Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about 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.

Health and care professionals should follow our general guidelines for people delivering care:

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]

Specific recognition issues for children

1.1.6

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

1.1.7

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]

1.1.8

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

Provide additional support:

1.2.5

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]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on supporting transitions between services.

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.

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 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

  • 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 on pre-trial therapy. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on access to care.

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.

1.4 Principles of care

Peer support

1.4.1

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

1.4.2

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

1.4.3

When providing information and support to family members and carers of people with PTSD, think about covering:

  • the treatment and management of trauma-related psychological and behavioural problems, including the person's possible risk to themselves and others

  • 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]

1.4.4

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]

1.4.5

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]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on principles of care.

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.

1.5 Language and culture

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), 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]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on planning treatment and supporting 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

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]

For a short explanation of why the committee made the 2018 recommendation and how it might affect practice, see the rationale and impact section on active monitoring.

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.

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]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on psychological interventions for the prevention of PTSD in children and young people.

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.

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]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on psychological interventions for the treatment of PTSD in children and young people.

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

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]

For a short explanation of why the committee made the 2018 recommendation and how it might affect practice, see the rationale and impact section on drug treatments for children and young people.

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 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]

For a short explanation of why the committee made the 2018 recommendation and how it might affect practice, see the rationale and impact section on psychological interventions to prevent PTSD in adults.

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.

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 but use other methods, including taps and tones, if preferred or more appropriate, such as for people who are visually impaired) 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]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on psychological interventions to treat PTSD in adults.

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 for adults

1.6.24

Do not offer drug treatments, including benzodiazepines, to prevent PTSD in adults. [2018]

1.6.25

Consider venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Review this treatment regularly. [2018]

In December 2018, this was an off-label use for venlafaxine. See NICE's information on prescribing medicines.

In December 2018, only sertraline and paroxetine had a UK marketing authorisation for this indication. See NICE's information on prescribing medicines.

1.6.26

Consider antipsychotics such as risperidone in addition to psychological therapies to manage symptoms for adults with a diagnosis of PTSD if:

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on drug treatments in adults.

Full details of the evidence and the committee's discussion are in evidence review F: pharmacological interventions for the treatment of PTSD in adults.

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]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on care for people with PTSD and complex needs.

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.

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.

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.