Treatment

When the PTSD is of short duration it is managed as an acute stress reaction.

Many patients will be seen by the GP shortly after the traumatic event. At this point the patient will require treatment for the physical injuries and will not complain or request for help specifically related to the psychological aspects of the trauma.

Assessment and coordination of care (1,2)

• for people with clinically important symptoms of PTSD presenting in primary care, GPs should take responsibility for assessment and initial coordination of care - includes determining the need for emergency physical or mental health assessment
  
  
• assessment of people with PTSD should be comprehensive, including an assessment of physical, psychological and social needs and a risk assessment
  
  • ensure that assessment is comprehensive and includes a risk assessment and assessment of physical, psychological and social needs, and is conducted by a competent healthcare professional
  • furthermore clinicians should keep in mind about the following:
  • PTSD can arise from single events e.g. - an assault or a road traffic accident or from repeated trauma e.g. - childhood sexual abuse, domestic violence or the repeated trauma associated with being a refugee
  • a small proportion of patients may have a delayed onset (around 15%)
  • patients may present with a range of symptoms related to PTSD
    • members of the primary care team should be sensitive when inquiring about previous traumatic experience (which might have occurred many months or years before), giving specific examples of traumatic events (1)
• 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 and involve the person and, if appropriate, their family or carers

Approach to managing comorbidities and complex needs

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.

People with PTSD should not be excluded from treatment based solely on comorbid drug or alcohol misuse.

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

Early interventions for PTSD:

• some patients may recover with no or limited interventions
  • without effective treatment, many people may develop chronic problems over many years
• severity of the initial traumatic response is a reasonable indicator of the need for early intervention, and treatment should not be withheld in such circumstances.
• where symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting, as a way of managing the difficulties presented by individual people with post-traumatic stress disorder (PTSD), should be considered
  • follow-up contact should be arranged within 1 month (1,2,)

Management of PTSD should be based on a multidimensional approach. Treatment options involve three approaches either alone or in combination:

• psychopharmacology
• psychological therapy
• education and supportive measures (1)

Adult with PTSD

Adult with subthreshold symptoms of PTSD

• 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

Adult with a diagnosis of acute stress disorder or clinically important symptoms of PTSD

An individual trauma-focused CBT intervention should be offered 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

An individual trauma-focused CBT intervention should be offered 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

Do not offer psychologically-focused debriefing for the prevention or treatment of PTSD.

Reference:

• NICE (December 2018).Post-traumatic stress disorder (NG116)
• Ursano RJ et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry. 2004;161(11 Suppl):3-31.