Table 7.
PTSD Stage |
Current Evidence-based Interventions
Recommended in Guidelines |
Potential Examples of Emerging Treatments |
Stage 0: Trauma-exposed asymptomatic but at risk | Watchful waiting (monitoring symptoms over time) | e.g., app-based monitoring |
Stage 1a. Undifferentiated symptoms of mild anxiety and distress | Psychoeducation, support from family and close relatives | e.g., a range of emerging interventions: cortisol, “cognitive vaccination”, ACE inhibitor, and attention training (see paragraph 5.2) |
Stage 1b. Subsyndromal distress with some behavioural and functional decline | Short interventions: i. Interaction-based: limited number of PE sessions, writing therapy |
i. Interaction-based: neuromodulation and neurofeedback and other technology-based interventions (see paragraph 5.4.3.1, 5.7.2-5.7.5) ii. non-interaction based interventions, such as (mindful) relaxation (see paragraph 5.4.2.4) |
PTSD Stage |
Current Evidence-based Interventions
Recommended in Guidelines |
Potential Examples of Emerging Treatments |
Stage 2: First episode of full-threshold symptoms that has different trajectories | Relatively straightforward symptom-focused interventions, such as PE, EMDR, TF-CBT, and CPT (see paragraph 3.3) |
Range of novel emerging treatments, based on availability and policy |
Stage 3: Persistent symptoms which may fluctuate with ongoing impairment | - | - |
a. Incomplete remission of the first episode |
i. Psychotherapeutic interventions that address multiple aspects of traumatization or sequential traumatization such as Brief Eclectic Psychotherapy for PTSD, Narrative Exposure Therapy (see paragraph 3.3) ii. Pharmacotherapeutic options regulating stress reactivity: SSRIs (paroxetine and sertraline; see paragraph 3.2) |
i. Intensification, changing modality, combination of therapies or modalities (novel psychotherapy plus pharmacotherapy) ii. Pharmacotherapeutic options regulating stress reactivity such as SNRIs, stellate ganglion block, prazosin, or mood stabilizers (see paragraphs 3.2 and 5.7.6) iii. Targeting emotional dysregulation, for instance with ACT, mindfulness, or medicinal cannabis (see paragraphs 5.3.1 and 5.4.2.3) |
b. Recurrence or relapse of PTSD and persistent impairments | Psychotherapeutic interventions that address the person in his/her context, such as interpersonal psychotherapy (see paragraph 3.3), schema therapy | - |
c. Multiple relapses or worsening following incomplete treatment response | Intensified treatment by means of i. ‘massed’ interventions such as highly intensive 1- to 3-week trauma-focused treatments (see paragraph 5.4) |
ii. e.g., interventions with emerging evidence of effect for treatment-resistant populations: 3MDR, MDMA-assisted psychotherapy, and neuromodulation therapies, DBS, rTMS (see paragraphs 5.4.3.4, 5.6 and 5.7) |
Stage 4: Severe unremitting illness of increasing chronicity |
i. Physical: effective medical management of comorbidities |
ii. Specific interventions for social and vocational assistance iii. e.g., treatment focused on moral injury, in case of a ‘moral injury subtype’ of PTSD (see paragraph 5.4.2.5) iv. e.g., interventions focused on maintenance and preventing further comorbidity: nonverbal therapy, service dogs, equine therapy, day treatment and stabilization (see paragraph 5.4.2.3-5.4.2.6) |
Note: (adapted from Nijdam et al., 2023 [904]).
Abbreviations: ACE, Angiotensin I Converting Enzyme; PE, prolonged exposure; EMDR, eye movement desensitization and reprocessing; TF-CBT, trauma-focused cognitive behavioral therapy; CPT, cognitive processing therapy; SSRI, selective serotonin reuptake inhibitors; SNRI, serotonin-norepinephrine reuptake inhibitors; ACT, acceptance and commitment therapy; 3MDR, multi-modal motion-assisted memory desensitisation and reconsolidation; MDMA, 3,4-methylenedioxymethamphetamine; DBS, deep brain stimulation; rTMS, repetitive transcranial magnetic stimulation.