The paradox of the biopsychological and sociocultural levels in post‐traumatic stress disorder
Authors: Andreas Maercker
Journal: World Psychiatry (2025)

It is fascinating to see how the field of post-traumatic stress disorder (PTSD) has evolved over the past 50 years. The team of authors led by C. Brewin1 – comprising psychologists, epidemiologists, psychiatrists, and intervention researchers – provides a comprehensive analysis of the significant developments in this field and the underlying empirical evidence. I would like to enumerate a few points on which I am in complete agreement with the authors. First, there is now an accepted set of different phenotypes of PTSD, which includes the "classic" PTSD known for several decades, complex PTSD, a severe dissociative condition, and other phenotypes that have been linked to childhood trauma. Second, the diagnosis should rely on the pattern of symptoms and resulting disabilities rather than on definitions of a trauma criterion, as is still often the case when diagnosing PTSD to this day. Third, delayed PTSD is essentially based on an altered stress sensitivity, and the patients display isolated post-traumatic symptoms prior to the full development of the condition. On all these points, the authors' thorough presentation deserves gratitude and dissemination in the professional community. Brewin et al's extension of the core psychopathology theory of PTSD from disturbed memory to identity changes is also noteworthy. However, a core phenomenon of trauma-related disorders should also be highlighted, which we refer to as the biopsychological-sociocultural paradox (in brief, the fact that traumatic experiences mostly disrupt biopsychological processes, while sociocultural processes usually foster recovery). In the field of biology, numerous studies have documented the existence of deficits and vulnerabilities related to PTSD in a multitude of regulatory systems and circuits. In the field of psychological processes, empirical research has initially focused on memory changes and then on identity impairments. In the clinical setting, this is evidenced by a focus on the core symptoms of patients' suffering, including re-experiencing, avoidance and the persistent (physiological) sense of threat. The paradox is that the most effective antidote for all these biopsychological disturbances is social support for those affected2. There is sufficient evidence from multiple studies to confirm that appropriate social support for victims or survivors can effectively reduce the impact of trauma-related disorders3. This phenomenon can be observed clinically in the shorter recovery times of socially well-connected and culturally integrated patients in treatment facilities4. It is worth noting that not all the various factors in the biopsychological areas are exclusively pathogenic. To give a few examples, there are protective factors such as a larger hippocampal volume or, in the psychological realm, the range of less avoidant coping strategies. Nevertheless, seeking social support of others – friends, family or members of one's cultural community – consistently yields greater protective effects than factors in the biological and psychological areas. The apparent contradiction between the biopsychological predominance of deficits and the social-interpersonal-cultural predominance of antidotes may be related to the ontological status of PTSD. It could be said that PTSD is a "silent suffering" of individuals: after traumatization, patients do not usually complain to others about their suffering. Those who have experienced such distress might find it normal and inevitable5, 6. Some have suggested that this may be one reason why this mental disorder was "discovered" so late compared to depression, psychosis and anxiety disorders. It is possible that, in these other conditions, behaviors, facial expressions and body postures signal to social partners that one is "ill". The philosophical basis of the embodiment of mental disorders recently described in this journal7 may be therefore comparatively less pronounced in PTSD. The cultural psychology of PTSD, with its admittedly not yet very advanced research program, suggests that PTSD could be a primarily "social disease". This, of course, does not undermine the suffering experienced by those afflicted with this disorder. However, this assertion is consistent with findings from prevention and treatment research, as discussed in the paper by Brewin et al. According to this, current preventive programs place a strong emphasis on dyadic or group cohesion aspects. What are the most pressing transcultural issues for reducing suffering after trauma in the future? In my view, it would be beneficial to first consider why there is such a low utilization of PTSD treatment services in cultures other than the European-North American (Global North) ones. Even in these Global North cultures, there are differences. In large groups of affected people, there is no perception of needing help. For example, after the 9/11 attacks in New York, the quickly established outpatient mental health emergency help centers had only a few requests from people seeking help. Could it be that there are different cultural scripts of post-traumatic suffering that go far beyond the symptom descriptions of the DSM and ICD? Many individuals who have experienced trauma have a self-perception of being "broken" or having "a kink in their lifeline"8. The provision of lists of cultural syndromes and idioms of distress for consequences of trauma, as mentioned by Brewin et al, could be improved from a scientific standpoint. A key question is how such divergent cultural idioms arise, and how they can be integrated into an overarching, systematic context. In light of the above, it seems reasonable to suggest that transcultural research that takes into account global matrices of values, norms and traditions may be a logical choice. For instance, a study conducted in Rwanda with traumatized individuals, many of whom were survivors of the genocide against the Tutsis in the 1990s, indicated that the values of not showing suffering and maintaining self- and community reputation, as well as Ubuntu (in short, humanity towards others), apparently mediate the expression of suffering9. After a thorough examination of the social and cultural factors influencing the expression of post-traumatic suffering and the utilization of specialized assistance, it may be possible to place the field of treatment on a more nuanced social and cultural foundation. Brewin et al's paper correctly emphasizes the significant potential of community-based interventions, particularly in addressing health disparities.