Clinical Guideline Published: March 2005 Post-traumatic Stress Disorder (PTSD) The management of PTSD in adults and children in primary and secondary care HEADER SLIDE – ALL You can add your own organisation's logo alongside the NICE logo if you want Clinical Guideline Published: March 2005

What is a NICE clinical guideline? Recommendations for good practice based on best available evidence DH ‘Standards for better health’ expects organisations to implement clinical guidelines Healthcare Commission monitors compliance with NICE guidance MAY BE OF INTEREST TO COMMISSIONERS AND MANAGERS 2

What is PTSD? A disorder that develops in response to a stressful event or situation of exceptionally threatening or catastrophic nature e.g. assault, road accidents, disaster, rape Symptoms include: re-experiencing symptoms (e.g. flashbacks, nightmares) avoidance of people or situations associated with the event emotional numbing hyperarousal symptoms SLIDE FOR ALL The guideline covers the diagnosis, early identification, and treatment of PTSD. PTSD is defined in ICD 10 (WHO 1992) Other symptoms include: depression, drug or alcohol misuse, anger, unexplained physical symptoms resulting in repeated attendance. Remember the disorder can occur at any age including childhood! ‘The torment engulfed my whole person’ ‘I felt like I was never going to be the same’ ‘(it)… catapulted me out of normality into another world’ ‘I just wanted to explode’ ‘The impact increased as time moved on - the enormity (is) almost indescribable’ 3

How common is PTSD? Probability of developing PTSD after a traumatic event: men 8 - 13% women 20 - 30% Annual prevalence: 1.5 - 3% Prevalence in PCT population of 170k: 2.5k - 5k people Prevalence in GP practice of 5k: 75 -150 people SLIDE FOR ALL Community based studies in the US indicate a life time prevalence for PTSD of approx 8% of the adult population GP practices can have between 75-150 people with PTSD. These people may not necessarily present or be diagnosed with PTSD. 4

What is the natural course of PTSD? Usual onset of symptoms a few days after the event Many recover without treatment within months/years of event (50% natural remission by 2 years), but some may have significant impairment of social and occupational functioning SLIDE FOR ALL Treatment means that about 20% more people with PTSD recover Generally 33% remain symptomatic for 3 years or longer with greater risk of secondary problems 5

What does the guideline cover? The care provided by primary, secondary and other healthcare professionals to: recognise, screen and diagnose PTSD assess and coordinate care treat all people with PTSD, including children support families and carers SLIDE FOR ALL 6

What is not covered? Adjustment disorders: symptoms of significant trauma but doesn’t meet criteria for PTSD Disorders such as: dissociative disorders personality changes following trauma (because of diagnostic uncertainty and lack of agreement) Note: many symptoms of these can be managed with interventions used in PTSD SLIDE FOR CLINICIANS It is recognised that many PTSD sufferers will have at least some of the features of ‘enduring personality changes’ or DESNOS (Disorders of Extreme Stress not otherwise specified). This guideline takes shows that these features need to be taken into consideration when treating PTSD sufferers. BUT the guidelines DO NOT apply to individuals whose main problem is a diagnosis of ‘enduring personality changes’ rather than PTSD The guideline is relevant to the work of occupational health professionals, social services, independent sector but does not cover their practice. Enduring personality changes after catastrophic experience: Diagnosis arose from clinical descriptions of concentration camp survivors and characterised by a hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of ‘being on edge’ as if constantly threatened, and estrangement. ‘Enduring personality changes after catastrophic experience’ can be an outcome of chronic PTSD, especially after experiences such as torture or being held for a long period as a hostage. Complex PTSD Many trauma survivors have experienced a range of different traumatic experiences over their life span or have experienced prolonged traumas such as childhood sexual abuse or imprisonment with torture. Several authors have suggested that many of these people develop a range of other problems besides PTSD, for example depression, low self-esteem, self-destructive behaviours, poor impulse control, somatisation and chronic dissociation or depersonalisation. It has been controversial whether these reactions form a separate diagnostic category. Herman (1993) and others suggested a separate diagnosis of ‘complex PTSD’ or ‘disorders of extreme distress not otherwise specified’ (DESNOS) to describe a syndrome that is associated with repeated and prolonged trauma. Initial research has found some evidence for the validity of this concept (e.g. Pelcovitz et al, 1997). However, it was decided not to include DESNOS as a separate diagnostic category in DSM–IV: instead, the DESNOS criteria were included among the ‘associated descriptive features’ of PTSD. This reflects the view that these characteristics are not a unique feature of survivors of childhood sexual abuse or other prolonged trauma, but instead apply in varying degrees to most PTSD sufferers. Dissociative disorders Dissociative disorders are characterised by a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. The ICD–10 dissociative (conversion) disorders include dissociative amnesia, dissociative fugue, dissociative disorders of movement and sensation, and other dissociative (conversion) disorders including multiple personality disorder. The disturbance may be sudden or gradual, transient or chronic. It is presumed that the ability to exercise a conscious and selective control is impaired in dissociative disorders, to a degree that can vary from day to day or even from hour to hour. However, it is usually difficult to assess the extent to which some of the loss of functions might be under voluntary control. Dissociative disorders are presumed to be psychogenic in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. People with PTSD may experience a peri-traumatic dissociation (a dissociative reaction at the time of the trauma), which may subsequently be associated with the complaint of psychogenic amnesia for an aspect of the traumatic event. The disorder is also associated with an increased rate of other dissociative symptoms. Indeed, in the preparation for the publication of DSM–IV, there was discussion as to whether PTSD should be listed as a dissociative disorder rather than an anxiety disorder (see Brett, 1993). Adjustment disorders Adjustment disorders are states of subjective distress and emotional disturbance that arise in the period of adaptation to a significant life change or stressful life event. Stressors include those that affect the integrity of an individual’s social network (e.g. bereavement, separation) or the wider system of social supports and values (e.g. migration, leaving the armed forces), or represent a major developmental transition or crisis (e.g. retirement). Manifestations vary and include depressed mood, anxiety or worry, a feeling of inability to cope, plan ahead or continue in the present situation, as well as some degree of disability in the performance of daily routine. Conduct problems may also occur. 7

How to treat PTSD: key messages Increased awareness and greater recognition of PTSD especially in primary care Increased provision of trauma focused psychological treatments Shift away from inappropriate use of medications and brief single session psychological treatments (debriefing) SLIDE FOR CLINICIANS 8

Immediate management of PTSD Psychological first aid Giving information and social support as soon as possible Avoid brief single session debriefing given to individuals alone following an event Watchful waiting if symptoms are moderate – assess whether natural recovery occurs, review at one month Screen at risk groups Following disaster Refugees and asylum seekers SLIDE FOR CLINICIANS 9

Interventions for PTSD over time: Within 3 months of trauma Treat PTSD within 1 month if symptoms are severe Introduce trauma focused CBT by first month if symptoms persist SLIDE FOR CLINICIANS 10

Interventions for PTSD over time: Beyond 3 months of trauma Trauma-focused CBT or EMDR as first line treatment for people with more than a 3 month history of symptoms Drug treatments should not be used in routine care in preference to a trauma focused psychological therapy Where drug treatments are used: general use: paroxetine or mirtazapine specialist use: amitriptyline or phenelzine SLIDE FOR CLINICIANS 11

Psychological treatments Interventions need to be focused on the trauma and structured: Trauma-focused CBT- therapist helps the PTSD sufferer to: Confront traumatic memories with less fear Modify misinterpretations which overestimate threat Develop skills to cope with stress SLIDE FOR CLINICIANS 12

Psychological treatments Eye motion desensitisation and reprocessing (EMDR) – a structured trauma-focused psychological intervention: PTSD sufferer is asked to recall an important aspect of the traumatic event The sufferer follows repetitive side to side movements, sounds or taps as the image is being focused on SLIDE FOR CLINICIANS 13

Challenges in treating PTSD Management of ongoing trauma eg domestic violence Ensure safety before starting treatment Comorbid drug and alcohol misuse: If severe treat it first Severe depression: Treat the depression first but most depression will get better SLIDE FOR CLINICIANS 14

Challenges in treating PTSD Ex-military personnel: Be aware of possible increased risk in some Personality disorder: Can still treat PTSD but may need to extend sessions Traumatic bereavement May complicate treatment SLIDE FOR CLINICIANS Refer to full guideline – Special considerations section 15

What special issues are there for children and young people? Diagnostic categories same as adult Important to talk to children directly and not rely solely on information from parents for diagnosis Symptoms may differ in younger children (e.g. re-enacting, repetitive play, emotional and behavioural disturbances) Offer trauma focused-CBT for children with PTSD Drug treatments should not be routinely prescribed SLIDE FOR ALL Broad categories of PTSD symptoms are present in children as well as adults (re-experiencing, avoidance/numbing and increased arousal) Don’t rely solely on information from parent/guardian during assessment – ask child or young person directly about symptoms, ask about sleep disturbance or significant changes to sleep patterns If children are seen in an emergency setting following a traumatic event, inform parents that PTSD could develop, describe possible symptoms and ask them to contact their GP should symptoms persist after 1 month Trauma focused CBT should be used when early acute severe traumatic stress symptoms are present within 1 month 16

What are the implementation actions for managers? Improve access to trauma focused psychological therapies Focus on the time to treatment not first assessment Shift to primary care Requires retraining some of the workforce Don’t forget children SLIDE FOR COMMISSIONERS AND MANAGERS This slide is intended as a discussion tool It starts with internal dissemination but moves on to undertaking a gap analysis Dissemination – Have the right people received the guidance? Consider what at are the actions for those receiving the guideline? Monitoring and audit: Consider a baseline assessment and plan change against this. Plan for audit Action Planning: Use local action planning templates, consider how progress is fed back into the organisation 17

How is cost assessed locally? NICE has developed a costing tool for PTSD A national costing report and local costing templates are available on the NICE website at www.nice.org.uk/costimpact SLIDE FOR COMMISSIONERS AND MANAGERS Costing templates will be available on the Implementation section of the website from June 2005 www.nice.org.uk 18

What services are provided in your area? Create your own local services list! Primary care based mental health services Psychological treatment services Community Mental Health Teams Traumatic stress services Social services Local authorities (occupational health) Non-statutory and voluntary organisations SLIDE FOR PRESENTER TO COMPLETE This slide allows you to add your own local information. It helps identify what services exist within your area. You can include contact details etc 19

Developing implementation plans Prioritise recommendations locally Involve stakeholders including service users Assess current state compared to recommendations using audits Assess the impact of making the required changes to fill the gap: cost, risk, resources Identify strategies to achieve this and a timescale to roll them out Identify barriers to implementation Evaluate implementation SLIDE FOR ALL 20

Audit against recommendations What should be audited? Key objectives: Patients involved in their care Treatment options are appropriate SO MEASURE………….. What isn’t recommended… Debriefing Ineffective psychological treatments Drug treatments NOT a first line treatment What is recommended… Watchful waiting Trauma-focussed treatments (CBT and EMDR) for adults and children Audit against recommendations SLIDE FOR CLINICIANS, MANAGERS, COMMISSIONERS Process: Single audit – all individuals with PTSD Or specific groups for e.g. people with chronic PTSD, a sample of patients from particular populations in primary care Measures Brief, single-session interventions (de-briefing) Watchful waiting Trauma focussed psychological treatment Trauma focussed CBT for older children Trauma focussed CBT for chronic PTSD in children and young people Drug treatments 21

Where is the guideline available? Quick reference guide: summary of recommendations for health professionals: www.nice.org.uk/cg026quickrefguide NICE guideline www.nice.org.uk/cg026niceguideline Full guideline: all of the evidence and rationale behind the recommendations: www.rcpsych.ac.uk/publications Information for the public: plain English version for sufferers, carers and the public www.nice.org.uk/cg026publicinfoenglish SLIDE FOR ALL The slides do not replace the full version of the guideline and should be used in conjunction with the Quick Reference Guide or Full Guideline – links displayed above 22

What other NICE guidance should be considered? Published: Anxiety December 2004 Depression December 2004 Self Harm July 2004 In development: Depression in children September 2005 Antenatal & postnatal mental health February 2007 SLIDE FOR ALL Refer to Obsessive Compulsive Disorder (OCD), Computerised CBT & Eating disorders if necessary 23

www.nice.org.uk SLIDE FOR ALL You can find more information on NICE and our work by visiting the website at www.nice.org.uk 24