The impact of trauma and how to intervene: a narrative review of psychotraumatology over the past 15 years

ABSTRACT

To mark 15 years of the European Journal of Psychotraumatology, editors reviewed the past 15-year years of research on trauma exposure and its consequences, as well as developments in (early) psychological, pharmacological and complementary interventions. In all sections of this paper, we provide perspectives on sex/gender aspects, life course trends, and cross-cultural/global and systemic societal contexts. Globally, the majority of people experience stressful events that may be characterized as traumatic. However, definitions of what is traumatic are not necessarily straightforward or universal. Traumatic events may have a wide range of transdiagnostic mental and physical health consequences, not limited to posttraumatic stress disorder (PTSD). Research on genetic, molecular, and neurobiological influences show promise for further understanding underlying risk and resilience for trauma-related consequences. Symptom presentation, prevalence, and course, in response to traumatic experiences, differ depending on individuals’ age and developmental phase, sex/gender, sociocultural and environmental contexts, and systemic socio-political forces. Early interventions have the potential to prevent acute posttraumatic stress reactions from escalating to a PTSD diagnosis whether delivered in the golden hours or weeks after trauma. However, research on prevention is still scarce compared to treatment research where several evidence-based psychological, pharmacological and complementary/ integrative interventions exist, and novel forms of delivery have become available. Here, we focus on how best to address the range of negative health outcomes following trauma, how to serve individuals across the age spectrum, including the very young and old, and include considerations of sex/gender, ethnicity, and culture in diverse contexts, beyond Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. We conclude with providing directions for future research aimed at improving the well-being of all people impacted by trauma around the world. The 15 years EJPT webinar provides a 90-minute summary of this paper and can be downloaded here [http://bit.ly/4jdtx6k].

HIGHLIGHTS

• Defining trauma is complex and multifaceted with survivors’ subjective interpretation of an experience being more important than the objective characteristics of an event. Research needs to consider sex/gender, age, and geographical and cultural contexts in defining trauma.

• Trauma may have multiple, often comorbid, mental and physical health outcomes, calling for transdiagnostic screening of trauma survivors. Assessments need to be improved to capture sex/gender differences, young and older trauma survivors and cultural contexts.

• Several (innovative) evidence-based interventions are available for prevention and treatment of trauma outcomes, but more research is needed on if and how to adapt these for optimal efficacy across sex/genders, the life span and local cultural contexts.

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., 2021; Olff et al., 2021). Even young children have been shown to be affected (Vasileva et al., 2021). Two special issues of this journal have addressed the impact of COVID-19 (Ford & Seedat, 2023; O’Donnell & Greene, 2021). 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., 2010; Massazza et al., 2022; Olff, 2023; Pardon et al., 2024; Vergunst et al., 2024, 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, 2024).

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., 2022). 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, 2024).

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, 2024; Norris et al., 2002; Olff, 2017; Olff et al., 2007; Tolin & Foa, 2008) 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., 2007). 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., 2024).

Unfortunately, although we see improvement since the introduction of the gender policy in this journal (Langeland & Olff, 2024), 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 (2024) 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, 2009; Havermans, van Alphen, et al., 2023; Hoeboer et al., 2025). 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., 2023; Hoeboer et al., 2025). 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, 2021; Charak et al., 2023; Dunn et al., 2019). 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., 2019) with lasting effects that extend into adulthood (Cloitre et al., 2020; Ford et al., 2020; Van Assche et al., 2020). 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., 2023; Wilker et al., 2015), poly-traumatization (Contractor et al., 2018), poly-victimization (Gilbar & Ford, 2020; Lee et al., 2022), or adverse childhood experiences (ACEs; Karatzias et al., 2020; Knipschild, Hein, et al., 2024).

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., 2015) and for simply summing the number of adversity types to produce a score that weights the impact of each adversity equally (Briggs et al., 2021).

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, 2017; Meier et al., 2024; Nkrumah et al., 2024). 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., 2019). 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., 2016) 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., 2019). 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., 2020).

While abuse of older adults is prevalent (Acierno et al., 2010) 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, 2017). Of note, cognitive decline may also result from traumatic brain injury (TBI) (Akhanemhe et al., 2024). 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., 2023; Trauma & Ageing, n.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., 2016; Kessler et al., 2017). 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., 2017). 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, 2023; Yousef et al., 2021). 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., 2017; Kaminer et al., 2018). 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, n.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. (2018) 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., 2015). Bonanno (Bonanno, 2021) 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, 2021). 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., 2016). 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, 2022). 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., 2017).

In the ICD-11 (WHO, 2022), 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, 2022). 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., 2020; Hansen et al., 2015; Hansen, Hyland, et al., 2017) 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., 2017; Robinson et al., 2024). Similarly, Robinson et al. (2024) 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., 2024). 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., 2022).

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, 2024; 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, 2023) such as healthcare workers (Coimbra et al., 2024; Hegarty et al., 2022) and refugees (Hoffman et al., 2019). Notably, research on the treatment of moral injury is progressing (Williamson et al., 2022; Ter Heide & Olff, 2023).

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, 2024). 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, 2024; Norman et al., 2024).

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, 2022), and in the DSM-5-TR as a stressor-related disorder alongside PTSD (APA, 2022). 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., 2024). Recent empirical data suggest that the two classifications might not capture the same clinical entity (Eisma et al., 2022). Regardless, the recognition of PGD as a condition in international classifications has accelerated research on its phenomenology (e.g. Eisma & Lenferink, 2023; Hennemann et al., 2023) and treatment (Tang et al., 2024), in particular, in the context of the global death toll of the COVID-19 pandemic (Djelantik et al., 2021).

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., 2013). Not surprisingly, the DSM-5 PTSD symptom cluster ‘negative alterations in cognition and mood’ increases the overlap with depressive symptoms (Hurlocker et al., 2018). Notably, over 90% of individuals with PTSD report either insomnia, nightmares, or both (Milanak et al., 2019), which are increasingly recognized for their role in undermining emotional learning necessary for PTSD recovery and treatment response (Colvonen et al., 2019; de Boer et al., 2020; van der Heijden et al., 2022).

Epidemiologic research suggests that substance use disorders (SUD) affect 2.2% of the world population (Castaldelli-Maia & Bhugra, 2022), with higher prevalence rates in higher income countries. Alcohol use disorder (AUD) is the most prevalent SUD world-wide (Glantz et al., 2020). 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., 2012; Roberts et al., 2022; Van den Brink, 2015). 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., 2022). 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., 2023). 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., 2024). 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., 2021).

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., 2023; Haering et al., 2024). 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., 2017), 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., 2023; Koss et al., 2020), but it is too simplistic to examine only PTSD as a potential psychological outcome (Koss et al., 2020). 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, 2014; Hoeboer et al., 2024; Koss et al., 2020; Mekawi et al., 2020; Olff et al., 2019). 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., 2009). 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., 2021).

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., 2022). 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., 2018; Binder, 2017; Bussières et al., 2023; Clemens et al., 2018; Engel et al., 2020, 2023; Lüönd et al., 2025; Nugent et al., 2014, 2016).

PTSD is associated with increased rates of obesity and metabolic disorders (e.g. type 2 diabetes mellitus; (Michopoulos et al., 2016), autoimmune disorders (e.g. rheumatoid arthritis, lupus; (Boscarino, 2004; Goldschen et al., 2023; Spitzer et al., 2020), thyroid disease, asthma, and obstructive sleep apnea (OSA) (Colvonen et al., 2015), the latter of which has been shown to impair inhibitory and extinction learning (Reist et al., 2021). Clemens et al. (Clemens et al., 2018) 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., 2025).

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., 2021, 2023). PTSD is common in chronic pain patients (Siqveland et al., 2017), possibly due in part to differences in neural processing (Miedl et al., 2024). 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., 2021; Meeker et al., 2021; Werner et al., 2021).

Trauma exposure and PTSD are associated with increased rates of cardiovascular disease, including stroke, myocardial infarction, hypertension, and heart failure (Edmondson et al., 2013; O’Donnell et al., 2021; O’Donnell & Greene, 2021), as well as risk factors such as increased carotid intima-media thickness (Spitzer et al., 2020; Vulic et al., 2019) and arterial plaque burden (Gharios et al., 2024). 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., 2016), PTSD has demonstrated an independent effect on cardiovascular risk after accounting for these factors (Seligowski et al., 2024). 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., 2020). There are alterations in brain function, structure, and neurotransmitter systems that overlap with a core neurocircuit involved in threat processing (Fragkaki et al., 2016; Lanius & Olff, 2017). 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., 2012; Stark et al., 2015). Mega-analyses of brain morphology data further suggest that PTSD is associated with reduced hippocampal volume (Logue et al., 2018). 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., 2016). Further, subtypes of PTSD (e.g. the dissociative subtype) may show varying neurobiological signatures compared to classical patterns in PTSD (Lebois et al., 2021). More recent work also suggests that specific neurobiological biotypes may underlie specific symptom trajectories following trauma exposure (Stevens et al., 2021). 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., 2022). Consideration of unique stressors (e.g. discrimination, refugee/migrant-related stress) is critical for understanding unique neural signatures for PTSD (Nicholson et al., 2022). In addition, prior stress, trauma, and environmental influences can affect ‘neurophenotypes’ and contribute to different imaging profiles (Lanius, 2015; Marinova & Maercker, 2015).

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., 2012; Stein et al., 2002). 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., 2024). 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., 2024). 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., 2024) which is also consistent with bivariate twin work on PTSD and MDD (Sartor et al., 2012).

Recent work has also included molecular genetic investigations of resilience (Cusack et al., 2023), 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., 2024).

2.10. Trauma consequences: sex/gender aspects

PTSD prevalence rates are twice as high in women compared to men (Hoeboer et al., 2025; Kilpatrick et al., 2013; Langevin et al., 2024; Olff, 2017; Olff et al., 2007; Tolin & Foa, 2008), 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., 2022).

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., 2012, 2013; Nillni et al., 2015; Pineles et al., 2016; Seligowski et al., 2020). In contrast, high progesterone levels appear to confer worse extinction retention in women with but not without PTSD (Pineles et al., 2016). Sex differences in PTSD prevalence appear to emerge in adolescence (Hiscox et al., 2023).

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., 2019). However, with increased sample sizes this is no longer significant (Nievergelt et al., 2024). Findings from neuroimaging studies indicate that women may have stronger activation of the locus coeruleus in response to fearful faces (Felmingham et al., 2010) and lower activation of the dorsal anterior cingulate during extinction recall (Shvil et al., 2014). Additionally, elevated heart rate and cytokine levels may be more salient indicators of PTSD risk in women than men (Kleim et al., 2010; Michopoulos et al., 2015; Seligowski et al., 2021). 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., 2020).

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., 2015), and sympathetic arousal measured via heart rate appears to be higher in women versus men with PTSD (Fonkoue et al., 2023; Seligowski et al., 2021). Further, low oestradiol levels are associated with worse sympathetic arousal and vascular function (Regitz-Zagrosek & Kararigas, 2017; Seligowski et al., 2020) 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. (2014) 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, 2023; O’Donnell & Palinkas, 2024). 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., 2018). 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, 2024).

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., 2021). 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., 2019).

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., 2021, 2022). 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., 2022) with a distinct profile of comorbidity from PTSD (Ford et al., 2022; van Der Kolk et al., 2019). 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., 2021). 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, 2008; Havermans, Hoeboer, et al., 2023; Moye et al., 2022). The prevalence of PTSD among those aged 60 and older ranges from 1.9% to 9.5% (Fox et al., 2020; Pietrzak et al., 2011). 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., 2015). 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., 2022). 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., 2020). 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., 2007). 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., 2022; Ho et al., 2020; Ng et al., 2020; Nielsen et al., 2023). 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., 2023; Michalopoulos et al., 2020). 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., 2017). 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., 2024; Oe et al., 2020; Primasari, Hoeboer, Bakker, et al., 2024; Salimi et al., 2023).

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., 2023; Maguire-Jack et al., 2020; Roberts et al., 2011; Slopen et al., 2016). The incongruence may be due in part to the adoption of adaptive neurophysiological mechanisms to counteract the impacts of stressors (Webb et al., 2024) which may however lead to more severe symptoms for those susceptible (Williams, 2018). 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., 2016; Dückers & Olff, 2017). Inclusivity of ethnoracially and culturally diverse participants is not always considered which can contribute to bias in research findings (Harnett et al., 2023).

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., 2022). Some data suggest that hydrocortisone might be efficacious, although more rigorous research is needed (Bertolini et al., 2022). Oxytocin holds some promise in the prevention of PTSD (Engel et al., 2019, 2020; Frijling, 2017; Olff, 2012) but only – as shown in posthoc analyses – for those with high levels of initial symptoms (van Zuiden et al., 2017). To prevent the transition from ASD to PTSD, prazozin was found effective in a small pilot open-label study (Magnin et al., 2023). 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., 2016, 2017). 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, 2021). Such interventions are tolerable and effective (Bragesjö et al., 2021). Traumatic events may have long term (>10 years) adverse outcomes including PTSD (Karchoud et al., 2024), emphasizing the importance of preventive interventions.

Psychoeducation as part of psychotherapy is common (Schnyder et al., 2015). However psycheducational stand-alone interventions have been controversial since the ‘debriefing’ debate (see e.g. Olff et al., 2019), but have garnered interest again (Knipschild, Klip, et al., 2024; Primasari, Hoeboer, Sijbrandij, et al., 2024). 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., 2021). 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., 2024). A psychological first-aid intervention was shown to decrease early PTSD symptoms but did not prevent it (Figueroa et al., 2022).

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., 2019). However, there is no evidence supporting universal psychological interventions for all trauma-exposed individuals irrespective of their symptoms (Roberts et al., 2019). Bisson et al. (Bisson et al., 2021; Bisson & Olff, 2021) 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., 2019).

After mass trauma and disasters we can assume that there will be a need for interventions targeting both adults (Eisma et al., 2019) and children (Dyregrov et al., 2018). First responders (Cogan et al., 2024), medical personnel (Greene et al., 2021), and military service members (Blais et al., 2021) 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., 2019).

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., 2021). 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., 2023). In addition, despite cumulative evidence on the impact of sleep disturbance on subsequent PTSD risk (e.g. Agorastos & Olff, 2021), early interventions targeting sleep within the acute aftermath of trauma to prevent PTSD remain a nascent area of research (Reffi, Kalmbach, et al., 2023; Swift et al., 2022). Although exciting new studies that seek to promote healthy sleep after trauma are underway (e.g. Sayk et al., 2024), there is also evidence suggesting sleep deprivation may be protective (e.g. Repantis et al., 2020).

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 (2014) 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., 2002) as well as the screening versus capacity to treat (Greene et al., 2022). 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., 2025).

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., 2018; 2023; Tan et al., 2023). 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., 2023).

3.4. Sex/gender aspects in preventive interventions

Although sex differences in PTSD symptom trajectories within one-year post-trauma (van Zuiden et al., 2022) 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., 2016). 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., 2024) 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 (2014). 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., 2015). 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, 2018) 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., 2016) and Child–Parent Psychotherapy (CPP: Guild et al., 2021) 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., 2021). 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., 2022; Purgato et al., 2018; Singla et al., 2017), 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., 2023). 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., 2024).

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., 2018) 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, 2021), 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., 2021). 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, 2023) 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., 2024).

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., 2021). A recent phase III trial found MDMA-assisted psychotherapy for individuals with severe PTSD to be highly efficacious (Mitchell et al., 2021), 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., 2023; Mitchell, Ot’alora, et al., 2023), 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., 2024), and identification of biological mediators of early life stress and other medical conditions (Thomaes et al., 2016).

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, n.d.; Bisson et al., 2019; Bisson & Olff, 2021) 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., 2021; Jensen et al., 2022; Oprel et al., 2021). 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., 2020; van der Hoeven, Assink, et al., 2023), and many continue to experience significant symptoms once treatment is complete (Lewis, Roberts, Andrew, et al., 2020). 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., 2024). Another systematic review in refugee populations showed positive effects, but only in the short term (Daniel et al., 2024). 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., 2025), or due to circumstances around for instance intimate partner violence that make help seeking potentially unsafe or impossible (Hoeboer et al., 2024; Nshimyumukiza et al., 2024; Sprague et al., 2017; Sprague & Olff, 2014). 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., 2015). 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., 2022; Brown et al., 2019; Ehlers et al., 2023; Wiedemann et al., 2023).

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., 2020). Another study showed no differences in cost-effectiveness between different forms of prolonged exposure for PTSD (Kullberg et al., 2023). Trauma-focused cognitive therapy for PTSD was more cost-effective than general CBT focusing on teaching coping techniques including exposure (Penington et al., 2024).

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. (2013) 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 (2018) 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., 2018). 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., 2023). Trauma-focused integrative interventions (Back et al., 2014; Hien et al., 2022) for PTSD/SUD show the most promise in treating individuals with PTSD/SUD (Roberts et al., 2022). 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., 2014). Simpson et al. (2021) 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., 2022). 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., 2023).

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., 2025), with more than 50% of patients whose PTSD remitted following trauma-focused therapy continuing to report insomnia at follow-up (e.g. Schnurr & Lunney, 2019). Importantly, residual symptoms of insomnia, nightmares, or OSA hinder patients’ response to PTSD treatment (e.g. Taylor et al., 2020) and may increase risk for future relapse (Kartal et al., 2021). The refractoriness of sleep disorders has therefore galvanized efforts to better target them among individuals with PTSD using novel approaches (Colvonen et al., 2018), such as delivering cognitive behavioural therapy for insomnia (CBT-I) prior to initiating PE (Colvonen et al., 2019) Indeed, CBT-I, the first-line treatment for insomnia (Edinger et al., 2021), exerts very large effects on PTSD symptom reduction (g = 1.3) (Hertenstein et al., 2022), and emerging evidence supports the efficacy and rationale of integrating it with PE to facilitate fear extinction learning (Hunt et al., 2023). 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., 2021) and morning blue light treatment for circadian rhythm stabilization (Vanuk et al., 2022).

Current evidence-based treatments for prolonged grief include cognitive behavioural therapy (e.g. Haneveld et al., 2022), as well as a 16-session manualized loss-focused psychotherapy (Shear et al., 2016), that has also shown efficacy on PTSD symptoms associated with bereavement (Na et al. 2021). 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., 2016). Future psychopharmacotherapy research should focus on compounds targeting biological pathways implicated in PGD, including the oxytocin (Bui et al., 2019; Gang et al., 2021; O’Connor et al., 2008), reward (O’Connor et al., 2008), and pain (Gang et al., 2021) 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., 2024; Kaltenbach et al., 2021; Kasparik et al., 2022; Kothgassner et al., 2019; Olff, 2015; Strelchuk et al., 2023).

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., 2023). 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., 2022). Guidance on how to adapt trauma-focused treatments remotely was published (Fisher, 2021; Wild et al., 2020). 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., 2021; Kothgassner et al., 2019; Rizzo & Shilling, 2017).

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., 2022; Ehlers et al., 2023; Simon et al., 2019; van der Meer et al., 2020).

Future research needs to determine the optimal levels of therapist guidance required for such interventions (Simon et al., 2023), 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. (2023) 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., 2021; Reffi, Drake, et al., 2023).

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., 2016). 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., 2022). 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., 2022), and #PuertoRicoSeLavanta to describe resilience after natural disasters (Rodríguez-Guzmán et al., 2021), and #DomesticViolence to comment on intimate partner violence during the pandemic (López et al., 2022).

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., 2019). 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., 2024). 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., 2022; Ehlers et al., 2014; Hendriks et al., 2010; van Pelt et al., 2021; Wagenmans et al., 2018; Zepeda Méndez et al., 2018). 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., 2022; Voorendonk et al, 2020; Wagenmans et al., 2018) and adolescents (van Pelt et al., 2021). 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., 2020).

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., 2020; van Gelderen et al., 2020), including veterans with mild traumatic brain injury (Roy et al., 2022). Further work is being undertaken to consider how this approach might be adapted for children and adolescents (Hoekstra et al., 2023).

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., 2011; Rosson et al., 2022) or Deep Brain Reorienting (DBR) targeting the brainstem-level neurophysiological sequence that transpired during a traumatic event (Kearney et al., 2023), or Targeted memory reactivation (TMR) which enhances memory consolidation by presenting reminder cues during sleep (van der Heijden et al., 2024).

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., 2023). 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., 2020; VA/DoD, 2023). Evidence for CIH therapies that can augment current evidence-based treatments is similarly promising, but not yet established (Michael et al., 2019). 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., 2020), 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., 2020; VA/DoD, 2023).

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., 2023). 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., 2023).

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., 2016; Olff, 2017; Roberts et al., 2011; Wade et al., 2016). The sex differentiation in treatment effects seems to emerge in adolescence (Hiscox et al., 2023). In a recent review of studies in the past five years in the journal Langeland and Olff (2024) 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., 2020).

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., 2023).

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., 2020; Forbes et al., 2020; Martin et al., 2021; Mavranezouli et al., 2020), including for children as young as 3–8 years (Hitchcock et al., 2022), 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., 2022).

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., 2024; Haim-Nachum et al., 2024; Pfaltz et al., 2022; Wadji et al., 2023). 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., 2023; Salloum et al., 2014) 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., 2024; van der Hoeven, Plukaard, et al., 2023).

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., 2020).

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., 2019). A review of interventions among older combat veterans indicated mixed results for evidence-based interventions including exposure-based therapies (Owens et al., 2005). 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. (2023) 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., 2020). 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., 2020). 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., 2017; Singla et al., 2017). 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., 2018; Murray et al., 2020; Rahman et al., 2016). 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., 2020).

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., 2017). 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., 2020). Schnyder et al. (2015) 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, 2024).

These kinds of advanced methods are showing great promise in improving our ability to predict mental health outcomes following trauma (Held, Splaine, et al., 2023), and in guiding treatment selection and personalizing interventions (Held, Patton, et al., 2023). Crucially, it is clear that artificial intelligence is going to play a pivotal role in substantially advancing all of these (Olff, 2024). 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, 2020) (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.

6. Future research recommendations

Box 1. Future Research Recommendations

1. Traumatic Events

 ● Assess exposure to traumatic events reducing variability across common standardized trauma assessments.

 ● Determine how best to define Criterion A – considering different geographical and cultural contexts.

 ● Improve understanding whether and how broadening the concept of trauma can lead to negative expectations even for less severe events and possibly increase vulnerability for developing symptoms of PTSD or other disorders.

 ● Increase measurement and context to integrate the ways that media use may be impacting individual and community level trauma exposure/ experiences.

 ● Move beyond the binary conceptualization of either sex or gender in trauma research.

 ● Pay attention to specific critical periods of trauma exposure in assessment with children and adolescents, and in assessment of trauma history with adults.

 ● Adapt trauma history protocols to capture a full lifetime assessment with older adults.

 ● Adapt trauma screening and assessment protocols to address ongoing trauma exposure as trauma history.

 ● Cross-cultural research to explore the ways in which subjective interpretation of events is influenced by cultural beliefs and norms as well as other contextual factors.

 ● Develop screening tools of trauma exposure that are inclusive of the range of potential trauma events experienced in none-Western settings.

2. Mental and Physical Health Consequences

 ● Identify factors that interfere with or facilitate long-term mental and physical natural recovery processes.

 ● Explore the resilience flexibility sequence in a variety of trauma populations and cultural contexts.

 ● Identify mechanisms explaining how traumatizing events and predictive risk factors translate into trajectories of lasting distress such as PTSD, D-PTSD, and CPTSD.

 ● Examine how discrepancies in diagnoses depending on the classification system may impact access to treatment as  well as its efficacy.

 ● Study the need for a formal diagnosis of moral injury in our diagnostic systems, as well as the conceptualization of moral injury in a global context.

 ● There are likely a multitude of biopsychosocial predictors involved in post-trauma responding; more research is needed to build biopsychosocial predictive risk models.

 ● Study how trauma as a transdiagnostic risk factor impacts various psychological sequelae, including SUD, PGD, depression, anxiety (disruptive behaviour problems in children and adolescents), insomnia, nightmares as well as physical health symptoms (e.g. pain, OSA).

 ● Study how transdiagnostic screening instruments may improve identification of trauma-related outcomes and access to care.

 ● Improve prediction of adverse mental health and physical outcomes, possibly with genetic or neurobiological risk markers.

 ● Study more gender diverse populations with PTSD in neurobiological and psychosocial research.

 ● Examine whether in children screening for a wide range of symptoms may improve diagnosis and adequate treatment.

 ● Study how traumatic events in childhood may intertwine with attachment styles and the implications for interventions.

 ● Screening and diagnostic assessment of trauma-related problems in very young children (0-4y) need to be developed – as well as in the very old (in particular with comorbid dementia and cognitive decline).

 ● Examine how in non-Western settings, screening measures that encompass universal, transdiagnostic, and culture-specific traumatic stress responses detect survivors who need treatment.

3. Preventive Interventions

 ● Consider promising agents for more rigorous research on pharmacological prevention of PTSD.

 ● Develop effective strategies for preventing stressful life events, family violence and adverse childhood experiences, as well as for breaking the intergenerational cycle of violence.

 ● Study psychoeducational interventions if not as prevention as a possible first step in stepped care in settings with limited access to mental health care.

 ● Examine which preventive interventions to offer and for whom.

 ● Translate causal mechanisms into targeted interventions that interfere with development and maintenance of PTSD.

 ● Consider to study mindfulness and yoga further for the prevention of PTSD.

 ● Design research to evaluate sex or gender-specific preventive interventions.

 ● Examine preventive interventions in older adults with this growing population worldwide.

 ● Design research to evaluate the effectiveness of prevention interventions in reducing the incidence of PTSD across the lifespan among people living in LMIC.

 ● Explore the ways that interventions may be adapted for greater access through changes to protocols, technology, and models of extender involvement.

 ● Evaluate the potential of brief sleep-focused treatments delivered early after trauma to prevent PTSD, given the growing evidence supporting their ability to facilitate fear extinction learning.

4. Treatment of Trauma-Related Disorders

 ● Study pharmacological augmentation as well as novel standalone pharmacological agents in the treatment of PTSD.

 ● Evidence-based pharmacotherapies for PGD need to be developed and tested.

 ● Identify patients with specific molecular biomarkers to design and test interventions targeting specific biological processes.

 ● Examine which of the evidence-based psychological treatments are most effective in specific populations or settings.

 ● Determine the best practices for promoting sleep health in trauma survivors, including the optimal sequence of integrated sleep- and PTSD-focused treatments, the effect of stand-alone sleep interventions on PTSD, and considerations for military versus civilian populations.

 ● Determine the optimal levels of therapist guidance required for digital interventions 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 or PTSD/SUD.

 ● Given increasing recognition of the benefits of integrating digital technologies into intervention efforts, extend treatment and assessment possibilities into the in vivo and experiential worlds outside of the therapy office.

 ● Improve clinical care by matching individuals to the most appropriate intervention.

 ● Systematic studies of factors that facilitate and impede the implementation of effective interventions for trauma-related disorders in routine clinical practice are needed.

 ● Systematic studies of the best ways of training therapists in routine clinical care in evidence-based psychological treatments for PTSD.

 ● Examine sex and gender differentiation in treatments beyond the binary conceptualization of sex and gender.

 ● Study sex and gender aspects in treatment efficacy in civilian samples around the world.

 ● Enhance knowledge on facilitating factors and barriers to treatment adherence, drop-out in youth is still high.

 ● Examine treatment adaptations in children with mild intellectual disability and the highly gifted ones.

 ● Study interventions using complementary/integrative interventions, also in children and older adults.

 ● Adapt and evaluate established interventions for older individuals given the large number of aging individuals with PTSD and other trauma-related disorders.

 ● Examine how in resource-constrained contexts, evidence-based trauma-focused interventions can be effectively delivered by non-specialist providers.

 ● Examine if and how to adapt evidence-based treatments for local cultural contexts.

5. Methodological developments

 ● Explore the use of artificial intelligence in psychotrauma research.

 ● Use computational models to refine causal theories related to exposure to and the impact of psychological trauma and related stressors/adversities.

 ● Enhance research and global collaboration by having robust FAIR data.

Funding Statement

No specific funding was obtained for this work

Disclosure statement

All authors are editors of the European Journal of Psychotraumatology.