1. Clinical Guideline Published: March 2005
Post-traumatic Stress Disorder (PTSD) The management of PTSD in adults and children in primary and secondary care
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Clinical Guideline
Published: March 2005

2. 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
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3. 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
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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

4. How common is PTSD?
Probability of developing PTSD after a traumatic event:
men %
women %
Annual prevalence: %
Prevalence in PCT population of 170k:
2.5k - 5k people
Prevalence in GP practice of 5k:
people
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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 people with PTSD. These people may not necessarily present or be diagnosed with PTSD. 4

5. 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
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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

6. 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
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7. 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
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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

8. 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)
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9. 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
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10. 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
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11. 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
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12. 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
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13. 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
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14. 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
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15. 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
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Refer to full guideline – Special considerations section 15

16. 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
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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

17. 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

18. 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
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Costing templates will be available on the Implementation section of the website from June 18

19. 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
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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

20. 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
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21. 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
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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

22. Where is the guideline available?
Quick reference guide: summary of recommendations for health professionals:
NICE guideline
Full guideline: all of the evidence and rationale behind the recommendations:
Information for the public: plain English version for sufferers, carers and the public
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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

23. 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
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Refer to Obsessive Compulsive Disorder (OCD), Computerised CBT & Eating disorders if necessary 23

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