Update information

We have reviewed the evidence and made new recommendations on the prevention, treatment and care of people with post-traumatic stress disorder (PTSD). These recommendations are marked [2018].

We have also made some changes without an evidence review (see table). These recommendations are marked [2005, amended 2018].

Recommendations marked [2005] last had an evidence review in 2005. In some cases minor changes have been made to the wording to bring the language and style up to date, without changing the meaning.

Recommendations that have been changed

Amended recommendation wording (change to meaning)

Recommendation in 2005 guideline

Recommendation in current guideline

Reason for change

1.3.1.1 PTSD may present with a range of symptoms (including re-experiencing, avoidance, hyperarousal, depression, emotional numbing, drug or alcohol misuse and anger) and therefore when assessing for PTSD, members of the primary care team should ask in a sensitive manner whether or not patients with such symptoms have suffered a traumatic experience (which may have occurred many months or years before) and give specific examples of traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth).

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).

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.

For clarity the recommendation has been split to separate awareness of symptoms from assessment.

Functional impairment has been added and symptoms updated compared with 2005 in light of new classification systems.

Reference to complex PTSD and the additional symptoms of complex PTSD (interpersonal difficulties or problems in relationships, negative self-perception, and emotional dysregulation) have been included after the publication of ICD-11 and the new diagnostic classification of complex PTSD.

Substance misuse has been removed as although this is a commonly coexisting condition it is not a core symptom of PTSD like all other bullet points in this recommendation.

The recommendation has been broadened to all settings so 'primary care' has been removed from recommendation 1.1.4.

'Traumatic experience' has been amended to '1 or more traumatic events' because of the possibility of multiple/repeated trauma.

1.3.1.2 General practitioners and other members of the primary care team should be aware of traumas associated with the development of PTSD. These include single events such as assaults or road traffic accidents, and domestic violence or childhood sexual abuse.

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

The recommendation has been broadened to all settings so 'primary care' has been removed.

Examples of types of traumatic events have been extended and clarified.

Traumatic childbirth has been broadened to include serious health problems and childbirth experiences.

1.3.1.3 For patients with unexplained physical symptoms who are repeated attendees to primary care, members of the primary care team should consider asking whether or not they have experienced a traumatic event and provide specific examples of traumatic events (for example, assaults, rape, road traffic accidents and childhood sexual abuse and traumatic childbirth).

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).

The recommendation has been broadened to all care settings.

To reduce repetition, examples of traumatic events have been replaced by a cross reference to recommendation 1.1.2.

1.3.1.4 When seeking to identify PTSD, members of the primary care team should consider asking adults specific questions about re-experiencing (including flashbacks and nightmares) or hyperarousal (including an exaggerated startle response or sleep disturbance). For children, particularly younger children, consideration should be given to asking the child and/or the parents about sleep disturbance or significant changes in sleeping patterns.

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.

Symptoms have been updated in line with recommendation 1.1.1.

1.3.3.1 For individuals at high risk of developing PTSD following a major disaster, consideration should be given (by those responsible for coordination of the disaster plan) to the routine use of a brief screening instrument for PTSD at 1 month after the disaster.

1.1.8 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.

The committee added that the screening instrument should be validated.

1.3.3.2 For programme refugees and asylum seekers at high risk of developing PTSD consideration should be given (by those responsible for management of the refugee programme) to the routine use of a brief screening instrument for PTSD as part of the initial refugee healthcare assessment. This should be a part of any comprehensive physical and mental health screen.

1.1.9 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.

Programme refugees has been changed to 'refugees' and 'validated' added to the recommendation for clarification.

1.3.4.1 When assessing a child or young person for PTSD, healthcare professionals should ensure that they separately and directly question the child or young person about the presence of PTSD symptoms. They should not rely solely on information from the parent or guardian in any assessment.

1.1.6 Do not rely solely on the parent or carer for information when it is developmentally appropriate to directly and separately question a child or young person about the presence of PTSD symptoms.

The recommendation has been reworded to emphasise when direct and separate questioning is appropriate.

1.3.4.2 When a child who has been involved in a traumatic event is treated in an emergency department, emergency staff should inform the parents or guardians of the possibility of the development of PTSD, briefly describe the possible symptoms (for example, sleep disturbance, nightmares, difficulty concentrating and irritability) and suggest that they contact their GP if the symptoms persist beyond 1 month.

1.1.7 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 events, increased behavioural difficulties, problems concentrating, hypervigilance, and difficulties sleeping) and suggest they contact their GP if the symptoms persist beyond 1 month.

Symptoms have been updated compared with 2005 in light of new classification systems. The normal responses to trauma has been added based on the opinion of the committee that it is helpful to 'normalise' the presence of some symptoms in the first few weeks as they can manifest but diminish as part of 'natural' recovery.

1.4.1 For PTSD sufferers presenting in primary care, GPs should take responsibility for the initial assessment and the initial coordination of care. This includes the determination of the need for emergency medical or psychiatric assessment.

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.

This change has been made to reflect that, before assessment, people with clinically important symptoms of PTSD will not have a diagnosis so it is not meaningful to talk about people with PTSD in this recommendation.

1.4.2 Assessment of PTSD sufferers should be conducted by competent individuals and be comprehensive, including physical, psychological and social needs and a risk assessment.

1.2.2 Assessment of people with PTSD should becomprehensive, including an assessment of physical, psychological and social needs and a risk assessment.

Competence has been removed from the recommendation as this is a general expectation of the NHS and is not specific to PTSD or to assessment.

1.4.4 Where management is shared between primary and secondary care, there should be clear agreement among individual healthcare professionals about the responsibility for monitoring patients with PTSD. This agreement should be in writing (where appropriate, using the Care Programme Approach [CPA]) and should be shared with the patient and, where appropriate, their family and carers.

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.

'Share it with' has been replaced by 'involve' to reflect that the person (and family if appropriate) would have a more active role in this process.

1.7.2 Where differences of language or culture exist between healthcare professionals and PTSD sufferers, this should not be an obstacle to the provision of effective trauma-focused psychological interventions.

1.5.2 Ensure that screening, assessment and interventions for PTSD are culturally and linguistically appropriate.

The recommendation has been simplified and broadened to apply to screening and assessment as well as interventions.

1.7.3 Where language or culture differences present challenges to the use of trauma-focused psychological interventions in PTSD, healthcare professionals should consider the use of interpreters and bicultural therapists.

1.5.3 If language or culture differences present challenges to the use of psychological interventions in PTSD, think about using interpreters or offering a choice of therapists. See recommendations on communication in the NICE guideline on patient experience in adult NHS services.

'Trauma-focused' has been removed to broaden the recommendation. A cross reference to NICE guidance published since 2005 has been added to provide further detail.

1.7.4 Healthcare professionals should pay particular attention to the identification of individuals with PTSD where the culture of the working or living environment is resistant to recognition of the psychological consequences of trauma.

1.5.1 Pay particular attention to identifying people with PTSD in working or living environments where there may be cultural challenges to recognising the psychological consequences of trauma (see recommendations on avoiding stigma and promoting social inclusion in the NICE guideline on service user experience in adult mental health)

A cross reference to NICE guidance published since 2005 has been added to provide further detail.

ISBN: 978-1-4731-3181-1

  • National Institute for Health and Care Excellence (NICE)