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Post-traumatic stress disorder
NICE Guideline, No. 116
This guideline replaces CG26.
This guideline is the basis of QS53.
Overview
This guideline covers recognising, assessing and treating post-traumatic stress disorder (PTSD) in children, young people and adults. It aims to improve quality of life by reducing symptoms of PTSD such as anxiety, sleep problems and difficulties with concentration. Recommendations also aim to raise awareness of the condition and improve coordination of care.
Who is it for?
- Healthcare professionals
- Other professionals who work with people at risk of or who have PTSD, including in criminal justice and education services and non-government organisations
- Commissioners and providers, including directors of public health, NHS trust managers and managers in clinical commissioning groups
- People at risk of or who have PTSD (including complex PTSD), their families and carers, and the public
Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Recommendations in this guideline relate to everyone who is at risk of or has post-traumatic stress disorder (PTSD). The guideline has looked at inequalities relating to gender, sexual orientation, gender reassignment, age, homelessness, refugees and asylum seekers, illegal immigrants, undocumented workers, people with neurodevelopmental disorders, people with coexisting conditions, and people who are critically ill.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
1.1. Recognition of post-traumatic stress disorder
- 1.1.1.
Be aware that people with post-traumatic stress disorder (PTSD), including complex PTSD, may present with a range of symptoms associated with functional impairment, including:
- re-experiencing
- avoidance
- hyperarousal (including hypervigilance, anger and irritability)
- negative alterations in mood and thinking
- emotional numbing
- dissociation
- emotional dysregulation
- interpersonal difficulties or problems in relationships
- negative self-perception (including feeling diminished, defeated or worthless). [2005, amended 2018]
- 1.1.2.
Be aware of traumatic events associated with the development of PTSD. These could be experiencing or witnessing single, repeated or multiple events and could include, for example:
- serious accidents
- physical and sexual assault
- abuse, including childhood or domestic abuse
- work-related exposure to trauma, including remote exposure
- trauma related to serious health problems or childbirth experiences (for example, intensive care admission or neonatal death)
- war and conflict
- torture. [2005, amended 2018]
- 1.1.3.
When assessing for PTSD, ask people specific questions about re-experiencing, avoidance, hyperarousal, dissociation, negative alterations in mood and thinking, and associated functional impairment. [2005, amended 2018]
- 1.1.4.
When assessing for PTSD, ask people with symptoms in recommendation 1.1.1 if they have experienced 1 or more traumatic events (which may have occurred many months or years before). Give specific examples of traumatic events as listed in recommendation 1.1.2. [2005, amended 2018]
- 1.1.5.
For people with unexplained physical symptoms who repeatedly attend health services, think about asking whether they have experienced 1 or more traumatic events and provide specific examples of traumatic events (see recommendation 1.1.2). [2005, amended 2018]
Specifific recognition issues for children
- 1.1.6.
Do not rely solely on the parent or carer for information when it is developmentally appropriate to directly and separately question a child or young person about the presence of PTSD symptoms. [2005, amended 2018]
- 1.1.7.
When a child who has been involved in a traumatic event is treated in an emergency department, emergency staff should explain to their parents or carers about the normal responses to trauma and the possibility of PTSD developing. Briefly describe the possible symptoms (for example, nightmares, repetitive trauma-related play, intrusive thoughts, avoiding things related to the event, increased behavioural difficulties, problems concentrating, hypervigilance, and difficulties sleeping), and suggest they contact their GP if the symptoms persist beyond 1 month. [2005, amended 2018]
Screening of people involved in a major disaster, refugees and asylum seekers
- 1.1.8.
For people at high risk of developing PTSD after a major disaster, those responsible for coordinating the disaster plan should think about the routine use of a validated, brief screening instrument for PTSD at 1 month after the disaster. [2005, amended 2018]
- 1.1.9.
For refugees and asylum seekers at high risk of PTSD, think about the routine use of a validated, brief screening instrument for PTSD as part of any comprehensive physical and mental health screen. [2005, amended 2018]
1.2. Assessment and coordination of care
- 1.2.1.
For people with clinically important symptoms of PTSD presenting in primary care, GPs should take responsibility for assessment and initial coordination of care. This includes determining the need for emergency physical or mental health assessment. [2005, amended 2018]
- 1.2.2.
Assessment of people with PTSD should be comprehensive, including an assessment of physical, psychological and social needs and a risk assessment. [2005, amended 2018]
- 1.2.3.
Where management is shared between primary and secondary care, healthcare professionals should agree who is responsible for monitoring people with PTSD. Put this agreement in writing (if appropriate, using the Care Programme Approach) and involve the person and, if appropriate, their family or carers. [2005, amended 2018]
Supporting transitions between services
- 1.2.4.
To support transitions when people with PTSD are moving between services:
- give the person information about the service they are moving to, including the setting
- and who will provide their care
- ensure there is effective sharing of information between all services involved
- involve the person and, if appropriate, their family or carers in meetings to plan the transition
- address any worries the person has, for example about changes to their routine or anxiety about meeting new people. [2018]
- 1.2.5.
Provide additional support:
- to children and young people with PTSD who are within the care system when they are transitioning between services or settings
- during admission and discharge to people with PTSD who are admitted to hospital because of other mental or physical health problems.
Follow NICE’s guidelines on transition from children’s to adults’ services for young people using health or social care services, common mental health problems: identification and pathways to care and transition between inpatient mental health settings and community or care home settings. [2018]
- 1.2.6.
During transitions between services for people with PTSD who need ongoing care, the referring team should not discharge the person before a care plan has been agreed in the new service. [2018]
To find out why the committee made the 2018 recommendations on supporting transitions between services and how they might affect practice, see rationale and impact.
1.3. Access to care
- 1.3.1.
Promote access to services for people with PTSD by:
- reassuring them that PTSD is a treatable condition
- providing care that places a positive emphasis on the range of interventions offered and their likely benefits
- ensuring that methods of access to services take into account the needs of specific
- populations of people with PTSD, including migrants and asylum seekers, people who are homeless or not registered with a GP, looked-after children and young people, and preschool-aged children
- minimising the need to move between different services or providers
- providing multiple points of access to the service, including self-referral
- establishing clear links to other care pathways, including for physical healthcare needs
- offering flexible modes of delivery, such as text messages, email, telephone or video consultation, or care in non-clinical settings such as schools or offices
- offering a choice of therapist that takes into account the person’s trauma experience – for example they might prefer a specific gender of therapist
- using proactive person-centred strategies to promote uptake and sustained engagement
- assessing the need for further treatment or support for people who have not benefited fully from treatment or have relapsed. [2018]
- 1.3.2.
Do not delay or withhold treatment for PTSD solely because of court proceedings or applications for compensation. Discuss with the person the implications of the timing of any treatment to help them make an informed decision about if and when to proceed, in line with Crown Prosecution Service guidance (Therapy: provision of therapy for child witnesses prior to a criminal trial or Therapy: provision of therapy for vulnerable or intimidated adult witnesses). [2018]
To find out why the committee made the 2018 recommendations on access to care and how they might affect practice, see rationale and impact.
1.4. Principles of care
Supporting people with PTSD
- 1.4.1.
Provide information in both verbal and written format and in line with recommendations in the NICE guidelines on service user experience in adult mental health and patient experience in adult NHS services. [2018]
- 1.4.2.
Give information and support to people with PTSD (and their family members or carers as appropriate) covering:
- common reactions to traumatic events, including the symptoms of PTSD and its course
- assessment, treatment and support options
- where their care will take place. [2018]
Peer support
- 1.4.3.
Tell people about and help them access peer support groups if they want to and could benefit. Peer support groups should:
- be facilitated by people with mental health training and supervision
- be delivered in a way that reduces the risk of exacerbating symptoms
- provide information and help to access services. [2018]
Maintaining safe environments
- 1.4.4.
Be aware of the risk of continued exposure to trauma-inducing environments. Avoid exposing people to triggers that could worsen their symptoms or stop them from engaging with treatment, for example, assessing or treating people in noisy or restricted environments, placing them in a noisy inpatient ward, or restraining them. [2018]
Involving and supporting families and carers
- 1.4.5.
Consider providing information and support to family members and carers of people with PTSD. This could cover:
- the treatment and management of trauma-related psychological and behavioural problems, including the person’s possible risk to themselves and others
- discussing with family members and carers how they are being affected by the person’s PTSD
- how they can support the person to access treatment, including what to do if they do not engage with, or drop out of treatment. [2018]
- 1.4.6.
Involve family members and carers, if appropriate, in treatment for people with PTSD as a way to:
- inform and improve the care of the person with PTSD and
- identify and meet their own needs as carers. [2018]
- 1.4.7.
Consider providing practical and emotional support and advice to family members and carers, for example directing them to health or social services or peer support groups. [2018]
- 1.4.8.
Think about the impact of the traumatic event on other family members because more than one family member might have PTSD. Consider further assessment, support and intervention for any family member suspected to have PTSD. [2018]
- 1.4.9.
For members of the same family who have PTSD after experiencing the same traumatic event, think about what aspects of treatment might be usefully provided together (such as psychoeducation), alongside individual treatments. [2018]
To find out why the committee made the 2018 recommendations on principles of care and how they might affect practice, see rationale and impact.
1.5. Language and culture
- 1.5.1.
Pay particular attention to identifying people with PTSD in working or living environments where there may be cultural challenges to recognising the psychological consequences of trauma (see recommendations on avoiding stigma and promoting social inclusion in the NICE guideline on service user experience in adult mental health). [2005, amended 2018]
- 1.5.2.
Ensure that screening, assessment and interventions for PTSD are culturally and linguistically appropriate. [2005, amended 2018]
- 1.5.3.
If language or culture differences present challenges to the use of psychological interventions in PTSD, think about using interpreters or offering a choice of therapists. See recommendations on communication in the NICE guideline on patient experience in adult NHS services. [2005, amended 2018]
1.6. Management of PTSD in children, young people and adults
Planning treatment and supporting engagement
- 1.6.1.
When discussing treatment options with people with PTSD (and their family members or carers as appropriate):
- give them information about any proposed interventions, including:
- -
their aim, content, duration and mode of delivery
- -
the likelihood of improvement and recovery
- -
what to expect during the intervention, including that symptoms can seem to get worse temporarily
- -
that recovery is more likely if they stay engaged with treatment
- take into account the person’s preferences, any previous treatment, associated functional impairment and coexisting conditions
- take into account any social or personal factors that may have a role in the development or maintenance of the disorder, such as childhood maltreatment and multiple traumatic experiences. [2018]
- 1.6.2.
Be aware that people with PTSD may be apprehensive, anxious, or ashamed. They may avoid treatment, believe that PTSD is untreatable, or have difficulty developing trust. Engagement strategies could include following up when people miss appointments and allowing flexibility in service attendance policies. [2018]
- 1.6.3.
For people with PTSD whose assessment identifies a significant risk of harm to themselves or others, establish a risk management and safety plan (involving family members and carers if appropriate) as part of initial treatment planning. [2018]
To find out why the committee made the 2018 recommendations on planning treatment and supporting engagement and how they might affect practice, see rationale and impact.
Active monitoring
- 1.6.4.
Consider active monitoring for people with subthreshold symptoms of PTSD within 1 month of a traumatic event. Arrange follow-up contact to take place within 1 month. [2018]
To find out why the committee made the 2018 recommendation on active monitoring and how it might affect practice, see rationale and impact.
Psychologically-focused debriefifing
- 1.6.5.
Do not offer psychologically-focused debriefing for the prevention or treatment of PTSD. [2018]
To find out why the committee made the 2018 recommendation on psychologically-focused debriefing and how it might affect practice, see rationale and impact.
Psychological interventions for the prevention and treatment of PTSD in children and young people
Prevention for children and young people
- 1.6.6.
Consider active monitoring or individual trauma-focused cognitive behavioural therapy (CBT) within 1 month of a traumatic event for children and young people aged under 18 years with a diagnosis of acute stress disorder or clinically important symptoms of PTSD. [2018]
- 1.6.7.
Consider a group trauma-focused CBT intervention for children and young people aged 7 to 17 years if there has been an event within the last month leading to large-scale shared trauma. [2018]
- 1.6.8.
Group trauma-focused CBT interventions for children and young people who have been exposed to large-scale shared trauma within the last month should:
- be based on a validated manual
- typically be provided over 5 to 15 sessions
- be delivered by trained practitioners with ongoing supervision
- include psychoeducation about reactions to trauma, strategies for managing arousal and flashbacks, and safety planning
- involve elaboration and processing of the trauma memories
- involve restructuring trauma-related meanings for the individual
- provide help to overcome avoidance. [2018]
To find out why the committee made the 2018 recommendations on psychological interventions for the prevention of PTSD in children and young people and how they might affect practice, see rationale and impact.
Treatment for children and young people
- 1.6.9.
Consider an individual trauma-focused CBT intervention for children aged 5 to 6 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 1 month after a traumatic event. [2018]
- 1.6.10.
Consider an individual trauma-focused CBT intervention for children and young people aged 7 to 17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3 months after a traumatic event. [2018]
- 1.6.11.
Offer an individual trauma-focused CBT intervention to children and young people aged 7 to 17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event. [2018]
- 1.6.12.
Individual trauma-focused CBT interventions for children and young people should:
- be based on a validated manual
- typically be provided over 6 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas
- be delivered by trained practitioners with ongoing supervision
- be adapted to the child or young person’s age and development
- involve parents or carers as appropriate
- include psychoeducation about reactions to trauma, strategies for managing arousal and flashbacks, and safety planning
- involve elaboration and processing of the trauma memories
- involve processing trauma-related emotions, including shame, guilt, loss and anger
- involve restructuring trauma-related meanings for the individual
- provide help to overcome avoidance
- prepare them for the end of treatment
- include planning booster sessions if needed, particularly in relation to significant dates (for example trauma anniversaries). [2018]
- 1.6.13.
Consider eye movement desensitisation and reprocessing (EMDR) for children and young people aged 7 to 17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event only if they do not respond to or engage with trauma-focused CBT. [2018]
To find out why the committee made the 2018 recommendations on psychological interventions for the treatment of PTSD in children and young people and how they might affect practice, see rationale and impact.
Drug treatments for children and young people
- 1.6.14.
Do not offer drug treatments for the prevention or treatment of PTSD in children and young people aged under 18 years. [2018]
To find out why the committee made the 2018 recommendation on drug treatments for children and young people and how it might affect practice, see rationale and impact.
Psychological interventions for the prevention and treatment of PTSD in adults
Prevention for adults
- 1.6.15.
Offer an individual trauma-focused CBT intervention to adults who have acute stress disorder or clinically important symptoms of PTSD and have been exposed to 1 or more traumatic events within the last month. These interventions include:
- cognitive processing therapy
- cognitive therapy for PTSD
- narrative exposure therapy
- prolonged exposure therapy. [2018]
To find out why the committee made the 2018 recommendation on psychological interventions to prevent PTSD in adults and how it might affect practice, see rationale and impact.
Treatment for adults
- 1.6.16.
Offer an individual trauma-focused CBT intervention to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 1 month after a traumatic event. These interventions include:
- cognitive processing therapy
- cognitive therapy for PTSD
- narrative exposure therapy
- prolonged exposure therapy. [2018]
- 1.6.17.
Trauma-focused CBT interventions for adults should:
- be based on a validated manual
- typically be provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas
- be delivered by trained practitioners with ongoing supervision
- include psychoeducation about reactions to trauma, strategies for managing arousal and flashbacks, and safety planning
- involve elaboration and processing of the trauma memories
- involve processing trauma-related emotions, including shame, guilt, loss and anger
- involve restructuring trauma-related meanings for the individual
- provide help to overcome avoidance
- have a focus on re-establishing adaptive functioning, for example work and social relationships
- prepare them for the end of treatment
- include planning booster sessions if needed, particularly in relation to significant dates (for example trauma anniversaries). [2018]
- 1.6.18.
Consider EMDR for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3 months after a non-combat-related trauma if the person has a preference for EMDR. [2018]
- 1.6.19.
Offer EMDR to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a non-combat-related trauma. [2018]
- 1.6.20.
EMDR for adults should:
- be based on a validated manual
- typically be provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas
- be delivered by trained practitioners with ongoing supervision
- be delivered in a phased manner and include psychoeducation about reactions to trauma; managing distressing memories and situations; identifying and treating target memories (often visual images); and promoting alternative positive beliefs about the self
- use repeated in-session bilateral stimulation (normally with eye movements[1]) for specific target memories until the memories are no longer distressing
- include the teaching of self-calming techniques and techniques for managing flashbacks, for use within and between sessions. [2018]
- 1.6.21.
Consider supported trauma-focused computerised CBT for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event if they prefer it to face-to-face trauma-focused CBT or EMDR as long as:
- they do not have severe PTSD symptoms, in particular dissociative symptoms and
- they are not at risk of harm to themselves or others. [2018]
- 1.6.22.
Supported trauma-focused computerised CBT interventions for adults should:
- be based on a validated programme
- typically be provided over 8 to 10 sessions
- involve elaboration and processing of the trauma memories; processing trauma-related emotions; restructuring trauma-related meanings for the individual; helping to overcome avoidance; and re-establishing adaptive functioning (for example, work and social relationships)
- include guidance and support from a trained practitioner to encourage people to complete the intervention, give feedback on homework assignments and review progress and outcomes. [2018]
- 1.6.23.
Consider CBT interventions targeted at specific symptoms such as sleep disturbance or anger, for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event only if the person:
- is unable or unwilling to engage in a trauma-focused intervention or
- has residual symptoms after a trauma-focused intervention. [2018]
To find out why the committee made the 2018 recommendations on psychological interventions to treat PTSD in adults and how they might affect practice, see rationale and impact.
Drug treatments for adults
- 1.6.24.
Do not offer drug treatments, including benzodiazepines, to prevent PTSD in adults. [2018]
- 1.6.25.
Consider venlafaxine[2] or a selective serotonin reuptake inhibitor (SSRI), such as sertraline[3] for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Review this treatment regularly. [2018]
- 1.6.26.
Consider antipsychotics such as risperidone[4], in addition to psychological therapies to manage symptoms for adults with a diagnosis of PTSD if:
- they have disabling symptoms and behaviours, for example severe hyperarousal or psychotic symptoms and
- their symptoms have not responded to other drug or psychological treatments.
Antipsychotic treatment should be started and reviewed regularly by a specialist (see how to use antipsychotic medication in NICE’s guideline on psychosis and schizophrenia in adults). [2018]
To find out why the committee made the 2018 recommendations on drug treatments for adults and how they might affect practice, see rationale and impact.
1.7. Care for people with PTSD and complex needs
- 1.7.1.
For people presenting with PTSD and depression:
- usually treat the PTSD first because the depression will often improve with successful PTSD treatment
- treat the depression first if it is severe enough to make psychological treatment of the PTSD difficult, or there is a risk of the person harming themselves or others. [2018]
- 1.7.2.
Do not exclude people with PTSD from treatment based solely on comorbid drug or alcohol misuse. [2018]
- 1.7.3.
For people with additional needs, including those with complex PTSD:
- build in extra time to develop trust with the person, by increasing the duration or the number of therapy sessions according to the person’s needs
- take into account the safety and stability of the person’s personal circumstances (for example their housing situation) and how this might affect engagement with and success of treatment
- help the person manage any issues that might be a barrier to engaging with trauma-focused therapies, such as substance misuse, dissociation, emotional dysregulation, interpersonal difficulties or negative self-perception
- work with the person to plan any ongoing support they will need after the end of treatment, for example to manage any residual PTSD symptoms or comorbidities. [2018]
To find out why the committee made the 2018 recommendations on care for people with PTSD and complex needs and how they might affect practice, see rationale and impact.
1.8. Disaster planning
- 1.8.1.
Ensure that disaster plans provide a fully coordinated psychosocial response to the disaster. A disaster plan should include:
- immediate practical help
- support for the affected communities in caring for those involved in the disaster
- access to specialist mental health, evidence-based assessment and treatment services
- clear roles and responsibilities for all professionals involved. [2005]
Terms used in this guideline
Active monitoring
Also known as watchful waiting. This means regularly monitoring a person who has some symptoms but who is not currently having clinical intervention for the condition.
Acute stress disorder
Acute stress disorder is a DSM-5 diagnosis that applies in the first month after a traumatic event. It requires the presence of 9 or more symptoms from any of the 5 categories of intrusion, negative mood, dissociation, avoidance and arousal. These can be starting or worsening after the traumatic event.
Clinically important symptoms
People with clinically important symptoms of PTSD refer to those who are assessed as having PTSD on a validated scale, as indicated by baseline scores above clinical threshold, but who do not necessarily have a diagnosis of PTSD. They are typically referred to in studies that have not used a clinical interview to arrive at a formal diagnosis of PTSD and instead have only used self-report measures of PTSD symptoms.
Combat-related trauma
Combat-related trauma refers to traumatic incidents associated with military combat. In many cases, the sorts of traumas that military personnel encounter are not particularly distinct from those encountered by civilians. However, they might include having to contend with challenging situations to which there is no correct answer, which may lead to shame or guilt (known as moral injuries).
Complex PTSD
Complex PTSD develops in a subset of people with PTSD. It is a diagnosis in the ICD-11, which defines it as arising after exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (for example, torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). The disorder is characterised by the core symptoms of PTSD; that is, all diagnostic requirements for PTSD are met. In addition, complex PTSD is characterised by:
- severe and pervasive problems in affect regulation
- persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the traumatic event
- persistent difficulties in sustaining relationships and in feeling close to others.
DSM-5 does not include a diagnosis of complex PTSD. It covers the complexity of presentation through a wider range of core PTSD symptoms (such as ‘negative mood and cognitions’) and the potential specifier of a ‘dissociative subtype’.
Disaster plan
A plan setting out the overall framework for starting, managing, coordinating and controlling staff and other resources to reduce, control or respond to an emergency.
Practitioner
A person with mental health training, particularly in PTSD, who also has training and competence in delivering interventions for PTSD.
Recommendations for research
As part of the 2018 update, the guideline committee removed the 2005 research recommendations and replaced them with the recommendations below.
Key recommendations for research
1. Stepped care for post-traumatic stress disorder
What is the clinical and cost effectiveness of stepped care for post-traumatic stress disorder (PTSD)?
To find out why the committee made the research recommendation on stepped care see appendix L of evidence review I: organisation and delivery of care for people with PTSD.
2. Sequencing and further line treatment
What is the clinical and cost effectiveness of sequencing and further line treatment in PTSD?
To find out why the committee made the research recommendation on sequencing and further line treatment, see appendix L of evidence review D: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults.
3. Trauma-informed approaches
What is the clinical and cost effectiveness of trauma-informed care or trauma-informed approaches?
To find out why the committee made the research recommendation on trauma-informed approaches, see appendix L of evidence review I: organisation and delivery of care for people with PTSD.
4. Personalisation and risk markers
What prognostic and prescriptive factors are important in determining the choice of PTSD treatment?
To find out why the committee made the research recommendation on personalisation and risk markers, see appendix L of evidence review D: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults.
5. Complex PTSD
What is the clinical and cost effectiveness of interventions to deliver stabilisation and reintegration for people with complex PTSD?
To find out why the committee made the research recommendation on complex PTSD, see appendix L of evidence review D: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults.
Other recommendations for research
1. Emotional freedom techniques
What is the clinical and cost effectiveness of emotional freedom techniques (EFT) for the treatment of PTSD in adults?
To find out why the committee made the research recommendation on EFT, see appendix L of evidence review D: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults.
Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee’s discussion.
Supporting transitions between services
Recommendations 1.2.4 to 1.2.6
Why the committee made the recommendations
There was not enough good evidence about access to care, developing care pathways and coordinating care, so the committee drew on sources from other mental health disorders describing pathways and systems that support access and engagement with care. Based on this information they used a formal consensus method to make recommendations on good practice.
The committee discussed strategies to improve care coordination and provide smooth transitions of care for people with post-traumatic stress disorder (PTSD). They agreed it was important to plan transitions in advance, involve families and carers, make sure everyone involved in the person’s care is aware of their role and responsibility, and ensure that different services are communicating with each other, as well as with the person with PTSD. They noted that overall coordination and continuity of care could be achieved by having a key professional to oversee the whole period of care – they agreed that this was already covered by recommendations 1.2.1 and 1.2.3. The committee also identified certain groups that might need extra support during care transitions.
How the recommendations might affect practice
These recommendations will help to improve the way in which care is provided and improve consistency between services. Any resource impact should be offset by time savings and efficiency benefits from improved care coordination and continuity. Full details of the evidence and the committee’s discussion are in evidence review J: care pathways for adults, children and young people with PTSD.
Access to care
Recommendations 1.3.1 and 1.3.2
Why the committee made the recommendations
In the absence of good evidence the committee used formal consensus to recommend some key strategies for promoting access to care. Based on their clinical experience the committee agreed that a common barrier to accessing care can be the person’s belief that PTSD is untreatable. The committee agreed it was important to present a more hopeful and optimistic picture of the treatment of PTSD.
They also discussed evidence on delivering care more flexibly. Qualitative evidence showed that some people with PTSD prefer to have their treatment away from a clinical environment. There was also clinical evidence that some types of remote care (for example, computerised trauma-focused cognitive behavioural therapy [CBT] and video consultation) can be as successful as face-to-face interventions. Based on this, the committee agreed that delivering care in more flexible ways, including by making it available in non-clinical locations like schools or offices, would improve access.
How the recommendations might affect practice
These recommendations will help to improve consistency in the way services are provided. Any resource impact should be offset by time savings and efficiency benefits from improved uptake and engagement. Currently video consultation is not available everywhere so this recommendation could have a moderate impact on resources. However, it is expected to save resources in the future, in particular in remote areas where therapists need to travel further to deliver trauma-focused CBT in person.
Full details of the evidence and the committee’s discussion are in evidence review J: care pathways for adults, children and young people with PTSD. Other supporting evidence and discussion is in evidence review H: principles of care, and evidence review I: organisation and delivery of care for people with PTSD.
Principles of care
Recommendations 1.4.1 to 1.4.9
Why the committee made the recommendations
Supporting people with PTSD
Recommendations 1.4.1 to 1.4.2 and 1.4.4
Based on the evidence and their own clinical experience, the committee discussed how people with PTSD are often apprehensive about making contact with services and may not know what treatments and help are available. They agreed that this underlined the need for good information and support, tailored to people’s needs, about interventions and services. This should cover what care and treatment people can expect and how it will be provided (for example where and by whom).
The committee discussed the importance of maintaining safe environments for people with PTSD. Based on their clinical experience, they agreed that a number of environmental triggers could worsen people’s symptoms or stop them from engaging in treatment. Practitioners assessing and treating people with PTSD – including those providing treatment for other mental or physical health conditions – should be aware of the need to minimise this risk.
Peer support
The evidence for peer support groups was limited but included some compelling reports from people with PTSD that sharing experiences with other people who had also experienced a traumatic event was beneficial, and this was reported for different types of traumatic experience. Findings suggested that peer support could also help people overcome their doubts and fears about having treatment by telling them about available help and support and encouraging them to engage with services.
Involving family members in treatment
Recommendations 1.4.6 and 1.4.9
There was evidence that involving families and carers in treatment provided extra support for the person while also giving the family or carer a greater understanding of PTSD. However, family or carer involvement was not universally reported as positive, with some people not liking the feeling of being talked about in their absence, so the committee agreed this should be discussed with the person first.
Limited evidence showed that involving families and carers in treatment had benefits for improving carer mental health and reducing parenting difficulties. However, the evidence was too uncertain to support any recommendations for specific interventions to support family members and carers. The committee recommended good practice points based on their own expert opinion.
Supporting families and carers
Recommendations 1.4.5 and 1.4.7 to 1.4.8
Qualitative evidence suggested that a common reason for not seeking help for PTSD is a lack of awareness about interventions and services. The committee agreed that information and support provided to family and carers could act as a facilitator for accessing services for both the carer and the person with PTSD.
The committee discussed the potential for more than one family member to have PTSD. They considered it important to raise awareness about this risk so that people are offered support promptly.
How the recommendations might affect practice
These recommendations are good practice points that will help to improve consistency of care. Any minor resource impact should be offset by time savings and efficiency benefits from improved uptake and engagement.
Peer support groups are not routinely offered everywhere but they are in fairly widespread use. The committee noted that facilitating access to these groups should not involve major resource implications. Any costs would be offset by potential savings associated with promoting earlier access to support that will help to prevent people from developing more severe problems.
Full details of the evidence and the committee’s discussion are in evidence review H: principles of care. Other supporting evidence and discussion is in evidence review G: psychological and psychosocial interventions for family members and evidence review J: care pathways for adults, children and young people with PTSD.
Planning treatment and supporting engagement
Recommendations 1.6.1 to 1.6.3
Why the committee made the recommendations
The committee agreed it was important to use a holistic approach when planning treatment, for example by thinking about every aspect of a person’s life that could be contributing to their continuing PTSD symptoms, whether they might have any other physical or mental health conditions, and whether they might be at significant risk of harm to themselves or others. It was also important to ask the person if any treatments had worked for them in the past and to take into account their preferences. In the committee’s opinion these were important points of good practice, along with providing information and support to help the person to make an informed choice about treatments.
The committee agreed that any strategies for promoting engagement need to be based on an understanding that people with PTSD are often highly anxious about having treatment and frequently avoid it. This was supported by evidence that common reasons for not seeking help include worry about engaging with a therapist, fear of exacerbating symptoms and stigmatisation. People may also have difficult emotions, such as shame, linked to the trauma, which can stop them from engaging with treatment. The committee agreed that healthcare professionals need to understand these reasons so that they don’t misinterpret why someone is not engaging and they know the best ways to help them – including by contacting them if they don’t come for an arranged appointment.
How the recommendations might affect practice
These recommendations are good practice points that will help to improve consistency of practice. Any minor resource impact should be offset by potential time savings and efficiency benefits from improved uptake and engagement.
Full details of the evidence and the committee’s discussion are in evidence review H: principles of care and evidence review J: care pathways for adults, children and young people with PTSD.
Active monitoring
Why the committee made the recommendation
There was no consistent evidence for effective interventions to prevent PTSD in people with subthreshold PTSD symptoms within 1 month of a traumatic event. The committee drew on their clinical experience and discussed how some people do not develop PTSD symptoms after a trauma even with no, or limited, interventions. Conversely, some people develop chronic symptoms if intervention is not provided early. Based on consensus, the committee agreed that active monitoring within the first month after the trauma could help professionals to judge whether people with less severe symptoms would need further intervention.
How the recommendation might affect practice
Any changes to practice should be minimal because active monitoring (known as watchful waiting in the 2005 version of this guideline) is already part of recommended practice.
Full details of the evidence and the committee’s discussion are in evidence review A: psychological, psychosocial and other non-pharmacological interventions for the prevention of PTSD in children and evidence review C: psychological, psychosocial and other non-pharmacological interventions for the prevention of PTSD in adults.
Psychologically-focused debriefing
Why the committee made the recommendation
Evidence on psychologically-focused debriefing, either individually or in groups, showed no benefit for children or adults, and some suggestion of worse outcomes than having no treatment. The committee agreed that psychologically-focused debriefing should not be offered. Providing an ineffective intervention can be regarded as harmful because it means that people are being denied access to another intervention with greater evidence of benefits.
How the recommendation might affect practice
Psychologically-focused debriefing was not part of previously recommended practice so there should be no impact on practice.
Full details of the evidence and the committee’s discussion are in evidence review A: psychological, psychosocial and other non-pharmacological interventions for the prevention of PTSD in children, evidence review B: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in children, evidence review C: psychological, psychosocial and other non-pharmacological interventions for the prevention of PTSD in adults and evidence review D: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults.
Psychological interventions for the prevention of PTSD in children and young people
Why the committee made the recommendations
There was no evidence for individual trauma-focused CBT for children and young people within the first month of trauma. Despite the lack of direct evidence, the committee decided to make a recommendation for this intervention in light of the strong evidence for its efficacy for children who have experienced trauma more than 1 month ago, and the evidence for benefits in adults within 1 month of trauma. There can be a lot of natural recovery in the early weeks and it can be difficult to gauge a child or young person’s readiness for intervention within 1 month of trauma. Based on consensus, the committee agreed that individual trauma-focused CBT and active monitoring could both be considered as options within 1 month of trauma for children and young people with clinically important PTSD symptoms or acute stress disorder, and that this decision was best left to clinical judgement.
There was evidence that trauma-focused CBT group interventions were effective for improving PTSD symptoms and other important outcomes for children and young people who had been exposed to ongoing trauma, for example from living in a war zone. The committee agreed that these findings could also apply to other types of large-scale shared traumas. There were some gaps and uncertainties in the evidence, for example in how long the benefits might last and whether they were specific to that intervention or could be explained by other general factors such as receiving attention from a therapist. Based on this evidence and the additional considerations, the committee recommended the intervention should be considered as a possible option. The cognitive and language demands of trauma-focused group CBT mean that it would not be suitable for children under 7 so the committee used an age range that reflected the age of children in the included studies.
Although specific group trauma-focused CBT interventions use the same broad approach, the committee was concerned that psychological interventions are not always delivered in a consistent way, so they agreed to specify the structure and content.
How the recommendations might affect practice
There is currently variation in care for children and young people with acute stress disorder or clinically important symptoms of PTSD within 1 month of a traumatic event. Recommending active monitoring or individual trauma-focused CBT as options to consider should improve consistency in practice and help to reduce the use of more resource-intensive interventions for which the effectiveness is unknown.
There is currently no guidance on interventions for children exposed to large-scale shared trauma, and current practice has involved providing a range of different interventions. Without a clear steer on what works best there has been variability in access to interventions, the type of interventions offered and the extent to which they have been evidence-based. The recommendation for group trauma-focused CBT will lead to more consistency in practice and improve clinical outcomes for children who might otherwise need more costly management for PTSD later in the care pathway.
Full details of the evidence and the committee’s discussion are in evidence review A: psychological, psychosocial and other non-pharmacological interventions for the prevention of PTSD in children.
Psychological interventions for the treatment of PTSD in children and young people
Recommendations 1.6.9 to 1.6.13
Why the committee made the recommendations
The evidence showed that trauma-focused CBT is effective in improving PTSD symptoms and other important outcomes, and that improvements last for at least a year. Benefits were seen for different specific trauma-focused interventions and different types of trauma. Trauma-focused CBT is more effective, as well as more cost effective, when it is provided individually than in a group so the committee agreed it should be delivered individually.
Most of the evidence for trauma-focused CBT came from children aged over 7 years. There was some evidence from 5 and 6 year olds so the committee agreed it could be an option for them, but could not be recommended with the same certainty.
There was no evidence for treatment with trauma-focused CBT between 1 and 3 months after a traumatic event compared with a non-active control, so the committee could not recommend it with the same certainty as for more than 3 months after trauma. However, by extrapolating from the broad evidence base for benefits more than 3 months after trauma and drawing on members’ own clinical experience, the committee agreed that trauma-focused CBT could be an option during this period.
Although specific trauma-focused CBT interventions use the same broad approach, the committee was concerned that psychological interventions are not always delivered in a consistent way, so they agreed to specify the structure and content. This recommendation was informed by the evidence and modified by the committee’s expert advice. For example, a typical number of sessions was recommended based on the evidence, but the committee agreed that more might be needed, including for those who have experienced multiple traumas.
There was limited evidence for eye movement desensitisation and reprocessing (EMDR) suggesting possible benefits on PTSD symptoms in children older than 7 years. However, EMDR was found to be less clinically effective and cost effective than all individual trauma-focused CBT interventions. On this basis, the committee decided it should be considered only if children do not respond to or engage with trauma-focused CBT.
How the recommendations might affect practice
Offering trauma-focused CBT more than 3 months after a traumatic event is in line with previously recommended practice and the committee was not aware of wide variation in practice. Considering trauma-focused CBT between 1 and 3 months after a traumatic event and recommending EMDR as an option are both new. They are only recommended as options to consider, which should limit their impact on practice, as should the fact that EMDR should only be considered for children who do not respond to or engage with trauma-focused CBT.
NICE’s previous guideline made recommendations for children with PTSD, whereas current recommendations are also relevant to children and young people with clinically important symptoms of PTSD. The structure, content and time of the assessment, as well as the benefits from treatment, are broadly the same for both populations and it was the committee’s view that there should not be a significant impact on practice.
Full details of the evidence and the committee’s discussion are in evidence review B: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in children.
Drug treatments for children and young people
Why the committee made the recommendation
There was very little evidence on the use of drug treatments to prevent or treat PTSD in children and young people. This limited evidence showed no significant benefits so the committee agreed drug treatment should not be offered.
How the recommendation might affect practice
This recommendation is in line with previously recommended practice so there should be no impact on practice.
Full details of the evidence and the committee’s discussion are in evidence review E: pharmacological interventions for the prevention or treatment of PTSD in children.
Psychological interventions for the prevention of PTSD in adults
Why the committee made the recommendation
Evidence showed that individual trauma-focused CBT interventions were effective for improving PTSD symptoms in adults who had experienced a traumatic event within the last month. They also reduced the number of adults who met the criteria to be diagnosed with PTSD after 1 month. There was also limited evidence from outside the UK that trauma-focused CBT is cost effective in adults at risk of PTSD.
There was evidence for a number of specific interventions within the trauma-focused CBT class, and the committee agreed it would be helpful to give some examples of named therapies that fall under this term.
The evidence of benefits was restricted to adults with clinically important symptoms or acute stress disorder, so the committee only recommended the intervention for these groups and not for people with less significant symptoms.
How the recommendation might affect practice
The recommendation is in line with previous recommended practice so there should not be a major change in practice.
Full details of the evidence and the committee’s discussion are in evidence review C: psychological, psychosocial and other non-pharmacological interventions for the prevention of PTSD in adults.
Psychological interventions for the treatment of PTSD in adults
Recommendation 1.6.16 to 1.6.23
Why the committee made the recommendations
Trauma-focused CBT
Recommendations 1.6.16 and 1.6.17
There was extensive evidence that trauma-focused CBT interventions improve PTSD symptoms as well as other important outcomes, and that these improvements can be maintained up to a year later. Benefits were seen across a wide range of types of trauma, including both single and multiple incident traumas. There was evidence for a number of specific interventions within the trauma-focused CBT class, and the committee agreed it would be helpful to give some examples of named therapies that fall under this term.
Most of the evidence for trauma-focused CBT interventions came from adults who had been exposed to 1 or more traumatic events more than 3 months ago, although there was limited evidence showing benefits between 1 and 3 months after trauma. The committee discussed this limited evidence alongside the broader evidence base that showed benefits within the first month and more than 3 months after trauma. They thought it was unlikely that effects would be different in this 2-month time period, so recommended trauma-focused CBT for adults with a diagnosis of PTSD or clinically important symptoms of PTSD more than 1 month after a traumatic event.
There was good evidence that offering up to 12 sessions of individual trauma-focused CBT was clinically and cost effective. Group trauma-focused CBT was not seen to be clinically or cost effective based on the guideline network meta-analysis and economic analysis, although the evidence was limited. Based on the standard number of sessions outlined in most validated treatment manuals and the most common number of sessions in the evidence base, the committee recommended providing 8 to 12 sessions. However, based on their clinical experience, they recommended offering more sessions if needed, including for people who have experienced multiple traumas.
Using both the evidence and their clinical experience, the committee outlined the structure and content of individual trauma-focused CBT interventions to make sure they are delivered in a consistent way because they were concerned that this may not happen in practice.
Psychoeducation was found to be highly clinically and cost effective in comparisons with psychological interventions according to the guideline network meta-analysis and economic analysis, but its evidence base was very limited and uncertain. The committee agreed that the evidence could not support a recommendation for psychoeducation on its own but it should be delivered as part of individual trauma-focused CBT.
Eye movement desensitisation and reprocessing
Recommendations 1.6.18 to 1.6.20
Less evidence was found on EMDR than on trauma-focused CBT, but the committee agreed that what was available justified recommending EMDR. Although studies that compared EMDR directly with trauma-focused CBT did not show significant differences, there was a trend towards EMDR. This trend in favour of EMDR was also present in the cost effectiveness results. The evidence suggested EMDR was not effective in people with military combat-related trauma, and this was in marked contrast to all other included trauma types for which benefits were observed. On this basis, the committee restricted their recommendation to non-combat-related trauma.
Most of the evidence for EMDR came from adults who had been exposed to 1 or more traumatic events more than 3 months ago, although there was limited evidence showing benefits between 1 and 3 months after trauma. Based on this limited evidence and by extrapolating from the stronger evidence for EMDR more than 3 months after trauma, the committee recommended considering EMDR between 1 and 3 months after a non-combat-related trauma. This recommendation was made with less certainty than treatment after 3 months because of the very limited direct evidence (a single study) and because limited evidence suggested non-statistically significant benefits of EMDR within 1 month of trauma.
Although EMDR interventions use the same broad approach, the committee was concerned that psychological interventions are not always delivered in a consistent way, so they agreed a specific structure and content based on the interventions in the evidence and modified by their expert opinion.
Supported trauma-focused computerised CBT
Recommendation 1.6.21 and 1.6.22
There was evidence that both supported and unsupported self-help, and computerised trauma-focused CBT in particular, were beneficial in terms of self-rated PTSD symptoms and other important outcomes. These benefits were maintained up to a year later. Both interventions were cost effective compared with other psychological interventions. The evidence was limited for some of the outcomes that were looked at, and it was unclear whether self-help was effective across different types of trauma. Although both supported and unsupported self-help were found to be effective, the former was more clinically and cost effective because the greater effect sizes were sufficient to offset the higher costs.
Taking the evidence for efficacy together with the gaps in the evidence, the committee agreed that supported computerised trauma-focused CBT should be considered as an option for adults with PTSD who prefer this to face-to-face trauma-focused CBT or EMDR. The committee was concerned that a lower intensity intervention might not be clinically appropriate for all adults with PTSD, so this recommendation was limited to those who do not have severe PTSD symptoms (in particular dissociative symptoms) and are not at risk of harm to themselves or others.
A number of computerised trauma-focused CBT interventions are available, and the committee felt it was important to specify their structure and content to make sure a minimum standard was set.
CBT interventions for specifific symptoms
There was some evidence that non-trauma-focused CBT is beneficial when targeted at specific symptoms such as sleep disturbance or anger, and also leads to improvements in PTSD symptoms, but it was not clear how long these benefits would be maintained. Non-trauma-focused CBT was less cost effective than individual trauma-focused CBT, EMDR and self-help, but more cost effective than other interventions such as present-centred therapy, group trauma-focused CBT, combined individual trauma-focused CBT and SSRIs, counselling and no treatment. The committee agreed the potential benefits of non-trauma-focused CBT were important, but that symptom-specific interventions should not be seen as an alternative to a trauma-focused first-line treatment. Instead, they could be an option when people are not ready to directly confront memories of the trauma and could promote uptake and engagement with a trauma-focused intervention. They could also be used to target residual symptoms after a trauma-focused intervention.
How the recommendations might affect practice
NICE’s previous guideline made recommendations for adults with PTSD, whereas current recommendations are also relevant to adults with clinically important symptoms of PTSD. The structure, content and time of the assessment, as well as the benefits from treatment, are broadly the same for both populations and it was the committee’s view that there should not be a significant impact on practice.
Both trauma-focused CBT and EMDR were already recommended and the committee did not think there was wide variation in practice. The new recommendation for non-trauma-focused CBT interventions targeted at specific symptoms represents a bigger change because previous recommendations stated that non-trauma-focused interventions should not be routinely offered to people with chronic PTSD. The impact on resources is difficult to predict because it is recommended only as an option to consider, but it might bring potential savings by improving uptake and engagement with trauma-focused therapies that should reduce missed appointments and early drop-out.
The recommendation for supported computerised trauma-focused CBT is also thought to represent a bigger change. Self-help-based interventions were not previously part of recommended practice and the committee was not aware of such interventions being in widespread use. The cost of supported computerised trauma-focused CBT includes, in addition to a therapist’s time, the cost of the digital mental health programmes and computers needed for delivery. If such an intervention is delivered in a public place (like a library), or the person’s home, there is no equipment cost. If the computer is used in a clinical practice setting, it can be shared by many people having computerised therapy, minimising the equipment cost. It could therefore lead to cost savings if part of routine practice is shifted from the more resource-intensive individual trauma-focused CBT and EMDR to the less resource-intensive supported computerised trauma-focused CBT.
The committee acknowledged that there would be a cost associated with providing extra trauma-focused therapy sessions if they are needed (for example, for people who have experienced multiple traumas). Previous recommended practice was to consider more than 12 sessions for people after multiple incident trauma, or who have chronic disability or significant coexisting conditions or social problems. However, in clinical practice the provision of additional sessions is variable.
Full details of the evidence and the committee’s discussion are in evidence review D: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults.
Drug treatments in adults
Recommendation 1.6.24 to 1.6.26
Why the committee made the recommendations
Prevention
There was no consistent evidence that any drug treatments are effective in preventing PTSD. Given the limited evidence of benefits and the potential harms, including side effects, the committee agreed that drug treatments should not be offered to prevent PTSD in adults. The committee specifically referred to benzodiazepines because of the lack of benefit in the evidence, concerns about harm and their clinical experience of these drugs being prescribed in practice.
Treatment
Recommendations 1.6.25 and 1.6.26
There was evidence that SSRIs and venlafaxine are effective in treating PTSD. There was a large number of studies for SSRIs but the sizes of the effects were smaller than for venlafaxine. The committee decided that either an SSRI or venlafaxine could be considered if a person prefers to have drug treatment, but they should not be offered as first-line treatment for PTSD. This is based partly on the lack of follow-up data for SSRIs and venlafaxine, and because evidence showed that SSRIs are less effective than any of the psychological interventions recommended. Economic modelling also showed SSRIs are less cost effective than EMDR, brief individual trauma-focused CBT or self-help with support.
There was no evidence for significant differential efficacy of specific SSRIs (sertraline, fluoxetine and paroxetine), so the committee agreed to allow prescribers to decide which SSRI to use.
However, they included sertraline as an example because it is 1 of 2 drugs licensed in the UK for this indication and the other drug, paroxetine, is more likely to be associated with discontinuation symptoms.
The committee agreed that it was important to review antidepressant treatment regularly to manage any side effects and to review clinical progress and outcomes.
There was some evidence that antipsychotics, either alone or in addition to routine medications, are effective in treating PTSD symptoms. However, it was more limited than the evidence supporting SSRIs and the psychological interventions (for example, the evidence for other important outcomes was limited and there were no follow-up data). The committee agreed that antipsychotics should not be seen as an alternative to a trauma-focused psychological intervention as first-line treatment for PTSD and should only be considered as an adjunct to psychological therapy. However, they might be beneficial for symptom management for adults with a diagnosis of PTSD if their symptoms have not responded to other drug or psychological treatments and they have disabling symptoms and behaviours that makes it difficult for them to engage with psychological treatment. Given the different side effect profiles, the committee agreed to leave the choice of antipsychotic to clinical judgement. Risperidone was included as an example because the evidence for risperidone included more participants.
The committee discussed concerns about the tolerability of antipsychotic drugs and agreed they should only be prescribed in a specialist setting, or after consultation with a specialist.
How the recommendations might affect practice
The committee was concerned that drug treatment within the first month of trauma may be reasonably common in clinical practice. Recommendation 1.6.24 will therefore help to reduce the use of non-evidence-based interventions and improve consistency of practice.
These recommendations represent a small change in practice because the previous guideline recommended drug treatment as an option only for adults who could not start a psychological therapy, did not want to start trauma-focused psychological therapy or who had gained little or no benefit from it.
In the UK, only paroxetine and sertraline are licensed for the treatment of PTSD so the recommendations involve off-licence use. Offering antipsychotics only in a specialist setting or after consultation with a specialist is expected to reduce variation in the way antipsychotics are used in current practice. Regular review of drug treatment is essential but might not be happening currently, so this should also improve consistency.
Full details of the evidence and the committee’s discussion are in evidence review F: pharmacological interventions for the treatment of PTSD in adults.
Care for people with post-traumatic stress disorder and complex needs
Recommendations 1.7.1 to 1.7.3
Why the committee made the recommendations
There was a lack of evidence on care for people with PTSD and complex needs, including people with coexisting conditions such as depression or substance misuse, so the committee used a formal consensus method to agree some overarching principles.
The evidence was limited on interventions for people who have complex PTSD, but it suggested that trauma-focused therapies could also benefit this group. Based on their clinical experience, the committee recommended modifications that may be needed to trauma-focused therapies to facilitate engagement for those with complex PTSD or other additional needs.
How the recommendations might affect practice
The committee acknowledged that there would be a cost associated with increasing the duration or the number of therapy sessions, if this is necessary for people with PTSD and additional needs. Previous recommended practice was to consider more than 12 sessions for people after multiple incident trauma, or who have chronic disability or significant coexisting conditions or social problems. However, in clinical practice the provision of additional sessions is variable.
Full details of the evidence and the committee’s discussion are in evidence review D: psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults and evidence review J: care pathways for adults, children and young people with PTSD.
Context
Post-traumatic stress disorder (PTSD) develops after a stressful event or situation of an exceptionally threatening or catastrophic nature. It is a disorder that can affect people of any age. Around 25–30% of people experiencing a traumatic event go on to develop PTSD.
PTSD can present with a range of symptoms. In adults the most common of these are vivid, distressing memories of the event or flashbacks, known as intrusive symptoms. Another prominent symptom is avoidance of trauma-related reminders or general social contact. People with PTSD often try to push memories of the event out of their mind and avoid thinking or talking about it in detail. On the other hand, people may also reflect excessively on questions that prevent them from coming to terms with the event – for example, why it happened to them, how it could have been prevented, or how they could take revenge. People with PTSD often have nightmares related to the trauma that affect their sleep.
Symptoms of PTSD often develop immediately after the traumatic event but in some people (fewer than 15%) onset is delayed. People may not present for treatment for months or years despite experiencing considerable distress. PTSD is a treatable disorder, even for people who present many years later, but assessment can be challenging because many people avoid talking about their problems even when presenting with associated complaints.
Children, particularly those aged under 8 years, may not complain directly of PTSD symptoms such as re-experiencing or avoidance. Instead, symptoms may take the form of re-enacting the experience, repetitive play or frightening dreams with no recognisable content.
It is common for people with PTSD to have other problems such as depression. If people have had repeated or multiple traumas, or have other significant mental health problems, their presentation of PTSD may be complex and adjustments may be needed to the way in which treatment is delivered.
Effective treatment of PTSD can only take place if the disorder is recognised. Opportunities for recognition usually come during routine healthcare, for example during physical treatment after an assault or an accident, or when a person discloses domestic violence or a history of childhood sexual abuse. Many people attending for medical services in hospital have experienced traumatic events, particularly in emergency departments, and orthopaedic and plastic surgery clinics. Up to 30% of children who attend an emergency department for a traumatic injury go on to develop PTSD. Identifying PTSD in children presents particular problems, but is improved by asking children directly about their experiences.
This guideline updates NICE’s 2005 guidance on PTSD. It covers children, young people and adults (aged 18 years and over) who are at risk of PTSD or have a diagnosis of PTSD, and their families and carers. It also covers people with comorbid conditions including drug and alcohol misuse and common mental health conditions.
The guideline covers all NHS and social care-commissioned services that provide care for people with PTSD.
Finding more information and resources
You can see everything NICE says on post-traumatic stress disorder in our interactive flowchart on post-traumatic stress disorder.
To find out what NICE has said on topics related to this guideline, see our web page on anxiety and mental health and behavioural conditions.
Update information
We have reviewed the evidence and made new recommendations on the prevention, treatment and care of people with post-traumatic stress disorder (PTSD). These recommendations are marked[2018].
We have also made some changes without an evidence review (see table). These recommendations are marked[2005, amended 2018].
Recommendations marked [2005] last had an evidence review in 2005. In some cases minor changes have been made to the wording to bring the language and style up to date, without changing the meaning.
Recommendations that have been changed
Amended recommendation wording (change to meaning)
| Recommendation in 2005 guideline | Recommendation in current guideline | Reason for change |
|---|---|---|
| 1.3.1.1 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). | 1.1.1 Be aware that people with post-traumatic stress disorder (PTSD), including complex PTSD, may present with a range of symptoms associated with functional impairment, including:
1.1.4 When assessing for PTSD, ask people with symptoms in recommendation 1.1.1 if they have experienced 1 or more traumatic events (which may have occurred many months or years before). Give specific examples of traumatic events as listed in recommendation 1.1.2. | For clarity the recommendation has been split to separate awareness of symptoms from assessment. Functional impairment has been added and symptoms updated compared with 2005 in light of new classification systems. Reference to complex PTSD and the additional symptoms of complex PTSD (interpersonal difficulties or problems in relationships, negative self-perception, and emotional dysregulation) have been included after the publication of ICD-11 and the new diagnostic classification of complex PTSD. Substance misuse has been removed as although this is a commonly coexisting condition it is not a core symptom of PTSD like all other bullet points in this recommendation. The recommendation has been broadened to all settings so ‘primary care’ has been removed from recommendation 1.1.4. ‘Traumatic experience’ has been amended to ‘1 or more traumatic events’ because of the possibility of multiple/repeated trauma. |
| 1.3.1.2 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 or childhood sexual abuse. |
1.1.2 Be aware of traumatic events associated with the development of PTSD. These could be experiencing or witnessing single, repeated or multiple events and could include, for example:
| The recommendation has been broadened to all settings so ‘primary care’ has been removed. Examples of types of traumatic events have been extended and clarified. Traumatic childbirth has been broadened to include serious health problems and childbirth experiences. |
| 1.3.1.3 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 and childhood sexual abuse and traumatic childbirth). | 1.1.5 For people with unexplained physical symptoms who repeatedly attend health services, think about asking whether they have experienced 1 or more traumatic events and provide specific examples of traumatic events (see recommendation 1.1.2). | The recommendation has been broadened to all care settings. To reduce repetition, examples of traumatic events have been replaced by a cross reference to recommendation 1.1.2. |
| 1.3.1.4 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. | 1.1.3 When assessing for PTSD, ask people specific questions about re-experiencing, avoidance, hyperarousal, dissociation, negative alterations in mood and thinking, and associated functional impairment. |
Symptoms have been updated in line with recommendation 1.1.1. |
| 1.3.3.1 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. | 1.1.8 For people at high risk of developing PTSD after a major disaster, those responsible for coordinating the disaster plan should think about the routine use of a validated, brief screening instrument for PTSD at 1 month after the disaster. | The committee added that the screening instrument should be validated. |
| 1.3.3.2 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. | 1.1.9 For refugees and asylum seekers at high risk of PTSD, think about the routine use of a validated, brief screening instrument for PTSD as part of any comprehensive physical and mental health screen. | Programme refugees has been changed to ‘refugees’ and ‘validated’ added to the recommendation for clarification. |
| 1.3.4.1 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. | 1.1.6 Do not rely solely on the parent or carer for information when it is developmentally appropriate to directly and separately question a child or young person about the presence of PTSD symptoms. | The recommendation has been reworded to emphasise when direct and separate questioning is appropriate. |
| 1.3.4.2 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 GP if the symptoms persist beyond 1 month. | 1.1.7 When a child who has been involved in a traumatic event is treated in an emergency department, emergency staff should explain to their parents or carers about the normal responses to trauma and the possibility of PTSD developing. Briefly describe the possible symptoms (for example, nightmares, repetitive trauma-related play, intrusive thoughts, avoiding things related to the events, increased behavioural difficulties, problems concentrating, hypervigilance, and difficulties sleeping) and suggest they contact their GP if the symptoms persist beyond 1 month. | Symptoms have been updated compared with 2005 in light of new classification systems. The normal responses to trauma has been added based on the opinion of the committee that it is helpful to ‘normalise’ the presence of some symptoms in the first few weeks as they can manifest but diminish as part of ‘natural’ recovery. |
| 1.4.1 For PTSD sufferers presenting in primary care, 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. | 1.2.1 For people with clinically important symptoms of PTSD presenting in primary care, GPs should take responsibility for assessment and initial coordination of care. This includes determining the need for emergency physical or mental health assessment. | This change has been made to reflect that, before assessment, people with clinically important symptoms of PTSD will not have a diagnosis so it is not meaningful to talk about people with PTSD in this recommendation. |
| 1.4.2 Assessment of PTSD sufferers should be conducted by competent individuals and be comprehensive, including physical, psychological and social needs and a risk assessment. | 1.2.2 Assessment of people with PTSD should becomprehensive, including an assessment of physical, psychological and social needs and a risk assessment. | Competence has been removed from the recommendation as this is a general expectation of the NHS and is not specific to PTSD or to assessment. |
| 1.4.4 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 [CPA]) and should be shared with the patient and, where appropriate, their family and carers. | 1.2.3 Where management is shared between primary and secondary care, healthcare professionals should agree who is responsible for monitoring people with PTSD. Put this agreement in writing (if appropriate, using the Care Programme Approach) and involve the person and, if appropriate, their family or carers. | ‘Share it with’ has been replaced by ‘involve’ to reflect that the person (and family if appropriate) would have a more active role in this process. |
| 1.7.2 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. | 1.5.2 Ensure that screening, assessment and interventions for PTSD are culturally and linguistically appropriate. | The recommendation has been simplified and broadened to apply to screening and assessment as well as interventions. |
| 1.7.3 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. | 1.5.3 If language or culture differences present challenges to the use of psychological interventions in PTSD, think about using interpreters or offering a choice of therapists. See recommendations on communication in the NICE guideline on patient experience in adult NHS services. | ‘Trauma-focused’ has been removed to broaden the recommendation. A cross reference to NICE guidance published since 2005 has been added to provide further detail. |
| 1.7.4 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. | 1.5.1 Pay particular attention to identifying people with PTSD in working or living environments where there may be cultural challenges to recognising the psychological consequences of trauma (see recommendations on avoiding stigma and promoting social inclusion in the NICE guideline on service user experience in adult mental health) | A cross reference to NICE guidance published since 2005 has been added to provide further detail. |
Footnotes
- [1]
Other methods of bilateral stimulation, including taps and tones, could be used if these are preferred or more appropriate (such as for people who are visually impaired).
- [2]
At the time of publication (December 2018), venlafaxine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.
- [3]
At the time of publication (December 2018), only sertraline and paroxetine have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.
- [4]
At the time of publication (December 2018), risperidone did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.
Your responsibility: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.
- NICE Clinical Guideline 26: Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care
- Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the prevention of PTSD in children: Post-traumatic stress disorder: Evidence review A
- Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in children and young people: Post-traumatic stress disorder: Evidence review B
- Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the prevention of PTSD in adults: Post-traumatic stress disorder: Evidence review C
- Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults: Post-traumatic stress disorder: Evidence review D
- Evidence reviews for pharmacological interventions for the prevention and treatment of PTSD in children: Post-traumatic stress disorder: Evidence review E
- Evidence reviews for pharmacological interventions for the prevention and treatment of PTSD in adults: Post-traumatic stress disorder: Evidence review F
- Evidence reviews for psychological and psychosocial interventions for family members of people at risk of, or with, PTSD: Post-traumatic stress disorder: Evidence review G
- Evidence review for principles of care: Post-traumatic stress disorder: Evidence review H
- Evidence reviews for organisation and delivery of care for people with PTSD: Post-traumatic stress disorder: Evidence review I
- Evidence reviews on care pathways for adults, children and young people with PTSD: Post-traumatic stress disorder: Evidence review J
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- Post-traumatic stress disorderPost-traumatic stress disorder
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