Yorkshire and Humber Psychological Practitioners Network
A quick glance at the Post-Traumatic Stress Disorder: Management Clinical Guidelines (CG26); what’s changed?
In December 2018 the new PTSD NICE guidelines were published. The new guidelines include new and updated recommendations on:
1. Access to care and supporting transitions between services
2. Principles of care, including providing support and information
3. Management of PTSD in Children, young people and adults
4. Care for people with PTSD and complex needs
These supplement the existing recommendations on:
• Recognition of PTSD
• Assessment and co-ordination of care
• Language and Culture
• Disaster Planning
Highlights/key updates and new recommendations include:
• Acknowledgement of the diverse amount of possible causes: homelessness, abuse, gender reassignment, childbirth, accidents and illegal immigration, and highlights the needs for GPs to provide detailed information to patients about the treatment available to them
• GP’s should refer service users with ‘clinically important’ PTSD symptoms for CBT within 1 month of experiencing a traumatic event1.
• Practitioners should be aware people with PTSD will also experience other difficulties, such as depression, and that by treating PTSD these additional symptoms may also be alleviated.
• For those with complex PTSD, increase the duration or number of sessions to engage the person, consider stability, and provide support with other issues which may be barriers such as housing or substance misuse
Treatment for adults
• These interventions include:
• cognitive processing therapy
• cognitive therapy for PTSD
• narrative exposure therapy
• prolonged exposure therapy
Trauma-focused CBT interventions for adults should:
o Be based on a validated manual
o Typically provided over 8-12 sessions or more if clinically indicated e.g. for multiple traumas
o Be delivered by trained practitioners with ongoing supervision
o Include psychoeducation
o Involve elaboration and processing of the trauma memories
o Involve processing trauma-related emotions, including shame, guilt, loss and anger
o Involve restructuring trauma-related meanings for the individual
o Provide help to overcome avoidance
o Have a focus on re-establishing adaptive functioning e.g. work and social relationships
o Prepare them for the end of treatment
o Include planning booster sessions if needed, particularly for significant dates e.g. trauma anniversaries
• To consider manualized EMDR for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1-3 months after a non-combat-related trauma if the person has a preference for EMDR.
• To offer EMDR for adults who have presented more than 3 months after a non-combat-related trauma.
• Drug treatment: these, particularly benzo’s, should not be used to prevent PTSD but if a service user has a preference for drug treatment then venlafaxine or an SSRI such as sertraline could be considered. Do not offer drug treatment to children under 18.
• If medication does not make a difference, to consider an antipsychotic, such as risperidone, in addition to psychological treatments if the person has psychotic symptoms or other disabling symptoms.
• For children and young people aged 7 to 17 who do not respond to CBT, they should be offered EMDR after three months.
• Children can be offered group trauma informed CBT after shared major trauma within the last month to prevent developing PTSD.
• Offer carers and family members support. Consider assessing family members who also experienced the same trauma and who may also have PTSD.
• We should be providing multiple points of access to improve access to treatment, and a choice of therapist
• Inform people with PTSD about peer support groups
• Do not offer psychological debriefing for the prevention or treatment of PTSD
• For people with subthreshold symptoms, consider active monitoring for 1 month and offer a 1 month follow up session
• Be aware and avoid/minimize the risk of trauma inducing environments e.g. admitting to noisy ward environments
• For those struggling to engage in psychological treatment, to consider alternative methods of communication such as text messaging and video. For adults who would prefer not to receive CBT or EMDR, computerised CBT should be considered (but not for those with severe symptoms or dissociation). Alternatively consider symptom focused treatment e.g. sleep or anger, if the person does not wish to engage in trauma focused therapy or for residual symptoms after a trauma focused intervention.
• Patients should be involved in and fully understand decisions about transitioning their care between services. The referring team should not discharge a person before a care plan has been agreed in the new service.
• Do not delay or withhold treatment solely based on court proceedings or compensation applications; discuss the implications of the timing of treatments with the person so that they can make an informed choice2.
• 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.
• No other new recommendations above and beyond the one below from the 2015 guidelines:
• The new guidelines acknowledged some people may require more than the standard 8-12 sessions of trauma focused psychological treatment, particularly for those who have experienced multiple traumas. It does refer to the new ICD-11 ‘Complex PTSD’ diagnosis but does not explain what this new diagnosis means or refers to. However, in recognizing symptoms it does recommend looking for emotion dysregulation and interpersonal difficulties which are key symptoms of Complex PTSD.
A useful larger summary with a bigger overview can be found here: https://www.guidelines.co.uk/mental-health/nice-ptsd-guideline/454542.article
1 The previous 2005 guidelines had suggested a watch and wait approach with follow up in a month for patients with milder symptoms, and a referral to CBT within a month for those with severe symptoms.
2 In line with Crown Prosecution Service guidance (Provision of therapy for child witnesses prior to a criminal trial or Therapy: provision of therapy for vulnerable or intimidated adult witnesses)
@YH_PPN www.nwppn.nhs.uk Dr Paul Boyden