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Post-traumatic stress disorder

Short Text

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

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

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

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:
NICE has also written information for the public explaining its quality standard 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 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.

Updates to this pathway

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

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

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Person 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

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Recognition 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

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Assessment 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

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Providing 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

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Managing 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 a pathway on personality disorders.

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

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Interventions 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.

Quality standards

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Anxiety disorders quality standard

Source guidance

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Early 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

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Interventions 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

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Drug 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

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Disaster 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

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Patient and service user experience in adult NHS and mental health services

Patient and service user experience in adult NHS and mental health services

Patient and service user experience in adult NHS and mental health services

NICE has produced pathways on:

Paths in this pathway

Pathway created: March 2012 Last updated: February 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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