Levels of evidence (I-IV) and grading of recommendations (A-D, GPP) are defined at the end of the Major Recommendations field.
Recognition of Post-traumatic Stress Disorder (PTSD)
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, for example, following an assault or an accident for which physical treatment is required, or when a person discloses domestic violence or a history of childhood sexual abuse. Identification of PTSD in children presents particular problems but is improved if children are asked directly about their experiences.
Recognition in Primary Care
PTSD can present with a range of symptoms, which in most adults are most commonly in the form of very vivid, distressing memories of the event or flashbacks (otherwise known as intrusive or re-experiencing symptoms). However, at times the most prominent symptoms may be avoidance of trauma-related situations or general social contacts. It is important when recognising and identifying PTSD to ask specific questions in a sensitive manner about both the symptoms and traumatic experiences. A number of problems such as depression are often comorbid with PTSD. Often these problems will improve with the treatment of the PTSD, but where this does not happen or the comorbid disorder impedes the effective treatment of the PTSD, it may be appropriate to consider providing specific treatment for that disorder.
GPP - PTSD may present with a range of symptoms (including re-experiencing, avoidance, hyperarousal, depression, emotional numbing, drug or alcohol misuse and anger) and therefore, when assessing for PTSD, members of the primary care team should ask in a sensitive manner whether or not patients with such symptoms have suffered a traumatic experience (which may have occurred many months or years before) and give specific examples of traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth).
GPP - General practitioners and other members of the primary care team should be aware of traumas associated with the development of PTSD. These include single events such as assaults or road traffic accidents, and domestic violence and childhood sexual abuse.
GPP - For patients with unexplained physical symptoms who are repeated attendees to primary care, members of the primary care team should consider asking whether or not they have experienced a traumatic event, and provide specific examples of traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth).
C - When seeking to identify PTSD, members of the primary care team should consider asking adults specific questions about re-experiencing (including flashbacks and nightmares) or hyperarousal (including an exaggerated startle response or sleep disturbance). For children, particularly younger children, consideration should be given to asking the child and/or the parents about sleep disturbance or significant changes in sleeping patterns.
Recognition in General Hospital Settings
Many people attending for medical services in a general hospital setting may have experienced traumatic events. This may be particularly so in emergency departments and in orthopaedic and plastic surgery clinics. For some people with PTSD, this may be the main point of contact with the healthcare system and the opportunity that this presents for the recognition and identification of PTSD should be taken.
GPP - PTSD may present with a range of symptoms (including re-experiencing, avoidance, hyperarousal, depression, emotional numbing and anger) and therefore when assessing for PTSD, members of secondary care medical teams should ask in a sensitive manner whether or not patients with such symptoms have suffered a traumatic experience and give specific examples of traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth).
Screening of Individuals Involved in a Major Disaster, Programme Refugees and Asylum Seekers
Many individuals involved in a major disaster will suffer both short- and long-term consequences of their involvement. Although the development of single-session debriefing is not recommended, screening of all individuals should be considered by the authorities responsible for developing the local disaster plan. Similarly, the vast majority of 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) will have experienced major trauma and may benefit from a screening programme.
C - For individuals at high risk of developing PTSD following a major disaster, consideration should be given (by those responsible for coordination of the disaster plan) to the routine use of a brief screening instrument for PTSD at 1 month after the disaster.
C - For programme refugees and asylum seekers at high risk of developing PTSD, consideration should be given (by those responsible for management of the refugee programme) to the routine use of a brief screening instrument for PTSD as part of the initial refugee healthcare assessment. This should be a part of any comprehensive physical and mental health screen.
Specific Recognition Issues for Children
Children, particularly those aged under 8 years, may not complain directly of PTSD symptoms such as re-experiencing or avoidance. Instead, children may complain of sleeping problems. It is therefore vital that all opportunities for identifying PTSD in children should be taken. Questioning the children as well as parents or guardians will also improve the recognition of PTSD. PTSD is common (up to 30%) in children following attendance at emergency departments for a traumatic injury. Emergency department staff should inform parents or guardians of the risk of their child developing PTSD following emergency attendance for a traumatic injury and advise them on what action to take if symptoms develop.
GPP - When assessing a child or young person for PTSD, healthcare professionals should ensure that they separately and directly question the child or young person about the presence of PTSD symptoms. They should not rely solely on information from the parent or guardian in any assessment.
GPP - When a child who has been involved in a traumatic event is treated in an emergency department, emergency staff should inform the parents or guardians of the possibility of the development of PTSD, briefly describe the possible symptoms (for example, sleep disturbance, nightmares, difficulty concentrating and irritability) and suggest that they contact their general practitioner if the symptoms persist beyond 1 month.
Assessment and Coordination of Care
C - For PTSD sufferers presenting in primary care, General Practitioners (GPs) should take responsibility for the initial assessment and the initial coordination of care. This includes the determination of the need for emergency medical or psychiatric assessment.
GPP - Assessment of PTSD sufferers should be conducted by competent individuals and be comprehensive, including physical, psychological and social needs and a risk assessment.
C - Patient preference should be an important determinant of the choice among effective treatments. PTSD sufferers should be given sufficient information about the nature of these treatments to make an informed choice.
C - Where management is shared between primary and secondary care, there should be clear agreement among individual healthcare professionals about the responsibility for monitoring patients with PTSD. This agreement should be in writing (where appropriate, using the Care Programme Approach) and should be shared with the patient and, where appropriate, their family and carers.
Support for Families and Carers
Families and carers have a central role in supporting people with PTSD. However, depending on the nature of the trauma and its consequences, many families may also need support for themselves. Healthcare professionals should be aware of the impact of PTSD on the whole family.
GPP - In all cases of PTSD, healthcare professionals should consider the impact of the traumatic event on all family members and, when appropriate, assess this impact and consider providing appropriate support.
GPP - Healthcare professionals should ensure, where appropriate and with the consent of the PTSD sufferer where necessary, that the families of PTSD sufferers are fully informed about common reactions to traumatic events, including the symptoms of PTSD and its course and treatment.
GPP - In addition to the provision of information, families and carers should be informed of self-help groups and support groups and encouraged to participate in such groups where they exist.
GPP - When a family is affected by a traumatic event, more than one family member may suffer from PTSD. If this is the case, healthcare professionals should ensure that the treatment of all family members is effectively coordinated.
Practical Support and Social Factors
Practical and social support can play an important part in facilitating a person's recovery from PTSD, particularly immediately after the trauma. Healthcare professionals should be aware of this and advocate for such support when people present with PTSD.
GPP - Healthcare professionals should identify the need for appropriate information about the range of emotional responses that may develop and provide practical advice on how to access appropriate services for these problems. They should also identify the need for social support and advocate the meeting of this need.
GPP - Healthcare professionals should consider offering help or advice to PTSD sufferers or relevant others on how continuing threats related to the traumatic event may be alleviated or removed.
Language and Culture
People with PTSD treated in the National Health Service (NHS) come from diverse cultural and ethnic backgrounds and some have no or limited English, but all should be offered the opportunity to benefit from psychological interventions. This can be achieved by the use of interpreters and bicultural therapists. In all cases, healthcare professionals must familiarise themselves with the cultural background of the sufferer.
GPP - Where a PTSD sufferer has a different cultural or ethnic background from that of the healthcare professionals who are providing care, the healthcare professionals should familiarise themselves with the cultural background of the PTSD sufferer.
GPP - Where differences of language or culture exist between healthcare professionals and PTSD sufferers, this should not be an obstacle to the provision of effective trauma-focused psychological interventions.
GPP - Where language or culture differences present challenges to the use of trauma-focused psychological interventions in PTSD, healthcare professionals should consider the use of interpreters and bicultural therapists.
GPP - Healthcare professionals should pay particular attention to the identification of individuals with PTSD where the culture of the working or living environment is resistant to recognition of the psychological consequences of trauma.
Care for All People with PTSD
PTSD responds to a variety of effective treatments. All treatment should be supported by appropriate information to sufferers about the likely course of such treatment. A number of factors, which are described below, may modify the nature, timing and course of treatment.
Care Across All Conditions
GPP - When developing and agreeing a treatment plan with a PTSD sufferer, healthcare professionals should ensure that sufferers receive information about common reactions to traumatic events, including the symptoms of PTSD and its course and treatment.
C - Healthcare professionals should not delay or withhold treatment for PTSD because of court proceedings or applications for compensation.
C - Healthcare professionals should be aware that many PTSD sufferers are anxious about and can avoid engaging in treatment. Healthcare professionals should also recognize the challenges that this presents and respond appropriately, for example by following up PTSD sufferers who miss scheduled appointments.
GPP - Healthcare professionals should treat PTSD sufferers with respect, trust and understanding, and keep technical language to a minimum.
GPP - Healthcare professionals should normally only consider providing trauma-focused psychological treatment when the sufferer considers it safe to proceed.
C - Treatment should be delivered by competent individuals who have received appropriate training. These individuals should receive appropriate supervision.
Comorbidities
C - When a patient presents with PTSD and depression, healthcare professionals should consider treating the PTSD first, as the depression will often improve with successful treatment of the PTSD.
C - For PTSD sufferers whose assessment identifies a high risk of suicide or harm to others, healthcare professionals should first concentrate on management of this risk.
C - For PTSD sufferers who are so severely depressed that this makes initial psychological treatment of PTSD very difficult (for example, as evidenced by extreme lack of energy and concentration, inactivity, or high suicide risk), healthcare professionals should treat the depression first.
C - For PTSD sufferers with drug or alcohol dependence or in whom alcohol or drug use may significantly interfere with effective treatment, healthcare professionals should treat the drug or alcohol problem first.
C - When offering trauma-focused psychological interventions to PTSD sufferers with comorbid personality disorder, healthcare professionals should consider extending the duration of treatment.
C - People who have lost a close friend or relative due to an unnatural or sudden death should be assessed for PTSD and traumatic grief. In most cases, healthcare professionals should treat the PTSD first without avoiding discussion of the grief.
Treatment of PTSD
Early Interventions
A number of sufferers with PTSD may recover with no or limited interventions. However, without effective treatment, many people may develop chronic problems over many years. The severity of the initial traumatic response is a reasonable indicator of the need for early intervention, and treatment should not be withheld in such circumstances.
Watchful Waiting
C - Where symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting, as a way of managing the difficulties presented by individual sufferers, should be considered by healthcare professionals. A follow-up contact should be arranged within 1 month.
Immediate Psychological Interventions for All
As described in this guideline, practical support delivered in an empathetic manner is important in promoting recovery for PTSD, but it is unlikely that a single session of a psychological intervention will be helpful.
GPP - All health and social care workers should be aware of the psychological impact of traumatic incidents in their immediate post-incident care of survivors and offer practical, social and emotional support to those involved.
A - For individuals who have experienced a traumatic event, the systematic provision to that individual alone of brief, single-session interventions (often referred to as debriefing) that focus on the traumatic incident should not be routine practice when delivering services.
PTSD where Symptoms are Present Within 3 Months of a Trauma
Brief psychological interventions (five sessions) may be effective if treatment starts within the first month after the traumatic event. Beyond the first month, the duration of treatment is similar to that for chronic PTSD.
B - Trauma-focused cognitive-behavioural therapy should be offered to those with severe post-traumatic symptoms or with severe PTSD in the first month after the traumatic event. These treatments should normally be provided on an individual out-patient basis.
A - Trauma-focused CBT should be offered to people who present with PTSD within 3 months of a traumatic event.
B - The duration of the trauma-focused CBT should normally be 8-12 sessions, but if the treatment starts in the first month after the event, fewer sessions (about 5) may be sufficient. When the trauma is discussed in the treatment session, longer sessions (for example, 90 min) are usually necessary. Treatment should be regular and continuous (usually at least once a week) and should be delivered by the same person.
C - Drug treatment may be considered in the acute phase of PTSD for the management of sleep disturbance. In this case, hypnotic medication may be appropriate for short-term use but, if longer-term drug treatment is required, consideration should also be given to the use of suitable antidepressants at an early stage in order to reduce the later risk of dependence.
B - Non-trauma-focused interventions such as relaxation or non-directive therapy, which do not address traumatic memories, should not routinely be offered to people who present with PTSD symptoms within 3 months of a traumatic event.
PTSD Where Symptoms Have Been Present For More Than 3 Months After a Trauma
Most patients presenting with PTSD have had the problem for many months, if not years. The interventions outlined below are effective in treating such individuals and duration of the disorder does not itself seem an impediment to benefiting from effective treatment provided by competent healthcare professionals.
Psychological Interventions
A - All PTSD sufferers should be offered a course of trauma-focused psychological treatment (trauma-focused CBT or eye movement desensitisation and reprocessing). These treatments should normally be provided on an individual out-patient basis.
B - Trauma-focused psychological treatment should be offered to PTSD sufferers regardless of the time that has elapsed since the trauma.
B - The duration of trauma-focused psychological treatment should normally be 8-12 sessions when the PTSD results from a single event. When the trauma is discussed in the treatment session, longer sessions than usual are generally necessary (for example, 90 min). Treatment should be regular and continuous (usually at least once a week) and should be delivered by the same person.
C - Healthcare professionals should consider extending the duration of treatment beyond 12 sessions if several problems need to be addressed in the treatment of PTSD sufferers, particularly after multiple traumatic events, traumatic bereavement or where chronic disability resulting from the trauma, significant comorbid disorders or social problems are present. Trauma-focused treatment needs to be integrated into an overall plan of care.
C - For some PTSD sufferers it may initially be very difficult and overwhelming to disclose details of their traumatic events. In these cases, healthcare professionals should consider devoting several sessions to establishing a trusting therapeutic relationship and emotional stabilisation before addressing the traumatic event.
B - Non-trauma-focused interventions such as relaxation or non-directive therapy, which do not address traumatic memories, should not routinely be offered to people who present with chronic PTSD.
C - For PTSD sufferers who have no or only limited improvement with a specific trauma-focused psychological treatment, healthcare professionals should consider the following options:
- an alternative form of trauma-focused psychological treatment
- the augmentation of trauma-focused psychological treatment with a course of pharmacological treatment.
GPP - When PTSD sufferers request other forms of psychological treatment (for example, supportive therapy/non-directive therapy, hypnotherapy, psychodynamic therapy or systemic psychotherapy), they should be informed that there is as yet no convincing evidence for a clinically important effect of these treatments on PTSD.
Drug Treatment
The evidence base for drug treatments in PTSD is limited. There is evidence of clinically significant benefits for mirtazapine, amitriptyline and phenelzine. (Dietary guidance is required with phenelzine.) For paroxetine there were statistically but not clinically significant benefits on the main outcome variables. Nevertheless, this drug has also been included in the list of recommended drugs. This is the only drug in the list of recommendations with a current UK product licence for PTSD.
A - Drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by specialist mental health professionals) in preference to a trauma-focused psychological therapy.
B - Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for initiation only by mental health specialists) should be considered for the treatment of PTSD in adults where a sufferer expresses a preference not to engage in a trauma-focused psychological treatment.
C - Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for initiation only by mental health specialists) should be offered to adult PTSD sufferers who cannot start a psychological therapy because of serious ongoing threat of further trauma (for example, where there is ongoing domestic violence).
C - Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or phenelzine for initiation only by mental health specialists) should be considered for adult PTSD sufferers who have gained little or no benefit from a course of trauma-focused psychological treatment.
C - Where sleep is a major problem for an adult PTSD sufferer, hypnotic medication may be appropriate for short-term use but, if longer-term drug treatment is required, consideration should also be given to the use of suitable antidepressants at an early stage in order to reduce the later risk of dependence.
C - Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or phenelzine for initiation only by mental health specialists) for PTSD should be considered as an adjunct to psychological treatment in adults where there is significant comorbid depression or severe hyperarousal that significantly impacts on a sufferer's ability to benefit from psychological treatment.
C - When an adult sufferer with PTSD has not responded to a drug treatment, consideration should be given to increasing the dosage within approved limits. If further drug treatment is considered, this should generally be with a different class of antidepressant or involve the use of adjunctive olanzapine.
C - When an adult sufferer with PTSD has responded to drug treatment, it should be continued for at least 12 months before gradual withdrawal.
General Recommendations Regarding Drug Treatment
C - All PTSD sufferers who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side-effects and discontinuation/withdrawal symptoms (particularly with paroxetine).
GPP - Adult PTSD sufferers started on antidepressants who are considered to have an increased suicide risk and all patients aged between 18 and 29 years (because of the potential increased risk of suicidal thoughts associated with the use of antidepressants in this age group) should normally be seen after 1 week and frequently thereafter until the risk is no longer considered significant.
GPP - Particularly in the initial stages of SSRI treatment, practitioners should actively seek out signs of akathisia, suicidal ideation and increased anxiety and agitation. They should also advise PTSD sufferers of the risk of these symptoms in the early stages of treatment and advise them to seek help promptly if these are at all distressing.
GPP - If a PTSD sufferer develops marked and/or prolonged akathisia while taking an antidepressant, the use of the drug should be reviewed.
GPP - Adult PTSD sufferers started on antidepressants who are not considered to be at increased risk of suicide should normally be seen after 2 weeks and thereafter on an appropriate and regular basis, for example, at intervals of 2-4 weeks in the first 3 months, and at greater intervals thereafter, if response is good.
Recommendations Regarding Discontinuation/Withdrawal Symptoms
C - Discontinuation/withdrawal symptoms are usually mild and self-limiting but occasionally can be severe. Prescribers should normally gradually reduce the dosage of antidepressants over a 4-week period, although some people may require longer periods.
C - If discontinuation/withdrawal symptoms are mild, practitioners should reassure the PTSD sufferer and arrange for monitoring. If symptoms are severe, the practitioner should consider reintroducing the original antidepressant (or another with a longer half-life from the same class) and reduce gradually while monitoring symptoms.
Chronic Disease Management
C - Chronic disease management models should be considered for the management of people with chronic PTSD who have not benefited from a number of courses of evidence-based treatment.
Children
It is particularly difficult to identify PTSD in children (see section above titled "Specific Recognition Issues for Children"). The treatments for children with PTSD are less developed but emerging evidence provides an indication for effective interventions.
Early Intervention
B - Trauma-focused CBT should be offered to older children with severe post-traumatic symptoms or with severe PTSD in the first month after the traumatic event.
PTSD Where Symptoms Have Been Present for More Than 3 Months After a Trauma
B - Children and young people with PTSD, including those who have been sexually abused, should be offered a course of trauma-focused CBT adapted appropriately to suit their age, circumstances and level of development.
C - The duration of trauma-focused psychological treatment for children and young people with chronic PTSD should normally be 8–12 sessions when the PTSD results from a single event. When the trauma is discussed in the treatment session, longer sessions than usual are usually necessary (for example, 90 min). Treatment should be regular and continuous (usually at least once a week) and should be delivered by the same person.
C - Drug treatments should not be routinely prescribed for children and young people with PTSD.
C - Where appropriate, families should be involved in the treatment of PTSD in children and young people. However, treatment programmes for PTSD in children and young people that consist of parental involvement alone are unlikely to be of any benefit for PTSD symptoms.
C - When considering treatments for PTSD, parents and, where appropriate, children and young people should be informed that, apart from trauma-focused psychological interventions, there is at present no good evidence for the efficacy of widely used forms of treatment of PTSD such as play therapy, art therapy or family therapy.
Disaster Planning
Both health and social services have a role in organising the appropriate social and psychological support for those affected by disasters.
GPP - Disaster plans should include provision for a fully coordinated psychosocial response to the disaster. Those responsible for developing the psychosocial aspect of a disaster plan should ensure it contains the following: provision for immediate practical help, means to support the affected communities in caring for those involved in the disaster and the provision of specialist mental health, evidence based assessment and treatment services. All healthcare workers involved in a disaster plan should have clear roles and responsibilities, which should be agreed in advance.
Definitions
Levels of Evidence
I: Evidence obtained from a single randomised controlled trial or a meta-analysis of randomised controlled trials
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
Grading of Recommendation
Grade A - At least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels I) without extrapolation
Grade B - Well-conducted clinical studies but no randomised clinical trials on the topic of recommendation (evidence levels II or III); or extrapolated from level I evidence
Grade C - Expert committee reports or opinions and/or clinical experiences of respected authorities (evidence level IV) or extrapolated from level I or II evidence. This grading indicates that directly applicable clinical studies of good quality are absent or not readily available.
Good practice point (GPP) - Recommended good practice based on the clinical experience of the Guideline Development Group (GDG)
