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Post-traumatic stress disorder overview

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These are the paths in the Post-traumatic stress disorder pathway:

Post-traumatic stress disorder HAI

About

What is covered

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.

Updates

Updates to this pathway

18 August 2014 Minor maintenance updates.
5 February 2014 Anxiety disorders quality standard added to the pathway
6 November 2013 Minor maintenance updates
15 February 2013 Minor maintenance updates

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 the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, 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.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

The management of post-traumatic stress disorder in adults and children in primary and secondary care

What is covered

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.

Updates

Updates to this pathway

18 August 2014 Minor maintenance updates.
5 February 2014 Anxiety disorders quality standard added to the pathway
6 November 2013 Minor maintenance updates
15 February 2013 Minor maintenance updates

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Post-traumatic stress disorder (PTSD). NICE clinical guideline 26 (2005)

Quality standards

Anxiety disorders

These quality statements are taken from the anxiety disorders quality standard. The quality standard defines clinical best practice for anxiety disorders care and should be read in full.

Quality statements

Assessment of suspected anxiety disorders

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with a suspected anxiety disorder receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.

Rationale

Accurate diagnosis of a person’s specific anxiety disorder can help them understand their condition and ensure that they are offered the most appropriate treatment at the earliest opportunity.

Quality measures

Structure
a) Evidence of local arrangements for people with a suspected anxiety disorder to receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that healthcare professionals receive training to perform assessments of anxiety disorders.
Data source: Local data collection.
Process
Proportion of people with a suspected anxiety disorder who receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Numerator – the number of people in the denominator who receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Denominator – the number of people with a suspected anxiety disorder.
Data source: Local data collection

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure they provide services for people who have a suspected anxiety disorder to diagnose specific anxiety disorders, and that the assessment services are delivered by fully trained healthcare professionals.
Healthcare professionals carry out an assessment for people who have a suspected anxiety disorder to diagnose specific anxiety disorders, or refer to a practitioner who is trained to carry out such an assessment.
Commissioners ensure that they commission services that carry out assessments for people with a suspected anxiety disorder to diagnose specific anxiety disorders.

What the quality statement means for service users and carers

People who may have an anxiety disorder are offered an assessment to find out whether they do have an anxiety disorder, what type of disorder it is and the effect it may have on their everyday life.

Source guidance

Definitions of terms used in this quality statement

Anxiety disorder
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Assessment of anxiety disorders
Assessment of anxiety disorders includes the nature, duration and severity of the presenting disorder and associated functional impairment. It also includes consideration of the ways in which the following factors may have affected the development, course and severity of the disorder:
  • a history of any mental health disorder
  • a history of a chronic physical health problem
  • any past experience of, and response to, treatments
  • the quality of interpersonal relationships
  • living conditions and social isolation
  • a family history of mental illness
  • a history of domestic violence or sexual abuse
  • employment and immigration status.
[NICE clinical guideline 123, recommendations 1.3.2.4 and 1.3.2.6]
A diagnostic or problem identification tool or algorithm may be used to inform the assessment. [NICE clinical guideline 123, recommendation 1.3.2.3, NICE clinical guideline 159, recommendations 1.2.7 and 1.4.9 to 1.4.12]
Assessment of social anxiety disorder
The assessment of social anxiety disorder is slightly different from the assessment of other anxiety disorders. It includes consideration of fear, avoidance, distress and functional impairment. It takes into account comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis and autism. A detailed description of the person’s current social anxiety and associated problems and circumstances is obtained, including:
  • feared and avoided social situations
  • what they are afraid might happen in social situations (for example, looking anxious, blushing, sweating, trembling or appearing boring)
  • anxiety symptoms
  • view of self
  • content of self-image
  • safety-seeking behaviours
  • focus of attention in social situations
  • anticipatory and post-event processing
  • occupational, educational, financial and social circumstances
  • family circumstances and support (for children and young people)
  • friendships and peer groups (for children and young people)
  • medication, alcohol and recreational drug use.
[NICE clinical guideline 159, recommendations 1.2.5 to 1.2.9 and 1.4.5 to 1.4.8]
Suspected anxiety disorder
An anxiety disorder may be suspected in people with a past history of an anxiety disorder, possible somatic symptoms of an anxiety disorder or recent experience of a traumatic event, and in people who avoid social situations. It may be suspected because of the person’s responses to initial questions about their symptoms. The 2-item Generalized Anxiety Disorder scale may be used to ask the person about their feelings of anxiety and their ability to stop or control worry. [NICE clinical guideline 123, recommendation 1.3.1]

Equality and diversity considerations

Consideration should be given to modifying the method and mode of delivery of assessment according to the needs of the person with a suspected anxiety disorder. Technology should be considered for people who may find it difficult to, or choose not to, attend a specific service, for example people with social anxiety who are anxious about attending a healthcare service. Communication needs should be considered for people who do not have English as their first language, for example by providing bilingual therapists or independent translators.
For people with sensory impairment or a learning disability, use of the distress thermometer and asking a family member or carer about the person’s symptoms should be considered.
When assessing people with a suspected anxiety disorder and a moderate to severe learning disability or moderate to severe acquired cognitive impairment, consideration should be given to consulting a relevant specialist.
Assessments should be culturally sensitive, using suitable explanatory models of common mental health disorders and addressing any cultural and ethnic needs. Relevant information, including cultural or other individual characteristics that may be important in subsequent care, should be identified during assessment. For example, if the boundary between religious or cultural practice and obsessive–compulsive symptoms is unclear, healthcare professionals should, with the service user’s consent, consider seeking the advice and support of an appropriate religious or community leader to support the therapeutic process.

Pharmacological treatment

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with an anxiety disorder are not prescribed benzodiazepines or antipsychotics unless specifically indicated.

Rationale

NICE guidance provides recommendations on pharmacological therapies for anxiety disorders. Benzodiazepines are associated with tolerance and dependence, and antipsychotics are associated with a number of adverse effects. Therefore they should not be used routinely to treat anxiety disorders.
Healthcare professionals should be aware of circumstances in which benzodiazepines and antipsychotics may be appropriate, such as short-term care and anxiety disorder crises.

Quality measures

Structure
Evidence of local monitoring arrangements to ensure that people with an anxiety disorder are not prescribed a benzodiazepine or an antipsychotic to treat their disorder unless specifically indicated.
Data source: Local data collection.
Process
a) Proportion of people who have an anxiety disorder and are prescribed a benzodiazepine that is not specifically indicated.
Numerator – the number of people in the denominator for whom a benzodiazepine is not specifically indicated.
Denominator – the number of people with an anxiety disorder who are prescribed a benzodiazepine.
b) Proportion of people who have an anxiety disorder and are prescribed an antipsychotic that is not specifically indicated.
Numerator – the number of people in the denominator for whom an antipsychotic is not specifically indicated.
Denominator – the number of people with an anxiety disorder who are prescribed an antipsychotic.
Data source: Local data collection.
Outcome
a) Rates of prescribing benzodiazepines.
b) Rates of prescribing antipsychotics.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are procedures and protocols in place to monitor the prescribing of pharmacological treatment for people with anxiety disorders to ensure that benzodiazepines and antipsychotics are not offered to treat that disorder unless specifically indicated.
Healthcare professionals ensure that people with anxiety disorders are not offered benzodiazepines or antipsychotics to treat that disorder unless specifically indicated.
Commissioners ensure that they monitor rates of prescribing of benzodiazepines and antipsychotics to treat anxiety disorders and only commission services from providers who can demonstrate they have procedures and protocols in place to monitor this prescribing.

What the quality statement means for service users and carers

People with an anxiety disorder are not offered benzodiazepines (medication used to help people sleep or act as a sedative) or antipsychotics (medication used mainly to treat psychotic conditions such as schizophrenia) for that disorder unless there are specific clinical reasons why these treatments may be of short-term benefit.

Source guidance

  • Obsessive-compulsive disorder and body dysmorphic disorder (NICE clinical guideline 31), recommendations 1.5.3.21, 1.5.3.22 and 1.5.6.21.
  • Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults (NICE clinical guideline 113), recommendations 1.2.25 (key priority for implementation), 1.4.7 and 1.4.8.
  • Social anxiety disorder (NICE clinical guideline 159), recommendation 1.6.2.

Definitions of terms used in this quality statement

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.

Psychological interventions

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with an anxiety disorder are offered evidence-based psychological interventions.

Rationale

Evidence-based psychological interventions can be effective treatments for anxiety disorders. They are recommended first-line treatments in preference to pharmacological treatment. Healthcare professionals should usually offer or refer for the least intrusive, most effective intervention first, in line with the stepped-care approach set out in the NICE guidance.

Quality measures

Structure
Evidence of local arrangements to ensure that people with an anxiety disorder are offered evidence-based psychological interventions.
Data source: Local data collection.
Process
Proportion of people with an anxiety disorder who receive evidence-based psychological interventions.
Numerator – the number of people in the denominator who receive evidence-based psychological interventions.
Denominator – the number of people with an anxiety disorder.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that they are able to provide evidence-based psychological interventions to people who are referred to them with anxiety disorders.
Healthcare professionals ensure that they offer evidence-based psychological interventions to people with anxiety disorders.
Commissioners ensure that they commission services from providers that are able to deliver evidence-based psychological interventions to meet the needs of people with anxiety disorders.

What the quality statement means for service users and carers

People with an anxiety disorder are offered psychological treatments (sometimes called ‘talking treatments’) that have been shown by evidence to be helpful for their disorder.

Source guidance

  • Common mental health disorders (NICE clinical guideline 123), recommendation 1.4.1.4.
  • Obsessive-compulsive disorder and body dysmorphic disorder (NICE clinical guideline 31), recommendations 1.5.1.8, 1.5.1.9 (key priority for implementation) and 1.5.1.10 (key priority for implementation).
  • Post-traumatic stress disorder (NICE clinical guideline 26), recommendations 1.9.5.1 and 1.9.5.2 (key priorities for implementation).
  • Social anxiety disorder (NICE clinical guideline 159), recommendations 1.3.2 (key priority for implementation), 1.3.4 (key priority for implementation), 1.3.7, 1.3.12, 1.5.3 (key priority for implementation) and 1.5.6.

Definitions of terms used in this quality statement

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Evidence-based psychological interventions
Evidence-based psychological interventions include both low-intensity interventions incorporating self-help approaches and high-intensity psychological therapies.
For adults with generalised anxiety disorder, panic disorder, post-traumatic stress disorder, obsessive–compulsive disorder or body dysmorphic disorder psychological interventions are offered based on the stepped-care approach. [NICE clinical guideline 123, recommendation 1.4.1.4]
Cognitive behavioural therapy has been specifically developed to treat social anxiety disorder in adults, children and young people [NICE clinical guideline 159, recommendations 1.3.2 and 1.5.3]
Psychological therapies have been specifically developed to treat obsessive–compulsive disorder, body dysmorphic disorder and post-traumatic stress disorder in children and young people. [NICE clinical guideline 31, recommendations 1.5.1.9 and 1.5.1.10; NICE clinical guideline 26, recommendation 1.9.5]

Equality and diversity considerations

For people with generalised anxiety disorder who have a learning disability or cognitive impairment, methods of delivering treatment and treatment duration should be adjusted if necessary to take account of the disability or impairment, with consideration given to consulting a relevant specialist.
It is important that healthcare professionals familiarise themselves with the cultural background of the person with an anxiety disorder. They should pay particular attention to identifying people with post-traumatic stress disorder whose work or home culture is resistant to recognising the psychological consequences of trauma.

Monitoring treatment response

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People receiving treatment for an anxiety disorder have their response to treatment recorded at each treatment session.

Rationale

Regular monitoring of psychological and pharmacological treatment response ensures that the effectiveness of treatment can be assessed and treatment adjusted if needed. It also provides an opportunity for healthcare professionals to monitor other outcomes such as effects on any long-term conditions and the person’s ability to continue or return to employment.

Quality measures

Structure
Evidence of local arrangements to monitor response to treatment for people being treated for an anxiety disorder at each treatment session and use the findings to adjust delivery of interventions.
Data source: Local data collection.
Process
Proportion of people receiving treatment for an anxiety disorder who have their response to treatment recorded at initial contact and each subsequent treatment session.
Numerator – the number of people in the denominator whose response to treatment is recorded at initial contact and each subsequent treatment session.
Denominator – the number of people receiving treatment for an anxiety disorder.
Outcome
Evidence from feedback that people receiving treatment for an anxiety disorder are aware of their progress.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to record response to treatment at each treatment session for people receiving treatment for anxiety disorders.
Healthcare professionals ensure that they record response to treatment at each treatment session for people receiving treatment for anxiety disorders and adjust treatment if needed.
Commissioners ensure that they commission services that record response to treatment at each treatment session for people receiving treatment for anxiety disorders.

What the quality statement means for service users and carers

People who are receiving treatment for an anxiety disorder have a check at each treatment session to find out how well their treatment is working and help decide how best to continue with their treatment.

Source guidance

  • Common mental health disorders (NICE clinical guideline 123), recommendations 1.5.1.3 (key priority for implementation) and 1.5.1.10.
  • Social anxiety disorder (NICE clinical guideline 159), recommendations 1.3.1 (key priority for implementation) and 1.5.1.

Definitions

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Monitoring
This includes individual routine outcome measurement, which can be made available for routine reporting and aggregation of outcome measures, as well as audit and review of effectiveness. Specific monitoring tools and routine outcome measures are used. [Adapted from NICE clinical guideline 123 and NICE clinical guideline 159]
Treatment for an anxiety disorder
Treatments for which responses are monitored include psychological interventions and pharmacological treatment.

Equality and diversity considerations

The method of collecting self-reported treatment responses should be tailored to the person with an anxiety disorder, according to their communication needs and preferences. It should be culturally appropriate, accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with anxiety disorders should have access to an interpreter or advocate if needed.

Effective interventions library

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.

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 each of the following topics.

Pathway information

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 the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, 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.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Glossary

Cognitive behavioural therapy.
Care Programme Approach.
Eye movement desensitisation and reprocessing.
Post-traumatic stress disorder.
Selective serotonin re-uptake inhibitor.

Paths in this pathway

Pathway created: March 2012 Last updated: August 2014

© NICE 2014

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