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Post-traumatic stress disorder
Short Text
Introduction
This pathway covers the diagnosis and treatment of PTSD in adults and children in primary and secondary care. PTSD can develop in people of any age following a stressful event or situation of an exceptionally threatening or catastrophic nature. Up to 30% of people experiencing a traumatic event may develop PTSD. PTSD does not usually develop following generally upsetting situations such as divorce, loss of job, or failing an exam.
Effective treatment of PTSD can only take place if the disorder is recognised. In some cases, for example following a major disaster, specific arrangements to screen people at risk may be considered. For the vast majority of people with PTSD, opportunities for recognition and identification come as part of routine healthcare interventions, such as treatment following an assault or accident, or when domestic violence or childhood sexual abuse is disclosed.
Symptoms often develop immediately after the traumatic event but the onset of symptoms may be delayed in some people (less than 15%). People with PTSD may not present for treatment for months or years after onset of symptoms. PTSD is treatable even when problems present many years after the traumatic event. Remember that PTSD can also develop in children following a traumatic event. Identification of PTSD in children presents particular problems, but is improved if children are asked directly about their experiences. Assessment can present significant challenges as many people avoid talking about their problems.
Source guidance
The NICE guidance that was used to create the pathway.
Post-traumatic stress disorder (PTSD). NICE clinical guideline 26 (2005)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Commissioning
These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
Education and learning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Pathway information
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on:
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
15 February 2013 Minor maintenance updates
Supporting information
Glossary
Cognitive behavioural therapy.
Care Programme Approach.
Eye movement desensitisation and reprocessing.
Post-traumatic stress disorder.
Selective serotonin re-uptake inhibitor.
Services for suspected post-traumatic stress disorder
Services for suspected post-traumatic stress disorder
People at risk after a disaster, and refugees and asylum seekers
People at risk after a disaster, and refugees and asylum seekers
People at risk after a disaster, and refugees and asylum seekers
Screening after a major disaster
Those coordinating the disaster plan should consider using a brief screening instrument for PTSD 1 month after the event for people at high risk of developing PTSD following a major disaster.
Screening refugees and asylum seekers
Those managing refugee programmes should consider using a brief screening instrument for PTSD for:
- programme refugees (people who are brought to the UK from a conflict zone through a programme organised by an agency such as the United Nations High Commission for Refugees) and
- asylum seekers at high risk of developing PTSD.
This should be part of the initial refugee healthcare assessment and of any comprehensive physical and mental health screen.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePerson with suspected PTSD
Person with suspected PTSD
Person with suspected PTSD
Symptoms typically associated with PTSD are as follows:
- re-experiencing – flashbacks, nightmares, repetitive and distressing intrusive images or sensory impressions; in children, these symptoms may include: re-enacting the experience, repetitive play or frightening dreams without recognisable content
- avoidance – avoiding people, situations or circumstances resembling or associated with the event
- hyperarousal – hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
- emotional numbing – lack of ability to experience feelings, feeling detached from other people, giving up previously significant activities, amnesia for significant parts of the event
- depression
- drug or alcohol misuse
- anger
- unexplained physical symptoms (resulting in repeated attendance).
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeRecognition in primary care and general hospital settings
Recognition in primary care and general hospital settings
Recognition in primary care and general hospital settings
If it is not immediately clear that symptoms relate to a specific traumatic event:
- ask patients if they have experienced a traumatic event and give examples (such as assault, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth)
- consider asking adults specifically about re-experiencing (including flashbacks and nightmares) or hyperarousal (including exaggerated startle response or sleep disturbance).
Specific recognition issues for children and young people
Do not rely solely on information from the parent/guardian in any assessment for PTSD – ask the child or young person separately and directly about PTSD symptoms.
Consider asking children and/or their parents/guardians about sleep disturbance or significant changes in sleeping patterns.
Children in emergency departments
Inform the parents/guardians that PTSD may develop in children who have been involved in traumatic events.
Briefly describe the possible symptoms to the parents/guardians (for example sleep disturbance, nightmares, difficulty concentrating and irritability).
Suggest to parents/guardians they contact the child's GP if the symptoms persist beyond 1 month.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAssessment and coordination of care
Assessment and coordination of care
Assessment and coordination of care
GPs should take responsibility for initial assessment and coordination of care of people with PTSD in primary care and determine the need for emergency medical or psychiatric assessment.
Ensure that assessment is comprehensive and includes a risk assessment and assessment of physical, psychological and social needs, and is conducted by a competent healthcare professional.
Give people with PTSD sufficient information about effective treatments and take into account their preference for treatment.
If management is shared between primary and secondary care, establish a written agreement outlining the responsibilities for monitoring people with PTSD. Share it with the person with PTSD and (if appropriate) their family and carers. Where appropriate, use the CPA.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeProviding support
Providing support
Providing support
Support to families and carers
Consider and, when appropriate, assess the impact of the traumatic event on all family members and consider providing appropriate support.
With the consent of the person with PTSD where appropriate, inform their family about common reactions to traumatic events, the symptoms of PTSD, and its course and treatment.
Inform families and carers about self-help and support groups and encourage them to participate.
Effectively coordinate the treatment of all family members if more than one family member has PTSD.
Practical and social support
Provide practical advice to enable people with PTSD to access appropriate information and services for the range of emotional responses that may develop.
Identify the need for social support and advocate for the meeting of this need.
Consider offering help and advice on how continuing threats related to the traumatic event may be alleviated or removed.
Language and culture
Familiarise yourself with the cultural and ethnic backgrounds of people with PTSD.
Consider using interpreters and bicultural therapists if language or cultural differences present challenges for trauma-focused psychological interventions.
Pay particular attention to the identification of people with PTSD where the culture of the working or living environment is resistant to recognition of the psychological consequences of trauma.
Providing best care
When developing and agreeing a treatment plan, ensure people with PTSD receive information about common reactions to traumatic events, the symptoms of PTSD, and its course and treatment.
Do not withhold or delay treatment because of court proceedings or applications for compensation.
Respond appropriately if a person with PTSD is anxious about and may avoid treatment (for example by following up those who miss scheduled appointments).
Keep technical language to a minimum and treat patients with respect, trust and understanding.
Only consider providing trauma-focused psychological treatment when the patient considers it safe to proceed.
Ensure that treatment is delivered by competent healthcare professionals who have received appropriate training.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeManaging comorbidities
Managing comorbidities
Managing comorbidities
Depression
Consider treating the PTSD first unless the depression is so severe that it makes psychological treatment very difficult, in which case treat the depression first.
NICE has produced a pathway on depression.
High risk of suicide or at risk of harming others
Concentrate first on the management of this risk in people with PTSD.
NICE has produced a pathway on the management of self-harm.
Drug or alcohol problem
Treat any significant drug or alcohol problem before treating the PTSD.
NICE has produced a pathway on alcohol-use disorders.
Personality disorders
For people with PTSD and a personality disorder, consider extending the duration of trauma-focused psychological interventions.
NICE has produced guidance on antisocial personality disorder and borderline personality disorder
Death of a close friend or relative
For patients who have lost a close friend or relative due to an unnatural or sudden death, assess for PTSD and traumatic grief and consider treating the PTSD first (without avoiding discussion of the grief).
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeInterventions for children and young people
Interventions for children and young people
Interventions for children and young people
Interventions in the first month after a trauma
Offer trauma-focused CBT to older children with severe post-traumatic symptoms or with severe PTSD in the first month after the event.
Interventions more than 3 months after a trauma
Offer children and young people a course of trauma-focused CBT adapted as needed to suit their age, circumstances and level of development. This should also be offered to those who have experienced sexual abuse.
For chronic PTSD in children and young people resulting from a single event, consider offering 8–12 sessions of trauma-focused psychological treatment. When the trauma is discussed, longer treatment sessions (90 minutes) are usually necessary.
Psychological treatment should be regular and continuous (usually at least once a week) and delivered by the same person.
Do not routinely prescribe drug treatments for children and young people with PTSD.
Involve families in the treatment of children and young people where appropriate, but remember that treatment consisting of parental involvement alone is unlikely to be of benefit for PTSD symptoms.
Inform parents (and where appropriate, children and young people) that apart from trauma-focused psychological interventions, there is no good evidence for the efficacy of other forms of treatment such as play therapy, art therapy or family therapy.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeEarly interventions
Early interventions
Early interventions
Watchful waiting
Consider watchful waiting when symptoms are mild and have been present for less than 4 weeks after the trauma.
Arrange a follow-up contact within 1 month.
Immediate psychological interventions for all
Be aware of the psychological impact of traumatic events in the immediate post-incident care of survivors and offer practical, social and emotional support.
For people who have experienced a traumatic event, do not routinely offer brief, single-session interventions (debriefing) that focus on the traumatic incident to that person alone.
Interventions for symptoms present within 3 months of a trauma
Offer trauma-focused CBT (usually on an individual outpatient basis) to people:
- with severe post-traumatic symptoms or with severe PTSD within 1 month after the event
- who present with PTSD within 3 months of the event.
Consider offering 8–12 sessions of trauma-focused CBT (or fewer sessions – about 5 – if the treatment starts in the first month after the event). When the trauma is discussed, longer treatment sessions (90 minutes) are usually necessary.
Ensure that psychological treatment is regular and continuous (usually at least once a week) and is delivered by the same person.
Consider the following drug treatment for sleep disturbance:
- hypnotic medication for short-term use
- a suitable antidepressant for longer-term use, introduced at an early stage to reduce later risk of dependence.
Do not routinely offer non-trauma-focused interventions (such as relaxation or non-directive therapy) that do not address traumatic memories.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeInterventions for symptoms present for more than 3 months after a trauma
Interventions for symptoms present for more than 3 months after a trauma
Interventions for symptoms present for more than 3 months after a trauma
Offer trauma-focused psychological treatment (trauma-focused CBT or EMDR) to all patients, usually on an individual outpatient basis.
Consider offering 8–12 sessions of trauma-focused psychological treatment when the PTSD results from a single event. When the trauma is discussed, longer treatment sessions (90 minutes) are usually necessary.
Ensure that trauma-focused psychological treatment is:
- offered regardless of the time elapsed since the trauma
- regular and continuous (usually at least once a week)
- delivered by the same person.
Consider extending trauma-focused psychological treatment beyond 12 sessions and integrating it into an overall care plan if several problems need to be addressed, particularly:
- after multiple traumatic events
- after traumatic bereavement
- where chronic disability results from the trauma
- when significant comorbid disorders or social problems are present.
If the person finds it difficult to disclose details of the trauma(s), consider devoting several sessions to establishing a trusting therapeutic relationship and emotional stabilisation before addressing the trauma.
Do not routinely offer non-trauma-focused interventions (such as relaxation or non-directive therapy) that do not address traumatic memories.
For people with PTSD with no or limited improvement after a specific trauma-focused psychological treatment, consider:
- an alternative form of trauma-focused psychological treatment
- pharmacological treatment in addition to trauma-focused psychological treatment.
If people with PTSD request other forms of psychological treatment (for example supportive therapy, non-directive therapy, hypnotherapy, psychodynamic therapy or systemic psychotherapy), inform them that there is no convincing evidence for a clinically important effect.
Chronic disease management
Consider chronic disease management models for people with chronic PTSD who have not benefited from a number of courses of evidence-based treatment.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeDrug treatments
Drug treatments
Drug treatments
Do not offer drugs as routine first-line treatment for adults with PTSD (for general use or by specialist mental health professionals) in preference to trauma-focused psychological therapy.
Consider paroxetine or mirtazapine (for general use) and amitriptyline or phenelzine (under specialist mental health care supervision) in adults with PTSDParoxetine is the only drug listed with a current UK product licence for PTSD at the date of publication of this pathway (March 2012). :
- if the person prefers not to engage in a trauma-focused psychological treatment
- if the person cannot start psychological treatment because of serious threat of further trauma
- if the person has gained little or no benefit from a course of trauma-focused psychological treatment
- as an adjunct to psychological treatment where there is significant comorbid depression or severe hyperarousal that significantly affects the person's ability to benefit from psychological treatment.
For sleep disturbance, consider:
- hypnotic medication for short-term use
- a suitable antidepressant for longer-term use, introduced at an early stage to reduce later risk of dependence.
When an adult with PTSD responds to drug treatment, continue the treatment for at least 12 months before gradual withdrawal.
When an adult with PTSD does not respond to drug treatment, consider increasing the dose within approved limits. If further drug treatment is considered, it should generally be with a different class of antidepressant or involve the use of adjunctive olanzapine.
Starting drug treatments
Inform all adults with PTSD who are prescribed antidepressants of potential side effects and discontinuation or withdrawal symptoms (particularly with paroxetine) at the time that treatment is initiated.
See adults with PTSD who are at increased risk of suicide, and all people with PTSD aged 18–29, after 1 week of starting antidepressants and frequently thereafter until the risk is not considered significant.
Seek out signs of akathisia, suicidal ideation and increased anxiety and agitation, particularly in the initial stages of SSRI treatment. Advise adults with PTSD of the risk of these symptoms and to seek help promptly if these are distressing.
Review the use of the drug if the person with PTSD develops marked and/or prolonged akathisia.
See adults with PTSD who are not considered to be at increased risk of suicide after 2 weeks of starting antidepressants and thereafter on an appropriate and regular basis (for example every 2–4 weeks in the first 3 months, and at greater intervals thereafter if response is good).
The NICE pathway on antenatal and postnatal mental health has recommendations about using drug treatments in pregnancy.
Discontinuation/withdrawal symptoms
Gradually reduce the dose of antidepressants over a 4-week period (some people may require longer periods).
If discontinuation/withdrawal symptoms are mild, reassure the person with PTSD and arrange for monitoring.
If symptoms are severe, consider re-introducing the original antidepressant (or another with a longer half-life from the same class) and reduce gradually while monitoring symptoms.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeDisaster planning
Disaster planning
Disaster planning
Ensure disaster plans contain provision for a fully coordinated psychosocial response.
Ensure that the psychosocial aspect of the plan contains:
- provision for immediate practical help
- means to support the role of the affected communities in caring for those involved in the disaster
- provision of specialist mental health, evidence-based assessment and treatment services.
Ensure that all healthcare workers involved in a disaster plan have clear roles and responsibilities agreed in advance.
For more information on disaster planning, see People at risk after a disaster, and refugees and asylum seekers in this pathway.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: March 2012 Last updated: February 2013
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