Post-traumatic stress disorder: evolving conceptualization and evidence, and future research directions.

The diagnosis of post-traumatic stress disorder (PTSD) has shaped understanding of trauma responses. Early diagnostic criteria and epidemiological findings, including sociocultural differences, are reviewed. Evidence shows post-traumatic reactions occur in contexts not previously defined as traumatic. Recent developments such as the DSM-5 dissociative subtype and ICD-11 complex PTSD indicate several distinct PTSD phenotypes. Psychological foundations involve disturbances to memory and identity, with a broader focus on identity accommodating group and communal influences. Biological foundations include genetic and neuroimaging studies. While prevention progress has been disappointing, psychological treatments like trauma-focused cognitive behavior therapy, EMDR, and non-trauma-focused therapies are effective. Emerging identity-based approaches and MDMA-assisted psychotherapy show promise. Adapting interventions in resource-limited settings and community-based approaches are priorities.

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Abstract

The understanding of responses to traumatic events has been greatly influenced by the introduction of the diagnosis of post-traumatic stress disorder (PTSD). In this paper we review the initial versions of the diagnostic criteria for this condition and the associated epidemiological findings, including sociocultural differences. We consider evidence for post-traumatic reactions occurring in multiple contexts not previously defined as traumatic, and the implications that these observations have for the diagnosis. More recent developments such as the DSM-5 dissociative subtype and the ICD-11 diagnosis of complex PTSD are reviewed, adding to evidence that there are several distinct PTSD phenotypes. We describe the psychological foundations of PTSD, involving disturbances to memory as well as to identity. A broader focus on identity may be able to accommodate group and communal influences on the experience of trauma and PTSD, as well as the impact of resource loss. We then summarize current evidence concerning the biological foundations of PTSD, with a particular focus on genetic and neuroimaging studies. Whereas progress in prevention has been disappointing, there is now an extensive evidence supporting the efficacy of a variety of psychological treatments for established PTSD, including trauma-focused interventions - such as trauma-focused cognitive behavior therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) - and non-trauma-focused therapies, which also include some emerging identity-based approaches such as present-centered and compassion-focused therapies. Additionally, there are promising interventions that are neither psychological nor pharmacological, or that combine a pharmacological and a psychological approach, such as 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy. We review advances in the priority areas of adapting interventions in resource-limited settings and across cultural contexts, and of community-based approaches. We conclude by identifying future directions for work on trauma and mental health.