, music preferences, and more. Interventions have increasingly utilized these technologies, making it easier and more reliable to track and review data with patients during and between sessions, and even allowing for automated support between sessions. For example, during the pandemic, many providers and patients switched to remote delivery of traditional therapies, with growing evidence supporting similar outcomes for both in-person and remote delivery. Guidelines on how to adapt trauma-focused treatments for remote delivery have been published. Research has also explored how virtual reality could play a key role in delivering PTSD interventions, especially exposure to trauma reminders and feared situations.

Many therapist-assisted digital interventions have been developed, primarily to deliver the content of trauma-focused cognitive behavioral therapy (CBT). Digital approaches usually require less therapist involvement and can be accessed remotely and more flexibly by users. There is now increasing evidence that these approaches can be helpful for adults with mild to moderate symptom severity, showing large positive effects.

Future research needs to determine the optimal level of therapist guidance required for such interventions, whether these interventions can also help children and young people, and whether digital therapy can be extended to individuals with more complex conditions, such as CPTSD, PTSD/SUD, or co-occurring sleep disorders. For instance, one study found that internet-delivered cognitive therapy offered greater benefits to patients meeting CPTSD criteria compared to a comprehensive non-trauma-focused CBT program. Moreover, recent studies found that digital CBT-I delivered 3–4 years before the COVID-19 pandemic protected against traumatic stress reactions during the initial weeks of stay-at-home orders in the United States. Given the increasing recognition of the benefits of integrating digital technologies into intervention efforts, continued innovation in this area will be necessary to expand treatment and assessment possibilities further into real-world and experiential settings outside the therapy office.

Positive and Negative Effects of Social Media

Online social networking (OSN), which includes public posts on platforms like X, Facebook, WhatsApp, and Instagram, as well as private messaging, is increasingly supplementing face-to-face interactions. Several studies have highlighted the negative impacts of OSN. For example, cyberbullying has been linked to an increased likelihood of clinically significant levels of distress. Importantly, interactions through OSN can also foster positive social support. During the pandemic, private messaging strategies were found to be comparable to in-person interactions in terms of support, unlike public posting. Public posting has also allowed trauma survivors to share their experiences and connect with others. For example, social media users used hashtags like #whyIdidntreport to describe barriers to reporting sexual assault, #PuertoRicoSeLavanta to describe resilience after natural disasters, and #DomesticViolence to comment on intimate partner violence during the pandemic.

An important difference exists between those who find social media helpful and those who experience secondary traumatization, which may explain how they engage with these technologies. After Typhoon Hato, social media use that involved viewing trauma was associated with increased PTSD, whereas social media exposure focused on gathering information or viewing heroic acts decreased PTSD. A similar pattern was observed after an aircraft accident in China, where vicarious trauma was seen among individuals with high exposure to peer communication and content recommended by algorithms. Individuals who intentionally use social media for knowledge and positive connections may benefit greatly, while more passive engagement strategies might lead to increased exposure to distressing content pushed by algorithms. More research is needed to understand how public and private OSN can help individuals and communities cope with trauma.

Innovations in Treatment

An interesting development in the field over the past few years has been the growing number of studies evaluating intensive or massed trauma-focused psychological therapies. One approach that has gained significant attention is a model developed in the Netherlands, which combines adapted forms of EMDR and Prolonged Exposure delivered over an 8-day period. While this model has not yet undergone evaluation through randomized controlled trials (RCTs), several non-controlled studies published in the last 6 years suggest high rates of treatment completion and very encouraging improvements in symptoms, with many patients no longer meeting diagnostic criteria for PTSD, in both adults and adolescents. Further recent work has also explored the possibility of adapting this model for individuals with mild intellectual disabilities and their families.

For helping those with severe and treatment-resistant PTSD, an approach that has received increased attention in recent years, with emerging evidence of effectiveness, is multi-modal motion-assisted memory desensitization and reconsolidation (3MDR). 3MDR is a new therapy that involves exposure to trauma-related reminders on a large screen and taxing working memory through a dual task involving bilateral stimulation, all while the patient walks on a treadmill. Several small trials have shown that 3MDR is effective in veteran populations, including those with mild traumatic brain injury. Further work is being done to explore how this approach might be adapted for children and adolescents.

Other interesting developments in PTSD treatment, though requiring more research, include neuroscientifically guided treatments like deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS), or Deep Brain Reorienting (DBR) which targets the brainstem-level neurophysiological sequence that occurred during a traumatic event. Another innovation is Targeted Memory Reactivation (TMR), which enhances memory consolidation by presenting reminder cues during sleep.

Complementary/Integrative Interventions

Complementary and integrative health (CIH) interventions encompass various treatments, from meditative mind-body practices (like yoga and mindfulness) to music and animal-assisted therapies. Although evidence is accumulating for many of these non-pharmacological and non-psychological treatments, empirical support for their effectiveness in addressing PTSD symptoms does not yet endorse their use as first-line therapies. Evidence for CIH therapies that can enhance current evidence-based treatments is also promising but not yet firmly established. However, since CIH therapies primarily focus on improving overall health and wellbeing rather than solely reducing symptoms, they have the potential to enhance quality of life even when symptoms do not fully disappear. Furthermore, for the significant number of individuals who cannot tolerate or choose not to engage in recommended trauma-focused treatments, CIH alternatives that do not require direct confrontation of traumatic events can be offered. In recent reviews and clinical guidelines, mindfulness and yoga have emerged as recommended second-line treatments.

A recent systematic review and meta-analysis of 10 clinical trials on neurofeedback for PTSD showed beneficial effects across diverse populations, including those with different types of trauma (military and civilians) and from various ethnic backgrounds. Although more research is needed, a recent review on dance therapy found some indication that it improves both psychological and physiological symptoms associated with trauma exposure. In summary, CIH interventions may serve as an initial step to encourage engagement in other treatments, but high-quality research is needed. For future research, a holistic approach is recommended, addressing symptoms beyond PTSD, including quality of life, wellness, and physical health. Identifying mechanisms of action, as well as potential for scalability and remote delivery, should be a focus of new research.

Sex/Gender Aspects in Treatment

Women were found more likely to seek psychotherapy and showed greater treatment gains compared to men, though these differences were generally small. Sex differences in treatment effects seem to appear during adolescence. A recent review of studies in this journal over the past five years showed little impact of sex and gender on treatment outcomes. Similarly, there was no indication of sex or gender differences in dropout rates for psychological therapies.

No clear sex or gender differences have been found for pharmacological interventions either. However, women were slightly more likely than men to receive medications, including antidepressants recommended for PTSD, but also medications that should not be prescribed for PTSD, such as benzodiazepines. Future research should focus on civilian populations, as most research on sex and gender differences in treatment has been conducted in veterans.

Lifespan Perspectives in Treatment

Treatment research with children and adolescents shows strong support for cognitive-behavioral treatment strategies, even for children as young as 3–8 years old. There is also growing evidence for treatments like EMDR and Narrative Exposure Therapy. Many trauma therapies for children and adolescents have been developed, showing significant similarities in techniques and mechanisms across five evidence-based trauma therapies. Common techniques include psychoeducation, relaxation, recording critical experiences, traumatic recollection, exposure, homework, cognitive restructuring, sharing the trauma story, future perspectives, and termination. The common mechanisms cover consolidation, trauma processing, therapeutic relationship, motivation, affect modulation, reciprocal integration, and sharing. Notably, almost all identified therapeutic mechanisms were present in all five therapies.

Social functioning is critical to mental health, and understanding the important social aspects for relationships in individuals exposed to child maltreatment is a rapidly growing area of research. Additionally, therapies may focus on enhancing parent-child relationships. An example of a parent-involved approach is the Stepped Care Trauma-Focused Cognitive Behavioral Therapy, where parents are trained to deliver trauma-focused components to their children at home with minimal therapist support. Furthermore, initial evidence suggests the effectiveness of the Integrative Attachment Trauma Protocol for Children (IATP-C). This integrative treatment model combines family therapy and EMDR therapy to improve behaviors, attachments, and symptoms of traumatic stress in children affected by early abuse, neglect, and placement outside the biological home.

However, much more research is needed as child and adolescent treatment research continues to lag behind adult interventions. It will also be important to ensure that ongoing treatment research includes considerations of inclusion and equity. Interventions for older individuals with PTSD are a comparably understudied topic. In a systematic review of narrative exposure therapy (NET), older age predicted better treatment results for PTSD and depression symptoms. A review of interventions among older combat veterans showed mixed results for evidence-based interventions, including exposure-based therapies. Treatment outcomes were complicated by the range of complex medical and mental health comorbidities among older adults, highlighting the potential need for more comprehensive treatment strategies for this population. A review showed that people with PTSD and dementia can benefit from PTSD treatment, including EMDR, prolonged exposure, acceptance and commitment therapy, and pharmacological treatment. Pilot work has suggested that exercise training combined with cognitive behavioral strategies may be one such approach. Additional work in this area is needed, especially as the world's population ages, increasing the demand for PTSD treatments for older adults.

Global and Contextual Perspectives in Treatment

There are no global recommendations for evidence-based trauma treatment. For instance, the American Psychiatric Association's Clinical Practice Guideline lists four strongly recommended treatments for PTSD: Cognitive Behavioral Therapy, Cognitive Processing Therapy, Cognitive Therapy, and Prolonged Exposure. Cultural differences may require a broader range of available treatments and adaptations to these approaches. Over the past 15 years, strong evidence has emerged supporting the effectiveness and safety of empirically supported psychotherapies for PTSD in various cultural contexts. In many cases, these treatments are delivered by non-specialist health providers through task-sharing models. There is also growing evidence for the effectiveness of transdiagnostic interventions for trauma survivors in low- and middle-income countries (LMICs), addressing a range of mental and behavioral health difficulties simultaneously. While there is now a substantial base of randomized controlled trial (RCT) evidence for the effectiveness of trauma interventions across different cultural settings, there is still very limited research demonstrating that these interventions can be successfully scaled up in resource-constrained contexts. Implementing task-sharing delivery models in LMICs requires prioritizing long-term training models centered on continuous supervision by local trainers and supervisors.

Research increasingly indicates that adapting evidence-based treatments for local cultural contexts, incorporating input from local experts, can enhance the acceptability and effectiveness of trauma interventions. However, there is debate about whether superficial adaptations (such as changes to language and terminology) are enough, or whether deeper cultural adaptation (such as including culturally based explanations of illness or local healing rituals) that might alter the core components of the intervention is needed. Researchers argue that a culturally sensitive psychotraumatology is critical when implementing treatments across different contexts, but untested cultural stereotypes should not be used as an excuse for failing to provide these treatments.

Methodological Developments

Over the last 15 years, there have been numerous advancements in methodological practices within the field of psychotrauma. These include crucial innovations in data collection, such as brain imaging, genetics research, and smartphone technology. At the same time, there has been remarkable progress in our ability to analyze data, including the development of advanced statistical software and models, the application of machine learning, and greatly improved capacity to process large datasets. Recently, there has also been a push to use computational models to refine theories related to the impact of trauma.

These advanced methods show great promise in improving our ability to predict mental health outcomes after trauma and in guiding treatment selection and personalizing interventions. Crucially, artificial intelligence (AI) is expected to play a key role in significantly advancing these areas. However, the full range of possibilities and potential challenges (such as the replicability of models) of integrating AI into the traumatic stress field are not yet fully understood. Studies that explore the use of AI in a thoughtful and nuanced way are encouraged.

Moving forward, research aims to continue publishing studies that advance our understanding of psychological trauma, its impact, and its treatment. The goal is not simply to apply new methods for their own sake, but to use the best available methods to answer specific research questions. This includes traditional, proven methods, but as trauma science progresses rapidly, there will likely be an increasing number of studies based on more robust data (e.g., larger samples, longitudinal studies, combining multiple data types) and more sophisticated analyses. In line with open science principles, research is encouraged to be based on Findable, Accessible, Interoperable, and Re-usable (FAIR) research data, to make a vast number of rich, potentially reusable datasets available globally. Publishing "Data Notes," which are short, peer-reviewed articles describing a dataset stored in a repository, can further increase the visibility of data. Sharing data will enhance global collaboration and accelerate solid research output for the foreseeable future.

Traumatic Events

Experiencing traumatic events is common worldwide, affecting many people in various communities. Understanding and measuring trauma are crucial for studying its effects and for global discussions on the topic. For instance, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revised (DSM-5-TR) defines traumatic events as direct or indirect exposure to actual or threatened death, serious injury, or sexual violence. This includes witnessing such events or learning about them if they happened to close family or friends. The DSM-5-TR also covers chronic or extreme exposure to traumatic details, like what first responders or police officers might experience. The International Classification of Diseases-11th Revision (ICD-11) broadly defines trauma as "an extremely threatening or horrific event or series of events," but neither manual provides a complete list of all possible traumatic events.

The term "trauma" is now used more widely by both the public and researchers, sometimes including less severe upsetting events. This broader use can be helpful by acknowledging harmful practices like emotional abuse as potentially traumatic. However, it can also lead to labeling stressful, but not truly traumatic, experiences as pathological, expecting negative health outcomes, and fostering a victim mindset. This can make it hard for health and legal professionals to agree on what constitutes a traumatic event and the reactions that qualify for treatment or compensation. A recent analysis of common trauma measures found little agreement in how events are described and questioned in research and practice.

Criterion A for PTSD outlines the specific characteristics of a traumatic event that might lead to PTSD. There is ongoing debate about how to define and use this criterion. Researchers have identified four main views: expanding Criterion A to include more events (such as indirect exposure through social media or racial discrimination), narrowing it to exclude certain events (like all forms of indirect exposure), removing it entirely, or keeping it as it is. Future research should aim to define Criterion A in a way that considers different geographical and cultural backgrounds, helping to improve research consistency and healthcare.

The types of potentially traumatic events affecting large groups of people also change over time. The recent COVID-19 pandemic, for example, led to many studies showing that COVID-19-related events could meet the PTSD Criterion A and cause a variety of mental health issues, even in young children. Climate change is another growing global issue, linked to more frequent traumatic experiences like disasters, violence, and forced migration due to extreme weather. Climate change disproportionately affects vulnerable populations, and its mental health impacts and protective factors have been explored in recent studies.

In summary, defining trauma is complex. A person's individual interpretation of an experience might be more important than the event's objective characteristics. Modern tools like text mining can help identify post-traumatic stress reactions. Future research needs to improve how traumatic event exposure is assessed to reduce differences across common standardized trauma tools.

Trauma Exposure: Sex/Gender Aspects

The study of sex and gender effects in psychological trauma has grown. Sex refers to biological factors, such as sex assigned at birth (female, male), while gender refers to social and cultural roles (e.g., woman, non-binary). Both sex and gender influence the rates of specific types of traumatic events and their effects. For example, men are more likely to experience certain types of violence and combat. Women, on the other hand, are more likely to experience physical and sexual assault, often at a younger age, which is linked to a higher risk of PTSD. Additionally, individuals in sexual and gender diverse (SOGD) communities face a disproportionately higher risk of sexual violence compared to cisgender heterosexual people.

Many past studies have not clearly distinguished between sex and gender, and most have defined both as only male or female. While there have been improvements in recent studies, future research needs to move beyond this limited view to better understand the roles of sex and gender in the impact of traumatic events. Guidelines exist to help improve how sex and gender are assessed in research.

Trauma Exposure: Lifespan Perspectives

Children and adolescents are reporting increasingly high rates of traumatic events. Studies often show that younger individuals report more lifetime trauma exposure than older individuals, which could be due to more actual exposure, better recognition of traumatic events, or memory effects. Conversely, older adults report lower levels of exposure, which is surprising for lifetime measures. It is unclear if this is due to forgetting, cognitive decline, or reluctance to report due to stigma or shame.

Exposure to any traumatic stressor in childhood increases the risk of negative social and psychological outcomes later in life. Interpersonal traumas (intentional acts by others, such as abuse or violence) during childhood are especially linked to psychological, relationship, and physical health problems in childhood and adolescence, with effects lasting into adulthood. Experiencing multiple types of severe danger, harm, or victimization in childhood increases the likelihood and severity of PTSD symptoms and other trauma-related disorders throughout life, showing a dose-response relationship. This phenomenon is known by various terms such as cumulative trauma exposure, poly-traumatization, poly-victimization, or adverse childhood experiences (ACEs).

However, caution is needed when interpreting childhood trauma studies due to research limitations. These studies often rely on adults recalling their childhood experiences. Many standard trauma measures, including those for childhood trauma, do not ask about the frequency, intensity, or duration of events, only if an event occurred. The ACEs research has been criticized for including only 10 types of childhood adversities and for simply adding up the number of adversity types, treating each with equal impact.

Given that childhood involves significant brain development and change, it is not surprising that early stressful events strongly affect emotion regulation and stress responses later in life. These events can alter brain circuits and biochemical systems, increasing the risk for psychiatric disorders. Most studies broadly define "childhood" as extending across early life (sometimes up to age 16), which may overlook crucial developmental periods. For example, some research suggests that exposures in very early childhood (before age 3) might be particularly impactful. Children who experienced multiple forms of victimization in early childhood (birth to 6 years) were also more likely to be re-victimized in middle childhood and adolescence, though the types of victimization changed over time and had different psychological effects depending on when they occurred. Future research should take a more detailed approach to understanding the effects of traumatic stress during different stages of childhood and adolescence.

Future research on childhood trauma should also use tools that measure the frequency, intensity, and duration of events. In addition to assessing traumatic events, it is important to identify positive experiences—especially in childhood, but also across a lifetime—that build resilience and aid recovery from trauma. While abuse of older adults is common, more research is needed to understand the long-term impact of early trauma and how trauma later in life affects older adults. PTSD has been linked to faster biological aging. Additionally, cognitive decline can result from traumatic brain injury. While tools exist for childhood adversities, there isn't yet a specific tool for "Adverse Older Adult Experiences." Traumatic experiences at the end of life, such as those related to dementia, require further investigation. Identifying trauma exposure and potential PTSD in patients with cognitive decline or dementia may require special diagnostic tools and interviews.

Trauma Exposure: Global and Contextual Perspectives

Research over the past 15 years confirms that trauma exposure is common worldwide, but its frequency varies significantly across countries. These differences in prevalence might be due to historical, geopolitical, economic, and cultural factors that affect rates of intentional and unintentional injuries and other adverse events. It is clear that people in countries affected by war and conflict face a much higher risk of experiencing or witnessing traumatic events. There is also a growing understanding that in regions with fewer resources and ongoing conflict, where violence is constant, trauma might be better viewed not as a single event but as a continuous state of living without a clear "before" or "after" period.

Additionally, what is considered "traumatic" likely differs across cultures. An event seen as extremely shocking in one setting might be an accepted part of life in another. Most of the terms used in psychotraumatology come from Western, educated, industrialized, rich, and democratic (WEIRD) countries. This can lead to bias because widely used trauma screening tools often reflect Western ideas of trauma. Cross-cultural research comparing the social meanings of different events could help us better understand the varying rates of PTSD across different cultural settings. In non-Western settings, there is a lack of screening tools that cover the full range of potential traumatic events experienced there. A large global project is currently designed to map traumatic experiences within cultural contexts. Overall, more research from researchers in the global South is needed regarding the definitions and prevalence of trauma exposure.

Mental and Physical Health Consequences of Trauma Exposure

Traumatic events can lead to a wide range of mental and physical health issues beyond just PTSD. How these symptoms appear, how common they are, and how they progress depend on a person's age, developmental stage, sex/gender, sociocultural background, and broader societal influences like health disparities and systemic discrimination. Common outcomes after trauma are discussed below, focusing on sex/gender, lifespan, and global perspectives on the consequences of trauma.

Resilience

The most common response to trauma (about two-thirds of individuals) is resilience. Factors that may help differentiate between outcomes of risk and resilience include emotional functioning, such as coping flexibility, coping strategies, self-belief, optimism, and resilience beliefs. Research also suggests that the most consistent predictors of resilience are personality, financial stability, education, social support, making meaning from experiences, and positive emotions. One critique of this research is that the quality of evidence varies, and even when a factor is statistically linked to a resilient outcome, its predictive power is often small. A promising area of study is a person's ability to regulate their emotions flexibly during and after a traumatic experience. Those who are better at managing emotions might have a greater chance of resilient outcomes post-trauma. This flexible self-regulation involves three steps: being sensitive to the context, having a variety of responses, and using feedback. It is important to note that while post-traumatic resilience offers many psychological benefits, these can come at a significant cost to overall health due to the physical toll of adapting to trauma's adverse effects. Resilience may also decline later in life when protective factors are lost, and risk factors like reduced health emerge.

PTSD, Dissociative-PTSD (D-PTSD), and Complex PTSD (CPTSD)

Exposure to trauma is linked to various negative outcomes for individuals, their families, and the broader community. PTSD is the most studied negative outcome, but it is described differently across diagnostic systems. The DSM-5-TR defines PTSD by 20 symptoms in four categories: intrusion (e.g., flashbacks), avoidance, negative changes in thoughts and mood, and changes in arousal and reactivity. It also includes Dissociative-PTSD (D-PTSD), which involves PTSD symptoms along with depersonalization (feeling detached from oneself) or derealization (feeling detached from reality). This subtype has been confirmed by research, though studies on related factors have shown mixed results.

The ICD-11 defines PTSD with three symptom clusters: re-experiencing, avoidance, and heightened awareness of current threat. It also includes Complex PTSD (CPTSD), which involves PTSD symptoms plus additional issues in three areas: problems with emotional regulation, a negative self-concept, and difficulties in relationships. The differences in how PTSD, D-PTSD, and CPTSD are defined in the DSM-5 and ICD-11 have led to studies examining how these differences impact estimated rates of these conditions. These differences are found to be both quantitative (leading to different rates) and qualitative (showing only moderate agreement between classifications). In places where treatment depends on a diagnosis, these differences could mean that people receive or are denied treatment based on which classification system is used. Research also suggests that the estimated effectiveness of a treatment might be influenced by the diagnostic system chosen.

Moral Injury

Traumatic events can also lead to moral injury, which is defined as "the deep psychological distress that can arise from being exposed to various situations involving acting, failing to act, or witnessing events that go against personal or shared core beliefs or expectations." Moral injury includes both the exposure to a potentially morally injurious event and the resulting symptoms of moral distress, often involving shame, guilt, despair, and a loss of morale. Many mental health disorders, including PTSD, can also result from morally injurious events.

Over the past 15 years, research on moral injury has grown rapidly. Studies initially focused on military personnel but now include other groups, such as healthcare workers and refugees. Notably, research on treating moral injury is also advancing. Future research could explore the need for a formal diagnosis for moral injury in diagnostic systems and how it is understood in different global contexts. There is still little known about how these types of events affect physical health. For assessment, since moral injury involves both the event and its consequences, future research could use tools that measure both, like the Moral Injury and Distress Scale (MIDS).

Prolonged Grief

After many years of research showing that pathological grief reactions are distinct from PTSD, Prolonged Grief Disorder (PGD) was recently included in the ICD-11 and the DSM-5-TR as a stressor-related disorder alongside PTSD. However, the criteria differ between these classification systems. The DSM-5-TR requires PGD symptoms to last at least 12 months (6 months for children), while the ICD-11 requires only 6 months of symptoms. A recent review of 48 studies identified several characteristics that distinguish between pathological grief and PTSD, but the studies varied widely and were mostly snapshots in time. Recent data suggest that the two classifications might not describe the same clinical condition. Regardless, the recognition of PGD in international classifications has spurred research into its characteristics and treatment, especially given the global deaths from the COVID-19 pandemic.

Other (Comorbid) Mental Health Outcomes

After trauma, it is common for people to experience major depressive disorder (MDD), anxiety disorders, substance use disorders (SUD), and sleep disorders. The co-occurrence of PTSD and MDD is especially high, with studies reporting rates as high as 52%. The DSM-5 PTSD symptom cluster related to "negative alterations in cognition and mood" increases the overlap with depressive symptoms. More than 90% of individuals with PTSD report insomnia, nightmares, or both, which are increasingly recognized as interfering with emotional learning needed for PTSD recovery and treatment.

Epidemiological research indicates that SUD affects 2.2% of the global population, with higher rates in wealthier countries. Alcohol use disorder (AUD) is the most common SUD worldwide. PTSD and SUD, including AUD, frequently occur together, with estimates suggesting that about half of individuals with PTSD have also met criteria for a SUD at some point in their lives. The co-occurrence of PTSD and SUD leads to a more complex, severe, and disabling course, with poorer treatment outcomes compared to having either disorder alone. Recent research suggests a bidirectional relationship between PTSD and SUD, with PTSD having a stronger effect on future SUD than the reverse. Despite significant progress in understanding PTSD/SUD co-occurrence, more rigorous research is needed to understand the biological, psychological, and social factors that contribute to their risk and maintenance.

About a quarter of people diagnosed with PTSD also have borderline personality disorder (BPD), and vice versa. Due to overlapping symptoms, particularly with Complex PTSD, there is debate about whether BPD should be a separate diagnosis. A co-occurring personality disorder is sometimes seen as a barrier to PTSD treatment. However, a recent meta-analysis found that patients with co-occurring personality disorders were not at higher risk for dropping out of PTSD treatment, though they might benefit less from it.

Transdiagnostic Perspectives and Survivor-Centered Approaches

Given the many, often co-occurring, outcomes of trauma, researchers have called for a comprehensive screening of trauma survivors for various disorders. While recent work suggests that different disorders share some treatment targets, it is important to consider the full and complex impact of traumatic exposure.

The negative impact of trauma can vary even among people who experience the same type of event, as there is no single universal experience or reaction to trauma. For example, PTSD is very common after sexual assault, with estimated rates varying widely depending on when it is measured. However, focusing only on PTSD as a potential outcome is too narrow. It is important to consider a broader range of psychological reactions (like depression, anxiety, sleep problems, and suicidal thoughts), physical reactions (like fractures and pain), and social reactions (like isolation, stigma, and discrimination). The interactions between survivors and their social networks are also important, especially in collectivist versus individualistic cultures. A broader socio-ecological perspective can be helpful. Additionally, there is a need for more survivor-centered, culturally appropriate, and trauma-informed services after sexual assault or trauma in general. A recent review identified seven main groups of underserved sexual assault survivors: ethnic and cultural minorities, people with disabilities, those who are financially vulnerable, sexual and gender minorities, individuals with mental health conditions, those with problematic substance use, and older adults.

A study with young people in Georgia showed that a comprehensive approach has the potential to provide effective services for those at risk of mental health problems. Future research should look into screening for multiple trauma-related outcomes and whether this broader screening can improve the identification of various trauma-related issues and access to care.

Impact of Trauma on Physical Health

The body's immediate stress response after trauma involves a series of reactions in the brain and hormones that help people cope. However, the ongoing activation of these systems, as seen in PTSD, can lead to physical health problems. It is believed that problems with biological regulation might connect trauma to mental health issues, increasing the risk for both psychiatric disorders and physical illnesses.

PTSD is linked to higher rates of obesity and metabolic disorders (like type 2 diabetes), autoimmune disorders (like rheumatoid arthritis, lupus), thyroid disease, asthma, and obstructive sleep apnea (OSA). OSA, in particular, has been shown to hinder learning processes important for PTSD recovery. Studies have found that childhood trauma is associated with obesity, diabetes, cancer, high blood pressure, chronic lung disease, and increased risk of heart attack and stroke. The more types of childhood maltreatment experienced, the higher the risk for these conditions. More research is needed to understand how different types of child maltreatment relate to physical symptoms and the mechanisms connecting them.

It is often hard to tell the difference between symptoms of physical health problems like pain (e.g., social withdrawal, sleep problems, concentration issues) and difficulties related to PTSD (e.g., avoidance, heightened arousal, re-experiencing). PTSD is common in people with chronic pain, possibly due to differences in how their brains process pain. Some coping behaviors and changes in daily routines after trauma can also negatively affect health, such as weight gain, smoking, using alcohol or drugs for self-medication, fear of sleep, and social isolation.

Trauma exposure and PTSD are linked to higher rates of cardiovascular disease, including stroke, heart attack, high blood pressure, and heart failure. They are also associated with risk factors like increased carotid artery wall thickness and arterial plaque buildup. While some of these risk factors might come from lifestyle changes related to PTSD (e.g., smoking, low physical activity, poor diet and sleep), PTSD has shown an independent effect on cardiovascular risk even after accounting for these factors. The ongoing elevated stress response in PTSD (e.g., increased sympathetic arousal, inflammation) may lead to high blood pressure and blood vessel damage, ultimately increasing cardiovascular risk. Inflammatory responses linked to the stress response in PTSD are also thought to increase the risk for several other physical health problems.

Neurobiological Consequences of Trauma

Trauma exposure and PTSD are linked to changes in brain activity, brain structure, and neurotransmitter systems. There are alterations in brain function, structure, and neurotransmitter systems that overlap with a core brain circuit involved in processing threats. Studies suggest that trauma and PTSD often relate to increased activity in the amygdala (involved in emotion) and dorsomedial prefrontal cortex (PFC), and reduced activity in the ventromedial PFC when processing emotional stimuli. Large-scale analyses of brain structure data also suggest that PTSD is associated with reduced size of the hippocampus, a brain region important for memory. The amygdala, PFC, and hippocampus form a neural network crucial for healthy emotional functioning and regulating responses to threat.

Importantly, findings about brain circuitry in PTSD can vary based on several key factors. Neuroimaging studies suggest that differences in brain activity related to PTSD may depend on the type of trauma experienced. Additionally, subtypes of PTSD (such as the dissociative subtype) may show different brain patterns compared to typical PTSD patterns. More recent work also indicates that specific biological brain types may underlie different symptom paths after trauma exposure. Many biological, psychological, and social factors are likely involved in how people respond after trauma; more research is needed to create predictive risk models that combine these factors.

A systematic review reported significant differences in experiences, exposures, and environmental factors among groups worldwide. Considering unique stressors (such as discrimination or stress related to being a refugee/migrant) is crucial for understanding specific brain patterns related to PTSD. Previous stress, trauma, and environmental influences can also affect "neurophenotypes" (observable brain characteristics) and contribute to different imaging profiles.

Genetic Risk for Trauma-Related Conditions

Studies of twins in civilian and veteran populations have shown that PTSD has a moderate genetic component, with heritability ranging from 30% to 72%. In children, the risk of Acute Stress Reactions (ASRs) or PTSD being passed from parent to child was linked to both upbringing and genes. Even when accounting for shared traumatic events, the correlations for upbringing and genes were similar. The field of molecular genetic studies on PTSD has seen significant changes in the last decade, driven by large-scale collaborations and lower genotyping costs. The Psychiatric Genomics Consortia workgroup for PTSD (PGC-PTSD), formed in 2013, brings together researchers globally to uncover the genetic makeup of PTSD, a disorder with fewer genetic discoveries compared to other conditions with similar heritability. The most recent meta-analysis from this group, involving over 1.2 million individuals from various ancestries, identified nearly 100 genetic locations associated with PTSD, with 85% of these being new discoveries.

Overall genetic risk for PTSD is moderately to highly linked with other psychiatric disorders, with the strongest genetic link found between PTSD and major depressive disorder (MDD). This finding aligns with twin studies on PTSD and MDD. Recent work has also explored the molecular genetics of resilience, though these studies are still preliminary due to limited sample sizes. In addition to more available genetic data on PTSD, new statistical genetic techniques are being used to better understand the underlying genetic risk for trauma-related conditions. Finally, a meta-analysis of epigenome-wide association studies identified 11 specific DNA changes associated with PTSD that might indicate susceptibility, the impact of trauma, or the long-term effects of PTSD itself.

Trauma Consequences: Sex/Gender Aspects

PTSD rates are twice as high in women compared to men. Women also experience higher rates of co-occurring disorders like major depression, anxiety, insomnia, and nightmares after trauma. Sex differences also appear in how PTSD symptoms change over the year after trauma. While men and women showed similar patterns of resilience, recovery, chronic symptoms, and delayed onset, the recovery pattern was more common in women, and delayed onset was more common in men.

In women, biological sex hormones appear to influence the higher risk for PTSD. Women with low estrogen levels experience worse PTSD symptoms and impaired fear inhibition. In contrast, high progesterone levels seem to worsen the ability to reduce fear responses in women with PTSD but not in those without it. Sex differences in PTSD prevalence appear to emerge during adolescence. A large multi-ethnic study identified genetic risk locations that differed by sex, showing that genetic heritability estimates varied by sex. However, with larger sample sizes, this difference is no longer significant. Brain imaging studies suggest that women might have stronger activation in a specific brain area (locus coeruleus) when seeing fearful faces and lower activation in another area (dorsal anterior cingulate) during fear reduction. Additionally, elevated heart rate and certain inflammatory markers may be stronger indicators of PTSD risk in women than in men. Cognitive and behavioral responses during and after trauma have been shown to fully explain the effects of sex differences and trauma type (accidental vs. interpersonal) on PTSD symptom severity six months after the event.

There are important sex differences in heart and metabolic disease risk after trauma. For example, inflammatory markers have been linked to worse PTSD symptoms and heightened physical arousal in trauma-exposed women, but not men. Heart rate, a measure of sympathetic arousal, appears higher in women with PTSD compared to men. Furthermore, low estrogen levels are associated with worse sympathetic arousal and blood vessel function in women, with and without PTSD. More neurobiological and psychosocial research on gender-diverse populations with PTSD is needed.

Trauma Consequences: Lifespan Perspectives

Children/Adolescents: While not all trauma-exposed children and adolescents develop PTSD, prevalence estimates vary significantly depending on the study group, assessment methods, and types of events. A large review of over 70 studies estimated that about 16% of children and adolescents develop PTSD after a potentially traumatic event, which is almost twice the rate seen in adults.

Due to climate change, children (and adults) are likely to face more natural disasters. Research has explored how to prepare children for natural disasters and the mental health aspects of such events. A recent review identified several PTSD risk factors for earthquake survivors of all ages, which could help identify families at risk. Child abuse and neglect in early childhood can lead to problems beyond PTSD and internalizing symptoms, including issues with attachment, emotions, and behavior. Young people exposed to traumatic events in multiple settings and by multiple perpetrators tend to have more severe trauma-related symptoms than those who experience many incidents or ongoing exposure to a single type of adversity. The negative cumulative effects of trauma exposure can occur from a combination of two types of traumatic adversity; some types of trauma (e.g., sexual and physical abuse, neglect, domestic violence) have combined adverse effects that are greater than the sum of their individual parts. Cumulative trauma or poly-traumatization at any point in childhood puts youth at risk for various post-traumatic and psychosocial problems, but its negative impact differs depending on the specific developmental period(s) in which it occurs.

Developmental Trauma Disorder (DTD) has been developed and proven as a comprehensive framework to describe the range of trauma-related problems experienced by children and adolescents who have been repeatedly victimized and whose attachment bonds have been disrupted. These problems include difficulties with self-regulation of bodily functions, emotions, attention, behavior, relationships, and identity formation. Although not a formal diagnosis in the DSM or ICD, this developmentally focused post-traumatic syndrome in children exposed to traumatic victimization and attachment disruption has been shown to be distinct from and can occur alongside PTSD, with a unique profile of co-occurring disorders. DTD has also been shown to explain greater psychosocial impairment than PTSD alone in both initial and replication studies. DTD can therefore provide clinicians and researchers with a framework to identify victimized youth who could benefit from trauma-focused treatment but who might otherwise only be considered for treatment related to other psychiatric disorders.

Older Adults: There has been relatively little research on the prevalence of PTSD in older adults compared to other age groups. Many individuals show symptoms that do not meet the full diagnostic criteria for PTSD. Available evidence suggests that the prevalence of PTSD decreases with older age. The prevalence of PTSD among those aged 60 and older ranges from 1.9% to 9.5%. The reasons for this decrease in PTSD among older individuals are unclear. Several explanations have been suggested, including a "survivor's bias" in the general population, meaning those with PTSD may be more vulnerable to serious illness, chronic stress, and risky behaviors. Other theories suggest that PTSD might present differently in older individuals, so current diagnostic criteria may not fully capture the disorder in this age group. Examples of such differences include reduced exposure to external triggers due to physical limitations or hearing loss, which may lessen hypervigilant behavior. Additional explanations for lower PTSD prevalence in older adults include interpreting mental health concerns as physical problems and higher stigma related to mental health among older individuals. It also remains unclear why traumatized individuals who initially cope well with events may develop delayed-onset PTSD later in life. Despite the lower prevalence, a significant number of older adults have PTSD, so more work in this area is justified. Furthermore, improvements in medical care and increased awareness of mental health disorders are likely to lead to higher rates of PTSD in older individuals in the near future.

Trauma Consequences: Global and Contextual Perspectives

Symptoms of PTSD and Complex PTSD (CPTSD) are reported in various cultures, showing that both diagnoses have some validity across cultures. However, growing evidence suggests that responses to trauma vary significantly across cultural contexts, and Western diagnostic systems may not fully capture the breadth of these responses. For example, physical symptoms, social isolation, and "thinking a lot" are commonly reported among trauma survivors in low- or middle-income countries (LMICs). This highlights the importance of culturally sensitive assessment tools to accurately identify trauma survivors needing support in different cultural settings, in addition to measures based on DSM and ICD. Trauma symptom screening tools have been developed for specific cultural settings through collaboration with local experts. Additionally, the Global Psychotrauma Screen (GPS), which assesses a wide range of common traumatic stress symptoms across different cultures, has been validated in various non-Western settings.

Further consideration of differences within cultures and contexts is also needed to better understand the impact of trauma and PTSD. For example, there are considerable ethnic and racial differences in the prevalence and impact of trauma exposure, revealing important factors to consider. Specifically, Black individuals in the United States face more risk factors for developing trauma-related disorders but often report similar or lower experiences of trauma and PTSD symptoms compared to groups with fewer risk factors. This discrepancy may be partly due to the adoption of adaptive neurophysiological mechanisms to counteract the effects of stressors, which may, however, lead to more severe symptoms for those who are susceptible. Similar mechanisms may explain the "vulnerability paradox," where lower levels of PTSD have been reported in countries with higher vulnerability ratings. The lack of inclusion of ethnically and culturally diverse participants is not always considered, which can lead to bias in research findings.

Preventive Interventions

Preventive Pharmacological Interventions

Currently, there is no "morning after pill" to prevent PTSD immediately following a traumatic event. Research has not proven the effectiveness of several medications, including the beta-blocker propranolol, gabapentin, and antidepressants (SSRIs), in preventing PTSD. Some data suggest that hydrocortisone might be effective, but more rigorous research is needed. Oxytocin shows some promise in preventing PTSD, but only for individuals with high initial symptoms, as shown in later analyses. Prazosin was found effective in a small pilot study for preventing the transition from acute stress disorder (ASD) to PTSD. In summary, much more research is needed before medications can effectively prevent PTSD shortly after trauma.

Preventive Psychological Interventions

Preventive interventions after a negative event can be used at various stages of care. Delivering early interventions has the potential to stop post-traumatic stress reactions from becoming a PTSD diagnosis, whether given immediately after the trauma or in the weeks following. Such interventions are well-tolerated and effective. Traumatic events can have negative outcomes, including PTSD, that last for more than 10 years, highlighting the importance of early prevention.

Psychoeducation, which involves teaching about psychological conditions, is a common part of psychotherapy. However, stand-alone psychoeducation interventions were once controversial, especially after debates about "debriefing," but they are gaining interest again. A systematic review of 10 studies found some evidence that psychoeducation improved attitudes toward and knowledge of mental health and was generally seen as acceptable and useful. However, it did not support the routine use of brief psychoeducation alone to prevent PTSD. In low- and middle-income countries (LMICs) with limited access to mental healthcare, easy-to-use psychoeducational interventions can be an initial step in a staged care approach. A psychological first-aid intervention was shown to reduce early PTSD symptoms but did not prevent PTSD entirely.

A systematic review and meta-analysis demonstrated the effectiveness of several early psychological interventions for individuals with traumatic stress symptoms after trauma exposure, especially for those who met the diagnostic criteria for Acute Stress Disorder (ASD) or PTSD. However, there is no evidence to support universal psychological interventions for all trauma-exposed individuals, regardless of their symptoms. The strongest evidence was found for trauma-focused cognitive behavioral therapy applied as a targeted intervention for trauma survivors who show symptoms within the first few months after the trauma, aiming to prevent worsening symptoms and the development of PTSD. A smaller review of seven studies on early interventions after sexual assault showed lasting effects on PTSD severity.

After widespread trauma and disasters, there will likely be a need for interventions targeting both adults and children. First responders, medical personnel, and military service members may be at risk of developing PTSD or other symptoms due to frequent exposure to potentially traumatizing experiences in their professions. For traumatic loss, little is known about specific strategies for prevention.

We still need to learn more about which interventions to offer and for whom. For example, a study of early Eye Movement Desensitization and Reprocessing (EMDR) therapy in rape survivors did not show greater effectiveness compared to "watchful waiting" in reducing post-traumatic stress symptoms and other psychological problems. Similarly, a review of early interventions for workplace trauma did not find clear benefits for any specific intervention or suggest which was superior, though generic debriefing was associated with negative outcomes. Additionally, despite growing evidence linking sleep problems to a higher risk of PTSD, early interventions targeting sleep in the immediate aftermath of trauma to prevent PTSD are still a developing area of research. While exciting new studies aimed at promoting healthy sleep after trauma are underway, some evidence even suggests that sleep deprivation might be protective.

In summary, for early or preventive interventions, high-quality evidence is needed, which can be challenging given the nature of this research. A framework for these interventions suggests they must be based on theory, practical for delivery soon after trauma, and ready for evaluation. Ethical considerations for early intervention, such as the potential for harm and the balance between screening and treatment capacity, must be addressed. New approaches using artificial intelligence (AI), such as large language models for screening or support, are promising avenues being explored.

Complementary/Integrative Preventive Interventions

Currently, there are few well-controlled studies and limited evidence to support mind-body interventions like mindfulness and yoga for preventing PTSD. However, given the low risk of negative effects associated with these interventions and their potential to improve overall health and wellness, they can be considered safe supportive or additional therapies.

Sex/Gender Aspects in Preventive Interventions

Although differences in PTSD symptom patterns within one year after trauma may suggest a need for sex or gender-specific preventive interventions, there is little research on this topic. Only one study to date has examined sex or gender differences in early interventions after trauma. In a group of U.S. Army soldiers who received a form of psychological first aid, men attended fewer sessions than women, and lower attendance was linked to worse symptom severity. Since these findings might not apply to other populations, more research is needed to better understand how men and women respond to early post-trauma interventions. Unsurprisingly, few prevention strategies specifically aim to reduce sexual violence among sexual and gender-diverse (SOGD) communities, and calls for action in this area are growing.

Lifespan Perspectives in Preventive Interventions

A framework for designing, delivering, and evaluating early interventions for children has been proposed. Key targets for early intervention include unhelpful trauma-related thoughts, excessive early avoidance, and social/interpersonal processes. Effective early interventions for children might also include preventive programs to support vulnerable women during pregnancy and the first two years of their child's life. Mental health problems in parents increase the risk for young people to develop trauma-related issues, and guidelines and initiatives for Children of Parents with Mental Illness (COPMI) offer tools for possible interventions in youth care and protection. For parents who struggle to provide emotional security in their attachment relationships with their children, interventions like Video Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) have shown effectiveness. In this intervention, parents receive feedback based on video recordings of their interactions with their children, aiming to improve parenting skills and prevent or reduce behavioral problems. Additionally, Parent Child Interaction Therapy (PCIT) and Child–Parent Psychotherapy (CPP) are potentially effective in strengthening attachment relationships.

For children who have recently experienced a stressful life event, a "Watchful Waiting" protocol has been developed. This protocol involves screening for post-traumatic stress symptoms at least twice during the first month after the event and, if necessary, referring the child for evidence-based treatment. For older adults, preventive interventions are a much-needed area of research, especially with the global increase in this population.

Cross-Cultural/Global Perspectives in Preventive Interventions

Interventions for PTSD and other stress-related disorders in low- and middle-income countries (LMICs) that involve shifting tasks to less specialized workers have mostly focused on treatment rather than prevention. There is a lack of randomized clinical trials (RCTs) on prevention and health promotion in these settings. Universal, selective, and indicated preventive interventions can likely be delivered widely in communities by primary care workers and community health workers. A review of 113 RCTs on primary-level and community health worker interventions for promoting mental health and preventing mental disorders in adults and children in LMICs was recently published. This included 30 RCTs on PTSD prevention in adults and 5 in children.

The systematic review found that promotion/universal prevention interventions might slightly reduce distress or PTSD symptoms in adults without risk factors compared to usual care. However, it is unclear whether selective prevention (for adults with risk factors) or indicated preventive interventions (for highly vulnerable adults) have any effect on distress/PTSD symptoms compared to usual care. In children, promotion/universal prevention interventions might slightly reduce distress/PTSD symptoms; selective interventions probably slightly reduce these symptoms; and indicated prevention might slightly reduce them. Considering that social and cultural factors can cause wide variations in PTSD prevention and promotion outcomes, these and other influencing factors will need to be analyzed in future RCTs. For example, exposure to interpersonal violence could be a social factor affecting sleep health in diverse and economically disadvantaged communities, which might then contribute to PTSD prevalence in these groups.

People in LMICs are also disproportionately affected by humanitarian crises. A review of psychological interventions (focused on practical support, hope, coping, and resilience) and social interventions (focused on strengthening social support) found that for children, psychosocial interventions were no more effective than control conditions (like waiting lists or no treatment) in reducing PTSD, depression, and anxiety symptoms at the end of the study or after three months. Acceptability was similar for both intervention and control groups, but information on side effects was often not reported, a common limitation in RCTs of psychological interventions. Notably, there was no RCT data on PTSD promotion/prevention for adults affected by humanitarian crises living in LMICs.

In summary, the varying quality of studies calls for more methodologically robust RCTs. Studies specifically designed to evaluate the effectiveness of preventive interventions in reducing PTSD incidence across the lifespan among people living in LMICs are needed.

Treatment of Trauma-Related Disorders

Pharmacological Interventions

For the past couple of decades, sertraline and paroxetine, two selective serotonin reuptake inhibitor (SSRI) antidepressants, have been the medications approved by most regulatory authorities for PTSD. As part of a special issue on PTSD prevention and treatment, a systematic review and meta-analysis of 115 studies found a small positive effect of SSRIs (fluoxetine, paroxetine, sertraline, venlafaxine) and the antipsychotic quetiapine in reducing PTSD symptoms when used alone. Prazosin and risperidone showed benefit when added to other treatments. Although effective in large trials, these medications have relatively small effects on PTSD symptom severity compared to trauma-focused therapies. This has led recent guidelines to recommend them only when trauma-focused therapies are not available. A recent systematic review showed that clonidine looked promising for improving sleep, nightmares, and PTSD symptoms, but the evidence comes from a small number of low-quality studies. Another review systematically analyzed ketamine interventions for PTSD and concluded that the reported effects were likely due to a placebo response.

A systematic review and meta-analysis of drug-assisted psychotherapies for reducing PTSD symptoms showed that methylenedioxymethamphetamine (MDMA)-assisted therapy was the only promising intervention, though based on a small number of participants. A recent Phase III trial found MDMA-assisted psychotherapy to be highly effective for individuals with severe PTSD, suggesting it has significant potential for those with severe PTSD and related conditions. In 2023, the Australian Therapeutic Goods Administration approved MDMA with psychotherapy for PTSD treatment, under strict prescribing rules. However, despite existing data including two large trials, the U.S. Food and Drug Administration recently reviewed MDMA combined with psychotherapy for PTSD but did not grant approval, requesting more rigorous data.

Furthermore, identifying patients with specific molecular markers can help in developing treatment strategies that target specific biological processes, improving clinical care by matching individuals to the most suitable intervention. Future research can explore how to reverse the biological effects of early life stress, prevent its effects through early therapeutic interventions, and identify biological factors linking early life stress to other medical conditions.

Psychological Interventions

There are several well-established, evidence-based psychological treatment approaches for PTSD, including EMDR (Eye Movement Desensitization and Reprocessing), Prolonged Exposure, Cognitive Processing Therapy, and Cognitive Therapy for PTSD. These approaches typically lead to significant reductions in PTSD symptoms. While there is less research on treatments for Complex PTSD (CPTSD), emerging evidence suggests that these established approaches may also be helpful for both adults and young people with CPTSD. Although these interventions are effective for many with PTSD, they do not work for everyone; some individuals drop out of treatment early, and many continue to experience significant symptoms even after treatment. The specific setting can influence outcomes. A review of 87 studies on patients in medical settings showed EMDR had beneficial effects on psychological and physical symptoms, though studies varied widely and had a high risk of bias. Another systematic review in refugee populations showed positive short-term effects. Therefore, it is important for studies to consider factors that might affect treatment effectiveness for individuals across different sociocultural contexts.

Generally, studies need to focus on populations that are currently underserved or understudied in trauma research. This includes those who do not respond to existing evidence-based trauma treatments, or those who never receive treatment due to barriers, such as circumstances related to intimate partner violence that make seeking help unsafe or impossible. Understanding why some treatments are not effective and developing tailored interventions for these groups is crucial to ensure that advancements in the field benefit all individuals affected by trauma.

Evidence-based psychological therapies for PTSD commonly emphasize education about the disorder, emotion regulation and coping skills, cognitive processing and reframing of thoughts, and emotional and trauma memory processing. Evidence suggests that similar psychological processes drive changes in PTSD symptoms across effective therapies, particularly changes in beliefs about the trauma, how memories are processed, and a decrease in unhelpful coping strategies like avoidance and rumination. A systematic review on PTSD treatment showed that trauma-focused interventions were cost-effective, but more research was needed on medication and other treatments. Another study found no differences in cost-effectiveness between different forms of prolonged exposure for PTSD. Trauma-focused cognitive therapy for PTSD was more cost-effective than general CBT focused on teaching coping techniques.

Large-scale efforts have been made in several countries to spread evidence-based PTSD treatments into regular clinical services. These efforts face various challenges and obstacles, and sometimes lead to a decrease in overall effectiveness. The quality of training (requiring supervision beyond manuals and workshops), strong organizational support, and proper infrastructure are important for maintaining these efforts. Therapist attitudes, such as skepticism toward evidence-based interventions and overestimating the risks of exposure to trauma memories, can hinder the implementation of trauma-focused treatments. Systematic studies of factors that help or hinder the use of effective interventions are needed.

Treating Comorbidities

Treating co-occurring PTSD and substance use disorders (SUD) presents a particular challenge for many clinicians. Trauma-focused integrated interventions show the most promise for individuals with both PTSD and SUD. Approaches that combine leading PTSD treatments, like Prolonged Exposure therapy, with cognitive-behavioral therapy for SUD, such as Relapse Prevention, are especially promising. Studies have found that trauma-focused, non-trauma-focused, and structured SUD interventions are valid options for individuals with co-occurring PTSD and SUD. However, recent meta-analyses suggest high rates of individuals dropping out and only modest treatment effects even with the most effective evidence-based interventions, including integrated trauma-focused approaches. While significant progress has been made in treating the complex co-occurrence of PTSD and SUD, more work is needed to improve existing treatments and develop new intervention methods. In the absence of strong evidence-based research, expert recommendations for assessing and treating this co-occurrence have recently been developed.

Another difficult clinical presentation is the co-occurrence of PTSD and sleep disorders, specifically insomnia, nightmares, or obstructive sleep apnea (OSA). Unfortunately, trauma-focused interventions do not consistently improve sleep to a significant clinical degree; more than 50% of patients whose PTSD improved after trauma-focused therapy still reported insomnia at follow-up. Importantly, remaining symptoms of insomnia, nightmares, or OSA hinder patients' response to PTSD treatment and may increase the risk of future relapse. The persistence of sleep disorders has spurred efforts to better target them among individuals with PTSD using new approaches, such as delivering cognitive behavioral therapy for insomnia (CBT-I) before starting Prolonged Exposure therapy. Indeed, CBT-I, the primary treatment for insomnia, has very large effects on reducing PTSD symptoms, and emerging evidence supports integrating it with Prolonged Exposure to help with fear extinction learning. Similar effects on fear extinction have been observed after other sleep-focused interventions like continuous positive airway pressure (CPAP) for OSA and morning blue light treatment for stabilizing circadian rhythms.

Current evidence-based treatments for prolonged grief include cognitive behavioral therapy, as well as a 16-session structured loss-focused psychotherapy, which has also shown effectiveness for PTSD symptoms related to bereavement. Finally, medications typically effective for PTSD, such as selective serotonin reuptake inhibitors (SSRIs), have not proven effective in reducing the core symptoms of prolonged grief disorder (PGD). Future research on drug treatments should focus on compounds that target biological pathways involved in PGD, including pathways related to oxytocin, reward, and pain.

Digital Technologies

A significant challenge for healthcare providers is to make evidence-based therapies for PTSD and related conditions widely available and accessible. As technology has become a pervasive part of daily life, research has focused on using it to improve access to effective treatments. Technologies like smartphones, smartwatches, and video games provide information about behaviors (e.g., app usage, step counts, heart rate, sleep) and connect people with their networks. Interventions have increasingly used these technologies, making it easier to track and review data with patients between sessions, and even allowing automated support. For example, during the pandemic, many providers and patients shifted to remote delivery of traditional therapies, with growing evidence suggesting similar outcomes for both in-person and remote treatment. Guidelines on how to adapt trauma-focused treatments for remote delivery were published. Research has also explored how virtual reality can play a key role in PTSD interventions, especially for exposure to trauma reminders and feared situations.

Several therapist-assisted digital interventions have been developed, mostly to deliver the content of trauma-focused CBT. Digital approaches typically require less therapist involvement and can be accessed remotely and more flexibly. There is increasing evidence that such approaches can be helpful for adults with mild to moderate symptom severity, showing significant positive effects. Future research needs to determine the ideal amount of therapist guidance for these interventions, whether they can also help children and young people, and if digital therapy can be extended to those with more complex issues, such as individuals with CPTSD, PTSD/SUD, or co-occurring sleep disorders. For instance, studies found greater benefits for internet-delivered cognitive therapy compared to a comprehensive non-trauma-focused CBT program for patients meeting CPTSD criteria. Moreover, recent studies found that digital CBT-I delivered years before the COVID-19 pandemic protected against traumatic stress reactions during the initial lockdown in the United States. Given the growing recognition of the benefits of integrating digital technologies into intervention efforts, continued innovation in this area is necessary, extending treatment and assessment possibilities further into real-world and experiential settings outside the therapy office.

Positive and Negative Effects of Social Media

Online social networking (OSN), including public platforms and private messaging, increasingly supplements face-to-face interactions. Several studies have highlighted the negative impact of OSN. For instance, cyberbullying has been linked to a higher likelihood of experiencing clinically significant levels of distress. Importantly, interactions through OSN can also provide positive social support. During the pandemic, private messaging strategies were found to be comparable to in-person interactions, unlike public posting. Public posting has also allowed trauma survivors to share their experiences. For example, social media users used hashtags like #whyIdidntreport to describe barriers to reporting sexual assault, #PuertoRicoSeLavanta to show resilience after natural disasters, and #DomesticViolence to comment on intimate partner violence during the pandemic.

An important difference between those who find social media helpful and those who experience secondary traumatization may explain how they engage with these technologies. Following Typhoon Hato, social media use involving viewing trauma was linked to increased PTSD, whereas exposure focused on gathering information or viewing heroic acts decreased PTSD. A similar pattern was observed after an aircraft accident in China, where indirect trauma was seen among individuals with high exposure to peer communication and algorithmic content recommendations. People who intentionally use social media for knowledge and positive connections may benefit greatly, while more passive engagement strategies might lead to increased exposure to distressing content pushed by algorithms. More research is needed to understand how public and private OSN can help individuals and communities cope with trauma.

Innovations in Treatment

An interesting development in the field over the past few years has been the growing number of studies evaluating intensive or concentrated trauma-focused psychological therapies. One approach that has gained significant attention is a model developed in the Netherlands, combining adapted forms of EMDR and Prolonged Exposure, delivered over an 8-day period. While this model has not yet been fully evaluated through randomized controlled trials (RCTs), several non-controlled studies have been published in the last six years. These studies suggest high rates of treatment completion and very encouraging improvements in symptoms, as well as loss of a PTSD diagnosis for both adults and adolescents. Further recent work has also explored adapting this model for people with mild intellectual disabilities and their families.

For those with severe and treatment-resistant PTSD, an approach gaining attention and showing emerging evidence of effectiveness is multi-modal motion-assisted memory desensitization and reconsolidation (3MDR). 3MDR is a new therapy that involves exposure to trauma-related reminders on a large screen and engaging working memory through a dual task involving bilateral stimulation, all while the patient walks on a treadmill. Several small trials have shown the effectiveness of 3MDR in veteran populations, including those with mild traumatic brain injury. Further work is being done to see how this approach might be adapted for children and adolescents.

Other interesting developments in PTSD treatment, though requiring more research, include neuroscientifically guided treatments such as deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS). Another approach is Deep Brain Reorienting (DBR), which targets brainstem-level physiological responses that occurred during a traumatic event. Targeted Memory Reactivation (TMR) is also being explored, which enhances memory consolidation by presenting reminder cues during sleep.

Complementary/Integrative Interventions

The group of complementary and integrative health (CIH) interventions includes various treatments, from meditative mind-body practices (like yoga, mindfulness) to music and animal-assisted therapies. While evidence is accumulating for many of these non-pharmacological and non-psychological treatments, empirical support for their effectiveness in addressing PTSD symptoms does not yet support their use as primary therapies. Evidence for CIH therapies that can enhance current evidence-based treatments is also promising but not yet fully established. However, since CIH therapies primarily focus on improving overall health and well-being rather than just reducing symptoms, they have the potential to enhance quality of life even when symptoms do not fully disappear. Furthermore, for the many individuals who cannot tolerate or choose not to engage in recommended trauma-focused treatments, CIH alternatives that do not require direct confrontation of traumatic events can be offered. In recent reviews and clinical guidelines, mindfulness and yoga have been suggested as second-line treatments.

A recent systematic review and meta-analysis of 10 clinical trials on neurofeedback for PTSD showed beneficial effects across different populations, including those with various types of trauma (military and civilians) and from different ethnic backgrounds. Although more research is needed, a recent review on dance therapy found some indication that it improved both psychological and physiological symptoms associated with trauma exposure.

In summary, CIH interventions may serve as an initial step to encourage engagement in other treatments, but high-quality research is needed. For future research, a holistic approach is recommended, addressing symptoms beyond PTSD, including quality of life, wellness, and physical health. Identifying how these interventions work, their scalability, and their potential for remote delivery may need to be the focus of new research.

Sex/Gender Aspects in Treatment

Women were found more likely to seek psychotherapy and made stronger treatment gains compared to men, though differences were generally small. Sex differences in treatment effects seem to appear during adolescence. A recent review of studies in the past five years showed little impact of sex and gender on treatment outcomes. There was also no indication of sex or gender differences in dropping out of psychological therapies. Similarly, no clear sex or gender differences have been found for drug treatments. However, women were found to be slightly more likely than men to receive medication, including antidepressants recommended for PTSD, but also medications that should not be prescribed for PTSD, such as benzodiazepines. Future research should focus on civilian samples, as most research on sex and gender treatment differences has been done in veterans.

Lifespan Perspectives in Treatment

Treatment research with children and adolescents has shown strong support for cognitive-behavioral treatment strategies, including for children as young as 3–8 years. There is also growing evidence supporting treatments like EMDR and Narrative Exposure Therapy. Numerous trauma therapies for children and adolescents have been developed, showing many common techniques and mechanisms across five evidence-based trauma therapies (Trauma-Focused Cognitive Behavioral Therapy; EMDR; KIDNET; Prolonged Exposure therapy for adolescents; Teaching Recovery Techniques). Common techniques include psychoeducation, relaxation, recording critical experiences, traumatic recollection, exposure, homework, cognitive restructuring, sharing the trauma story, future perspectives, and termination. The common mechanisms cover consolidation, trauma processing, therapeutic relationship, motivation, affect modulation, reciprocal integration, and sharing. Notably, almost all of these identified therapeutic mechanisms were considered present in all five therapies.

Social functioning is crucial for mental health, and understanding these social aspects important for relationships in individuals exposed to child maltreatment is a rapidly growing area of research. Additionally, therapies may focus on improving parent-child relationships. An example of an approach that involves parents is Stepped Care Trauma-Focused Cognitive Behavioral Therapy, where parents are trained to deliver trauma-focused components to their children at home with minimal therapist support. Furthermore, there are initial indications of evidence for the Integrative Attachment Trauma Protocol for Children (IATP-C): an integrative treatment model combining family therapy and EMDR therapy to improve behaviors, attachments, and symptoms of traumatic stress in children affected by early abuse, neglect, and placement outside the biological home.

However, much more research is needed as research in child and adolescent treatments continues to lag behind adult interventions. Moreover, it will be important to ensure that ongoing treatment research includes considerations of inclusivity and fairness. Interventions for older individuals with PTSD are a comparatively understudied topic. In a systematic review of narrative exposure therapy (NET), older age predicted better treatment results for PTSD and depression symptoms. A review of interventions among older combat veterans showed mixed results for evidence-based interventions, including exposure-based therapies. Treatment outcomes were complicated by the range of complex medical and mental health comorbidities among older adults, highlighting the potential need for more comprehensive treatment strategies for this population. A review showed that people with PTSD and dementia can benefit from PTSD treatment, including EMDR, prolonged exposure, acceptance and commitment therapy, and medication. Pilot work has suggested that exercise training combined with cognitive behavioral strategies may be one such approach. Additional work in this area is needed, especially as the world's population ages and there is a greater need for PTSD treatments for older adults.

Global and Contextual Perspectives in Treatment

There are no universal recommendations for evidence-based treatment. For example, the American Psychiatric Association's Clinical Practice Guideline strongly recommends four treatments for PTSD: Cognitive Behavioral Therapy, Cognitive Processing Therapy, Cognitive Therapy, and Prolonged Exposure. Cultural differences may require a broader range of available treatments and adaptations to these approaches.

Over the past 15 years, strong evidence has emerged supporting the effectiveness and safety of empirically supported psychotherapies for PTSD in various cultural contexts. In many cases, these treatments are delivered by non-specialist health providers through task-sharing models. There is also growing evidence for the effectiveness of broad interventions for trauma survivors in low- and middle-income countries (LMICs), which address multiple mental and behavioral health difficulties simultaneously. While there is now substantial evidence from randomized controlled trials (RCTs) for the effectiveness of trauma interventions in different cultural settings, there is still very limited research showing that these interventions can be successfully expanded in resource-limited contexts. Implementing task-sharing delivery models in LMICs requires prioritizing long-term training models centered on continuous supervision by local trainers and supervisors.

Research increasingly suggests that adapting evidence-based treatments for local cultural contexts, with input from local experts, can improve the acceptability and effectiveness of trauma interventions. However, there is debate about whether superficial adaptations (like changes to language) are enough, or if deeper cultural adaptations (like including culturally based explanations of illness or local healing rituals) are needed, which might alter the core components of the intervention. Experts argue that a culturally sensitive approach to psychological trauma is critical when implementing treatments across different contexts, but untested stereotypes about culture should not be used as an excuse for failing to provide these treatments.

Methodological Developments

A final note on advancements in research methods in the field of psychological trauma over the last 15 years and what is expected in the future. There have been countless improvements in research practices, as shown by studies published in EJPT since its beginning. These include key innovations in collecting data, such as brain imaging, genetics research, and smartphone technology, among others. At the same time, there has been unmatched progress in the ability to analyze data, including the development of advanced statistical software and models, the use of machine learning, and greatly improved capacity to process large datasets. Recently, there has also been a push to use computational models to refine theories related to the impact of trauma.

These advanced methods show great promise in improving the ability to predict mental health outcomes after trauma and in guiding treatment choices and personalizing interventions. Crucially, it is clear that artificial intelligence (AI) will play a key role in significantly advancing all of these areas. However, the full range of possibilities, as well as potential problems (for example, related to whether models can be repeated), of integrating AI into the traumatic stress field are not yet fully understood. Studies that explore the use of AI in a thoughtful and nuanced way are welcome.

Going forward, EJPT aims to continue publishing studies that enhance the understanding of psychological trauma, its impact, and its treatment. The goal is not simply to publish papers that apply new methods for their own sake. Instead, the journal seeks studies that use the best available methods to answer specific research questions. This includes traditional and proven methods, but as the science of trauma continues to evolve rapidly, the expectation is to increasingly publish studies based on more robust data (meaning larger samples, long-term studies, combining multiple types of data) and with more sophisticated analyses. In line with Open Science principles, the hope is to see research increasingly based on Findable, Accessible, Interoperable, and Re-usable (FAIR) research data, to make a vast number of rich, potentially reusable datasets available globally. Consider publishing "Data Notes," which are short, peer-reviewed articles describing a dataset stored in a repository, to make the dataset even more visible. Sharing data will enhance global collaboration and accelerate strong research output, at least for the next 15 years.

1. Bad Events

1.1. What is Trauma?

Many people around the world experience bad events that can cause deep hurt. Doctors and experts study these events to understand how they affect people.

One main guide, the DSM-5-TR, says a bad event is when someone sees or is part of actual or feared death, serious harm, or abuse. This also includes learning about terrible things that happened to close family or friends. Some jobs, like police officers, may see many bad events through their work. The ICD-11 guide simply calls trauma an "extremely scary or terrible event."

However, these guides do not list every kind of bad event. Also, people now use the word "trauma" more often, even for things that are not as severe. This can be good because it helps people see that things like emotional abuse are hurtful. But it can also mean that everyday stress is sometimes called trauma, which might make people feel like victims. It is sometimes hard for doctors and other helpers to agree on what counts as a traumatic event and what kind of help someone should get.

It is important to look at how we define these bad events. What one person or culture sees as deeply upsetting might be seen differently by another. Experts believe we need more study on how to best define these events for different people and places.

Times change, and so do the kinds of bad events people face. For example, the COVID-19 sickness caused many bad experiences that led to mental health problems, even for young children. Also, changes in the weather are causing more natural disasters, like storms and floods, which lead to more trauma. These problems affect some people more than others, especially those who are already struggling.

In short, it is not easy to define trauma. How a person feels about an event might be more important than what the event actually was. We need more research to better understand and measure how people are affected by bad events.

1.2. Trauma and Sex/Gender

Scientists are looking more at how being a man or woman (sex) and how society sees men and women (gender) affect traumatic events.

Both sex and gender can change what kind of bad events people face. For example, men may be more likely to experience war. Women may be more likely to experience physical and sexual attacks, often at a younger age. These types of events can make it more likely to get PTSD. Also, people who do not fit into usual ideas of male or female sex or gender may be more likely to experience sexual violence.

In the past, many studies did not clearly say if they were looking at sex or gender, and often only thought there were two choices (male or female). To better understand how sex and gender affect trauma, future studies should look beyond these two simple ideas.

1.3. Trauma Over a Lifetime

Children and young people are saying they have experienced more bad events. It seems that younger people report more lifetime trauma than older people. We need to find out why this is. Maybe younger people are really experiencing more, or they just recognize more events as traumatic, or maybe older people simply forget some events. Older adults report fewer bad events, which is strange for something that happened over a whole lifetime. This could be due to forgetting, memory problems, or not wanting to talk about it due to shame.

When children experience any type of very stressful event, it can lead to problems later in life, like mental health issues or trouble getting along with others. Bad things done by other people, like abuse or family fights, are especially harmful to children. These can cause lasting problems into adulthood. When a child experiences many different types of bad events, it can make trauma symptoms worse. This is sometimes called "cumulative trauma" or "adverse childhood experiences" (ACEs).

But we need to be careful when studying childhood trauma. Often, grown-ups try to remember things from their childhood, which can be hard. Also, many tests for trauma do not ask how often or how bad an event was, just if it happened. The ACEs list, for example, only includes 10 types of bad experiences and assumes they all hurt the same amount.

When children are young, their brains are still growing. Stressful events can change how their brains handle feelings and stress later on. This can raise the chance of mental health problems. Most studies group all of "childhood" together, but it is important to look at different ages, like very young children (before age 3). Bad events at different ages can cause different problems.

Future studies should ask how often, how bad, and how long bad events lasted. It is also important to look at good things that happened, especially in childhood, that help people bounce back from trauma.

Older adults also experience abuse, but we do not know enough about how early trauma affects them later in life, or how new trauma affects older adults. Trauma can make the body age faster. Memory problems can also come from head injuries. We have tools to look at bad childhood experiences, but not yet for bad experiences in older adults. We need special ways to find and help older adults with trauma, especially those with memory loss.

1.4. Trauma Around the World

For the last 15 years, we have learned that bad events happen everywhere, but how often they happen changes from country to country. These differences can be due to history, politics, money, and culture, which affect how many harmful things happen.

It is clear that people living in countries with war are much more likely to see or experience bad events. Also, in poor countries or war zones where violence is always happening, trauma may not be a single event, but a constant way of life. It is also likely that what counts as a "traumatic" event can change based on culture. What is very shocking in one place might be a normal part of life in another. Most of the words and ideas about trauma come from rich, Western countries. This means our current ways of checking for trauma might miss things that are important in other cultures. We need more studies that compare the meaning of different events across cultures to truly understand trauma worldwide.

2. Ways Trauma Affects Health

Bad events can cause many different health problems, not just PTSD. How these problems look, how often they happen, and how long they last can change based on a person's age, sex/gender, culture, and how society treats them. We will talk about common problems after trauma and how sex, gender, age, and culture play a part.

2.1. Bouncing Back

Most people (about two-thirds) bounce back well after trauma. How well someone handles their feelings, their ways of coping, how much they believe in themselves, their hopeful outlook, and their beliefs about getting better can all help them bounce back. Being a certain type of person, having enough money, being educated, having support from others, finding meaning in life, and feeling good emotions are also things that help people recover.

But some experts say that even when these things help, they do not always predict who will bounce back. It might be better to look at how good a person is at managing their feelings during and after a bad event. People who are better at handling their feelings may have an easier time recovering.

It is important to know that even when people bounce back, it can take a toll on their body due to the stress of dealing with the trauma. This ability to bounce back might also get weaker as people get older, especially if they lose support or their health declines.

2.2. PTSD and Similar Problems

Having a bad event happen can lead to many negative effects for people who experience it, their families, and their communities. PTSD (Post-Traumatic Stress Disorder) is the most studied problem. Different health guides describe PTSD in slightly different ways.

The DSM-5-TR guide lists 20 symptoms for PTSD. These symptoms fall into four groups: reliving the event, avoiding things that remind one of the event, negative changes in thoughts and feelings, and feeling keyed up or jumpy. This guide also includes a type of PTSD called Dissociative-PTSD, where people also feel disconnected from themselves or their surroundings.

The ICD-11 guide describes PTSD with three groups of symptoms: reliving the event, avoiding things related to it, and feeling like danger is still present. This guide also includes Complex PTSD (CPTSD), which has the regular PTSD symptoms plus extra problems with managing feelings, negative self-image, and trouble with relationships.

Because these guides describe PTSD and similar conditions in different ways, studies have looked at how this changes how many people are thought to have these problems. It has been found that the differences affect both the number of cases and how the problems are described. This means that depending on which guide is used, people might get different diagnoses and, as a result, different treatment or help.

2.3. Moral Injury

Bad events can also cause moral injury. This is a deep sadness or hurt that comes from doing, not doing, or seeing things that go against a person's deep beliefs about what is right or wrong. Moral injury often leads to feelings of shame, guilt, and hopelessness. It can also cause other mental health problems, including PTSD.

In the last 15 years, there has been a lot more study on moral injury. It first focused on soldiers, but now includes other groups like healthcare workers and refugees. We are also learning more about how to help with moral injury.

Future studies might look at if moral injury should be an official diagnosis. We also need to understand moral injury better in different parts of the world and how it affects physical health. When checking for moral injury, it is important to ask about both the bad event itself and the feelings it caused.

2.4. Long-Lasting Sadness

After many years of study, a problem called Prolonged Grief Disorder (PGD) has been added to health guides like the ICD-11 and DSM-5-TR. It is now seen as a separate condition, but also related to PTSD. However, the rules for PGD are different in each guide. For example, the DSM-5-TR says symptoms must last at least 12 months, but the ICD-11 says 6 months.

Recent studies show that the two guides might not be talking about the exact same problem. Still, making PGD an official condition has led to more research on what it looks like and how to treat it. This is especially important after the many deaths from the COVID-19 sickness.

2.5. Other Mental Health Problems

After trauma, it is common for people to also have deep sadness (depression), anxiety, problems with alcohol or drugs, and sleep problems.

Depression and PTSD often go hand-in-hand. Many people with PTSD also have depression. PTSD symptoms like negative changes in thoughts and feelings can make it seem like depression. Also, most people with PTSD have trouble sleeping or have bad dreams. These sleep problems can make it harder to get better from PTSD.

Problems with alcohol and drugs are also common after trauma. About half of people with PTSD will also have problems with alcohol or drugs at some point. Having both PTSD and drug or alcohol problems makes things harder and treatment less effective. Studies show that PTSD can lead to drug or alcohol problems, and less often, drug or alcohol problems lead to PTSD. We need more research to understand why these problems often happen together and how to best treat them.

About one-fourth of people with PTSD also have borderline personality disorder. Because some of the symptoms are similar to Complex PTSD, some wonder if borderline personality disorder is truly a separate problem. Having a personality disorder might make it seem harder to treat PTSD, but studies show that people with both are not more likely to quit PTSD treatment. They might just get less benefit from it.

2.6. Looking at All Problems Together

Because trauma can cause many different problems that often happen at the same time, experts say we should screen for all possible problems when helping trauma survivors. While many problems may share similar treatment goals, it is important to understand how trauma affects a person in many complex ways.

There is no one way trauma affects everyone, even after the same type of event. For example, after sexual assault, PTSD is common, but its rates can vary a lot. It is too simple to only look at PTSD. It is important to also look at other problems like depression, anxiety, sleep issues, thoughts of self-harm, physical pain, and social problems like feeling alone or being treated unfairly. This is especially true in cultures where people are more focused on the group rather than just themselves. Taking into account a person's whole life and community can be very helpful.

Also, we need more services that focus on the person, understand trauma, and are right for different cultures, especially after sexual assault. Some groups of people, like those from different ethnic backgrounds, those with disabilities, those without much money, those who are gay or transgender, and older people, often do not get the help they need.

One study with young people showed that looking at all problems together can help people at risk of mental health issues. Future studies should look at how screening for all kinds of trauma-related problems can help more people get the right care.

2.7. Trauma and Physical Health

When a bad event happens, the body's stress systems kick in. If these systems stay active for a long time, like with PTSD, it can lead to physical health problems. Some believe that changes in the body due to trauma can lead to both mental and physical sickness.

People with PTSD are more likely to be overweight and have problems like type 2 diabetes. They may also have immune system problems (like arthritis), thyroid issues, asthma, and sleep apnea (a breathing problem during sleep). Sleep apnea can make it harder to learn to not be afraid. Studies show that childhood trauma is linked to being overweight, diabetes, cancer, high blood pressure, and heart problems. The more types of harm a child faced, the higher the risk for these problems. We need to learn more about how different types of childhood harm are linked to body problems.

It is often hard to tell the difference between symptoms of physical pain (like feeling lonely, sleep problems, or trouble focusing) and symptoms of PTSD (like avoiding things, being jumpy, or reliving the event). PTSD is common in people with long-term pain. Some ways people cope after trauma, like gaining weight, smoking, drinking too much, or isolating themselves, can also hurt their health.

Trauma and PTSD are linked to more heart problems like stroke, heart attack, and high blood pressure. While some of these problems come from unhealthy behaviors linked to PTSD (like smoking or bad diet), PTSD itself seems to raise heart risk even after accounting for these behaviors. This may be because the body's stress response stays high in PTSD, leading to high blood pressure and damage to blood vessels. The body's stress response also causes swelling inside the body, which can lead to other health problems.

2.8. Brain Changes from Trauma

Trauma and PTSD can change how the brain works, its shape, and its chemical signals. There are changes in brain parts and chemicals that are involved in how we handle threats. Studies show that people with trauma and PTSD may have parts of the brain that react too much to upsetting things, while other parts react too little. Also, a part of the brain important for memory, the hippocampus, may shrink. These brain areas are key for handling emotions and stress.

It is important to know that brain changes in PTSD can vary. Different types of trauma can affect the brain differently. Also, certain kinds of PTSD, like the dissociative type, might show different brain patterns. Newer studies suggest that different types of brain changes might explain different ways people react after trauma. Many things, both body and mind, play a role in how someone reacts to trauma. More research is needed to predict who will be affected and how.

Different experiences, like being treated unfairly or being a refugee, can create unique brain patterns related to PTSD. Also, past stress, trauma, and surroundings can change how the brain looks and works.

2.9. Genetic Risk for Trauma Problems

Studies of twins show that PTSD can be passed down in families, with genes playing a role in 30% to 72% of cases. In children, how parents raise them and their genes both seem to affect their risk for trauma reactions or PTSD.

In the last 10 years, we have learned much more about the genes linked to PTSD. A large group of researchers from around the world found nearly 100 gene spots linked to PTSD. The genes for PTSD are often linked to genes for other mental health problems, especially depression.

New studies are also looking at the genes for "bouncing back" after trauma, but this research is still new. Newer ways of studying genes are helping us understand the hidden genetic risks for trauma-related problems. Also, studies are finding changes in how genes work, which may show who is more likely to get PTSD, how trauma affects them, or the lasting effects of PTSD.

2.10. Trauma Effects: Sex/Gender Aspects

PTSD happens twice as often in women as in men. Women also have higher rates of other problems after trauma, like depression, anxiety, trouble sleeping, and bad dreams. In the first year after trauma, men and women show different patterns of PTSD symptoms. Both sexes can bounce back, recover, have long-lasting symptoms, or have delayed symptoms, but women are more likely to recover, and men are more likely to have delayed symptoms.

In women, body hormones like estrogen seem to play a part in the higher risk for PTSD. Women with low estrogen often have worse PTSD symptoms and trouble getting rid of fear. On the other hand, high progesterone levels might make it harder for women with PTSD to overcome fear. Sex differences in PTSD rates seem to start in the teenage years.

One large study found different genes linked to PTSD in men and women. But with more people in the study, these differences were not as strong. Brain studies show women may react more strongly to scary faces and have less activity in certain brain areas when trying to get rid of fear. Also, a faster heartbeat and certain chemicals in the body might be better signs of PTSD risk in women than in men. How people think and act during and after trauma seems to explain why there are sex differences in PTSD symptoms.

There are also important sex differences in heart and body problems after trauma. For example, certain chemicals linked to swelling in the body are connected to worse PTSD symptoms and being keyed up in women, but not in men. A faster heartbeat also seems higher in women with PTSD. Low estrogen in women is linked to a faster heartbeat and unhealthy blood vessels, with or without PTSD. We need more research on how trauma affects people of all genders.

2.11. Trauma Effects Over a Lifetime

Children/Adolescents – It is clear that not all children and teenagers who experience trauma get PTSD. However, about 16% of children and teenagers develop PTSD after a bad event, which is almost twice the rate seen in adults. This depends on the study, how it was done, and the type of event.

With climate change, children (and adults) are likely to face more natural disasters. There are ways to help prepare children for these events and deal with their mental health impact. A recent study found risk factors for PTSD in earthquake survivors of all ages, which can help find families who need help.

Child abuse or neglect can lead to problems beyond PTSD, such as attachment issues and problems with emotions and behavior. Children who experience trauma in many different places or from many different people often have worse trauma symptoms than those who face one type of bad event often. The more types of bad events a child experiences (like abuse, neglect, or violence at home), the more likely they are to have PTSD and other problems. This is sometimes called "cumulative trauma." The impact of these multiple traumas changes depending on the child's age when they happen.

A new idea called Developmental Trauma Disorder (DTD) has been created to describe the many problems that children who have experienced a lot of trauma may have. These problems include trouble controlling their body, emotions, attention, behavior, relationships, and sense of self. Even though DTD is not an official diagnosis in major health guides, it helps doctors and researchers understand that children who have experienced many traumas and have attachment problems may have different needs than those with just PTSD. DTD can help identify young people who need trauma-focused treatment but might otherwise only be treated for other mental health problems.

However, we need much more research on treating children and teenagers because it is not as far along as adult treatments. Also, it is important to make sure these studies include many different kinds of people and are fair to everyone.

Older Adults – Not many studies have looked at PTSD in older adults compared to younger groups. Many older people have some PTSD symptoms but not enough to be officially diagnosed. The information we have suggests that PTSD becomes less common as people get older. This might be because people with PTSD are more likely to get sick or have risky behaviors, so fewer of them live to old age.

Some experts also think that PTSD might look different in older people, so current tests might not catch it. For example, older adults might not be exposed to as many things that trigger their memories due to limited movement or hearing loss. Other reasons for lower rates in older adults could be that they see mental health problems as physical issues, or they feel more shame about mental health. It is also unclear why some people who coped well with trauma when it happened develop PTSD later in life.

Even though PTSD is less common in older adults, many still have it, so more study is needed. Also, as people live longer and mental health awareness grows, we will likely see more older adults with PTSD in the future.

2.12. Trauma Effects: Global and Cultural Views

PTSD and CPTSD symptoms are seen in many cultures, meaning these problems exist in different parts of the world. But there is growing proof that people react to trauma in very different ways depending on their culture. The Western ways of diagnosing trauma may not cover all of these reactions. For example, in poorer countries, people often report body pains, social isolation, and "thinking a lot" after trauma. This shows that we need assessment tools that understand different cultures, along with the main health guides, to find people who need help. Some screening tools have been made for specific cultures with the help of local people. There is also a global tool (GPS) that checks for many different trauma symptoms that are common across cultures, and it has worked well in many non-Western places.

We also need to look closer at differences within cultures to better understand trauma and PTSD. For example, Black people in the United States often face more risks for trauma-related problems, but they sometimes report the same or fewer trauma and PTSD symptoms compared to groups with less risk. This might be because they have developed strong ways to cope with stress, but this coping can sometimes lead to more severe symptoms for those who are sensitive. A similar pattern, called the "vulnerability paradox," has been seen in countries with higher risks, where people report less PTSD. Studies need to include people from many different backgrounds to avoid skewed results.

3. Stopping Problems Before They Start

3.1. Medicines to Prevent Trauma

Right now, there is no "morning after pill" to stop PTSD after a bad event. Studies have shown that many medicines, like certain blood pressure pills, nerve pain pills, and antidepressants, do not work to prevent PTSD. Some studies suggest a medicine called hydrocortisone might help, but more strong research is needed. A hormone called oxytocin shows some promise, but only for people who already have many symptoms right after the trauma. One small study found a medicine called prazosin helped stop Acute Stress Disorder from turning into PTSD. In short, we need much more research before we can use medicine to prevent PTSD soon after trauma.

3.2. Mental Health Help to Prevent Trauma

Getting mental health help soon after a bad event can prevent stress from turning into PTSD. These early interventions are safe and work. Bad events can cause problems that last for more than 10 years, so preventing them early is very important.

Teaching people about mental health as part of therapy is common. But just giving information without other help has been debated. Some new studies are looking at it again. A review of 10 studies found that teaching alone can improve knowledge and attitudes about mental health, but it does not seem to prevent PTSD on its own. In poorer countries where mental health care is hard to get, teaching people about mental health can be a first step. One type of emergency support called psychological first-aid helped lower early PTSD symptoms but did not prevent PTSD entirely.

A review of early mental health help showed it works for people who already have stress symptoms after trauma, especially if they meet the rules for Acute Stress Disorder or PTSD. But there is no proof that everyone who experiences trauma needs mental health help if they do not have symptoms. Experts agree that the strongest help is trauma-focused therapy for people who show symptoms in the first few months after trauma, to stop things from getting worse. Smaller studies show early help after sexual assault can have lasting benefits.

After big traumas like disasters, many adults and children will need help. People in jobs like first responders and medical staff may be at risk for PTSD because they often see bad things. For losing a loved one, we do not know much about how to prevent long-lasting grief.

We still need to learn more about what kind of help to offer and to whom. For example, one study found that a therapy called EMDR right after rape did not work better than just waiting and watching to see if symptoms got worse. Another review found no clear benefits for any specific early help for people who experienced trauma at work, though some general talks actually had negative results. Also, even though we know sleep problems can lead to PTSD, there is not much research on early sleep help to prevent PTSD. While new studies on helping sleep after trauma are happening, some evidence even suggests that not sleeping might be helpful.

Overall, we need strong studies on early or preventive help, which can be hard to do in these situations. We need help that is based on good ideas, practical, and easy to test. We also need to think about any possible harm these early helps could cause, and if we have enough resources to help everyone who needs it. New ways of using computers and AI (artificial intelligence) to screen or help people after trauma are exciting and being looked into.

3.3. Other Ways to Prevent Trauma

There are not many strong studies yet to show that mind and body practices like mindfulness and yoga can prevent PTSD. However, since these practices usually do not cause harm and can improve overall health, they might be good as extra help or just for well-being.

3.4. Sex/Gender in Preventing Trauma

Even though men and women deal with PTSD symptoms differently in the first year after trauma, we do not have much information on specific ways to prevent trauma for different sexes or genders. Only one study has looked at sex differences in early help after trauma. It found that male soldiers went to fewer sessions than female soldiers, and lower attendance meant worse symptoms. We need more research on this, especially for people outside of the military. Also, there is a lack of ways to prevent sexual violence for people of all sexual orientations and gender identities.

3.5. Preventing Trauma Over a Lifetime

A plan has been suggested for how to create and test early help for children. This help could focus on changing bad thoughts about trauma, stopping too much avoidance, and improving social skills. Helping new mothers who are struggling, especially during pregnancy and the first two years of a child's life, can also prevent problems. When parents have mental health issues, their children are more likely to have trauma-related problems. There are guides and programs to help children of parents with mental illness. For parents who struggle to provide a safe and loving bond with their children, therapies that use video feedback to improve parenting skills have been shown to work. Other therapies that help parents and children together, like Parent-Child Interaction Therapy (PCIT) and Child-Parent Psychotherapy (CPP), can also improve family bonds.

For children who have recently been through a stressful event, a "Watchful Waiting" plan has been created. This means checking for trauma symptoms at least twice in the first month after the event. If needed, the child is then sent for treatment that is known to work.

For older adults, we greatly need more research on ways to prevent trauma, as this part of the population is growing around the world.

3.6. Preventing Trauma Globally and Culturally

Most efforts to train people in poorer countries to help with PTSD and stress have focused on treatment, not prevention. But programs that shift some tasks to community health workers or primary care workers could offer prevention at a large scale. A review of many studies found that programs to promote mental health or prevent mental disorders in adults and children in poorer countries might slightly reduce stress or PTSD symptoms in adults who are not already at risk. For adults who are at risk, or highly likely to get mental disorders, it is not clear if these programs help much. For children, general prevention programs might slightly reduce symptoms, while programs for children at risk probably help a little, and programs for children who are very likely to get problems might also help a little.

Since social and cultural factors can change how well prevention works, future studies need to look at these things. For example, violence in a person's life might lead to sleep problems in certain groups of people, which could then lead to more PTSD.

People in poorer countries are also hit hard by crises like war. A review of mental health help for children in these situations found that such help was no better than no treatment or usual treatment for reducing PTSD, depression, or anxiety. We also do not have studies on preventing PTSD in adults affected by crises in poorer countries.

Overall, we need better studies to see how well prevention programs work to lower PTSD rates across different age groups and in poorer countries.

4. Treating Trauma Problems

4.1. Medicines for Trauma

For the last couple of decades, the main medicines approved for PTSD are sertraline and paroxetine. These are types of antidepressants. A review of 115 studies found that these antidepressants, along with some others and an antipsychotic medicine called quetiapine, had a small positive effect on reducing PTSD symptoms when used alone. Other medicines like prazosin and risperidone were helpful when added to other treatments. Although these medicines work in large studies, their effects on PTSD symptoms are usually small compared to therapies that focus on trauma. Because of this, some guidelines only suggest them if trauma-focused therapies are not available. Another review found a medicine called clonidine looked promising for sleep and PTSD, but the studies were small and not very strong. Another review found that a drug called ketamine likely helped PTSD due to a placebo effect (where people feel better just because they think they are getting medicine).

A review of therapies using medicine showed that MDMA-assisted therapy was the only promising treatment, but it was based on a small number of people. A recent large study found MDMA-assisted therapy worked very well for people with severe PTSD. This suggests it could be very helpful for those with severe PTSD and other problems. Australia approved MDMA with therapy for PTSD in 2023, but with strict rules. However, the US Food and Drug Administration recently did not approve MDMA with therapy for PTSD, asking for more strong information.

Also, finding patients with special body markers can help create treatments that target specific body processes. This could improve care by matching people to the best help. Future studies can look at if the body changes from early life stress can be reversed, how to stop these effects with early therapy, and find the body changes that link early life stress to other health problems.

4.2. Mental Health Therapies

There are many proven mental health therapies for PTSD, like EMDR, Prolonged Exposure, and Cognitive Processing Therapy. These therapies usually lead to big improvements in PTSD symptoms. There is less research on treatments for CPTSD, but it seems these same therapies can help both adults and young people with CPTSD. While these therapies work for many, they do not work for everyone. Some people quit therapy too soon, and many still have significant symptoms after treatment. The place where therapy is given can also affect how well it works. For example, a review found EMDR helped people in medical settings, but the studies were not all strong. Another review showed good short-term results for refugees. So, it is important to build on what we know and pay attention to what might change how well treatments work for each person in their specific culture.

It is very important for studies to focus on people who are not currently getting enough help, like those who do not get better with current treatments, or those who cannot get treatment because of problems like domestic violence. Understanding why treatments do not work for some and creating new help for these groups will be key.

Proven mental health therapies for PTSD often include teaching about trauma, learning skills to manage emotions, changing thoughts, working through feelings, and dealing with trauma memories. Studies show that these therapies work by changing beliefs about the trauma, how memories are processed, and by reducing unhelpful ways of coping like avoiding things or worrying a lot.

A review of PTSD treatments found that trauma-focused therapies were good value for money, but more research was needed for medicines and other treatments. Another study found no difference in cost for different types of Prolonged Exposure therapy. Trauma-focused cognitive therapy for PTSD was better value than general therapy that only taught coping skills.

Many countries have tried to make proven PTSD treatments more widely available. This has faced challenges. Experts say that good training for therapists (with supervision) and strong support from clinics are needed for these efforts to work. Checking how well people are doing in therapy can also help clinics improve their services. When therapists doubt new treatments or worry too much about talking about trauma memories, it can stop these treatments from being used. We need to study what helps and what hurts the use of effective treatments.

4.2.1. Treating Multiple Problems

Treating PTSD along with drug or alcohol problems is a big challenge for many doctors. Therapies that combine trauma-focused help with help for drug or alcohol problems show the most promise. Combining leading PTSD therapies, like Prolonged Exposure, with therapies for drug problems, like Relapse Prevention, is especially promising. Studies have found that trauma-focused, general, and specific drug problem therapies can all be good choices for people with both PTSD and drug problems. However, even with the best treatments, many people quit therapy, and the effects are only modest. While we have learned a lot about treating these complex problems, we need more work to make treatments better and find new ways to help. When there is not enough strong research, experts have made suggestions for how to check for and treat these problems.

Another tough problem is when PTSD happens with sleep disorders, like insomnia, nightmares, or sleep apnea. Sadly, trauma-focused therapies do not always make sleep much better. More than half of people who get better from PTSD after therapy still have insomnia later. Important to note, ongoing sleep problems make it harder for people to get better from PTSD treatment and can make them more likely to have problems again later. Because sleep problems are so hard to treat, new ways of helping people with PTSD are being tried, like treating insomnia first with therapy before starting other PTSD therapy. Therapy for insomnia is very effective at reducing PTSD symptoms, and combining it with other PTSD therapies shows promise in helping people overcome fear. Similar good effects have been seen with other sleep treatments, like special masks for sleep apnea and morning light therapy for sleep rhythm.

Current proven treatments for long-lasting grief include cognitive behavioral therapy, as well as a specific therapy for grief. This grief therapy has also helped with PTSD symptoms related to loss. However, medicines usually used for PTSD, like antidepressants, have not worked well for the main symptoms of long-lasting grief. Future medicine research should look at drugs that target body pathways involved in grief, such as those related to bonding, reward, and pain.

4.2.2. Technology in Treatment

A big challenge for healthcare providers is to make proven therapies for PTSD available to many people and in ways that are easy to access. Since technology is everywhere now, research is using it to improve access to treatments.

Things like smartphones, smartwatches, and video games give us information about our behaviors (like app use, steps, heart rate, sleep). They also connect us with others to share health goals or music. Therapies are using these tools more and more. They make it easier to track progress between sessions and review information with patients. Some even allow for automated help between sessions. During the pandemic, many doctors and patients switched to online therapy, and studies show it works about as well as in-person therapy. Guides have been published on how to do trauma therapy remotely. Research also shows that virtual reality can play a key role in PTSD therapy, especially for facing trauma reminders and feared situations.

Many digital therapies that involve a therapist have been created, mostly to deliver trauma-focused therapy. Digital approaches need less therapist time and can be used remotely and more flexibly. There is growing proof that these approaches can help adults with mild to moderate symptoms, and they show big improvements.

Future research needs to figure out how much therapist help is best for these digital therapies. Also, if they can help children and young people, and if they can work for more complex problems like CPTSD, PTSD with drug problems, or sleep disorders. For example, one study found that online cognitive therapy helped people with CPTSD more than a general coping skills program. Also, recent studies found that using digital insomnia therapy years before the COVID-19 pandemic protected people from trauma stress during the early weeks of lockdowns.

Since we are seeing more benefits from using technology in therapy, we need to keep finding new ways to use it. This will help treatments and assessments reach people outside of the therapy office.

4.2.3. Good and Bad of Social Media

Using social media (like X, Facebook, WhatsApp, and Instagram) is a big part of how people interact now. Studies show that social media can have negative impacts. For example, cyberbullying is linked to high levels of distress.

But interactions on social media can also provide good social support. During the pandemic, private messages were found to be as helpful as in-person talks. Public posts have also allowed trauma survivors to share their stories. For example, people used hashtags to talk about why they did not report sexual assault, showed strength after natural disasters, and discussed domestic violence during the pandemic.

An important difference is how people use social media. Those who find it helpful might be actively seeking information and positive connections. After a typhoon, seeing trauma on social media was linked to more PTSD, but gathering information or seeing heroic acts was linked to less PTSD. A similar pattern was seen after a plane crash, where people who saw a lot of bad content through algorithms had more trauma. People who use social media with a clear purpose for knowledge and good connections may benefit, while just passively scrolling might lead to seeing more upsetting content.

More research is needed to understand how public and private social media can help individuals and communities cope with trauma.

4.3. New Treatment Ideas

An exciting change in the field is the rise of studies looking at intensive or fast-paced trauma-focused mental health therapies. One popular method, developed in the Netherlands, combines types of EMDR and Prolonged Exposure over 8 days. While this method has not been tested in major comparison studies yet, many other studies show that people stick with it and have very good improvements in symptoms and no longer meet the diagnosis for PTSD, both for adults and teenagers. Newer work is also looking at how to change this method for people with mild learning disabilities and their families.

For people with severe PTSD that is hard to treat, a new method called 3MDR (multi-modal motion-assisted memory desensitization and reconsolidation) is getting attention. It shows promise. 3MDR involves seeing trauma reminders on a big screen and doing a task that uses the brain's working memory, all while walking on a treadmill. Small studies show it works for soldiers, even those with mild brain injuries. More work is being done to adapt this for children and teenagers.

Other interesting new ideas for treating PTSD, though they need more research, include brain treatments like deep brain stimulation and transcranial magnetic stimulation, or a therapy called Deep Brain Reorienting that targets brain reactions during trauma. Also, Targeted Memory Reactivation, which helps memory during sleep, is being studied.

4.4. Other Help and Whole-Person Care

Complementary and integrative health (CIH) treatments include many different things, from mind-body practices like yoga and mindfulness to music and animal-assisted therapies. While there is growing evidence for many of these, they are not yet proven to be first-line treatments for PTSD. Also, while they show promise for boosting other proven treatments, this is not yet fully confirmed. However, since CIH therapies mostly focus on making people feel better and improving their overall health, not just reducing symptoms, they can improve quality of life even if symptoms do not fully go away. Also, for many people who cannot or choose not to do regular trauma treatments, CIH options that do not make them directly face traumatic events can be offered. In recent guides, mindfulness and yoga are suggested as second-line treatments.

A recent review of 10 studies on neurofeedback (a type of brain training) for PTSD showed good effects for many different people, including soldiers and civilians from various backgrounds. While more research is needed, a recent review on dance therapy suggested it might help with both mental and physical symptoms of trauma.

In short, CIH treatments might be a good first step to get people involved in other treatments, but we need strong research. Future studies should look at the whole person, not just PTSD, including quality of life, well-being, and physical health. We also need to understand how these treatments work and if they can be used for many people or online.

4.5. Sex/Gender in Treatment

Women were found to be more likely to seek mental health therapy and make better progress than men, though the differences were usually small. These sex differences in treatment seem to start in the teenage years. However, in a recent review of studies, there was little effect of sex or gender on how well treatments worked. Also, there was no sign of sex or gender differences in people quitting therapy.

Similarly, no clear sex or gender differences have been found for medicine treatments. But women were slightly more likely than men to get antidepressants for PTSD, and also medicines like benzodiazepines, which should not be given for PTSD.

Future research should focus on regular people, not just soldiers, as most studies on sex and gender differences in treatment have been done with soldiers.

4.6. Treatment Over a Lifetime

Research on treating children and teenagers shows strong support for therapies that use cognitive behavioral strategies. This includes children as young as 3–8 years old. Other treatments like EMDR and Narrative Exposure Therapy also have growing support. Many trauma therapies for children and teenagers have been developed, and they share many similar techniques and ways they help. These include teaching about trauma, relaxation, writing about bad experiences, talking about trauma, facing fears, doing homework, changing thoughts, sharing the trauma story, thinking about the future, and ending therapy. They all help with remembering, motivation, handling feelings, connecting with others, and the relationship with the therapist.

Being able to get along with others is very important for mental health, and understanding these social parts for children who have been harmed is growing fast. Also, therapies can help improve the relationship between parents and children. One example is a therapy where parents are taught to deliver parts of trauma-focused therapy to their children at home, with a little help from a therapist. Also, there are early signs that a therapy called Integrative Attachment Trauma Protocol for Children (IATP-C), which combines family therapy and EMDR, helps children who have experienced early abuse, neglect, and being moved from their homes.

However, we need much more research for child and teen treatments because it is still behind adult treatments. Also, it is important that ongoing treatment research includes everyone and is fair.

Treatments for older adults with PTSD have not been studied as much. In one review, older age actually predicted better results for PTSD and depression symptoms with a therapy called Narrative Exposure Therapy (NET). A review of treatments for older soldiers had mixed results for proven therapies, partly because older adults often have many other medical and mental health problems. This suggests they might need more complete treatment plans. Studies show that people with PTSD and memory problems can benefit from PTSD treatment. One early study suggested that exercise combined with cognitive behavioral strategies might be helpful for older adults. More work is needed in this area, especially as the world's older population grows.

4.7. Treatment Around the World

There are no global rules for proven treatments. For example, a main American guide lists four strongly recommended treatments for PTSD. Differences in culture may mean we need more types of treatments and ways to change existing ones.

Over the last 15 years, strong proof has shown that proven mental health therapies for PTSD work well and are safe in many cultures. Often, these therapies are delivered by non-specialist health workers through sharing tasks. There is also growing proof that therapies that address many problems at once (transdiagnostic interventions) can help trauma survivors in poorer countries by treating a range of mental and behavior problems at the same time. While we have many studies showing these treatments work in different cultures, there is limited research showing they can be successfully used for many people in places with fewer resources. To make these work in poorer countries, we need long-term training with constant supervision by local trainers.

Research increasingly shows that changing proven treatments to fit local cultures, with help from local experts, can make them more accepted and effective. However, there is a debate about whether simple changes like language are enough, or if deeper cultural changes are needed (like including local ideas about sickness or healing rituals) that might change the main parts of the therapy. Experts say that understanding culture is key when using treatments in different places, but we should not use stereotypes about culture as an excuse not to offer these treatments.

5. Better Ways to Study

Here are some final thoughts on how we have improved our ways of studying trauma over the last 15 years, and where we expect to go next. There have been many advances in how we collect information, like brain scans, gene research, and smartphone technology. At the same time, we have made great progress in how we look at this information, including better computer programs, using machine learning, and being able to handle huge amounts of data. Recently, there has also been a push to use computer models to make our ideas about trauma more accurate.

These new methods are showing great promise in helping us predict mental health problems after trauma. They can also help choose the best treatment and make it fit for each person. Most importantly, it is clear that artificial intelligence (AI) will play a huge role in moving all of this forward. But we do not yet fully understand all the good things and possible problems (like if results can be copied in other studies) of using AI in the trauma field. We look forward to studies that explore AI in a thoughtful way.

Going forward, this journal wants to keep publishing studies that help us understand trauma, its effects, and how to treat it. We do not just want papers that use new methods for the sake of it. Instead, we are looking for studies that use the best methods available to answer specific research questions. This includes old and new proven methods. We expect that as the science of trauma keeps growing quickly, we will publish more studies based on stronger information (like bigger groups of people, studies that follow people over time, and combining different types of information) with smarter ways of looking at the data. Of course, following our open science rules, we hope to see more research based on data that is easy to find, access, combine, and reuse, so that many useful datasets are available to everyone around the world. (Look for our call for papers on making data easier to use.) Consider publishing "Data Notes," which are short, reviewed articles that describe a dataset stored online, to make the data even more visible. Sharing data will help people around the world work together and lead to strong research results, at least for the next 15 years.