Exposure to Traumatic Events
The consequences to the individual of exposure to traumatic events vary widely. For most people there will be no lasting adverse impact on wellbeing, or any distress will be limited and resolve in the time following the event/s. In others it may cause or contribute to, a range of psychological disorders as well as social and physical problems. The nature and timing of the traumatic exposure may, in part, determine the individual’s response to it. Psychological disorders caused or contributed to by exposure to traumatic events include but not limited to: PTSD, Complex PTSD, depressive disorders, anxiety disorders, substance use disorders, somatic symptom disorders, psychosis and personality disorders.
Mental health clinicians should routinely ask about a trauma history as part of their assessment and consider trauma history in their formulation of difficulties presented by the person accessing services. A full and comprehensive assessment of mental health needs (undertaken by an individual who has the skills required to do so), is vital in order to determine the nature of an individual’s difficulties and needs, an assessment of risk, and co-produce an appropriate management plan.
In the UK, in a recent study (6) just over 30% of young people experienced trauma and 8% developed post traumatic stress disorder (PTSD) by the age of 18 years. There is a greater likelihood of PTSD and Complex PTSD (CPTSD) (1) in ‘at risk’ child populations, i.e., those who had experienced certain adverse childhood experiences (highly stressful, potentially traumatic events) such as abuse or neglect. Rates of PTSD are also much higher in clinical services with ICD-11 PTSD prevalence rates at 24% in a clinical sample in Scotland (7).
For adults in the UK who have lived through traumatic experiences, recent research suggests that 5.3% of people develop PTSD (2). One large survey of the general population in England found that 3 in 100 adults screened positive for PTSD. It is much more common in certain groups of people. Some studies have found that PTSD develops in about:
- 10% rescue workers internationally (3)
- 50% female rape victims (4)
- 8-22% of veterans across their lifespan (5)
This topic page covers therapies and interventions that can help manage response to traumatic events and prevent post-traumatic stress disorder (PTSD) in children, young people and adults and while they may be effective for populations requiring specific consideration (e.g. people with Intellectual Disabilities or dementia), expert assessment is required to determine whether the approach is likely to be appropriate, taking into account available evidence base and preference of the person using services.
Full guidance on best practice in identifying, assessing and managing PTSD can be found in the Matrix guidance on PTSD, NICE (2018) https://www.nice.org.uk/guidance/ng116 (8) and ISTSS guidance (https://istss.org/clinical-resources/treating-trauma/international-practice-guidelines-for-post-trauma) (9)
This topic does not cover Complex PTSD or the wider impact that stress or adverse life events can have. However, guidance for CPTSD is available in CPTSD topic page of the Matrix guidance
Prevention and early treatment following exposure to traumatic events
Research has focused on the impact of psychological interventions and therapies across a number of stages following a traumatic event. This includes preventative approaches, early interventions following detection of PTSD symptoms, treatment of PTSD and treatment of chronic or complex PTSD. This topic focuses primarily on early intervention and treatment of PTSD.
Preventing PTSD
People respond to traumatic events in different ways. The principles involved in preventing PTSD following a traumatic event include promoting natural recovery and support whilst monitoring any symptoms that may lead to clinical diagnosis.
It is recommended that people involved in traumatic events are offered support in an empathic trauma-informed and responsive manner with decisions about care being co-produced with the affected individual as aligned with the National Trauma Training Programme (10). This should include practical, pragmatic support delivered in an empathic manner in accordance with the principles of psychological first aid. Guidance on Psychological First Aid is available through the NES learning platform https://learn.nes.nhs.scot/61302 and Preparing Scotland paper: responding to the psychosocial and mental health needs of people affected by emergencies (2013) (11). All people presenting with symptoms within the first few months of traumatic events should be offered an assessment of mental health needs by a practitioner with appropriate training prior to being offered an intervention. A period of “watchful waiting” in the month following a traumatic event may be appropriate to see if symptoms naturally improve.
There is quality evidence (A) that a Stepped/Collaborative Care approach (which involves screening and direct assessment, followed by the provision of flexible and modular interventions based on an individual’s needs) can have some impact on symptoms (low efficacy). Guidance on access and coordination of care can be found here (https://www.nice.org.uk/guidance/ng116/chapter/Recommendations) (8)
There is insufficient evidence to support any single universal intervention (one provided to everyone exposed) to prevent PTSD in the immediate aftermath of a traumatic event affecting a number of people. The National Institute for Health and Care Excellence (NICE) recommends against psychological debriefing.
Preventing PTSD in Children and Young people:
Currently there is limited research informing early interventions to reduce traumatic stress symptoms in children and young people. In line with the NICE guidelines (8), we recommend against individual single session psychological debriefing based on 2 studies (12,13) which did not demonstrate any benefit in the reduction of PTSD symptoms and suggested that the intervention may slow recovery. One RCT identified a significant reduction in developing PTSD with a targeted family psychosocial intervention and this intervention is recommended (14).
In line with the National Trauma Training Programme, there are a number of pragmatic approaches that are likely to be helpful for infants, children and young people after a traumatic event (10). Key is the presence of a safe, predictable and emotionally available adult. Re-establishing routines around mealtimes and sleeping can be reassuring and provide a sense of stability and safety to a young person. Encouraging social connections within family members and the extended family is important, as well as keeping connected to religious communities, school communities and youth groups. It is helpful to adopt an approach of active listening to a child or young person and to value a young person’s cultural identity as part of the healing process. A period of “active monitoring” in the first month may be appropriate to see if symptoms naturally improve and to allow professionals to target those children and young people with impairing traumatic symptoms to access targeted support (8).
Preventing PTSD in Adults:
There is some limited evidence for interventions that treat early symptoms of PTSD or acute stress disorder and prevent further development of symptoms. The recommendation is to provide individual CBT with a trauma focus or an alternative evidence based psychological therapy such as EMDR (as per evidence table) as soon as symptoms of PTSD or acute stress disorder are identified.
| Recommendation | Who For? | List of Interventions | Type of Psychological Practice | Level of Evidence | Level of Efficacy |
| First line intervention | Children and young people with early signs of PTSD. Family involvement. | Child and Family traumatic Stress Intervention (CFTSI) (14) | Enhanced/ Specialist | B | Medium |
| Recommendation | Who For? | List of Interventions | Type of Psychological Practice | Level of Evidence | Level of Efficacy |
| First line intervention | Adults with symptoms of acute stress disorder or early signs of PTSD | Individual CBT with a Trauma Focus for acute stress disorder and PTSD symptoms (8) | Specialist | A | Medium |
| Alternative recommendation | Adults with symptoms of acute stress disorder or early signs of PTSD which are not combat related. | EMDR for PTSD symptoms (8) | Specialist | B | Medium |
(1) WHO. ICD-11 for Mortality and Morbidity Statistics: 6B40 Post traumatic stress disorder. 2022; Available at: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/2070699808, 2023.
(2) Karatzias T, Hyland P, Bradley A, Cloitre M, Roberts NP, Bisson JI, et al. Risk factors and comorbidity of ICD-11 PTSD and complex PTSD: Findings from a trauma-exposed population based sample of adults in the United Kingdom. Depress Anxiety 2019 Sep;36(9):887-894.
(3) Berger W, Coutinho ESF, Figueira I, Marques-Portella C, Luz MP, Neylan TC, et al. Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers. Soc Psychiatry Psychiatr Epidemiol 2012 Jun;47(6):1001-1011.
(4) Shalev AY, Gevonden M, Ratanatharathorn A, Laska E, van der Mei, Willem F, Qi W, et al. Estimating the risk of PTSD in recent trauma survivors: results of the International Consortium to Predict PTSD (ICPP). World Psychiatry 2019 Feb;18(1):77-87.
(5) Nichter B, Norman S, Haller M, Pietrzak RH. Psychological burden of PTSD, depression, and their comorbidity in the U.S. veteran population: Suicidality, functioning, and service utilization. J Affect Disord 2019 Sep 1;256:633-640.
(6) Lewis SJ, Arseneault L, Caspi A, Fisher HL, Matthews T, Moffitt TE, et al. The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. Lancet Psychiatry 2019 Mar;6(3):247-256.
(7) Karatzias T, Shevlin M, Fyvie C, Hyland P, Efthymiadou E, Wilson D, et al. Evidence of distinct profiles of Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) based on the new ICD-11 Trauma Questionnaire (ICD-TQ). J Affect Disord 2017 Jan 1;207:181-187.
(8) NICE. Post-traumatic stress disorder . 2018;NG116.
(9) ISTSS. ISTSS Guidelines Position Paper on Complex PTSD in Children and Adolescents. 2017; Available at: https://istss.org/getattachment/Treating-Trauma/New-ISTSS-Prevention-and-Treatment-Guidelines/ISTSS_CPTSD-Position-Paper-(Child_Adol)_FNL.pdf.aspx 2022.
(10) NHS Education for Scotland. National Trauma Training Programme. 2022; Available at: www.transformingpsychologicaltrauma.scot/ 2022.
(11) Scottish Government. Preparing Scotland: responding to the psychosocial and mental health needs of people affected by emergencies. 2013; Available at: https://www.gov.scot/publications/preparing-scotland-responding-psychosocial-mental-health-needs-people-affected-emergencies/ 2022.
(12) Zehnder D, Meuli M, Landolt MA. Effectiveness of a single-session early psychological intervention for children after road traffic accidents: a randomised controlled trial. Child Adolesc Psychiatry Ment Health 2010 Feb 8;4:7-2000-4-7.
(13) Stallard P, Velleman R, Salter E, Howse I, Yule W, Taylor G. A randomised controlled trial to determine the effectiveness of an early psychological intervention with children involved in road traffic accidents. J Child Psychol Psychiatry 2006 Feb;47(2):127-134.
(14) Berkowitz SJ, Stover CS, Marans SR. The Child and Family Traumatic Stress Intervention: secondary prevention for youth at risk of developing PTSD. J Child Psychol Psychiatry 2011 Jun;52(6):676-685.
With thanks to the Matrix Cymru team for sharing the results of their evidence review and associated guidance.
Advisory group:
Shumela Ahmed, Dr Millia Begum, Dr Caroline Bruce, Dr Richard Cosway, Dr Paula Easton, Dr Sandra Ferguson, Claire Fyvie, Dr Alasdair Forrest, Alison Haustein Swain, Prof. Thanos Karatzias, Dr Nina Koruth, Linda Mitchell, Dr Leeanne Nicklas, Brodie Patterson, Prof. Kevin Power, Charlotte Strong.
Technical groups:
Dr Millia Begum, Dr Paula Easton, Dr Regina Esiovwa, Dr Richard Cosway, Dr Sandra Ferguson, Prof. Thanos Karatzias, Dr Leeanne Nicklas, Dr Lisa Reynolds, Brodie Patterson.