PTSD: there is still much to discover
PTSD is a global challenge. Clinical overview, guideline comparison, and future treatment developments.
What can happen after a traumatic event?
Defined and studied in the United States, especially since the Vietnam War and its effects on veterans, PTSD can occur in people of all ages, from children and adolescents to adults, and can also occur in family members, witnesses and rescuers involved in a traumatic event. PTSD can also result from repeated and continuous exposure to episodes of violence and degradation.
PTSD is a debilitating psychiatric condition that may arise after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. First included in the DSM-III in 1980, PTSD has since evolved conceptually and diagnostically. It is now recognised as a disorder with diverse clinical trajectories and varying levels of complexity, including chronic forms and complex PTSD (cPTSD) as defined by the ICD-11.
As it is a complex mental disorder resulting from multiple factors, both personal and environmental, the diagnosis of PTSD is neither straightforward nor simple and is generally referred to as “the acute stress disorder that occurs following exposure to a traumatic event”.
People have different levels of susceptibility and vulnerability to stress, depending on their degree of direct involvement in the traumatic experience. However, several studies have shown that, especially in the case of children and adolescents, even indirect exposure, such as through the media, to events involving their own country or city, for example, can lead to PTSD. Some victims experience anxiety and bad memories that resolve with appropriate treatment and time. At the opposite extreme, however, there are individuals in whom the traumatic event causes long-term negative effects.
Epidemiology
Global data suggest a lifetime prevalence of PTSD around 3.9%, increasing to 5.6% in populations exposed to war or mass violence. Certain subgroups - such as survivors of sexual assault, refugees, ICU patients, and emergency responders - present much higher rates, often exceeding 20%.
Women are twice as likely to develop PTSD as men, likely due to both exposure type and differential neurobiological responses to trauma. Other risk factors include early life adversity, prior psychiatric history, and lack of social support.
Diagnosis and classification
In DSM-5, PTSD is diagnosed when symptoms from four distinct clusters (intrusion, avoidance, changes in thinking and mood, changes in arousal and reactivity) persist beyond one month and cause impairment. In contrast, ICD-11 simplifies PTSD criteria to three core elements: re-experiencing, avoidance, and a persistent sense of threat. It also introduces Complex PTSD, characterised by additional disturbances in self-organisation: affect dysregulation, negative self-concept, and interpersonal difficulties.
This divergence is not just semantic. ICD-11’s model is increasingly adopted in Europe and provides a framework for recognising chronic, developmental, or interpersonal trauma presentations.
Management guidelines in Europe
In Europe, clinical management is primarily guided by the NICE guideline (NG116, 2018) from the UK, and the ISTSS international guideline.
Both recommend trauma-focused psychological therapies as first-line treatment, including:
- Trauma-focused Cognitive Behavioural Therapy (CBT-TF)
- Eye Movement Desensitisation and Reprocessing (EMDR)
Pharmacotherapy is reserved for patients who refuse or cannot access psychotherapy. Benzodiazepines and antipsychotics are explicitly discouraged.
The ISTSS guidelines further support a modular, population-sensitive approach and formally endorse the ICD-11 framework, including cPTSD. They are widely used in specialised services, refugee clinics, and humanitarian settings. Access to trained trauma therapists remains a limiting factor in several European countries. Telehealth and digital solutions are expanding but still under assessment.
Clinical guidelines in the United States
The two main reference documents in the U.S. are the VA/DoD Clinical Practice Guideline (2023) and the newly updated APA Clinical Practice Guideline (2025). Both guidelines endorse trauma-focused psychotherapy as first-line (strong recommendation), particularly: Cognitive Processing Therapy (CPT), Prolonged Exposure (PE) and Trauma-focused CBT. They consider EMDR and Narrative Exposure Therapy (NET) as second-line (conditional recommendation). Both recommend SSRIs (fluoxetine, sertraline, paroxetine) or SNRIs (venlafaxine) as pharmacological options, with conditional support.
Unlike European systems, pharmacotherapy plays a slightly larger role in U.S. protocols, especially when psychotherapy access is limited. However, benzodiazepines and antipsychotics are discouraged in both systems.
The APA 2025 guideline introduces new types of recommendations:
- Implementation considerations (e.g. cultural adaptations, shared decision-making)
- Research priorities (e.g. complex trauma, diverse populations, psychedelics)
Although DSM-5 does not include Complex PTSD, the APA guideline explicitly acknowledges the ICD-11 construct and includes systematic reviews on this population.
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Area
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Europe
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USA
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First-line therapy
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TF-CBT, EMDR
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TF-CBT, PE, CPT
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EMDR
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Strongly recommended
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Second-line
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SSRIs/SNRIs
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Only when psychotherapy not possible
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Earlier and more broadly integrated
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Complex PTSD
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Recognised (ICD-11)
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Not formally recognised (DSM-5)
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New therapies (e.g., MDMA, ketamine)
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Investigational only
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Also investigational, APA 2025:
insufficient evidence
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A complex and multifaceted disorder
PTSD is a complex and multifaceted disorder, with substantial variability in symptomatology, comorbidities, and response to treatment. While most patients benefit from first-line trauma-focused psychotherapies, a significant proportion remain symptomatic, particularly those with complex trauma histories or comorbid psychiatric conditions.
Ongoing research is expanding our understanding of the neurobiological mechanisms underlying PTSD, including dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered amygdala-prefrontal connectivity, and epigenetic changes. These findings are guiding the development of novel therapeutic approaches beyond the traditional model of psychotherapy and SSRIs (MDMA-assisted psychotherapy, Ketamine, digital and telehealth interventions, experimental use of psychedelics and neuromodulation techniques).
At the same time, greater attention is being paid to cultural adaptation, individualised care plans, and the integration of complex PTSD frameworks, especially in populations exposed to repeated or developmental trauma.
- American Psychological Association. APA Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. 2025.
- Koenen, K. C., Ratanatharathorn, A., Ng, L., et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychological Medicine, 47(13), 2260–2274. 2017.
- Maercker, A., Brewin, C. R., Bryant, R. A., et al. Diagnosis and classification of disorders specifically associated with stress: Proposals for ICD-11. World Psychiatry, 12(3), 198–206. 2013.
- National Institute for Health and Care Excellence. Post-traumatic stress disorder (NG116). 2018
- Mitchell, J. M., Bogenschutz, M., Lilienstein, A., et al. MDMA-assisted therapy for severe PTSD: A randomized, double-blind, placebo-controlled phase 3 study. Nature Medicine, 27(6), 1025–1033. 2021.