Recent guidance should ensure that sufferers of post-traumatic stress disorder receive the therapy they need, as Dr Peter Saul explains

The recent terrorist attacks at home and a series of disasters and conflicts abroad have raised awareness of post-traumatic stress disorder (PTSD) over the past few years. Yet, until this year, there have been no generally available national guidelines covering clinical management of PTSD.

The publication of a NICE guideline that helps professionals in both primary and secondary care to recognise and facilitate treatment for this distressing condition is therefore particularly welcome and timely.

Many of the NICE recommendations are in accordance with US guidelines such as the Expert Consensus Guideline on the treatment of PTSD,1 and the Department of Veterans Affairs/Department of Defense (VA/DoD) clinical practice guideline for the management of post-traumatic stress.2

Defining PTSD

Like many NICE guidelines, this document both offers help in managing patients and serves as a ‘primer’ on PTSD – a condition that may still be neglected in medical school teaching, and is often poorly understood even by experienced GPs.

The definition of the condition provided by the guideline is particularly useful: "PTSD develops following a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.” Up to 30% of those who suffer a traumatic event may develop PTSD, and it can affect all age groups.

Stressful events such as divorce, natural bereavement or job loss are not recognised triggers for PTSD.

Sufferers include survivors of disasters and accidents, as well as victims of sexual abuse, assault and violent crime. The primary health care team should be aware that PTSD can result from any of these events.Many of the asylum seekers who have registered at GP practices in the UK may have been through events that are likely to cause PTSD.

The guidance has critical relevance for many of these vulnerable groups, and helps to raise awareness among clinicians that trauma-induced psychopathology may cause symptoms in patients with such a history.

The evidence base

The nature and extent of PTSD have been recognised only recently; therefore the evidence base for intervention is relatively weak.

Recommendations for therapeutic measures such as trauma-focused cognitive behavioural therapy are backed by sound (Grade A) evidence, and there is good clinical evidence to support recommendations relating to drug therapy and the avoidance of non-trauma-focused interventions.

Much of the rest of the guideline, however, particularly in relation to recognition and initial assessment, relies on recommended good practice.

Figure 1 (below) shows the grading scheme for evidence and recommendations.

Figure 1: Grading scheme for evidence and recommendations

Recognising PTSD in primary care

Symptoms of PTSD often develop immediately after the event but are delayed in almost 15% of sufferers.

However, individuals may not present until months or years after the onset of symptoms. The most characteristic symptoms of PTSD are:

  • Re-experiencing symptoms, e.g. nightmares and flashbacks and repeated distressing sensory impressions of the event
  • Avoiding reminders of the trauma, including avoiding people and situations resembling or associated with the event
  • Symptoms of hyperarousal, including hypervigilance, exaggerated startle response, irritability and sleep problems
  • Emotional numbing, including an inability to experience emotions and feelings of detachment from others.

Assessing PTSD can be difficult because many individuals avoid talking about their problems even when they present with related complaints.

In the case of an adult, the GP should ask specific questions, in a sensitive way, about the individual’s symptoms and traumatic experiences.In children, evidence of sleep disturbance may be a more useful indicator of PTSD.

Most primary care clinicians are unfamiliar with PTSD, so an assessment tool, such as that found in the Expert Consensus Guideline would have been useful as an aid to diagnosis and monitoring the effectiveness of therapy.

Management of PTSD

The guideline charges GPs with responsibility for initial assessment and coordination of care of patients who present in primary care (see Box 1, below) and for deciding whether the individual needs emergency medical or psychiatric assessment. Individuals suffering from PTSD are in need of practical, social and emotional support and this should also be offered.

Box 1: Post-traumatic stress disorder – key points for GPs
  • Characteristic features include re-experiencing the trauma (e.g. flashbacks, nightmares, intrusive images and thoughts), avoidance of reminders of the trauma, and emotional numbing and hyperarousal
  • Symptoms may develop immediately after the event, or months or years later: in either case they are amenable to treatment
  • Clinicians should ask sensitively about a history of traumatic events when presented with such symptoms
  • GPs need to take responsibility for initial assessment and coordination of care. Further management will normally involve those trained in psychological therapies. Patients and families need to be kept informed about treatment plans and options
  • Treatment should not be delayed.Where symptoms are mild and of less than 1 month’s duration, watchful waiting should be employed, with follow-up of the patient, and practical, social and emotional support offered. Patients with more severe or longer-term symptoms should be offered trauma-focused cognitive behavioural therapy
  • Brief single-session interventions (debriefing) are not recommended
  • Drugs should not be used as first-line therapy
  • In the presence of co-morbidities such as depression or substance abuse, the PTSD should be addressed first unless these co-morbidities restrict management or pose a threat to the patient’s wellbeing

Psychological therapy

For patients with symptoms that are mild and have been present for less than 4 weeks following the trauma, watchful waiting is a legitimate approach to management.

For all other individuals, regardless of the length of time since the traumatic event, trauma-focused psychological therapies, such as trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing, should be offered. The duration of treatment is likely to be between 8 and 12 sessions.

The guideline recommends that brief single-session interventions (‘debriefing’) that focus on the event should not be used routinely.This will result in many emergency organisations having to rethink staff support policies.

In the light of the poor provision of psychological services in many areas of the UK, the guideline lays down a challenge to health commissioners.

They must ensure that GPs have access to the key trauma-focused cognitive behavioural therapy services their patients need, since few of us will have the skills or resources to offer these in practice.

Drug therapy

The NICE guideline advocates a conservative approach to drug therapy. For example, selective serotonin reuptake inhibitors are recommended only as a second-line treatment, or where there is associated depression or inability to engage in non-drug therapy.

There is little support for other psychological therapies such as anxiety management or exposure therapy, or for play therapy in children, all of which are considered valuable by the US guidelines. Indeed, the VA/DoD guideline suggests a much wider range of therapies, including ‘spiritual support’.It must be remembered, however, that NICE has to confine its recommendations to those treatments available on the NHS.

Conclusion

GPs will undoubtedly find the NICE PTSD guideline useful in helping to identify sufferers, and as a map to management. It is particularly helpful in giving guidance on how clinicians should manage patients with co-morbidity, and how to prioritise actions and monitor patients.

Most importantly of all, the flag has been raised for patients suffering from a previously neglected but important condition.

Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. Clinical Guideline 26 can be downloaded from the NICE website: www.nice.org.uk

References

  1. Foa EB, Davidson JRT, Frances A. The Expert Consensus Guideline series: Treatment of posttraumatic stress disorder. J Clin Psychiatry 1999; 60 (Suppl 16).
  2. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress.Version 1.0. Washington, DC: Department of Veterans Affairs, Department of Defense, 2004.

Guidelines in Practice, September 2005, Volume 8(9)
© 2005 MGP Ltd
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