e-Learning | Post-traumatic stress disorder (PTSD)

This is an updated guideline from NICE on Post-Traumatic Stress Disorder PTSD. The last guideline came out in 2005. I don't think this really changes our management much (i.e. watch and wait for 1 month and then refer for most patients), but I will summarise the symptoms we should be looking out for and also the management. I found it very interesting what the evidence was for different treatments and was a bit surprised.

I use the term 'clinically important symptoms' of PTSD. NICE advises that these are people who reach the threshold for diagnosis of PTSD, but who don't yet have a diagnosis of it. It seems to be a term mainly used in research.

I also use the term CBT quite freely as we aren't going to be deciding on what kind of CBT a patient has.

Presentation in adults

The following symptoms are found in PTSD. They should be associated with functional impairment.

  • Re-experiencing.
  • Avoidance.
  • Hyper-arousal (including hyper-vigilance, anger and irritability).
  • Negative alterations in mood and thinking.
  • Emotional numbing.
  • Dissociation.
  • Emotional dysregulation,
  • Interpersonal difficulties.
  • Negative self-perception (including feeling diminished, defeated or worthless).

Unexplained physical symptoms. It is worth asking people who regularly attend with unexplained physical symptoms if they have experienced a traumatic event.

Presentation in children

It is worth counselling parents about possible presentations of PTSD in children after a traumatic event. If symptoms haven't settled within a month, they should seek review.

  • Nightmares.
  • Trauma related play.
  • Intrusive thoughts.
  • Avoidance of things related to the event.
  • Increased behavioural difficulties.
  • Problems concentrating.
  • Hyper-vigilance.
  • Difficulties sleeping.

Triggers

Among all the other more obvious triggers, work-related trauma can be a cause, even if the exposure is remote.

Triggers may also have happened months or years before the presentation.

Access to care

  • Promote access be reassuring patients that it is a treatable condition with a range of options for treatment.
  • Do not delay or withhold treatment because of court-proceedings or claims for compensation.
  • Consider other family members who may have experienced the same trauma.

Preventing PTSD after a traumatic event

Adults with sub-threshold symptoms.

Consider active monitoring (watchful waiting) for the first month. Do not offer psychologically focused debriefing (it doesn't work).

Adults with acute stress disorder or 'clinically important symptoms' of PTSD.

Offer CBT within the first month. There is evidence that it is effective.

Children and young people.

If they have acute stress disorder or 'clinically important symptoms' of PTSD then offer CBT within the first month. There aren't any studies on the first month, but expert opinion felt that it was likely to be helpful for some individuals.

Treatment of children and young people

Do not offer medication. There is only limited evidence available and what evidence there is doesn't show that it is effective.

5 to 6 yr olds.

Consider CBT if they have presented after 1m. There is some evidence that it is effective in this age group.

7 to 17 yr olds.

1 to 3m after the event. Consider CBT. There aren't many studies available for children presenting between 1 and 3m, which is why the advice is only to 'consider' it, rather than to offer it.

More than 3m. Offer CBT. Consider EMDR (eye movement desensitisation and reprocessing) if CBT doesn't work, or if they haven't engaged in it. There is only evidence for the use of EMDR in the over 7s and it isn't as effective as other treatments.

Psychological treatment of adults

Offer CBT if they present after 1 month. There is good evidence for it's efficacy after 3m, and some evidence of efficacy after 1m.

Consider EMDR if they present at 1-3m with non-combat related PTSD, if they have a preference for it. There is evidence that it is not effective for combat related PTSD. There is less evidence for the use of EMDR between 1 and 3 months than for its use after 3m. What evidence there is for EMDR suggests that it may be more effective and cost-effective than CBT, but there is not as much research on EMDR as there is for CBT

Offer EMDR if they present after 3m.

Consider supported trauma-focused computerised CBT if they present after 3m (as long as they don't have severe PTSD or are a risk to themselves or others as it is less likely to be effective than other treatments). Both supported and unsupported computerised CBT are effective, but supported is more effective.

CBT aimed at specific symptoms (eg sleep or anger) can be considered after 3m if they are unable or unwilling to engage with trauma-focused CBT, or if they have residual symptoms after engaging with it.

Drug treatment in adults.

Prevention. There is no evidence that drugs prevent PTSD after a traumatic event.

Treatment. Consider venlafaxine or an SSRI. All SSRIs are likely to be effective, but sertraline has an indication for PTSD. Paroxetine does too, but has more withdrawal side-effects. The evidence suggests that venlafaxine is more effective than SSRIs, but a lot more studies have been done on SSRIs in PTSD than on venlafaxine. Drug treatment is not as cost-effective as any of the psychological interventions listed above (which I found very surprising given how cheap these drugs are).

Antipsychotics may be used by specialists.

Patients with co-morbidities

Depression. Normally treat the PTSD first as the depression is likely to resolve. If the depression is making the psychological treatments difficult, or if the person is at risk of harming themselves or others, then you may need to treat the depression first.

Drugs or alcohol. Patients with addictions should not be excluded from treatment.

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