TTreating post-trreating post-traumatic stress disorder in adultsaumatic stress disorder in adults

NICE Pathways bring together everything NICE says on a topic in an interactiveflowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latestversion of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/post-traumatic-stress-disorderNICE Pathway last updated: 04 December 2018

This document contains a single flowchart and uses numbering to link the boxes to theassociated recommendations.

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1 Adult with post-traumatic stress disorder (PTSD) or clinically-important symptoms of PTSD presenting more than 1 month after atraumatic event

No additional information

2 Trauma-focused cognitive behavioural therapy

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.

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 ifthey have experienced multiple traumas

be delivered by trained practitioners with ongoing supervision

include psychoeducation about reactions to trauma, strategies for managing arousal andflashbacks, 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 socialrelationships

prepare them for the end of treatment

include planning booster sessions if needed, particularly in relation to significant dates (forexample trauma anniversaries).

Rationale and impact

See the NICE guideline to find out why we made these recommendations and how they might

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affect practice.

3 Eye movement desensitisation and reprocessing

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.

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.

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 ifthey 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) for specifictarget memories until the memories are no longer distressing (other methods of bilateralstimulation, including taps and tones, could be used if these are preferred or are moreappropriate – such as for people who are visually-impaired)

include the teaching of self-calming techniques and techniques for managing flashbacks,for use within and between sessions.

Rationale and impact

See the NICE guideline to find out why we made these recommendations and how they might

affect practice.

4 Supported trauma-focused computerised cognitive behaviouraltherapy

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

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they are not at risk of harm to themselves or others.

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-relatedemotions; restructuring trauma-related meanings for the individual; helping to overcomeavoidance; and re-establishing adaptive functioning (for example, work and socialrelationships)

include guidance and support from a trained practitioner to encourage people to completethe intervention, give feedback on homework assignments and review progress andoutcomes.

Rationale and impact

See the NICE guideline to find out why we made these recommendations and how they might

affect practice.

5 Cognitive behavioural therapy for specific symptoms

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.

See the NICE guideline to find out why we made this recommendation and how it might affect

practice.

6 Drug treatment

Consider venlafaxine1 or a SSRI, such as sertraline2 for adults with a diagnosis of PTSD if the

person has a preference for drug treatment. Review this treatment regularly.

Consider antipsychotics such as risperidone3, 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 orpsychotic symptoms and

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their symptoms have not responded to other drug or psychological treatments.

Antipsychotic treatment should be started and reviewed regularly by a specialist (see NICE's

recommendations on antipsychotic medication for psychosis and schizophrenia).

For information on using drug treatments in pregnancy and the postnatal period see NICE's

recommendations on pharmacological treatments for antenatal and postnatal mental health

problems. See also what NICE says on medicines optimisation.

Rationale and impact

See the NICE guideline to find out why we made these recommendations and how they might

affect practice.

TTreating post-trreating post-traumatic stress disorder in adultsaumatic stress disorder in adults NICE Pathways

1 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 GMC's Prescribing guidance: prescribing

unlicensed medicines for further information.2 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 GMC's Prescribing guidance: prescribing

unlicensed medicines for further information.3 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 GMC's Prescribing guidance: prescribing

unlicensed medicines for further information.

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Glossary

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

(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)

ASD

acute stress disorder

CBT

cognitive behavioural therapy

clinically important symptoms of PTSD

(refers to people 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 may 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))

CPA

care programme approach

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Disaster plan

(a plan setting out the overall framework for the initiation, management, coordination and control

of staff and other resources to reduce, control or respond to an emergency)

Disaster plans

(plans setting out the overall framework for the initiation, management, coordination and control

of staff and other resources to reduce, control or respond to an emergency)

EMDR

eye movement desensitisation and reprocessing

people with clinically important symptoms of PTSD

(refers 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)

PTSD

post-traumatic stress disorder

SSRI

selective serotonin re-uptake inhibitor

SSRIs

selective serotonin re-uptake inhibitors

Practitioners

(people with mental health training, particularly in PTSD, who also have training and

competence in delivering interventions for PTSD)

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Sources

Post-traumatic stress disorder (2018) NICE guideline NG116

Your responsibility

Guidelines

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.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after

careful consideration of the evidence available. When exercising their judgement, health

professionals are expected to take these recommendations fully into account, alongside the

individual needs, preferences and values of their patients. The application of the

recommendations in this interactive flowchart is at the discretion of health professionals and

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their individual patients and do not override the responsibility of healthcare professionals to

make decisions appropriate to the circumstances of the individual patient, in consultation with

the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable

the recommendations to be applied when individual health professionals and their patients wish

to use it, in accordance with the NHS Constitution. They should do so 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.

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.

Medical technologies guidance, diagnostics guidance and interventional proceduresguidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after

careful consideration of the evidence available. When exercising their judgement, healthcare

professionals are expected to take these recommendations fully into account. However, the

interactive flowchart does not override the individual responsibility of healthcare professionals to

make decisions appropriate to the circumstances of the individual patient, in consultation with

the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful

discrimination, advance equality of opportunity, and foster good relations. Nothing in this

interactive flowchart should be interpreted in a way that would be inconsistent with compliance

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.

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