Post-traumatic stress disorder The management of PTSD in adults and children

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Post-traumatic stress
disorder
The management of PTSD
in adults and children
in primary and secondary care
National Clinical Practice Guideline Number 26
National Collaborating Centre for Mental Health
commissioned by the
National Institute for Clinical Excellence
published by
Gaskell and the British Psychological Society
© The Royal College of Psychiatrists & The British Psychological
Society, 2005
Gaskell is an imprint of the Royal College of Psychiatrists. The views
presented in this book do not necessarily reflect those of the Royal
College of Psychiatrists, and the publishers are not responsible for any
error of omission or fact. The Royal College of Psychiatrists is a
registered charity (no. 228636).
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical, or
other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or retrieval
system, without permission in writing from the publishers. Enquiries in
this regard should be directed to the Royal College of Psychiatrists.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British
Library.
ISBN 1-904671-25-X
Printed in Great Britain by Cromwell Press Limited, Trowbridge,
Wiltshire.
Additional material: data CD–ROM created by Pixl8
(www.pixl8.co.uk).
developed by
National Collaborating Centre for Mental Health
Royal College of Psychiatrists’ Research Unit
6th Floor
83 Victoria Street
London
SW1H 0HW
commissioned by
National Insitute for Clinical Excellence
MidCity Place
London
WC1V 6NA
www.nice.org.uk
published by
Royal College of Psychiatrists
17 Belgrave Square
London
SW1X 8PG
www.rcpsych.ac.uk
and
British Psychological Society
St Andrews House
48 Princess Road East
Leicester
LE1 7DR
www.bps.org.uk
GASKELL
Contents
Guideline Development Group membership
v
Acknowledgements
vi
List of abbreviations
vii
1
2
3
4
5
6
Introduction
1.1
National guidelines
1.2
The national PTSD guideline
1
3
Post-traumatic stress disorder
2.1
The disorder
2.2
Incidence and prevalence
2.3
Diagnosis and differential diagnosis
2.4
Aetiology of PTSD
2.5
Treatment and management of PTSD in the NHS
2.6
Primary care
2.7
Economic burden of PTSD
5
7
8
14
17
17
19
Experiences of PTSD sufferers and carers
3.1
Personal testimonies from PTSD sufferers
3.2
Understanding PTSD from the sufferer’s perspective
3.3
Summary of PTSD sufferer concerns
3.4
Carers’ testimonies
3.5
Understanding the impact of PTSD on carers
3.6
Summary of carer needs
3.7
Clinical practice recommendations
21
32
34
34
37
37
37
Methods used to develop this guideline
4.1
Overview
4.2
The Guideline Development Group
4.3
Clinical questions
4.4
Systematic clinical literature review
4.5
Health economics review strategies
4.6
Stakeholder contributions
4.7
Validation of this guideline
39
39
40
40
49
50
51
Psychological treatment of PTSD in adults
5.1
Introduction
5.2
Definitions
5.3
Previous systematic reviews
5.4
Studies considered for review
5.5
Evidence statements
5.6
Clinical summary for psychological treatments
5.7
Recommendations for psychological treatments for chronic PTSD
5.8
Research recommendations
52
52
57
57
57
61
63
64
Pharmacological and physical interventions for PTSD in adults
6.1
Introduction
6.2
Current clinical practice
6.3
Limitations of the literature: comparing RCTs of pharmacological
and psychological treatment
6.4
Issues and topics covered by this review
6.5
Studies included
6.6
Study characteristics
6.7
General issues arising in the management of antidepressant medication
6.8
Repetitive transcranial magnetic stimulation
6.9
Clinical summary
6.10 Clinical practice recommendations
6.11 Research recommendations
66
66
67
68
68
69
75
77
78
79
80
7
8
9
Early intervention for PTSD in adults
7.1
Introduction
7.2
Current practice
7.3
Studies included
7.4
Treatment for all
7.5
Treatment for all – clinical summary
7.6
Early psychological interventions for acute PTSD and acute stress disorder
7.7
Clinical summary of early psychological interventions
7.8
Early intervention drug treatments for PTSD
7.9
Clinical summary of early intervention drug treatments
7.10 Economic evaluation of early versus later delivery of psychological treatment
7.11 Clinical practice recommendations
81
81
82
82
84
85
87
88
88
89
92
Predictors of PTSD and screening for the disorder
8.1
Introduction
8.2
Risk factors
8.3
Screening
8.4
Clinical practice recommendations
8.5
Research recommendations
93
93
98
103
103
Children and young people with PTSD
9.1
Introduction
9.2
Developmental differences
9.3
Incidence, prevalence and natural history
9.4
Diagnostic and assessment measures
9.5
Psychological interventions
9.6
Clinical summary of psychological interventions
9.7
Pharmacological interventions
9.8
Clinical summary of pharmacological interventions
9.9
Clinical practice recommendations
9.10 Research recommendations
104
104
105
106
108
113
114
114
115
115
10 Special considerations
10.1 Introduction
10.2 Disaster planning
10.3 Ex-military personnel
10.4 Phased interventions in settings of continuing threat
10.5 Working with refugees and asylum seekers
10.6 Role of the non-statutory sector
10.7 Recommendations
117
117
118
119
120
121
122
11 Summary of recommendations
11.1 Key recommendations for implementation
11.2 Guidance
11.3 Recognition of PTSD
11.4 Assessment and coordination of care
11.5 Support for families and carers
11.6 Practical support and social factors
11.7 Language and culture
11.8 Care for all people with PTSD
11.9 Treatment of PTSD
11.10 Disaster planning
11.11 Research recommendations
123
123
124
125
126
126
126
127
128
131
132
Appendices
133
References
155
iv Contents
Guideline Development Group
membership
Dr Jonathan Bisson (Co-Chair)
Clinical Senior Lecturer in Psychiatry, Cardiff University
Mrs Pamela Dix
PTSD Sufferer Representative
Professor Anke Ehlers (Co-Chair)
Professor of Experimental Psychopathology, Institute of Psychiatry, King’s College London
Mrs S. Janet Johnston, MBE
Clinical Director, Ashford Couselling Service
Retired senior social worker, Kent County Council
Founder, Dover Counselling Centre
Mr Christopher Jones
Health Economist, National Collaborating Centre for Mental Health
Ms Rebecca King
Project Manager, National Collaborating Centre for Mental Health
Ms Rosa Matthews
Systematic Reviewer, National Collaborating Centre for Mental Health
Mr Andrew Murphy
PTSD Sufferer Representative
Ms Peggy Nuttall
Research Assistant, National Collaborating Centre for Mental Health
Mr Cesar De Oliveira
Systematic Reviewer, National Collaborating Centre for Mental Health
Mr Stephen Pilling (Guideline Facilitator)
Co-Director, National Collaborating Centre for Mental Health
Director, Centre for Outcomes, Research and Effectiveness, University College London
Consultant Clinical Psychologist, Camden and Islington Mental Health and Social Care Trust
Professor David Richards
Professor of Mental Health, University of York
Dr Clare Taylor
Editor, National Collaborating Centre for Mental Health
Ms Lois Thomas
Research Assistant, National Collaborating Centre for Mental Health
Dr Stuart Turner
Consultant Psychiatrist, Capio Nightingale Hospital
Chair of Trustees, Refugee Therapy Centre
Honorary Senior Lecturer, University College London
Ms Heather Wilder
Information Scientist, National Collaborating Centre for Mental Health
Professor William Yule
Professor of Applied Child Psychology, Institute of Psychiatry, King’s College London
v
Acknowledgements
The Post-Traumatic Stress Disorder Guideline Development Group and the National Collaborating
Centre for Mental Health review team would like to thank the following people.
Those who wrote and submitted personal testimonies that have been included in chapter 3 of
this guideline.
Those who acted as advisers on specialist topics:
Ms Cristel Amiss and Ms Fernande Sambura (Black Women’s Rape Action Project)
Professor Chris Brewin (Professor of Clinical Psychology, University College London)
Dr Chris Freeman (Consultant Psychiatrist, Royal Edinburgh Hospital)
Ms Caroline Garland (Consultant Clinical Psychologist, Psychoanalyst, Tavistock and Portman NHS
Trust, London)
Ms Ruth Hall and Ms Woini Samuel (Women Against Rape)
Dr John Spector (Consultant Clinical Psychologist, Watford General Hospital)
Dr Dave Tomson (General Practitioner and Consultant in Patient-Centred Primary Care,
Collingwood Surgery, North Shields)
Dr Guinevere Tufnell (Consultant Child and Adolescent Psychiatrist, The Traumatic Stress Clinic,
Great Ormond Street Hospital)
Dr Felicity de Zulueta (Consultant Psychiatrist, Psychotherapist, South London and Maudsley NHS
Trust)
The healthcare professionals who participated in the primary care focus group:
Dr Dorothy Dunn (Psychologist in Primary Care)
Dr Lesley Duke (General Practitioner)
Dr Brian Fine (General Practitioner)
Dr Judy Leibowitz (Psychologist in Primary Care)
Dr Tim Owen (General Practitioner)
Dr Guy Pilkington (General Practitioner)
Mike Scanlon (Community Psychiatric Nurse and Primary Care Mental Health Worker)
Dr Dave Tomson (General Practitioner)
The authors of the following systematic reviews who allowed the NCCMH review team access to
their data files:
Professor Chris Brewin (University College London)
Professor Emily Ozer (University of California)
Dr Paul Ramchandani (University of Oxford)
Dr Guinevere Tufnell (The Traumatic Stress Clinic, Great Ormond Street Hospital)
The following for granting permission to reproduce their material:
American Psychological Association
John Wiley & Sons Limited
Oxford University Press
World Health Organization
vi
List of abbreviations
I, IIa, IIb, III, IV
levels of evidence forming the basis for an evidence statement (for full
definitions, see Table 4.1, p. 47)
A, B, C, GPP
grades of evidence forming the basis for a guideline statement (for full
definitions, see Table 4.1, p. 47)
A&E
accident and emergency
AGREE
appraisal of guidelines research and evaluation
CAMHS
child and adolescent mental health services
CAPS
Clinician-Administered PTSD Scale for DSM–IV
CBT
cognitive–behavioural therapy
CCTR
Cochrane Central Register of Controlled Trials
CDSR
Cochrane Database of Systematic Reviews
CI
confidence interval
CINAHL
Cumulative Index to Nursing and Allied Health Literature
CMHT
community mental health team
DARE
Database of Abstracts of Reviews of Effects
DTS
Davidson Trauma Scale
EMBASE
Exerpta Medica Database
EMDR
eye movement desensitisation and reprocessing
GP
general practitioner
GPP
good practice point
HTA
Health Technology Appraisal
ICD–10
International Classification of Diseases, 10th edn
IES (–R)
Impact of Event Scale (–Revised)
k
number of studies, the evidence from which has been used to compile an
evidence statement
MAOI
monoamine oxidase inhibitor
n
number of participants
NCCMH
National Collaborating Centre for Mental Health
NHS
National Health Service
NICE
National Institute for Clinical Excellence
NSF
National Service Framework (for mental health)
PCL
PTSD Checklist
PDS
Post-traumatic Diagnostic Scale
PTSD
post-traumatic stress disorder
RCT
randomised controlled trial
RR
relative risk/risk ratio
SD
standard deviation
SMD
standard mean difference
SSRI
selective serotonin reuptake inhibitor
WHO
World Health Organization
vii
1 Introduction
This guideline has been developed to advise on the treatment and management of posttraumatic stress disorder (PTSD). The guideline recommendations have been developed by a
multidisciplinary team of healthcare professionals, PTSD sufferers and guideline methodologists
after careful consideration of the best available evidence. (The term ‘PTSD sufferer’ was chosen
for use in the guideline on the basis of a survey conducted by sufferer members of the Guideline
Development Group. People with the disorder were presented with a range of options such as
‘people with PTSD’, ‘patients with PTSD’ and ‘PTSD sufferer’ and asked to indicate which term
they preferred; ‘PTSD sufferer’ was the term favoured by the majority.) It is intended that the
guideline will be useful to clinicians and service commissioners in providing and planning highquality care for those with PTSD while also emphasising the importance of the experience of care
for patients and their families.
1.1 National guidelines
1.1.1 What are clinical practice guidelines?
Clinical practice guidelines are ‘systematically developed statements that assist clinicians and
patients in making decisions about appropriate treatment for specific conditions’ (Department of
Health, 1996). They are derived from the best available research evidence, using predetermined
and systematic methods to identify and evaluate all the evidence relating to the specific condition
in question. Where evidence is lacking, the guidelines will incorporate statements and recommendations based upon the consensus statements developed by the guideline development group.
Clinical guidelines are intended to improve the process and outcomes of healthcare in a number
of different ways. Clinical guidelines can:
provide up-to-date evidence-based recommendations for the management of conditions
and disorders by healthcare professionals
be used as the basis to set standards to assess the practice of healthcare professionals
form the basis for education and training of healthcare professionals
assist patients and carers in making informed decisions about their treatment and care
improve communication between healthcare professionals, patients and carers
help identify priority areas for further research.
1.1.2 Uses and limitations of clinical guidelines
Guidelines are not a substitute for professional knowledge and clinical judgement. Guidelines can
be limited in their usefulness and applicability by a number of different factors: the availability of
high-quality research evidence, the quality of the methodology used in the development of the
guideline, the generalisability of research findings and the uniqueness of individual patients.
Although the quality of research in PTSD is variable, the methodology used here reflects current
international understanding on the appropriate practice for guideline development (AGREE
Collaboration, 2001), ensuring the collection and selection of the best research evidence available
and the systematic generation of treatment recommendations applicable to the majority of
patients and situations. However, there will always be some patients for whom clinical guideline
recommendations are not appropriate and situations in which the recommendations are not
readily applicable. This guideline does not, therefore, override the individual responsibility of
healthcare professionals to make appropriate decisions in the circumstances of the individual
patient, in consultation with the patient and/or carer.
In addition to the clinical evidence, cost-effectiveness information, where available, is taken into
account in the generation of statements and recommendations of the clinical guidelines.
1
Whereas national guidelines are concerned with clinical and cost-effectiveness, issues of
affordability and implementation costs are to be determined by the National Health Service (NHS).
In using guidelines, it must be remembered that the absence of empirical evidence for the
effectiveness of a particular intervention is not the same as evidence for ineffectiveness. In
addition, and particularly relevant in mental health, evidence-based treatments are often
delivered within the context of an overall treatment programme including a range of activities,
the purpose of which may be to help engage the patient and provide an appropriate context for
the delivery of specific interventions. It is important to maintain and enhance the service context
in which these interventions are delivered, otherwise the specific benefits of effective
interventions will be lost. Indeed, organising care so as to support and encourage a good
therapeutic relationship is at times more important than the specific treatments offered.
1.1.3 Why develop national guidelines?
The National Institute for Clinical Excellence (NICE) was established as a Special Health Authority
for England and Wales in 1999, with a remit to provide a single source of authoritative and
reliable guidance for patients, professionals and the public. Its guidance aims to improve
standards of care, to diminish unacceptable variations in the provision and quality of care across
the NHS and to ensure that the health service is patient-centred. All guidance is developed in a
transparent and collaborative manner using the best available evidence and involving all relevant
stakeholders.
The National Institute for Clinical Excellence generates guidance in a number of different ways,
two of which are relevant here. First, national guidance is produced by the Technology Appraisal
Committee to give robust advice about a particular treatment, intervention, procedure or other
health technology. Second, NICE commissions the production of national clinical practice
guidelines, each focused upon the overall treatment and management of a specific condition. To
enable this latter development, NICE established seven National Collaborating Centres in
conjunction with a range of professional organisations involved in healthcare.
1.1.4 National Collaborating Centre for Mental Health
This guideline has been commissioned by NICE and developed within the National Collaborating
Centre for Mental Health (NCCMH). This is a collaboration of the professional organisations
involved in the field of mental health, national service-user and carer organisations, a number of
academic institutions and NICE. The NCCMH is funded by NICE and led by a partnership between
the Royal College of Psychiatrists’ Research Unit and the British Psychological Society’s equivalent
unit, the Centre for Outcomes Research and Effectiveness. Members of the NCCMH reference
group come from the following organisations:
Royal College of Psychiatrists
British Psychological Society
Royal College of Nursing
National Institute for Social Work
College of Occupational Therapists, now replaced by the Clinical Effectiveness Forum for
the Allied Health Professions
Royal College of General Practitioners
Royal Pharmaceutical Society
Rethink Severe Mental Illness
Manic Depression Fellowship
Mind
Centre for Evidence-based Mental Health
Centre for Economics in Mental Health
Institute of Psychiatry.
The NCCMH reference group provides advice on a full range of issues relating to the development
of guidelines, including the membership of experts, professionals, patients and carers within
guideline development groups.
2 Introduction
1.1.5 From national guidelines to local protocols
Once a national guideline has been published and disseminated, local healthcare groups will be
expected to produce a plan and identify resources for its implementation, along with appropriate
timetables. Subsequently, a multidisciplinary group involving commissioners of healthcare,
primary-care and specialist mental health professionals, patients and carers should undertake the
translation of the implementation plan into local protocols. The nature and pace of the local plan
will reflect local healthcare needs and the nature of existing services; full implementation may
take a considerable time, especially where substantial training needs are identified.
1.1.6 Auditing the implementation of guidelines
This guideline identifies key areas of clinical practice and service delivery for local and national
audit. Although the generation of audit standards is an important and necessary step in the
implementation of this guidance, a more broadly based implementation strategy should be
developed. Nevertheless, it should be noted that the Healthcare Commission will monitor the
extent to which primary care trusts, trusts responsible for mental health and social care, and
health authorities have implemented these guidelines.
1.2 The national PTSD guideline
1.2.1 Who has developed this guideline?
The Guideline Development Group was convened by the NCCMH and supported by funding from
NICE. The Group consisted of PTSD sufferers and professionals from psychiatry, clinical
psychology, nursing and social work services. Staff from the NCCMH provided leadership and
support throughout the process of guideline development, undertaking systematic searches,
information retrieval, appraisal and systematic review of the evidence. Members of the Group
received training in the process of guideline development. The National Guidelines Support and
Research Unit, also established by NICE, provided advice and assistance regarding aspects of the
guideline development process.
All members of the Group made formal declarations of interest at the outset, updated at every
meeting. The members met a total of 19 times throughout the process of guideline development.
For ease of evidence identification and analysis, some members of the Group became topic leads,
covering identifiable treatment approaches. The NCCMH technical team supported group
members, with additional expert advice from special advisers where necessary. All statements and
recommendations in this guideline have been generated and agreed by the whole Guideline
Development Group.
1.2.2 For whom is this guideline intended?
This guideline will be of relevance to adults and children of all ages who suffer from PTSD.
The guideline covers the care provided by primary, secondary and other healthcare professionals
who have direct contact with, and make decisions concerning the care of, PTSD sufferers. The
guideline will also be relevant to the work (but will not cover the practice) of those in
occupational health services, social services and the independent sector.
Traumatic experiences can affect the whole family and often the community. The guideline
recognises the role of both family and community in the treatment and support of PTSD
sufferers.
1.2.3 Specific aims of this guideline
The guideline makes recommendations and suggests good practice points for the treatment and
management of PTSD. Specifically, it aims to:
evaluate the role of specific psychological interventions in the treatment and management
of PTSD
The National PTSD Guideline
3
evaluate the role of specific pharmacological interventions in the treatment and
management of PTSD
evaluate the role of early psychological and pharmacological interventions shortly after
traumatic event
address the issues of diagnosis, detection and the use of screening techniques in high-risk
situations
provide key review criteria for audit, which will enable objective measurements to be made
of the extent and nature of local implementation of this guidance, particularly its impact
upon practice and outcomes for people with PTSD.
The guideline does not cover treatments that are not normally available on the NHS.
4 Introduction
2 Post-traumatic stress disorder
2.1 The disorder
This guideline is concerned with the diagnosis, early identification and treatment of post-traumatic
stress disorder (PTSD) as defined in ICD–10 (World Health Organization, 1992), code number
F43.1. This disorder is one that people may develop in response to one or more traumatic events
such as deliberate acts of interpersonal violence, severe accidents, disasters or military action. The
guideline is concerned with the care of people for whom PTSD is the main problem after
experiencing a traumatic event. The disorder can occur at any age, including childhood.
The best-validated diagnostic instruments, and most randomised controlled treatment trials of
PTSD, use the stricter diagnostic criteria for PTSD of DSM–IV (American Psychiatric Association,
1994). However, this does not limit the applicability of the results for the purposes of this guideline.
The available evidence suggests that treatments that are effective for PTSD as defined in DSM–IV
are also effective for PTSD as defined in ICD–10 (Blanchard et al, 2003a). In contrast to ICD–10,
DSM–IV distinguishes between acute stress disorder (duration less than 1 month) and PTSD
(symptom duration 1 month or longer). The literature on acute stress disorder was therefore
included in the NICE review of the evidence, as it is relevant for early interventions in PTSD.
The guideline does not apply to people whose main problem is the ICD–10 diagnosis of ‘Enduring
personality changes after catastrophic experience’ (F62.0), the concept corresponding to
‘Disorders of extreme distress not otherwise specified/complex PTSD’ (see definition 2.3.6.1),
which may develop after extreme prolonged or repeated trauma, such as repeated childhood
sexual abuse or prolonged captivity involving torture. The guideline does not address dissociative
disorders, which may develop after traumatic events, or adjustment disorders (F43.2), which may
develop after less severe stressors.
2.1.1 Traumatic stressors
The diagnosis of PTSD is restricted to people who have experienced exceptionally threatening and
distressing events. The ICD–10 definition states that PTSD may develop after ‘a stressful event or
situation ... of an exceptionally threatening or catastrophic nature, which is likely to cause
pervasive distress in almost anyone’ (World Health Organization, 1992: p. 147). Thus, PTSD would
not be diagnosed after other upsetting events that are described as ‘traumatic’ in everyday
language, such as divorce, loss of a job or failing an examination. In these cases, a diagnosis of
adjustment disorder may be considered.
The DSM–IV highlights that a traumatic stressor usually involves a perceived threat to life (either
one’s own life or that of another person) or physical integrity, and intense fear, helplessness or
horror. Other emotional responses of trauma survivors with PTSD include guilt, shame, intense
anger or emotional numbing.
Whether or not people develop PTSD depends on their subjective perception of the traumatic
event as well as on the objective facts. For example, people who are threatened with a replica
gun and believe that they are about to be shot, or people who only contract minor injuries
during a road traffic accident but believe at the time that they are about to die, may develop
PTSD. Furthermore, those at risk of PTSD include not only those who are directly affected by a
horrific event, but also witnesses, perpetrators and those who help PTSD sufferers (vicarious
traumatisation). People at risk of PTSD include:
victims of violent crime (e.g. physical and sexual assaults, sexual abuse, bombings, riots)
members of the armed forces, police, journalists and prison service, fire service, ambulance
and emergency personnel, including those no longer in service
victims of war, torture, state-sanctioned violence or terrorism, and refugees
survivors of accidents and disasters
women following traumatic childbirth, individuals diagnosed with a life-threatening illness.
5
2.1.2 Symptoms of PTSD
The most characteristic symptoms of PTSD are re-experiencing symptoms. Sufferers involuntarily
re-experience aspects of the traumatic event in a vivid and distressing way. This includes flashbacks
in which the person acts or feels as if the event is recurring; nightmares; and repetitive and
distressing intrusive images or other sensory impressions from the event. Reminders of the
traumatic event arouse intense distress and/or physiological reactions.
In children, re-experiencing symptoms may take the form of re-enacting the experience, repetitive
play or frightening dreams without recognisable content. Chapter 9 addresses the recognition
and treatment of PTSD in children and young people.
Avoidance of reminders of the trauma is another core symptom of PTSD. These reminders include
people, situations or circumstances resembling or associated with the event. Sufferers from PTSD
often try to push memories of the event out of their mind and avoid thinking or talking about it in
detail, particularly about its worst moments. On the other hand, many ruminate excessively about
questions that prevent them from coming to terms with the event, for example about why the event
happened to them, about how it could have been prevented or about how they could take revenge.
Symptoms of hyperarousal include hypervigilance for threat, exaggerated startle responses,
irritability, difficulty in concentrating and sleep problems.
However, PTSD sufferers also describe symptoms of emotional numbing. These include inability to
have any feelings, feeling detached from other people, giving up previously significant activities
and amnesia for significant parts of the event.
Many PTSD sufferers experience other associated symptoms, including depression, generalised
anxiety, shame, guilt and reduced libido, which contribute to their distress and affect their
functioning.
2.1.3 Course and prognosis
The onset of symptoms is usually in the first month after the traumatic event, but in a minority
(less than 15%; McNally, 2003) there may be a delay of months or years before symptoms start to
appear.
Post-traumatic stress disorder shows substantial natural recovery in the initial months and years
after a traumatic event. Whereas a high proportion of trauma survivors will initially develop
symptoms of PTSD, a substantial proportion of these individuals recover without treatment in the
following years, with a steep decline in PTSD rates occurring in the first year (e.g. Breslau et al,
1991; Kessler et al, 1995). On the other hand, at least a third of the individuals who initially
develop PTSD remain symptomatic for 3 years or longer, and are at risk of secondary problems
such as substance misuse (e.g. Kessler et al, 1995). This raises the important questions of when
treatment should be offered after a traumatic event and how people who are unlikely to recover
on their own can be identified. These questions are addressed in the guideline sections on early
intervention after trauma (Chapter 7) and screening for PTSD (Chapter 8). One important
indicator of treatment need appears to be the severity of PTSD symptoms from around 2–4 weeks
after the trauma onwards (e.g. Shalev et al, 1997; Harvey & Bryant, 1998). However, it is
important to note that symptom severity in the initial days after trauma (up to about 1 week) is
not a good predictor of persistent PTSD (Shalev, 1992; Murray et al, 2002). Importantly, evidence
suggests that the chances that a PTSD sufferer will benefit from treatment do not decrease with
time elapsed since the traumatic event (Gillespie et al, 2002; Resick et al, 2002).
2.1.4 Impairment, disability and secondary problems
Symptoms of PTSD cause considerable distress and can significantly interfere with social,
educational and occupational functioning. It is not uncommon for PTSD sufferers to lose their
jobs, either because re-experiencing symptoms, sleep and concentration problems make regular
work difficult, or because they are unable to cope with reminders of the traumatic event they
encounter at work. The resulting financial problems are a common source of additional stress,
and may be a contributory factor leading to extreme hardship such as homelessness.
The disorder has adverse effects on the sufferer’s social relationships, leading to social
withdrawal. Problems in the family and break-up of significant relationships are not uncommon.
6 Post-traumatic stress disorder
Sufferers may also develop further, secondary psychological disorders as complications of the
PTSD. The most common complications are:
substance use disorders: PTSD sufferers may use alcohol, drugs, caffeine or nicotine to
cope with their symptoms, which may eventually lead to dependence
depression, including the risk of suicide
other anxiety disorders, such as panic disorder, which may lead to additional restrictions in
the sufferer’s life (for example, inability to use public transport).
Other possible complications of PTSD include somatisation, chronic pain and poor health
(Schnurr & Green, 2003). Sufferers from PTSD are at greater risk of medical problems, including
circulatory and musculoskeletal disorders, and have a greater number of medical conditions than
people without PTSD (Ouimette et al, 2004).
2.2 Incidence and prevalence
The available estimates of PTSD prevalence and incidence so far stem mainly from large-scale
epidemiological studies conducted in the USA and Australia, and are restricted to data on adults.
It remains to be investigated whether these data apply to the UK, and to children (see Chapter 9).
The main findings from the epidemiological research on PTSD are as follows:
the majority of people will experience at least one traumatic event in their lifetime (Kessler
et al, 1995)
intentional acts of interpersonal violence, in particular sexual assault, and combat are more
likely to lead to PTSD than accidents or disasters (Kessler et al, 1995; Stein et al, 1997;
Creamer et al, 2001)
men tend to experience more traumatic events than women, but women experience higher
impact events (i.e. those that are more likely to lead to PTSD; Kessler et al, 1995; Stein et
al, 1997)
women are more likely to develop PTSD in response to a traumatic event than men; this
enhanced risk is not explained by differences in the type of traumatic event (Kessler et al,
1995).
Examples of people at risk of PTSD in the UK include people who have been exposed to or have
witnessed an extreme traumatic stressor, such as deliberate acts of violence, physical and sexual
abuse, accidents, disaster or military action. This includes both direct personal experience of the
trauma and the threat to physical integrity of the individual involved. People who have
experienced threat to their own life or the life of others while in medical care, such as during
anaesthesia, complications during childbirth or as a result of medical negligence, are also at risk.
Special populations such as people in military service, emergency workers and the police are likely
to have an increased risk of exposure to trauma, and are thus at risk of PTSD. Many refugees have
experienced a range of traumatic events and may therefore, among other problems, suffer from
PTSD.
2.2.1 Prevalence
Post-traumatic stress disorder is common. In a large, representative sample in the USA, Kessler et
al (1995) estimated a lifetime prevalence of PTSD of 7.8% (women 10.4%, men 5.0%), using
DSM–III–R criteria. Estimates for 12-month prevalence range between 1.3% (Australia; Creamer et
al, 2001) and 3.6% (USA; Narrow et al, 2002). Estimates for 1-month prevalence range between
1.5–1.8% using DSM–IV criteria (Stein et al, 1997; Andrews et al, 1999) and 3.4% using the less
strict ICD–10 criteria (Andrews et al, 1999). The disorder remains common in later life, but with
the suggestion of a greater proportion of sub-syndromal PTSD in the older age group (van Zelst
et al, 2003).
2.2.2 Incidence
Kessler et al (1995) found that the risk of developing PTSD after a traumatic event is 8.1% for
men and 20.4% for women. For young urban populations, higher risks have been reported:
Incidence and prevalence
7
Breslau and colleagues found an overall risk of 23.6% (Breslau et al, 1991) and a risk of 13% for
men and 30.2% for women (Breslau et al, 1997).
2.2.3 Influence of type of traumatic event
Different types of traumatic events are associated with different PTSD rates. Rape was associated
with the highest PTSD rates in several studies. For example, 65% of the men and 46% of the
women who had been raped met PTSD criteria in the study by Kessler et al (1995). Other traumatic
events associated with high PTSD rates included combat exposure, childhood neglect and physical
abuse, sexual molestation and (for women only) physical attack and being threatened with a
weapon, kidnapped or held hostage. Accidents, witnessing death or injury, and fire or natural
disasters were associated with lower lifetime PTSD rates (Kessler et al, 1995). Other research has
shown high PTSD rates for torture victims, survivors of the Holocaust and prisoners of war.
2.3 Diagnosis and differential diagnosis
2.3.1 Diagnostic criteria
The ICD–10 diagnosis of PTSD requires that the patient, first, has been exposed to a traumatic
event, and second, suffers from distressing re-experiencing symptoms. Patients will usually also
show avoidance of reminders of the event, and some symptoms of hyperarousal and/or
emotional numbing. The ICD–10 research diagnostic criteria for PTSD are as follows (reproduced
with permission from World Health Organization, 1993: pp. 99–100):
(A)
The patient must have been exposed to a stressful event or situation (either short or longlasting) of exceptionally threatening or catastrophic nature, which would be likely to cause
pervasive distress in almost anyone.
(B)
There must be persistent remembering or ‘reliving’ of the stressor in intrusive ‘flashbacks’,
vivid memories, or recurring dreams, or in experiencing distress when exposed to
circumstances resembling or associated with the stressor.
(C)
The patient must exhibit an actual or preferred avoidance of circumstances resembling or
associated with the stressor, which was not present before exposure to the stressor.
(D) Either of the following must be present:
(1) inability to recall, either partially or completely, some important aspects of the period
of exposure to the stressor
(2) persistent symptoms of increased psychological sensitivity and arousal (not present
before exposure to the stressor), shown by any two of the following:
(a)
difficulty in falling or staying asleep
(b)
irritability or outbursts of anger
(c)
difficulty in concentrating
(d)
hypervigilance
(e)
exaggerated startle response.
(E)
Criteria B, C, and D must all be met within 6 months of the stressful event or the end of a
period of stress. (For some purposes, onset delayed more than by 6 months may be
included, but this should be clearly specified.)
The DSM–IV diagnosis of PTSD is stricter, in that it puts more emphasis on avoidance and
emotional numbing symptoms. It requires a particular combination of symptoms (at least one reexperiencing symptom, three symptoms of avoidance and emotional numbing, and two
hyperarousal symptoms). In addition, DSM–IV requires that the symptoms cause significant
distress or interference with social or occupational functioning. Several studies have found that
trauma survivors who experience most, but not all, DSM–IV symptoms of PTSD show significant
distress and need treatment (e.g. Blanchard et al, 2003b).
In contrast to the ICD–10 definition, a DSM–IV diagnosis of PTSD further requires that the symptoms
have persisted for at least 1 month. In the first month after trauma, trauma survivors may be
diagnosed as having acute stress disorder according to DSM–IV, which is characterised by symptoms
8 Post-traumatic stress disorder
of PTSD and dissociative symptoms such as depersonalisation, derealisation and emotional
numbing. The ICD–10 diagnosis does not require a minimum duration. For the purposes of this
guideline, we include PTSD symptoms that occur in the first month after trauma. A special section
on early intervention (Chapter 7) is dedicated to the management of these early PTSD reactions.
Appendix 13 (source: Ehlers, 2000) compares the diagnostic criteria for post-traumatic stress
disorder in ICD–10 and DSM–IV.
2.3.2 Assessment instruments
Well-validated, structured clinical interviews that facilitate the diagnosis of PTSD include the
Structured Clinical Interview for DSM–IV (SCID; First et al, 1995), the Clinician-Administered PTSD
Scale (CAPS; Blake et al, 1995) and the PTSD Symptom Scale – Interview version (PSS–I; Foa et al,
1993). All these instruments are based on the DSM–IV definition of PTSD.
There is a range of useful self-report instruments of PTSD symptoms; these include:
Impact of Event Scale (IES; Horowitz et al, 1979) and Impact of Event Scale – Revised (IES–
R; Weiss & Marmar, 1997);
Post-traumatic Diagnostic Scale (PDS; Foa et al, 1997)
Davidson Trauma Scale (Davidson et al, 1997)
PTSD Checklist (Weathers & Ford, 1996).
2.3.3 Clinical aspects of the diagnostic interview
When establishing the diagnosis of PTSD it is important to bear in mind that people with this
disorder find talking about the traumatic experience very upsetting. They may find it hard to
disclose the exact nature of the event and the associated re-experiencing symptoms and feelings,
and may initially not be able to talk about the most distressing aspects of their experience. This
may particularly be the case for people who experienced the trauma many years ago or have a
delayed onset of their symptoms.
2.3.3.1
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. C
2.3.3.2
Assessment of PTSD sufferers should be conducted by competent individuals and be
comprehensive, including physical, psychological and social needs and a risk
assessment. GPP
2.3.3.3
When developing and agreeing a treatment plan with a PTSD sufferer, healthcare
professionals should ensure that sufferers receive information about common
reactions to traumatic events, including the symptoms of PTSD and its course and
treatment. GPP
2.3.3.4
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. C
2.3.3.5
Healthcare professionals should be aware that many PTSD sufferers are anxious about
and can avoid engaging in treatment. Healthcare professionals should also recognise
the challenges that this presents and respond appropriately, for example by following
up PTSD sufferers who miss scheduled appointments. C
2.3.3.6
Patient preference should be an important determinant of the choice among effective
treatments. PTSD sufferers should be given sufficient information about the nature of
these treatments to make an informed choice. C
2.3.3.7
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
Diagnosis and differential diagnosis
9
appropriate, using the Care Programme Approach) and should be shared with the
patient and, where appropriate, their family and carers. C
2.3.4 Identification of PTSD in primary care
The main presenting complaint of sufferers does not necessarily include intrusive memories of the
traumatic event. Patients may present with depression and general anxiety, fear of leaving their
home, somatic complaints, irritability, inability to work or sleep problems. They may not relate
their symptoms to the traumatic event, especially if significant time has elapsed since that event.
Older adults report more frequently somatic and physical complaints (Gray & Acierno, 2002) and
are often reluctant to report traumatic events or admit to emotional or psychological difficulties
(Comijs et al, 1999). Practitioners may also need to distinguish PTSD from traumatic or complicated
grief reactions that may develop a year or more following a bereavement, with symptoms
including intense intrusive thoughts, pangs of severe emotion, distressing yearnings, feeling
excessively alone and empty, excessively avoiding tasks reminiscent of the deceased, unusual sleep
disturbances and maladaptive levels of loss of interest in personal activities (Horowitz et al, 1997).
Epidemiological research has shown that the diagnosis of PTSD is greatly underestimated if the
interviewer does not directly ask about the occurrence of specific traumatic events (Solomon &
Davidson, 1997).
2.3.4.1
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, childhood sexual
abuse and traumatic childbirth). GPP
Checklists of common traumatic experiences and symptoms may be helpful for some patients
who find it hard to name them. Both the CAPS (Blake et al, 1995) and the PDS (Foa et al, 1997)
include checklists.
2.3.5 Trauma and families
2.3.5.1
People who have lost a close friend or relative due to an unnatural or sudden death
should be assessed for PTSD and traumatic grief. In most cases, healthcare
professionals should treat the PTSD first without avoiding discussion of the grief. C
2.3.5.2
In all cases of PTSD, healthcare professionals should consider the impact of the
traumatic event on all family members and, when appropriate, assess this impact and
consider providing appropriate support. GPP
2.3.5.3
Healthcare professionals should ensure, where appropriate and with the consent of
the PTSD sufferer where necessary, that the families of PTSD sufferers are fully
informed about common reactions to traumatic events, including the symptoms of
PTSD and its course and treatment. GPP
2.3.5.4
When a family is affected by a traumatic event, more than one family member may
suffer from PTSD. If this is the case, healthcare professionals should ensure that the
treatment of all family members is effectively coordinated. GPP
Please see also the special section on the assessment of children (Chapter 9).
2.3.6 Differential diagnoses
Post-traumatic stress disorder is not the only disorder that may be triggered by a traumatic event.
Differential disorders (and indicators) to be considered are:
depression (predominance of low mood, lack of energy, loss of interest, suicidal ideation)
specific phobias (fear and avoidance restricted to certain situations)
adjustment disorders (less severe stressor, different pattern of symptoms; see below)
enduring personality changes after catastrophic experience (prolonged extreme stressor,
different pattern of symptoms; see below)
dissociative disorders
10 Post-traumatic stress disorder
neurological damage due to injuries sustained during the event
psychosis (hallucinations, delusions).
Of course, PTSD may also exist comorbidly with many of the above disorders, in particular
depression and anxiety disorders.
2.3.6.1 Enduring personality changes after catastrophic experience, DESNOS and ‘complex’ PTSD
Many trauma survivors have experienced a range of different traumatic experiences over their life
span or have experienced prolonged traumas such as childhood sexual abuse or imprisonment
with torture. Several authors have suggested that many of these people develop a range of other
problems besides PTSD, for example depression, low self-esteem, self-destructive behaviours,
poor impulse control, somatisation and chronic dissociation or depersonalisation. It has been
controversial whether these reactions form a separate diagnostic category. Herman (1993) and
others suggested a separate diagnosis of ‘complex PTSD’ or ‘disorders of extreme distress not
otherwise specified’ (DESNOS) to describe a syndrome that is associated with repeated and
prolonged trauma. Initial research has found some evidence for the validity of this concept (e.g.
Pelcovitz et al, 1997). However, it was decided not to include DESNOS as a separate diagnostic
category in DSM–IV: instead, the DESNOS criteria were included among the ‘associated
descriptive features’ of PTSD. This reflects the view that these characteristics are not a unique
feature of survivors of childhood sexual abuse or other prolonged trauma, but instead apply in
varying degrees to most PTSD sufferers.
The ICD–10 distinguishes between PTSD and ‘enduring personality changes after catastrophic
experience’ (F62.0). The latter diagnosis arose from clinical descriptions of concentration camp
survivors and is characterised by a hostile or distrustful attitude towards the world, social
withdrawal, feelings of emptiness or hopelessness, a chronic feeling of ‘being on edge’ as if
constantly threatened, and estrangement. ‘Enduring personality changes after catastrophic
experience’ can be an outcome of chronic PTSD, especially after experiences such as torture or
being held for a long period as a hostage.
The ICD–10 research diagnostic criteria for ‘enduring personality changes after catastrophic
experience’ require:
(A)
A definite and persistent change in the individual’s pattern of perceiving, relating to and
thinking about the environment and the self following exposure to extreme stress.
(B)
At least two of the following:
(1) a permanent hostile or distrustful attitude toward the world
(2) social withdrawal
(3) a constant feeling of emptiness or hopelessness
(4) an enduring feeling of being on edge or being threatened without external cause
(5) a permanent feeling of being changed or being different from others.
(C)
The personality change causes significant interference with personal or social functioning
or significant distress.
(D) The personality change developed after the catastrophic event, and the person did not
have a personality disorder prior to the event that explains the current traits.
(E)
The personality change must have been present for at least 2 years, and is not related to
episodes of any other mental disorder (other than PTSD) or brain damage or disease.
The NICE guideline focuses on the treatment of PTSD, as there is as yet little research on the
treatment of ‘enduring personality changes after catastrophic experience’. It is, however,
recognised that many PTSD sufferers will have at least some of the features of this disorder or the
corresponding concept of DESNOS (complex PTSD). The guideline therefore takes into account
that these features need to be considered when treating PTSD sufferers. However, the guideline
does not apply to individuals whose main problem is a diagnosis of ‘enduring personality
changes after catastrophic experience’ rather than PTSD.
2.3.6.2 Dissociative disorders
Dissociative disorders are characterised by a partial or complete loss of the normal integration
between memories of the past, awareness of identity and immediate sensations, and control of
Diagnosis and differential diagnosis
11
bodily movements. The ICD–10 dissociative (conversion) disorders include dissociative amnesia,
dissociative fugue, dissociative disorders of movement and sensation, and other dissociative
(conversion) disorders including multiple personality disorder. The disturbance may be sudden or
gradual, transient or chronic. It is presumed that the ability to exercise a conscious and selective
control is impaired in dissociative disorders, to a degree that can vary from day to day or even
from hour to hour. However, it is usually difficult to assess the extent to which some of the loss
of functions might be under voluntary control. Dissociative disorders are presumed to be
psychogenic in origin, being associated closely in time with traumatic events, insoluble and
intolerable problems, or disturbed relationships.
People with PTSD may experience a peri-traumatic dissociation (a dissociative reaction at the time
of the trauma), which may subsequently be associated with the complaint of psychogenic
amnesia for an aspect of the traumatic event. The disorder is also associated with an increased
rate of other dissociative symptoms. Indeed, in the preparation for the publication of DSM–IV,
there was discussion as to whether PTSD should be listed as a dissociative disorder rather than an
anxiety disorder (see Brett, 1993).
2.3.6.3 Adjustment disorders
Adjustment disorders are states of subjective distress and emotional disturbance that arise in the
period of adaptation to a significant life change or stressful life event. Stressors include those
that affect the integrity of an individual’s social network (e.g. bereavement, separation) or the
wider system of social supports and values (e.g. migration, leaving the armed forces), or
represent a major developmental transition or crisis (e.g. retirement). Manifestations vary and
include depressed mood, anxiety or worry, a feeling of inability to cope, plan ahead or continue
in the present situation, as well as some degree of disability in the performance of daily routine.
Conduct problems may also occur.
2.3.7 Is PTSD the main problem?
This guideline applies to patients for whom PTSD is the main problem. Whether or not PTSD is
the problem that should be the focus of treatment depends on the severity and urgency of other
disorders and problems, such as social problems, health problems and safety issues. This may
include practical problems such as safe housing, support in court cases, and a range of
psychological symptoms. In order to establish whether or not PTSD is the main psychological
problem, it is useful to ask trauma survivors:
what symptoms or problems bother them the most
whether they think that they would need help with their other symptoms or problems if
the PTSD symptoms could be taken away
whether or not the other problems were present before the traumatic event.
Individuals should be fully assessed before a management plan is devised. Other factors, for
example suicide risk, may determine what the most important focus should be in the first
instance. Simply because there is a trauma history, it should not be assumed that there is PTSD.
Epidemiological studies give further insight into common patterns of comorbidity.
Comorbid diagnoses
In two large epidemiological studies conducted in the USA and Australia, 85–88% of the men and
78–80% of the women with PTSD had comorbid psychiatric diagnoses (Kessler et al, 1995;
Creamer et al, 2001). This raises the following clinically important questions:
Is PTSD primary or secondary to comorbid disorders such as depression, substance misuse
or anxiety disorders?
Will the treatment of PTSD lead to improvement in the comorbid conditions?
Which disorder should be treated first?
Whether or not the comorbid diagnoses are secondary to PTSD (i.e. are complications of the PTSD)
can usually be determined by the time course of symptom onset and their functional relationship.
Kessler et al (1995) showed that PTSD was primary to comorbid affective or substance use disorders
in the majority of cases, and was primary to comorbid anxiety disorders in about half of the cases.
12 Post-traumatic stress disorder
In many cases comorbid problems that are secondary to the PTSD, such as comorbid depression,
general anxiety or alcohol or substance misuse, improve with trauma-focused psychological
treatment. Treatment studies of PTSD show that with the successful treatment of PTSD, comorbid
symptoms of depression and anxiety are also greatly reduced. For example, patients with
comorbid secondary major depression no longer met diagnostic criteria for major depression
after PTSD treatment (Blanchard et al, 2003b).
2.3.7.1
When a patient presents with PTSD and depression, healthcare professionals should
consider treating the PTSD first, as the depression will often improve with successful
treatment of the PTSD. C
However, in patients with a long history of PTSD or patients who have experienced multiple
traumatic events and losses, the depression can become so severe that it needs immediate
attention (i.e. it is a suicide risk), and dominates the clinical picture to the extent that it makes
some forms of PTSD treatment impossible (for example, owing to extreme lack of energy, social
withdrawal and inactivity). Psychological treatments for PTSD often involve discussing the
traumatic events and their meanings in detail. Extremely severe depression would need to be
treated before patients could benefit from such trauma-focused treatments. (We use the term
‘trauma-focused’ treatment for a range of psychological treatments of PTSD that help the patient
come to terms with the traumatic event by working through the trauma memory and discussing
the personal meanings of the traumatic event.)
2.3.7.2
For PTSD sufferers who are so severely depressed that this makes initial psychological
treatment of PTSD very difficult (for example, as evidenced by extreme lack of energy
and concentration, inactivity, or high suicide risk), healthcare professionals should
treat the depression first. C
2.3.7.3
For PTSD sufferers whose assessment identifies a high risk of suicide or harm to others,
healthcare professionals should first concentrate on management of this risk. C
Similarly, many patients with PTSD misuse both alcohol and a range of drugs in an attempt to
cope with their symptoms, and treatment of their PTSD symptoms will help them with reducing
their substance use. However, if substance dependence (i.e. withdrawal symptoms, tolerance) has
developed, this will need to be treated before the patient can benefit from trauma-focused
psychological treatments. In cases where the drug or alcohol dependence is severe, collaborative
working with specialist substance misuse services may be required.
2.3.7.4
For PTSD sufferers with drug or alcohol dependence, or in whom alcohol or drug use
may significantly interfere with effective treatment, healthcare professionals should
treat the drug or alcohol problem first. C
Personality disorders
Patients with personality disorders may present two kinds of problems with regard to PTSD. First,
as a result of their interpersonal difficulties they may at times find themselves in situations in
which they are more likely to be harmed and suffer PTSD as a consequence of the harm suffered.
Second, in some cases there is a history of abuse in childhood as a factor in the development of
the personality disorder. This may also lead to adult PTSD, although the PTSD is unlikely to be the
main focus of their presentation. It has been assumed by some therapists and researchers that
personality disorder is a contraindication for many treatments. However, recent research suggests
that individuals with personality disorder can benefit from structured psychological treatments
for comorbid disorder such as anxiety and depression, although such treatments may not directly
affect the problems associated with personality disorder (Dreessen & Arntz, 1998). Patients with
personality disorder therefore could benefit from trauma-focused psychological interventions.
2.3.7.5
When offering trauma-focused psychological interventions to PTSD sufferers with
comorbid personality disorder, healthcare professionals should consider extending the
duration of treatment. C
Social and physical problems
People with PTSD often have difficult life circumstances. For example, they may have housing or
serious financial problems, live under ongoing threat (e.g. still live with the perpetrator of
violence) or experience continued trauma. Refugees face multiple problems of building up a new
Diagnosis and differential diagnosis
13
life and adjusting to a new culture and language. Chapter 10 addresses the special problems in
the treatment of refugees.
These adverse life circumstances may be the PTSD sufferer’s most pressing concern and, if so, will
need to be addressed before treatment of the PTSD is indicated. Similarly, PTSD sufferers who
were injured in the traumatic event might still be undergoing medical treatment, might be
waiting for further surgery or might have to cope with permanent physical disability. These
physical problems might be their most pressing concern at present and might also have an
impact on treatment duration.
2.3.7.6
Healthcare professionals should consider offering help or advice to PTSD sufferers or
relevant others on how continuing threats related to the traumatic event may be
alleviated or removed. GPP
2.3.7.7
Healthcare professionals should normally only consider providing trauma-focused
psychological treatment when the sufferer considers it safe to proceed. GPP
2.3.7.8
Healthcare professionals should identify the need for appropriate information about
the range of emotional responses that may develop and provide practical advice on
how to access appropriate services for these problems. They should also identify the
need for social support and advocate for the meeting of this need. GPP
2.3.7.9
Where a PTSD sufferer has a different cultural or ethnic background from that of the
healthcare professionals who are providing care, the healthcare professionals should
familiarise themselves with the cultural background of the PTSD sufferer. GPP
2.3.7.10
Where differences of language or culture exist between healthcare professionals and
PTSD sufferers, this should not be an obstacle to the provision of effective traumafocused psychological interventions. GPP
2.3.7.11
Where language or culture differences present challenges to the use of traumafocused psychological interventions in PTSD, healthcare professionals should consider
the use of interpreters and bicultural therapists. GPP
2.3.7.12
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. GPP
2.4 Aetiology of PTSD
2.4.1 The traumatic event
It is now recognised that the traumatic event is a major cause of the symptoms of PTSD.
Historically, this has been the subject of considerable debate. Charcot, Janet, Freud and Breuer
suggested that hysterical symptoms were caused by psychological trauma, but their views were
not widely accepted (see reviews by Gersons & Carlier, 1992; Kinzie & Goetz, 1996; van der Kolk
et al, 1996). The dominant view was that a traumatic event in itself was not a sufficient cause of
these symptoms, and experts searched for other explanations. Many suspected an organic cause.
For example, damage to the spinal cord was suggested as the cause of the ‘railway spine
syndrome’, micro-sections of exploded bombs entering the brain as the cause of ‘shell shock’ and
starvation and brain damage as causes of the chronic psychological difficulties of concentration
camp survivors. Others doubted the validity of the symptom reports and suggested that
malingering and compensation-seeking (‘compensation neurosis’) were the major cause in most
cases. Finally, the psychological symptoms were attributed to pre-existing psychological
dysfunction. The predominant view was that reactions to traumatic events were transient, and
that therefore only people with unstable personalities, pre-existing neurotic conflicts or mental
illness would develop chronic symptoms (Gersons & Carlier, 1992; Kinzie & Goetz, 1996; van der
Kolk et al, 1996).
It was the recognition of the long-standing psychological problems of many war veterans,
especially Vietnam veterans, and of rape survivors that changed this view and convinced clinicians
and researchers that even people with sound personalities could develop clinically significant
psychological symptoms if they were exposed to horrific stressors. This prompted the
14 Post-traumatic stress disorder
introduction of post-traumatic stress disorder as a diagnostic category in DSM– III (American
Psychiatric Association, 1980). It was thus recognised that traumatic events such as combat, rape
and man-made or natural disasters give rise to a characteristic pattern of psychological
symptoms. The ICD–10 classification emphasised the causal role of traumatic stressors in
producing psychological dysfunction even more clearly, in that a specific group of disorders,
‘reaction to severe stress, and adjustment disorders’, was created. These disorders are ‘thought
to arise always as a direct consequence of the acute severe stress or continued trauma. The
stressful event ... is the primary and overriding causal factor, and the disorder would not have
occurred without its impact’ (World Health Organization, 1992: p. 145).
The criteria of what constitutes a traumatic stressor have been modified since the diagnosis of
PTSD was introduced. Initially PTSD was thought to occur only following an event ‘outside the
range of usual human experience’. However, epidemiological data showed that PTSD may
develop in response to traumatic events such as road traffic accidents or assault, which are so
widespread that they are not ‘outside the range of usual human experience’. The criteria for what
constitutes a traumatic stressor have therefore been modified over the years (reviewed by
McNally et al, 2003). The DSM–IV now emphasises threat to physical integrity as a common
element of trauma, and takes into account that the person’s subjective response to the event is
crucial in determining whether the event is experienced as traumatic, by specifying that the
person must experience extreme fear, helplessness or horror during the event. The ICD–10
emphasises that the event must be of an ‘exceptionally threatening or catastrophic nature’.
2.4.2 Trauma memories
The characteristic re-experiencing symptoms in PTSD appear to be the result of the way the
traumatic event is laid down in memory. Trauma is overwhelming, and exceeds people’s resources
for information processing. The resulting memory for the event appears to be different from
ordinary autobiographical memories. This has the effect that aspects of the memory can be easily
triggered, and are re-experienced as if they were happening right now, rather than as memories
of a past event. The exact mechanisms of the memory abnormalities are currently being
investigated (Brewin et al, 1996; McNally, 2003; Brewin, 2005; Ehlers et al, 2004).
2.4.3 Fear conditioning
Classical conditioning theory suggests that stimuli experienced at the time of trauma become
associated with fear. Consequently, stimuli resembling those present during the traumatic event
trigger severe distress, and are avoided (see, for example, Keane et al, 1985).
2.4.4 Individual interpretations of the traumatic event and its
consequences
The degree of threat that people perceive during a traumatic event depends on their
interpretation of what is happening. For example, whether or not people perceive that their life is
in danger during the traumatic event has a large impact on the likelihood of developing PTSD.
Similarly, the conclusions they draw from the event are important factors in maintaining PTSD;
for example, if PTSD sufferers feel guilty or ashamed about what happened, and blame
themselves for things they think they are responsible for, they are unlikely to come to terms with
the event and resume their former lives. If PTSD sufferers interpret the trauma as meaning that
they are at great risk of further trauma, they continue to feel threatened in their everyday life.
The interpretations characteristic of PTSD not only concern the traumatic event, but also its
consequences, including responses of others in the aftermath of the event, initial PTSD symptoms
and physical injuries (e.g. Foa et al, 1999; Ehlers & Clark, 2000).
2.4.5 Unhelpful coping strategies
Trauma memories are painful and PTSD symptoms are distressing. In their efforts to cope with
the event and the symptoms they are experiencing, trauma survivors may resort to a range of
coping strategies that appear to be helpful at the time, but prolong or exacerbate symptoms.
These include effortful suppression of trauma memories and emotions, rumination about the
event, dissociation, social withdrawal, avoidance and substance use (e.g. Ehlers & Clark, 2000).
Aetiology of PTSD
15
2.4.6 Social support and relationships with significant others
Lack of social support in the aftermath of trauma is associated with greater risk of chronic PTSD
(Brewin et al, 2000; Ozer et al, 2003). The experience of a traumatic event often has a negative
impact on survivors’ ability to trust other people and engage in close relationships, in particular if
the event involved intentional harm by others. Sufferers may feel alienated from others and
withdraw from previously significant relationships. This may contribute to the maintenance of the
problem, and interfere with a trusting relationship with health professionals (e.g. Ehlers et al,
2000).
2.4.7 Litigation
The hypothesis that reports of PTSD symptoms are mainly due to malingering and compensationseeking (‘compensation neurosis’) has not been supported by systematic research. On the other
hand, protracted legal proceedings may exacerbate the distress of PTSD sufferers and make it
difficult for them to put the event in the past (Blanchard et al, 1996; Ehlers et al, 1998). This may
well explain much of the association between PTSD symptoms and litigation, but the relationship
is a complex one and is more fully considered in Chapter 8.
2.4.8 Hypothalamic–pituitary–adrenal axis abnormalities
People with current PTSD may show abnormally low levels of cortisol compared with normal
controls and with traumatised individuals without current PTSD (e.g. Yehuda et al, 1995). In
addition, PTSD sufferers may also have an increased number of lymphocyte glucocorticoid
receptors. When given a low dose of dexamethasone, PTSD sufferers exhibit hypersuppression of
cortisol. Thus, PTSD sufferers tend to show a very different pattern of hypothalamic–pituitary–
adrenal (HPA) axis response from patients with major depression. The pattern of findings
suggests that the HPA axis in PTSD is characterised by enhanced negative feedback (Yehuda et al,
1995). There may also be a downregulation of corticotrophin-releasing factor receptors at the
anterior pituitary due to chronic increases in corticotrophin-releasing factor (Bremner et al,
1997). Overall, the pattern of findings suggests that the HPA axis in PTSD is set to produce large
responses to further stressors.
2.4.9 Neurochemical abnormalities
Several neurotransmitter systems may be dysregulated in PTSD. Research suggests a sensitisation
of the noradrenergic system. Another subgroup of PTSD sufferers seems to be characterised by a
sensitised serotonergic system. Endogenous opiates have been suspected to mediate the
symptoms of emotional numbing and amnesia. The dopaminergic, gamma-aminobutyric acid
(GABA) and N-methyl-D-aspartate systems have also been implicated in PTSD, but the evidence for
these hypotheses is sparse at this stage (Charney et al, 1993).
2.4.10 Hippocampal size
People with long-standing PTSD may have a smaller hippocampus than controls. Latest findings
suggest that small hippocampus size may be a vulnerability factor, rather than a consequence of
trauma (Gilbertson et al, 2002; see McNally, 2003, for a review).
2.4.11 Vulnerability factors
A range of vulnerability factors for PTSD have been identified (Brewin et al, 2000; Ozer et al,
2003). These include a previous personal or family history of anxiety disorders or affective
disorders, neuroticism, lower intelligence, female gender and a history of previous trauma.
Genetic factors and the impact of early trauma on the neurobiological system may also have a
role (Heim & Nemeroff, 2001). Overall, the amount of variance explained by these factors is small.
Chapter 8 is dedicated to a systematic review of factors that may be useful in screening for
people at risk for PTSD after traumatic events.
16 Post-traumatic stress disorder
2.5 Treatment and management of PTSD in the NHS
Emotional reactions to traumatic events started to achieve a high priority in the UK after the
disasters of the 1980s, including the Bradford football stadium fire, the sinking of the Herald of
Free Enterprise ferry and the King’s Cross fire. In the aftermath of each of these events,
committed people established treatment services. Following research into the needs of UK
citizens held in Kuwait and Iraq as the ‘human shield’ in the first Gulf War (Easton & Turner,
1991), the Department of Health established two national treatment facilities (on short-term
contracts) to help promote the development of services in the UK. Since then, there has been an
expansion of these specialist centres across the country and a model of cooperation has
developed (e.g. through the UK Trauma Group; www.uktrauma.org.uk). Statutory services for
certain specialist groups such as refugees and war veterans have lagged behind, and have often
been supported primarily by the voluntary sector. Recently, statutory services have started to
grow in these areas as well.
One of the challenges of recent years has been to help local services gain the skills to treat as
many people with PTSD as possible. To an increasing degree this has been achieved, and now
people with PTSD and related disorders are being treated in a range of National Health Service
(NHS) and non-statutory settings, including primary care, general mental health services and
specialist secondary care mental health services. However, the provision and uptake of such
services still varies across England and Wales and reflects the demands of particular populations
(for example, refugees or war veterans) and the presence or absence of specialist services. The
decade prior to 2005 has seen a significant expansion of special services, but the provision is still
subject to considerable local variation, and some PTSD sufferers may have to go through many
steps before they can obtain referral to a treatment service, or they may face unreasonably long
delays.
The challenge for the future will be to see services devolved into primary care settings, where this
is feasible. There is a need to develop a pathway of care that offers prompt, evidence-based
services in local communities, supported by specialist services for more refractory or complex
problems. We hope that this guideline will be a stimulus to this process.
2.6 Primary care
2.6.1 First presentations
Many individuals will consult their general practitioner shortly after experiencing a traumatic
event, but will not present a complaint or request for help specifically related to the
psychological aspects of the trauma; for example, an individual who has been physically
assaulted or involved in a road traffic accident or an accident at work might present requiring
attention to the physical injuries sustained. This provides an opportunity for an assessment of the
patient’s psychological state. Similarly, individuals who have been involved in such events often
present at local emergency departments, notification of which is sent to general practitioners.
Others suffering from a potentially adverse psychological reaction to trauma include people who
might have been traumatised as a result of domestic violence or childhood sexual abuse and
might not necessarily have presented with complaints related to this previously. The key point
here is that primary care staff should consider that PTSD can arise not simply from single events
such as an assault or a road traffic accident but also from the repeated trauma associated with
childhood sexual abuse, domestic violence or the repeated trauma associated with being a
refugee.
A small proportion of PTSD cases have delayed onset (probably less than 15%; McNally, 2003).
The assessment of such presentations is essentially the same as for non-delayed presentations.
There is evidence to suggest that delayed presentations of PTSD, even those that occur some
years after the traumatic event, are likely to respond to treatment (Foa et al, 1991; Gillespie et
al, 2002; Resick et al, 2002). A long period between the trauma and the onset and presentation
of symptoms should therefore not be a disincentive to the identification and referral for
treatment.
Primary care 17
2.6.1.1
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 might have occurred many months or years before),
giving specific examples of traumatic events (for example, assaults, rape, road traffic
accidents, childhood sexual abuse and traumatic childbirth). GPP
2.6.1.2
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.
GPP
2.6.2 Repeated presentations
A number of people may previously have presented with PTSD and received treatment for it.
Although the response to effective interventions for the treatment of PTSD is now generally
good, a small but significant number do not respond to such treatment. It is important to
reassess individuals who have not responded and to consider other diagnoses and comorbidity.
There is some evidence to suggest that returning for a second period of treatment may be
beneficial and it is important therefore not to assume that failure of a previous treatment means
that a person will not respond well to treatment in the future. For example, the presence of a
continuing threat might have impaired an individual’s ability to benefit from previous treatment,
the treatment provided might have been inadequate, or the patient might not have been able to
tolerate the treatment offered at the time.
2.6.3 Comorbid presentations
Post-traumatic stress reactions are associated with significant comorbidities. Most prominent
among these comorbidities is depression. Depression that does not respond to conventional
treatments or that might have arisen following a traumatic event should alert the general
practitioner or other primary care team member to the possibility of a post-traumatic stress
reaction. The inappropriate use of prescribed drugs or the misuse of street drugs or alcohol,
particularly if associated with avoidance of certain situations, to facilitate sleep or to avoid other
psychological difficulties, should also alert the practitioner to the possibility of PTSD.
As detailed in the section on screening and assessment (2.3.2 and 2.3.3), a few simple questions
may be required to identify patients who require further and more detailed assessment.
2.6.4 Watchful waiting
A significant number of people presenting with acute reactions or established PTSD can be
expected to recover within a relatively short space of time (Rothbaum et al, 1992; Bryant, 2003).
The rate of remission is higher for those with milder symptoms. For such people some element of
brief education, support and advice in the context of their presentation followed by watchful
waiting may be most appropriate, with the individual either encouraged to return for further
assessment or offered a specific appointment time if there is sufficient concern on the part of the
general practitioner or the primary care team member.
2.6.4.1
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 sufferers, should be considered by healthcare professionals. A follow-up
contact should be arranged within 1 month. C
2.6.5 Immediate management of PTSD
The immediate management of PTSD in part depends upon the nature of the trauma and the
circumstances in which it arose. In the rare event that it arose as part of a major disaster, manmade or natural, specific resources to support individuals involved in this may be available and it
will be for the general practitioner and other members of the primary care mental health team to
facilitate the individual’s access to such services as may be available. More usually, however, the
18 Post-traumatic stress disorder
trauma will arise as a result of a smaller-scale incident. In the latter circumstances a number of
treatment options are available. For some people relatively low-key brief interventions provided in
primary care can offer the appropriate level of intervention. For others, more complex and longstanding interventions are required; inevitably some of these people will be required to wait for
treatment, and this will leave the general practitioner and other members of the primary care
mental health team with a potentially significant management problem. This might relate to
specific PTSD symptoms, for example intrusive recollections or nightmares concerning the event,
specific sleep disturbance, social withdrawal, irritability or more generalised distress. In such
circumstances strategies such as advice on sleep hygiene, advice to rely on the natural support
from their families and others available (including, where appropriate, support groups) and
where possible pharmacological interventions (see Chapter 6) should be considered. Depending
on the waiting time for appropriate psychological or other specialist interventions, the general
practitioner may also consider regular reviewing of individual patients.
2.6.6 Persisting PTSD and chronic disease management
Regardless of offers of treatment or actual courses of treatment, a number of individuals with
PTSD will achieve negligible or only partial recovery and will continue to suffer from PTSD
symptoms for a considerable period. The degree of disability that people with chronic PTSD suffer
can be significant and can considerably impair functioning in an individual’s personal, social and
occupational life. This may be associated with problems such as chronic sleep disturbance and
occasionally with alcohol or drug misuse. More often it is characterised by significant social
avoidance. In these circumstances the focus of management in primary care may be on the
disabling symptoms rather than the underlying PTSD. Advice on sleep hygiene and (where
appropriate) pharmacological interventions may have some benefit in dealing with sleep-related
problems. An encouragement to engage in structured and supported activities with some
facilitation from primary or secondary care mental health staff may also be of value to people
with the chronic social avoidance associated with PTSD, as may contact with other individuals
who have undergone a similar experience. In some areas support groups exist and individuals
should be made aware of these and of national organisations.
Chronic disease management models, where the practice identifies and helps individuals develop
appropriate coping strategies to cope with their chronic problems, should be considered. Models
such as those that have been developed for the treatment of depression (Katon et al, 2001),
drawing on previous work for the treatment of chronic physical conditions such as diabetes or
arthritis, offer some promise. Regular routine contact, often through members of the primary
care staff other than the general practitioner, and regular if not frequent reviews with the general
practitioner, offer a real opportunity.
2.6.6.1
Chronic disease management models should be considered for the management of
people with chronic PTSD who have not benefited from a number of courses of
evidence-based treatment. C
2.7 Economic burden of PTSD
Methods of economic evaluation command a fairly high level of consensus and are reported by
Drummond et al (1997). However, costing data for PTSD treatments and their consequent
outcomes are scarce to non-existent. In the absence of known quantity-of-life or quality-of-life
data, the preferred approach is to conduct a cost-effectiveness analysis to examine alternative
interventions. In this form of economic evaluation, alternatives are assessed by both their impact
on costs and meaningful health-related gains. This approach delivers the incremental cost per
unit of benefit achieved.
In the case of PTSD, as with other disorders for which multiple treatments are practised, it is
useful to examine the additional costs that one intervention or programme imposes over the
other, compared with the additional effects or benefits each delivers (Drummond et al, 1997).
Since there may be a significant difference in cost between patients at first presentation and
patients continuing a treatment programme, there is a pressing need to compare incremental
costs with incremental outcomes, and future studies should present these in a cost-effectiveness
Economic burden of PTSD 19
analysis with allowance for uncertainty of costs and consequences. Unfortunately, despite efforts
to prevent and treat the condition, the majority of economic evaluations of PTSD fail to meet
rigorous criteria for health economic appraisal.
‘Neurotic disorders’ have been estimated to cost the NHS up to £5600 million per year (Holmes,
1994). In addition, the Department of Health (1995) estimated that 91 million working days each
year in the UK are lost through stress-related illness, at a cost to industry of £3700 million. In
2003–4, social and welfare costs of claims for incapacitation and severe disablement from severe
stress and PTSD amounted to £103 million, which is £55 million more than was claimed 5 years
previously (Hansard, 2004). Therefore, PTSD presents an enormous economic burden on families,
the national health services and society as a whole.
To remedy this situation, there is a need for robust efficacy data and reliable cost estimates for
alternative treatments. Prospective studies should report direct costs alongside indirect costs,
which can be significant. For example, a patient who prior to leaving work garnered the average
national earnings of £25170 per year (Incomes Data Services, 2003) would lose £483.04 for every
week of absence, as well as opportunities for career advancement. At an estimated, approximate
cost to the NHS of £825 for ten treatment sessions (1–1½ h in duration), every month of work
absence would equate to an amount that could pay for more than 25 sessions of therapy.
Post-traumatic stress disorder presents an excessive health and economic burden on patients,
families, healthcare workers, hospitals and society as a whole. Its effects extend far beyond the
healthcare sector, and affect the quality of life as well as the ability to function socially and
occupationally. The economic and social impact of PTSD is felt not only by those who experience
the disorder, but also by families, co-workers, employers and the wider society (McCrone et al,
2003).
As was done in the case of bipolar disorder (Birnbaum et al, 2003), the totality of direct and
indirect costs surrounding PTSD should be analysed and compared with other mental health
disorders. Considerations of whether patients have equal access to treatment must be included
alongside rigorous cost-effectiveness analyses of alternative programmes for distinct types of
trauma and socio-demographic factors. Indirect costs to other sectors also must be measured,
including those borne by schools, social care agencies, employers and the welfare system, to
name but the major ones (Knapp, 2003).
The problem is identifying which patients are likely to benefit from certain treatments, and
traumatic events present different patterns of onset and remission. Depending on a number of
factors, including individual susceptibilities to a given trauma, the normal range of those exposed
to traumatic events who will develop PTSD is 15–71% (Kessler et al, 1995; Breslau et al, 1998; L.
G. Ost, personal communication, 2004).
Other traumatic events imbue different patterns of PTSD. For instance, it has been reported that
the lifetime prevalence of PTSD following the murder of a family member is 71%, assault of a
family member 63%, experiencing physical life threat or being seriously injured 63%, physical
assault 58%, rape 57%, rape of a family member 50% and sexual molestation 17% (as reported
by Ost and colleagues; L. G. Ost, personal communication, 2004). Thus, the type of trauma
appears to influence significantly one’s likelihood of experiencing PTSD as well as its pattern of
remission and responsiveness to treatment (Breslau et al, 1998).
Therefore, treating populations of individuals who are most likely to need treatment is expected
to be more cost-effective than treating the chronic condition at a later stage. As can be seen
from the above, chronic PTSD limits years and quality of life as well as functional independence.
Efficient service utilisation based upon additional rigorous health economic evaluations would
reduce this social and economic burden of PTSD, to ensure the optimal care is delivered within
the constraints of the national budget.
20 Post-traumatic stress disorder
3 Experiences of PTSD sufferers and carers
This chapter describes the experiences of a number of PTSD sufferers and also those involved as
family members or carers of PTSD sufferers. The testimonies set out below, which present both
positive and negative experiences of services and treatment, were chosen because they illustrate
a range of experience of sufferers and carers, and because they encompass both the initial
trauma and the subsequent impact it had on people’s lives. Sufferers’ (and carers’) struggles to
obtain appropriate treatment and the benefit derived from such treatments are also described.
These testimonies and the subsequent commentaries are a central element of this guideline, as
they provide an important context in which the effective treatment and management of PTSD can
be understood. Many of the recommendations in Chapter 2 and in other parts of the guideline
were developed in response to or shaped by the concerns and experiences of the sufferers
represented here.
3.1 Personal testimonies from PTSD sufferers
3.1.1 Testimony one
I am a survivor of an industrial disaster that took place over 30 years ago, in which 144 people
died, most of them children. I was 8 years old at the time. The disaster happened on the last day
of school before the half-term holiday. During the first lesson of the morning there was a
rumbling sound, which got progressively louder. The teacher assured us that there was nothing
to worry about – it was only thunder. The next thing I remember was waking up covered in
material. I could see a small aperture of light above me and I could hear screams for help, but
could not move. Those screams got less and less as time went on. I was pinned down with my
desk against my stomach. My right leg was caught in the radiator and hot water was coming out
of it. On my left shoulder was a fellow pupil’s head – she was dead and as time went on her eyes
became more sunken into her head and her face became puffy.
The rescuers saw me through the aperture above me. As the firemen pulled me out I was passed
in a human chain out into the schoolyard, where I was seen by medics before being sent to
hospital. The rescue operation itself was somewhat of a chaotic affair, with miners from the local
colliery, emergency services and voluntary bodies all coming to help. Debris was moved from one
part to another with no indication as to whether anyone was under it. I was the last to come out
of the school alive. Only four out of the 34 pupils in the class survived.
I had to grow up very quickly – one minute I was a young boy with no cares in the world. The
next minute I had death on my shoulder; I couldn’t play because the majority of my friends were
gone, and I had recurrent nightmares. I sustained physical injuries to my head and stomach but
these would heal with time – it was the psychological injuries that would go on for much longer
and still have an impact over 30 years later.
At first, I could not go to school, as I feared that the disaster would happen again. In addition,
my ability to concentrate was extremely poor. It was not until my O levels some 6 years later that
I really settled down into education, eventually getting my degree. The attitude of the education
authority at the time was not to push individuals back into education but to let them find their
way back into the system.
After the disaster, psychological and psychiatric services – in their infancy at that time – were
offered to the survivors. I always remember visiting a child psychologist and being told by her
that whenever I had bad thoughts I should think of nice things like birthday parties and balloons.
As an 8-year-old at the time, I wondered who needed the help. In fact much of the burden for
the aftermath of the disaster fell on the local general practitioners and they really had to pick up
the pieces and are to be praised for the role they played in the community.
I had nightmares for many years, flashbacks of what happened on that day (the girl’s face on my
shoulder), a fear of noise (particularly thunder), a fear of crowds, and a sense of guilt as to why I
21
survived and others had died. The absolute torment of these issues engulfed my whole person,
sending me into the depths of despair and depression.
Events (such as the earthquakes in Turkey) can trigger off flashbacks and deep depression. The
depression totally immobilises me. I can’t even pick up a razor to shave, unable to look in the
mirror; I question my existence. It becomes so intense that I have to go to bed for a couple of
days and wait for it to pass.
How have I overcome or come to terms with these issues? The answer is that I haven’t – I have
learnt to live with them. The effect of the disaster will be with me until I die. Some survivors have
been able to manage it and come to terms with it better than others. I have found that over the
years I have been able to talk about it more easily without getting upset. Indeed, talking about it
has helped me to come to terms with it and it’s surprising how often new facts come out, having
been released from my subconscious. My advice to any one involved in a traumatic event is to
speak about it and to release the anger and frustration that inevitably builds up within you.
3.1.2 Testimony two
After my final tour of duty in the military, I came home in 1993 feeling like my whole life had
changed and that my attitude to my friends and life in general had changed. I had flashbacks,
problems sleeping, was absolutely terrified of bangs and fireworks, and felt guilty and ashamed
that I was the only one who seemed to be affected. My self-confidence had gone, I struggled
with mood swings and had difficulty socialising.
I had my first breakdown in 1995, which resulted in my GP [general practitioner] prescribing
Seroxat [paroxetine] that made me act in a frenzied and uncontrollable way when I had either
forgotten to take it or tried to come off it. I was not offered any counselling or a referral to a
psychiatrist and no investigations were conducted to find the cause of my problems.
I had a second major breakdown in 1999. I could no longer cope with my job because I couldn’t
deal with any confrontational issues, and was desperate to commit suicide. My life consisted of
these spiralling periods of self-doubt, self-hate and worthlessness. I had no idea what was wrong,
only that I felt I was going mad. I had many other problems, including anxiety, hyperventilating,
sweating and social phobia, to name just a few. There were no clinics I could go to and no
support groups. All I wanted to do was talk to someone and tell them how I felt and what I was
going through, and how I could not cope. I went to my GP after I admitted to my wife that I
wanted to kill myself.
In the end I saw a critical incident debriefer for 10 sessions (funded by my employer on the
recommendation of SSAFA [Soldiers, Sailors, Airmen and Families Association] Forces Help) who
eventually diagnosed PTSD in 1999. I cried for hours because for the first time in 6 years someone
had told me I was ill. When PTSD was explained to me, I fitted every criterion. I knew then that I
was not going mad, that I was not the only one who felt this way, and that my problems were
normal responses to abnormal occurrences. I was prescribed more drugs (dothiepin [dosulepin])
that were steadily increased until I reached the maximum limit, but they turned me into a
zombie. Again no psychological intervention was offered.
When I was first referred to a CMHT [community mental health team] in 1999, the CPN
[community psychiatric nurse] would stare at the ceiling and fidget while I tried to explain to him
what happened and how I felt. I didn’t feel that I could build up any trust with him and he
admitted that he did not have the skills or understanding to help me. On one occasion I
explained that I had had a problem with Seroxat and as a result was scared to go back to the GP
who had prescribed it. It seemed that the CPN did not at first believe me when I said that I found
Seroxat to be addictive because he had to ask his colleague to confirm what I had told him.
Imagine how I felt when he said this, implying that he did not believe a thing I said? I refused to
go back after that and was sent a letter saying that because I had not attended my last
appointment they considered me fully recovered and were not going to send me any more
appointments. Maybe a questionnaire or a visit to ascertain why I had stopped going might have
been better?
It was about a year before I saw anyone again, but I never once got to see a consultant
psychiatrist, only the junior doctors who rotated every 6 months. Every time they changed, the
new one never read my notes; it was always, ‘OK, let’s start by you telling me about yourself’. I
22 Experiences of PTSD sufferers and carers
could never build up any relationship of mutual trust and understanding. Once my wife came
with me to see a junior psychiatrist because she was very concerned about my high dose of
medication (250 mg of dothiepin [dosulepin]), which made me sleep extremely heavily and for
long periods. The psychiatrist agreed to reduce my medication to 225 mg, but I was
dumbfounded when on my next visit she asked me if our sex life was now better as she felt that
my wife’s concerns were due to her being sexually frustrated.
By now I had been to Combat Stress (a charity that helps ex-service personnel who are suffering
from mental health problems) for a 1-week residential stay. This helped but initially was only a
week at a time with a 6-month gap of nothing. I needed more help.
One psychiatrist had written to my GP and told him that they could no longer provide help for
me because they had done everything they could and did not have the skills or resources in this
area to help me further and recommended that I visit Combat Stress again, as they were the
specialists who could really help me. My GP unfortunately did not agree and as a result I was
denied my right to treatment. My GP also denied that he had even received letters from the
CMHT when I questioned his decisions. After making a complaint to the senior partner I changed
my doctor because I could no longer trust him.
When I needed help the most, I was let down. I was taken off the psychiatrist’s books but was
not told that I was no longer going to be getting any appointments. When I phoned 4 weeks
later needing to see a psychiatrist I was told that I had to be re-referred via my GP. I went to him
and was re-referred only to a CPN, not to a psychiatrist, who had clearly not read my notes. I
refused to go over what I had been through again and told the CPN to read my notes because it
was all in there. I was then informed that this was an initial appointment and that because his
books were full they could not see me for another 2 to 3 months. I never did get an appointment
from him. This was when I lost all hope in the NHS.
After this I reduced my own medication and using some of my war pension I set up a website
about PTSD which explained about the different ways people can help themselves with
techniques I had been taught and learnt myself. I wrote everything in a language that anybody
could understand and included links to other groups around the world that could help PTSD
sufferers wherever they came from. It revived very painful and upsetting memories but my whole
motive was to provide information and support to fellow PTSD sufferers so that they did not have
to go through the hell that I had to endure. I thought that if I could save just one life, prevent
one person from committing suicide, then it was all worth while. My website is now the number
one PTSD self-help/information (non-medical) website in the world and I have had many
hundreds of thousands of visits to its pages and hundreds of messages of thanks and support.
After another year of being unemployable, I slowly managed to begin a new, ‘drug free’, life, and
with the support of my family I started a new job. Now I have been taken on full-time at work
and although I still have to deal with the anxiety, stress, shakings, avoidance and sweating on a
daily basis, I am slowly rebuilding a life that just 3 years ago I thought was impossible.
There is hope for people who suffer from PTSD: you can rebuild a life again with the support of
your family and friends. I have proven this, but it is not easy and there will be many times when
you want to give in. Just accept that you will never be the person who you were before your
problems started and accept the new you, warts and all (that’s hard, I know, but it is possible).
I feel that healthcare professionals need training and education to understand PTSD (that it can
arise as a result of military action) and that it can and should be treated. It is their responsibility
to provide treatment in a sensitive, caring and understanding way and not to put PTSD sufferers
on medication without adequate review or to reject us as the Ministry of Defence and our
communities have done.
3.1.3 Testimony three
The death of my brother in a mass disaster catapulted me out of normality into another world for
which I was totally unprepared. Visiting the scene a few days later was one surreal experience of
many. Seeing the debris, being at what was basically an enormous gravesite, was something I
needed to do. But it had an effect on me that even now, so many years later, remains almost
impossible to put into words. What I needed was information, as well as practical help and
support to get me through the hideous first days. What I mostly got instead, sometimes from
Sufferers’ testimonies
23
well-intentioned people, ranged from insensitivity to overprotection. They seemed to have
expectations of the ‘right’ way for people in my position to behave – and I didn’t fulfil those
expectations.
I first went to see my GP several weeks later. I used the excuse of not feeling well to see her and
during the appointment I told her what had happened. She said that anger was an inappropriate
emotion – she wasn’t uncaring, but she seemed to have no understanding of what I might need.
I didn’t even know this myself, but I left the surgery feeling even angrier than when I had gone to
see her – she was the professional and I expected that she would have some clue about what to
suggest to make me feel better.
I tried to get on with my life while becoming very involved in trying to find out why the disaster
had happened. I got to know other people whose relatives were killed in the disaster and we
formed a support group of our own. We once invited a therapist from a trauma clinic to come
and talk to us about post-traumatic stress disorder. While she was describing how we might be
feeling I felt I couldn’t stand it and left the room. Others did the same or put their heads down
on the table and cried. Some of it was relief at the recognition that maybe someone understood
and was acknowledging what we felt. Some of it was dread – how could we survive feeling this
way?
At social events with friends and people from work, I couldn’t relate to the ordinary things that
were supposed to be amusing and meaningful any more. My experience put me in another
category – I felt like I was never going to be the same again.
The next crunch time came for me when I was sitting on the tube [the London Underground] 8
months after the disaster. I was reading a newspaper article that was describing what might have
happened to the bodies of those who had been killed – what they could have felt, how they
would have been conscious before they died. As I looked around at the other people on the train
I felt desperately trapped and wanted to scream at them.
I went to see a therapist at the trauma clinic I had found out about at the support group. I had
to fill in a lengthy questionnaire about how I was feeling, without any explanation as to why I
was doing it. I felt like screaming all over again – couldn’t someone just help me? In the session
with the therapist I didn’t feel capable of saying what I wanted because I had no rapport with
him. The gap between my experience and him seemed to me unbridgeable. I felt as if I was of
more use to him than he was to me and so I didn’t go back.
I felt more and more incapable of relating to people who didn’t share my experience. The
constant effort of behaving ‘normally’ put a huge strain on my life – I was always on edge, badtempered and intolerant, highly apprehensive about something happening to my children or my
husband. Getting a decent night’s sleep seemed impossible. Words beginning with ‘d’ always
became ‘death’ and ‘destruction’. The rest of the world seemed to want me to ‘put it behind
me’, to ‘get over it’. I veered between avoiding things that reminded me of what had happened
and thinking obsessively about it.
The fifth anniversary brought another crisis. How could I carry on a normal life feeling as I did?
I decided to seek help again – six sessions with a local counsellor who listened to what I had to
say and tried to help me find ways of calming down. I saw this as a good way to spend the
waiting time while I got an appointment at the trauma clinic to see another therapist. The
sessions I had with him were definitely of benefit and much more productive than my first
attempt. We had a rapport and he was completely non-judgemental of me in a way that I
found really helpful.
I can see now that it was terribly frustrating not to have it sufficiently acknowledged by the first
doctors and therapists I saw that there was something badly wrong. It seemed to be a real
struggle – I felt like I had to jump through a number of hoops to ‘prove’ that something was
wrong with me. At the same time, I resented the idea that the rest of the world was somehow
‘normal’ and I was not! How much did my brother’s death contribute to how I felt? How much
was it to do with the fact that so many others had been killed at the same time? How much was
it to do with the way people had responded to me afterwards? I still can’t be sure, but I do know
that most of what happened in the aftermath made it worse. Those to whom I will always be
grateful, however, are the people who offered not sympathy but practical help. What would also
have been of benefit to me was straightforward, objective, non-judgemental medical information
and advice.
24 Experiences of PTSD sufferers and carers
Sixteen years on, life remains stressful but mostly manageable. I have joy in my family and find
the work that I do to help others in similar circumstances very rewarding. I was right in thinking
that I would never be the same again. I still have extremely strong feelings about what happened
and sometimes wonder if I should – with the information I have now about trauma and PTSD –
try some form of therapy again. I am sure it is never too late to try.
3.1.4 Testimony four
Other than two paramedics I was the first medic (I am a nurse) on the scene of a mass disaster. I
had good reason to believe that members of my immediate family were involved. I was involved
in resuscitation, had a person die in my arms and witnessed trauma and death, while looking for
my loved ones among the carnage. I prepared equipment, stretchered casualties, and moved and
helped to identify dead bodies. I later found out that my loved ones were not directly involved.
My feelings about what I had witnessed and experienced changed over time – through disbelief,
numbness and a sinking feeling, reactions common after something so traumatic. The impact
increased as time moved on – the reality, enormity and the closeness of losing loved ones are
almost indescribable. I have gone through many phases of this condition and my PTSD has been
determined by psychiatrists as being moderate to severe, and chronic (it is 8 years since it
happened). PTSD has affected every aspect of my life and my family.
In the immediate aftermath of the disaster I could not find any help. There were no counsellors at
the scene or available afterwards, and my local health centre kept usual hours. I went there the
next day at 6.30 a.m. in a drunken state to seek assistance, but there was no one to talk to. I
later returned to the health centre, demanding to see a doctor. A young locum advised me to ‘see
it through’ and did not offer help, counselling or sedation.
The next day a local GP came to see me, but she spent more time telling me about her own
experiences of the disaster. This was frustrating because I desperately wanted to let off steam. In
the end I spoke to the police on the third day to ‘let it out’. I also rang my employers, who at first
were empathetic; they suggested occupational health, but I didn’t see the point, as all they
would do would be to refer me to a psychiatrist, nurse or a therapist. When they rang back the
next day I was told that two professionals were vying for my case, although I had to wait to see
them.
The next day I rang and said that if I didn’t get help I was either going to go ballistic or knock
someone’s door down. The following day I met a therapist who was nice, empathetic, but
ineffectual. She told me that she had not dealt with PTSD before but would like to try
desensitising treatment that she had ‘read about’. Her attempts to try and get me to relive the
event while waving hands and lights in my face caused nothing but anguish.
I saw this therapist for months, but after making no progress I saw the other therapist who had
previously been interested. When her interventions also failed, she wrote in my notes ‘Mr — is
not responding, or is unwilling to respond to treatment’! I also felt that the GPs were also clearly
out of their depth. They were not willing in many cases to refer on to others as they believed that
no treatment should be offered for PTSD for at least 3 months as most people would get better
with no intervention. However, I felt that I desperately needed help in the days following the
disaster.
I feel I irritated all the professionals that I contacted because I openly admitted the problem, cried
for help, admitted that I was sleepless and drinking too much. But I had no help of any kind from
them. Months later I saw a psychiatrist, who told me that he had read things on the internet! The
only useful thing he did was to prescribe Prozac [fluoxetine] (although I found this hard to
understand as I was suffering from PTSD not depression). The dose was ineffectual at first but he
doubled the dose, which flattened my emotions and helped me to sleep. At the time that was
useful, although perhaps inappropriate. Nothing else happened with this man.
At first my employers pledged their support, but were soon eager to have me back at work.
Fourteen months after the event I was sacked on the grounds of ill health (I had hardly attended
work during this time). Years later I sought another referral – I had to wait 10 months to be seen.
Again this person was nice, but repeated visits proved fruitless. This therapist referred me to
another psychiatrist. This man was the most sensible of all; he said ‘given [my] history of
unsuccessful interventions, there was little else that could be done, save chemical intervention’.
Sufferers’ testimonies
25
Now, this wasn’t good news, but he was realistic, with no rubbish, so I appreciated this. I was
prescribed Cipramil [citalopram] in varying doses, until I settled on 20 mg twice daily. The
troublesome side-effects are lowering of libido and increasingly vivid nightmares, but on balance
my quality of life is at its best since the event. I feel this is down to the medication, the passage
of time and being able to work again part time.
I also meet with a few other people who were closely involved in the disaster. This ‘self-help’
group is perhaps the best ‘intervention’ I have had because it is with people who have had the
same experience, really understand and do not patronise me.
3.1.5 Testimony five
In 2000 I was arrested for being part of a group fighting for democracy in my home country. I
was held in prison for 2 months, during which time the police raped me. They beat me around
the head so badly that my eardrum was perforated. I was released, but later they arrested my
husband and took him away in the middle of the night. I don’t know if he is alive or not. Officials
kept coming to my house to interrogate me. They threatened to imprison me again, so in 2002 I
fled the country, leaving my daughter with my mother.
On arrival in the UK I was interviewed by immigration officials. My English is not good, so an
interpreter, who was a man from my community, was present. But I couldn’t tell them what had
happened because we can’t talk about rape in my community – it is so shameful. I couldn’t even
tell my solicitor what had happened – he was also a man and I felt uncomfortable speaking to
him. I was refused asylum.
I couldn’t understand why I was being treated so badly and found that I was always crying. At
my appeal hearing I still couldn’t speak about the rape, but I told them I had been in prison and
tortured. They didn’t ask me any questions about where I had come from or what I had been
through. I was really upset during the hearing and I cried. My appeal was refused some months
later. My solicitor didn’t do anything more to help me.
I had a friend who came with me to the appeal hearing. She saw that I was crying all the time
and suggested I should go to Women Against Rape (WAR) and tell them what happened. So I did
and it was the first time I had been able to talk about it and it helped me a lot. The Home Office
wanted to send me out of London but I was referred to the Medical Foundation who took me on
for counselling, so I was allowed to stay in London. And WAR found me a new solicitor who
made a fresh appeal on my behalf. But after about 6 months the Home Office closed my file, and
I had to leave the flat where I was living and lost my money.
My solicitor arranged some emergency accommodation through social services, but I was only
allowed to stay for 2 weeks. I had a specialist report about my ear and a psychological report,
which diagnosed that I was suffering from post-traumatic stress disorder. But although some
people in social services wanted to house me, others decided my medical evidence was not
enough. After the two weeks, I was homeless again. It was awful – it was just before Christmas
and the weather was freezing.
When I was homeless I had many problems. I was sleeping in a park and my bag was stolen by
two boys. I went to the police for help, but they arrested me! I went to many charities that are
meant to help asylum seekers but no one would help me. The Refugee Arrivals Project let me stay
a few nights but then told me to leave, saying I could sleep at the airport. When I asked the
Medical Foundation for help they said I was not an emergency. What is the point of trying to
make someone feel better with counselling if you know they have nowhere to sleep that night? I
slept at the airport, on the street, in a church corridor. I just wanted to die. Fortunately after a
while some nuns took me in to their hostel.
Because of the torture I suffered I have physical and mental health problems.
I suffer from repeated ear infections and terrible headaches. When my ear is infected it is so
painful I can’t see (I am awaiting a third operation). I am also nervous, angry and want to be
alone. I can’t watch TV or speak to anyone. I tried to get help from a GP because I was crying all
the time and I couldn’t sleep. I keep seeing what happened back home, reliving the rape over and
over. I have bad memories and I can’t get these things from my mind. And I really miss my
husband and my daughter. But the GP was not good or sympathetic. I told him that I am upset,
and that I have other problems like constipation. He just told me that I have depression, and gave
26 Experiences of PTSD sufferers and carers
me sleeping pills and told me to eat vegetables. I then saw another GP, who was more
understanding. He changed my pills. He recognised that I have flashbacks and that I need help. I
still see a psychologist every 2 weeks and she makes practical suggestions about my health. She
told me to come off the tablets gradually.
WAR contacted my MP and then eventually I won the right to stay in the UK. They helped me get
housing and income support. I see them often and it helps me a lot to meet with other women
who have suffered like me, and to work out how to improve our situation.
Winning my immigration case was the most important thing. Everything else depended on that.
It made me feel so much better, especially now that I am hoping my daughter will be able to join
me here. Now I am like a human being – before I didn’t feel human.
3.1.6 Testimony six
In 1989 I was raped by a man I met in a disco while backpacking in Australia. I was 19 and alone.
I didn’t handle it very well, not least because I had contracted an STD through the attack. I didn’t
report the attack because for the first 2 weeks afterwards I felt it was my fault; I also felt I could
not face having to go through a trial. On returning to the UK I told no one except my best friend;
but because it upset her so much, I decided there was no point in telling anyone else. Also at the
same time there was a family crisis brewing and the last thing I wanted to do was add fuel to the
fire. I did a year at college, where I began to drink heavily, got a boyfriend, with whom I had sex
five times in 3 years, and got a job in the Midlands. After about a year of starting the job, I began
behaving very strangely (e.g. sitting on the edge of my bed and rocking backwards and forwards)
and my boyfriend sent me to the doctors, who sent me to Relate, which was the only service in
the area that even vaguely came near to addressing problems such as mine. While well meaning,
the person I saw at Relate was not qualified in any way to deal with my problems, though at
least it gave me an outlet to talk.
Soon I got a new job, left the area and split up with my boyfriend. Six months later I went back
to Australia to live in Sydney for a year. I felt fine about being back in Australia but on my return I
continued to drink heavily and while out in clubs would, to my shame, tell people what had
happened to me in 1989. I sought a counsellor, one of whom offered ‘to re-enact the attack’, but
I declined and, despite her protestations, stopped seeing her.
In 2000 I started a new relationship with a man who was a big socialiser. My drinking and drug
taking escalated and while I was doing very well in work, the pressure was growing and cracks
were appearing. My partner told me I had to seek help, so I went to see a few more counsellors
privately but none seemed able to help me. I stopped seeing them as they seemed to increase
my despair at ever being able to find the right sort of help. While I was aware that my
behaviour was destructive, I seemed unable to get out of the circle of depression and selfmedication.
In May 2002, I was attacked at the top of my street. A man ran up behind me and brought me
down to the floor. He threatened to rape me but eventually walked away leaving me physically
unharmed. I reported the attack and the police were very good but they never caught the man. I
had a leaflet from Victim Support but had no actual support to speak of. I took a week off sick
and then returned to work, but a few weeks later my partner and my manager advised me to
take more time off. During this two-month period, I visited my sister, where I broke down and
became hysterical. My sister – a community psychiatric nurse – was very concerned and insisted
that I visit my GP. My GP referred me to the local Traumatic Stress Clinic, where I saw a therapist
who told me I was clinically depressed and had post-traumatic stress disorder and that it was
likely that the latter was chronic, dating back to the first attack in Australia. He recommended
antidepressants and for the first time in years, I felt I had hope.
While on a waiting list for psychological treatment I had my first alcohol-related blackout, during
which I started a physical fight with my partner’s family. I then stopped drinking for a month
because I was afraid of what I might do. I was offered a choice of two treatments and chose
exposure therapy, which started in January 2003. It was very hard work but my therapist was
excellent – I could tell her everything about my habits, feelings and failures without feeling
judged. The treatment sessions were an hour long and once we had gone through my thoughts
and feelings about pretty much everything, we wrote out a narrative of the attack and then finetuned it. We also recorded it and I would read it through a number of times and we would note
Sufferers’ testimonies
27
down the most stressful points and rate then in terms of anxiety. For ‘homework’ this would be
repeated and there would be various other bits of relevant reading. I had one more alcoholrelated blackout during this time.
The treatment ended successfully in June, but my relationship finished a month later (it had been
breaking down since my first blackout). I moved out and stayed with a friend, while focusing on
work as a way of avoiding the miserable reality of my life. When work stopped for a period, my
drinking and blackouts increased. I felt anxious a lot of the time, and in November I took too
many antidepressants (five as opposed to two) and talked openly about suicide. My housemate
and mother took me to my GP and the following day I saw my psychiatrist at the Traumatic Stress
Clinic. He increased my antidepressant dose and suggested I start a course of cognitive–
behavioural therapy with my original therapist.
In January 2004 I started the treatment and it was a revelation to me. The literature I received
plus the homework proved to be extremely illuminating; discovering what my ‘trigger points’ are,
what core beliefs I hold, and where they come from, has been very helpful. I now understand
why I behave the way I do. I believe it was a very important part of my recovery, as I have been
given the tools to help myself and put them to use as soon as I could. I have learnt to recognise
certain feelings, which I’ve discovered are triggers, and stop any negative behaviour. Throughout
the treatment, I kept records of my thoughts and how much alcohol I had had, both of which
were very useful as I could see my thoughts and actions written down in black and white, which
made it easier to understand the thread that held them all together. I am now better than I have
been for years, more confident, calmer, my anxiety has stopped and I can at last see a realistic
future ahead of me – one I am looking forward to.
In the last year, I bought a house, stopped smoking, joined Weight Watchers and started to
exercise regularly. Things are also going very well for me professionally. I feel incredibly lucky to
have received effective treatment that helped me to break out of a miserable, vicious circle of
depression, excessive drinking and anxiety that would only have got worse. I am in no doubt that
the help of the staff and the treatment I received saved my life, or at least gave me back a life I
think is worth living.
3.1.7 Testimony seven
I never told anyone what had happened to me until I was in my mid-40s. Until that point my
partner and friends had no inkling of the secret that I had carried with me all my life. I had a
successful career, a happy marriage and was, on the surface, outgoing and assertive. But on the
inside I felt very differently. I was waiting, constantly on alert for my secret to be found out. I
found it difficult to trust people and had sleep problems and other physical ailments now readily
identified as being stress induced. My body, for decades, had lived on a knife-edge, on high alert.
I am one of five children, and was sexually abused by my father from the age of 10 until I was
15½ when I managed to leave home. In September 1994 I was devastated to discover that I was
not the only family member to have been sexually abused. Even though our abuser was dead by
that time, the impact on me was massive.
The enormity of what had happened to me overwhelmed me. I was swallowed up by a
continuous stream of flashbacks replaying the ugliness of my childhood: the theft of innocence
through escalating abuses with rapes on a daily basis towards the end; the physicality of the
onslaught on my small, defenceless, body; the inevitability of pregnancy and, following a suicide
attempt, the nightmare of the miscarriage (trying to ram the small foetus down the bath
plughole before finally flushing it down the toilet).
I had panic attacks that felt like heart attacks, but I was unable to speak about the evilness that was
my childhood. Saying it would make it real, and I had struggled all my life to not think about it.
I had always known that I had been sexually abused. That knowledge had never left me. But
the enormity of that knowledge and the constant pressure of having to maintain my silence
had created a legacy within my body. Headaches, irritable bowel, back pain, gynaecological
problems, an irrational fear of thunderstorms, startle reaction, and sleeplessness were all clear
indicators that something was wrong. But not one doctor ever asked me if I had ever been
subjected to sexual abuse as a child. My body was crying out, saying that something was
wrong. But because no one asked me the question, I knew, as the child had known, that it was
not OK to talk about it.
28 Experiences of PTSD sufferers and carers
Suicidal thoughts intruded once again and it felt like the only recourse I had – to escape the
constant barrage of flashbacks. My life was a mess. I was off work sick. My husband could only
look on, helplessly, as I shrivelled up before him, into the posture of a small child. I remember his
hands hanging by his sides, unable to reach out to me because I recoiled at the mere thought of
a man’s hand touching my body. My father, though dead, was there. I could see him, smell him,
taste him. I gagged on the memory it was so real. It was real. I was in a parallel universe, twinned
with the past and present.
Eventually I gained the courage I needed to disclose my secret to my GP, which was a painful and
shocking experience. She sat motionless, and months later told me that she had felt helpless,
aware that her knowledge about such abuse and the long-term impact was inadequate.
Notwithstanding her lack of experience, we made our way together down a pathway that could,
so easily, have been the wrong one for me.
Given the state I was in, my GP could have had me admitted to hospital – and it is likely that I
would have gone down that downward spiral of madness and the likelihood of misdiagnosis.
But, she had enough about her to realise that I might be suffering something more readily
identifiable as PTSD – and in doing so, she started me on the pathway that saved my life.
In 1994–95 I was able to gain immediate access to trauma counselling through my employer.
During 16 sessions I worked in partnership with the counsellor to explore the memories that had
so carefully been hidden (not all of them, though, for I am amnesic about large periods of my life
prior to the age of 10). My counsellor worked gently with me and together we slowly unpeeled
the onionskin of memories. She tried several approaches with me before she found the one that
worked best for me. The approach was eclectic and focused on the trauma but in a way that was
humane and minimised triggering further trauma. My counsellor used different techniques as the
need arose and was able to hear what I needed rather than imposing theoretical models that
would have been unworkable for me. It was a partnership, and was important because it meant
that an early foundation of trust was laid. Gradually I came to understand the link between my
fear of thunderstorms with my childhood experiences. I understood why I had avoided certain
environments and why intimacy of any kind (including friendship) was so difficult.
My sexual relationship with my partner had taken a massive downward spiral – any touch evoked
painful and intrusive memories. Initially I submitted to his sexual desires, because I felt guilty
about saying ‘no’. But in saying ‘yes’, it only made it worse. The flashbacks intensified and I felt
that life was no longer worth living. It had been impossible to believe that I could ever escape
from the world that my life had become.
I was able to find the will to live and my counsellor was instrumental in that, because she gave
me the time to reflect on my experience and the feelings associated with it. But for me, sanity
came through meeting others who had endured a similar childhood (I met these survivors
through the group CISters). It gave me an insight that my counsellor had never achieved into the
full impact on my life that the abuse had made. I was a workaholic, obese, with no real friends –
and the only good thing I had going for me was that I had a determination in my heart that my
abuser was NOT going to win.
Slowly I gained ground and as each new insight came I was able to see my symptoms diminish.
The panic attacks tapered off, the intensity of the flashbacks dwindled, and my irritable bowel
began to loosen some its hold on me. I was able to breathe again.
PTSD still walks beside me – the chronic impact of the abuse is not easily shaken off. At times of
stress some of the symptoms return (such as startle reaction and insomnia) – but it is extremely
rare for me to have flashbacks, which have only occurred twice in 7 years. I saw my counsellor
again in 2001 for six sessions after a car accident and in 2003 for another six sessions after I was
diagnosed with fibromyalgia. It was helpful to see the same person because she knew my history
and was able to connect the feelings of helplessness I felt on both of these occasions to my
feelings about my childhood. But life is easier and simpler, and my returning good health
brought with it a return to work and the opportunity for a new way of living: finally being able
to relax after years of living on the edge of my nerves and looking over my shoulder.
Anger was not an emotion I allowed myself as a child or as an adult. But anger is what I feel at
times, and it is a powerful motivator and lifesaver. At times I wonder how my life would have
been if someone had asked me decades ago whether I had ever been abused in my life. That
question would have given me an opportunity to disclose my secret, and perhaps I would have
gained a new quality of life, years earlier, rather than having to wait until I was nearly 50.
Sufferers’ testimonies
29
3.1.8 Testimony eight
It was November 2003 and I was on duty as a firefighter in South Wales, when I received
notification that my wife and son had been involved in a car accident. I drove immediately to the
scene of the accident not knowing how badly injured they were or even if they had been killed.
When I arrived I saw several emergency vehicles on the scene and what looked like a bad accident
from the amount of 999 personnel rushing around.
I remember seeing a paramedic carrying out resuscitation on a casualty, which I immediately
thought was my wife. I felt tremendous anxiety and rushed over to see. However, it was not my
wife but one of the young men in the other car. My wife did not require resuscitation, but had
suffered multiple fractures and injuries and was trapped in her car. When she saw me she became
very upset and begged me not to leave her while they cut her out. She looked in a bad way – I
feared she might not be able to walk.
My son was also badly injured with a large head wound. I went to comfort him for a few minutes
while the fire service cut my wife out. I helped put my son into an ambulance. In addition to the
nasty laceration to his head my son was emotionally distraught, which caused tension between
the ambulance staff and myself, as I believed he should go with his mother to the same hospital.
I soon learnt that three of the four boys in the other car involved in the accident were killed
instantly. I was sad for their parents but more concerned that my family would be OK and survive.
After their injuries were dealt with in the A&E units there was then the start of various out-patient
appointments to attend. We have four children and the practical demands of coping with every
day and family life, and the logistics of ensuring my wife’s and son’s attendance at the various
hospital appointments, was therefore very demanding. After the crash I had mixed feelings; I
would feel angry at the way the crash happened and that there was nothing I could do to stop it
or help. I was physically exhausted, but was finding it hard to sleep. As soon as the bedroom light
went out at night a light would come on in my head and all I could do was lie there and think.
When I would eventually fall asleep, I would wake up with nightmares of the crash. I could not get
away from it. It was all I could think about in the day and all I would dream about at night.
I had to try and be strong for the kids, but when I would get a moment to myself, I would just
break down and cry. I didn’t like feeling like this so I would just keep busy. Keeping on the move
was stopping me getting upset, but was making me more run down. I wanted things back to
normal; seeing my wife and son in pain every day was driving me mad – I just wanted to explode.
I found myself getting even more angry and short-tempered. I was looking for confrontation, I
wanted to take it out on someone, but I knew I couldn’t as it would look as if I could not cope,
so I kept it bottled up inside.
I was finding this a great strain and visited the brigade’s medical adviser where we agreed that I
should be referred to the local NHS traumatic stress service, with which South Wales Fire and
Rescue have a partnership. I went to meet a cognitive–behavioural therapist with a special interest
in post-traumatic stress disorder. After a few meetings with this therapist he diagnosed me as
suffering from PTSD and depression. I was prescribed various antidepressants on his recommendation by my GP. My therapist then started my CBT treatment, which included breathing retraining
to help control my anxiety symptoms when I had an intrusive image of the accident, and grounding
techniques to help me with flashbacks of trauma and feelings of anger and frustration.
We then made an audiotape of what had happened that night in great detail, including what I
saw, heard, smelt, touched, tasted and so on while at the scene of the accident, including all my
thoughts and feelings, as though I were reliving it again. I took this tape home and listened to it
for an hour a day, marking on a chart my anxiety feelings at the start, during and after approximately an hour. I also incorporated the breathing and grounding techniques to help me cope with
the reliving with the tape. After a few weeks of this treatment the tape started to get boring,
apart from a few incidents that my therapist referred to as ‘hot spots’. We made a new tape with
just these hot spots and added new information after them to emphasise what actually happened.
For example to ‘I thought my wife was dead’ we added ‘she is not dead but is still recovering
from her injuries’. Once again, after a few weeks of listening to it every day it got boring as well
and I was then able to think of events of that night and not get upset, angry or frustrated.
Before I met with my therapist for CBT I didn’t think I needed help or that I was depressed, but
after just a few meetings with him I could see that I did. I found my therapist very easy to talk to,
understanding, a good listener and very helpful. The treatment he provided definitely helped me
30 Experiences of PTSD sufferers and carers
get over this traumatic time in my life. I am now back at work attending road traffic accidents as
normal with no fear or reliving of my wife’s accident. She is now seeing my therapist for CBT as
she is suffering with PTSD. We are both hopeful that she can also recover with this therapy and
that time heals her physical injuries.
3.1.9 Testimony nine
Working for the London Ambulance Service as an A&E paramedic, I expected a certain amount of
trauma, but my experience with handling stress had been good and I believed nothing could
affect me. For 4 years on the front line I was faced with many traumatic jobs, which I handled
well. Although there was a counsellor on site, I usually talked to my fellow crewmates if something
was troubling me. So I was not really expecting that I would ever feel traumatised by my job.
It all started in July 2001 without my really being aware of it, through a build-up of stressful
situations. I was called to a job where we were verbally abused and physically threatened. I went
home feeling upset but that it was nothing I couldn’t handle – it was just an ordinary day. One
week later a very similar situation occurred, but this time I felt slightly more anxious than the
week before, vulnerable and what I can only describe as ‘stressed out’. One week after that, while
on the nightshift with a crewmate we were threatened again and this time I feared for my life. As
we were running away from the man who had threatened us, I felt that I was running for my life:
I seemed to float down the stairs from his flat, and the heavy medical response box that I was
carrying felt weightless. When we were finally in a safe place we realised that the man did not
actually leave the floor of his flat – we were both shaken up by this and went home. I went
straight to bed when I got in, but was awoken suddenly by a major flashback from the night
before. I was convinced that the man who I thought was going to kill me was in my bedroom – I
could not breathe, my chest felt so tight, and my heart was racing. I was having a panic attack.
The next morning I called work. I was hysterical, but the station officer was very understanding;
he told me to go my GP, take some time off from work, and offered me the opportunity to see
the counsellor at work. I said I would probably like to see the counsellor but that I could not face
it at that moment. I went to my GP, who was sympathetic and prescribed diazepam. I don’t think
this really made me feel much better, but it helped me to relax and made sleeping much easier. I
did not stay on the tablets for very long.
In the following few weeks I felt hypervigilant (that is, highly aware of my surroundings and any
slightest noise). It seemed like someone had turned up the volume in my head. I could not face
going out of the house at first, and the thought of going to London, where I worked, seemed
almost impossible. I was very tearful, anxious and could not sleep very well. I was scared most of
the time and paranoid. I felt like a little person in a very big world. I had no confidence and my
self-esteem was very low. What was hard for me to comprehend at the time was why was I
feeling like this because my crewmate, who had also feared for her life, was not affected by this.
I wondered how she was able to go back to work when my whole life was turned upside down.
Other colleagues asked me why I was off work with stress when my crewmate was all right. This
made me feel really low and totally worthless.
After about 4 weeks I contacted work to make an appointment with the counsellor because I
knew that I needed help. Work arranged for someone to come and collect me and take me to
London to see the counsellor as I could not manage this on my own. Over a period of 2 months I
started to see the counsellor regularly. It was a task just getting into London for the meetings,
but I could tell her how I was feeling and I knew she would not judge me or make me feel bad in
any way – she was a tower of strength. She told me that I had symptoms consistent with PTSD
(my GP, who was not so experienced in PTSD, agreed with this). I was aware of what other people
thought of me, but after time I didn’t really care about this. I knew that I had PTSD, that I had
had a common reaction to very stressful events, and that I was not going mad.
My counsellor explained everything to me about PTSD and we worked together to set tasks: my
goal was to go back to the place where I had feared for my life. But I was also given other tasks
to perform, such as taking a walk, going shopping or visiting a friend, which don’t even feel like
tasks now, but at the time just thinking about going out would make my heart race and my chest
tighten. Some of the tasks at the time made me feel really bad, bringing on feelings of fear and
failure. I knew I had to be strong and not to give up – some days I was proud of myself for going
shopping when the shops were full of people! In the end, though, the treatment I received from
my counsellor was a great success.
Sufferers’ testimonies
31
Although at first I had wanted to resign from work because I felt that I would never be able to
continue with the job that I loved so much, after about 6 months I started to cope with many
tasks that I had been set, such as driving to London alone. I returned to work gradually and
returned to full duties in February 2002. I was lucky to have a good station officer who realised
that my returning to work slowly would be less stressful and manageable. Had it not been for
him and my counsellor I feel that I would never have been able to get on with my life.
At first the fact that I had PTSD affected my whole family, especially my boyfriend, who I live
with. I found it very difficult to socialise and we did not have a holiday for over a year. I was very
dependent on my boyfriend to take me out, but he was very supportive and patient. I have got
some really good friends who were also very understanding and supportive.
I am a very confident and outgoing person and feel that I am stronger now than I have been in
my whole life. It is really strange how a bad situation, which almost destroyed you, can make you
grow in character. I am on maternity leave at the moment after having a beautiful baby girl – I
am still a paramedic and hopefully will be back on the road next year.
3.2 Understanding PTSD from the sufferer’s perspective
The testimonies illustrate some of the traumatic events that can lead to the development of PTSD:
being a survivor of a major disaster; combat (multiple trauma); sudden loss of a relative or friend;
losing or fearing that one has lost relatives or friends in a major disaster; rape and childhood
sexual abuse; and exposure to trauma in people who work for the emergency services. However,
it should be emphasised that these testimonies do not represent all of the traumatic events that
may culminate in PTSD.
3.2.1 Recognising and diagnosing PTSD
People with PTSD usually recognise all too painfully that there is something drastically wrong, but
may not be able to put a name to their feelings and symptoms. Without a diagnosis, sufferers can
feel as if they are losing their grip on the world around them, and even on a sense of who they are.
Sufferers can languish for years without a diagnosis. Disclosure may be a problem, particularly in
cases of rape or sexual abuse both in the indigenous and refugee population, which can lead to
significant delays in diagnosis. What is clear from many of the testimonies is that if the condition
is unrecognised, left untreated or is poorly managed, then the symptoms can be prolonged or
can worsen significantly over time. Sufferers may withdraw into themselves and be unable to
communicate with their families.
The effect of a traumatic event on children not recognised or treated for PTSD can last a lifetime.
The sufferer in the first testimony, who received no systematic treatment for PTSD, speaks of the
‘psychological injuries’ lasting for over 30 years. The sufferer in the seventh testimony who had
been abused as a child felt that she could not speak about what happened to her because she
was never encouraged to do so by healthcare professionals despite presenting with many
physical complaints. She remained silent until she was middle-aged.
Once a diagnosis is made, the relief for some sufferers can be immense: professional recognition
of a named and identifiable condition can make sufferers feel that someone understands and
acknowledges how they might be feeling; as the sufferer in the second testimony puts it, he now
knew that his problems ‘were normal responses to abnormal occurrences’. However, the relief or
emotional release can precipitate extreme distress. As the person in the third testimony puts it, it
can make the sufferer refocus on what might be the reality of the situation: ‘how could we
survive feeling this way?’
3.2.2 Effect of PTSD on personal relationships and working life
For some people, PTSD can alter every aspect of their lives. The emotions generated by PTSD and
the physical symptoms associated with it can have a profound effect on the sufferer’s
relationship with family and friends. Some sufferers might withdraw from people close to them,
and coping strategies, such as drinking alcohol, can further distance sufferers from their social
32 Experiences of PTSD sufferers and carers
and familial circles, as can the symptoms themselves (mood swings, irritability, etc.). It is not
uncommon for people with PTSD to feel that they can no longer relate to the world around them
or to other people who have not experienced trauma. Ordinary events seem meaningless. The
inability to share the traumatic experience with many people can, as the sufferer in the third
testimony phrases it, put one ‘into another category’. Other people’s reactions to the events may
seem invalid or untrustworthy. The sense of difference that PTSD might produce in the sufferer
can further isolate these individuals. Protracted isolation can lead to a loss of self-confidence and
self-esteem, culminating in periods of severe depression. Isolation was certainly experienced by
the narrators of testimonies five and six, who felt that they could not talk to close family or other
members of their community about being raped.
Some sufferers who have lost relatives in a disaster or other traumatic event can have
overwhelming feelings of apprehension about losing other members of their family. This might
result in overprotectiveness.
Post-traumatic stress disorder can also have a detrimental effect on employment. For some
people the symptoms are so severe that they are unable to function properly in the workplace,
although it can also be the case that some PTSD sufferers can perform very highly. Some sufferers
attest to a lack of understanding from employers, even if the event or events have been job or
service-related: for instance in combat or in the medical profession or emergency services.
For children, the memories of the event can have a significant impact on schooling and emotional
development. Concentration might be poor, and educational performance affected as a result,
although as in adults, it may also be that children can ‘lose themselves’ in schoolwork.
3.2.3 Sufferers’ experience of services and treatment
The experiences described in this chapter cover a period of over 30 years. In the 1960s and 1970s
there was often very limited knowledge on the part of many mental healthcare professionals of
the nature and treatment of trauma-related psychological problems. However, as described in
Chapter 2 and borne out by a number of the testimonies, there have been considerable
improvements in the understanding of PTSD and in the provision of services in the UK.
Nevertheless, the availability of effective services still varies considerably. It is a central aim of this
guideline to address these variations in practice.
In the immediate aftermath of a traumatic event, people may want to talk to someone in a
professional capacity (as did the authors of the second and fourth testimonies), which may mean
nothing more than being listened to, shown understanding, and given some practical
information about health issues and contact details for services and voluntary organisations.
In the first few months following a traumatic event, finding someone to work with who has
appropriate training in the treatment of PTSD, with whom the sufferer can build up a relationship
of trust and understanding, is crucial. It is important that these individuals are listened to and
their symptoms taken seriously. Furthermore, the sufferer can be badly affected if doctors or
therapists attempt treatments for which they have no competency or administer treatments that
have no evidence for effectiveness. Such a situation could lead to a complete breakdown in the
therapeutic relationship, especially if a lack of knowledge is coupled with an absence of trust.
It can also be detrimental if sufferers feel that they have to prove that ‘there was something
badly wrong’, as was the case with the narrator of the third testimony. This struggle to prove the
gravity of the condition may exacerbate the symptoms over time. It is also important that
sufferers maintain sustained contact with one professional if this is required, otherwise they
could feel that they are being passed from one professional to another.
If treatment is not working, this is not necessarily because the sufferer is a ‘poor responder’ or is
‘resistant’ to treatment, just that the right treatment, or the right combination of treatments, has
not yet been found.
What is implicit in testimonies two and three is that the sufferers in general felt psychological
therapy would have been the right form of treatment, had it been delivered by an appropriately
trained professional. For the sufferer in the fourth testimony medication was prescribed to help
manage sleep problems and to act as a sedative, but for the sufferer in the second testimony
medication had a deleterious effect. The latter individual expressed some surprise that
counselling or psychological therapy was not offered at the same time.
Understanding PTSD from the sufferer’s perspective
33
In contrast, in testimonies six, seven and eight, where the sufferers had received treatment more
recently, there is a marked difference in the experience of services and provision of treatment
(this includes the person with chronic PTSD). The sufferers in these testimonies praised a trusting
and sympathetic relationship with healthcare professionals, well-delivered, effective psychological
treatment and continuity of care.
3.2.4 Sufferers’ perspective on coping and recovery
Although PTSD sufferers can recover naturally in the first few weeks or months – and even years –
after a traumatic event without treatment, all of the sufferers above expressed a need for some
form of support and treatment, and made the connection between lack of support and
treatment and a worsening of their symptoms.
Some of the sufferers found a way through the disorder by founding support groups with other
people affected by the traumatic event. The person in the fourth testimony accredits this with
being the ‘best intervention of all’. The person in the second testimony reduced and stopped his
medication himself and started up a successful website dedicated to ex-service men and women
suffering from PTSD. The person in the third testimony found her work helping others who had
lost relatives in disasters enriching. The person in the first testimony speaks publicly about what
happened to him, and finds that talking is the best means of coming to terms with the disorder.
These strategies can be an important means of providing people with the self-confidence to
return to work if they have lost their job as a result of PTSD.
These means of coping are also important milestones on the road to recovery. Testimonies six,
seven and eight are stories of recovery, although some people will never completely come to
terms with the trauma. They will learn to cope with it on a day-to-day basis, knowing that its
effects will be with them for the rest of their life; others may find that with the passage of time
and the right treatment they may be able to find some kind of equilibrium and quality of life
returning; yet others may find that taking control of their own treatment and finding support
from friends and family members will allow them to put some structure and meaning back into
their life even if they still experience PTSD symptoms daily; others might be coping with the
disorder but consider trying a different form of therapy.
As has already been suggested, PTSD can change a person irreversibly; and as the narrator of the
second testimony understood it, recovery is a process, part of that process being learning to live
with this change, moving to acceptance if that is possible.
3.3 Summary of PTSD sufferer concerns
The following concerns emerged from the personal testimonies above and the subsequent
commentary. They emphasise the need for a listening and caring approach, backed by practical
information and social support at the scene if needed. They also highlight the need for greater
awareness and understanding on the part of healthcare professionals in both primary and secondary care. This requires improved training in the diagnosis and treatment of PTSD, the provision to
sufferers and their families and carers of good written and verbal information about the nature,
course and treatment of PTSD, and improved continuity between services when treating PTSD.
3.4 Carers’ testimonies
3.4.1 Testimony one
I first met my husband in October 1998; at this time he was a serving police officer and had been
in his job for about 14 years. The first thing I noticed about him was that he would drink to
excess on a regular basis (I was very relieved when he stopped drinking suddenly about 3 months
after we met). I remember him telling me about his experiences in the police and about some of
the things he had seen and dealt with. I was horrified at what he told me. I had no idea what
post-traumatic stress disorder was or that he was suffering from it until he told me in 1999 (it
had been diagnosed by his GP in 1994).
34 Experiences of PTSD sufferers and carers
When we moved in together I began to notice more about his condition. He became more
withdrawn and tense, which resulted in outbursts of temper or uncontrollable sobbing,
particularly after work. He became more and more stressed out and could not relax. This became
apparent particularly at night, when he would be very restless and often wake himself up either
screaming or shouting. He still does this today and suffers nightmares about the things he dealt
with in the police.
The flashbacks he experiences are also very distressing for both of us. My husband just goes
completely blank and it’s as if he is not there, he’s in a different place. He goes very pale and his
breathing becomes erratic and he gets a pain in his chest and begins sweating. He feels
embarrassed when this happens and usually disappears somewhere until it has passed. This
makes him angry and frustrated and if I try to comfort or support him he more or less pushes me
away, preferring to cope with it on his own. My husband has a very short fuse and is easily
irritated at the slightest thing. Although he has never been physically violent towards me, I still
find his outbursts of temper quite worrying.
Because of panic attacks and ever-increasing flashbacks my husband retired on ill-health grounds
in 2002. The pressure of work, and the lack of support from his colleagues and supervisors, had
also become too much for him. My husband feels complete and utter deep-rooted bitterness and
hatred towards the people in the police force who had a duty of care towards him, but who
failed him time after time, despite the fact that they knew about the PTSD. During 2½ years of
sick leave he only received two sick visits and one phone call. It was only when the police set up a
welfare department with trained counsellors that my husband received any care, but even then
he had to ask to see someone and had to go in his own time.
Since he has retired he has no self-confidence and motivation, preferring to remain indoors most
of the day, usually at his computer. He feels totally inadequate, as if he is on the scrap heap, and
this makes him depressed. It causes an atmosphere at home and makes life unbearable at times.
He has no interest in his hobbies any more and can’t concentrate on anything for long. His shortterm memory is terrible (he can’t remember things I’ve told him the previous day), although he
can recount things that happened years ago, things that he would ordinarily have forgotten
about. He is smoking very heavily and his appetite is poor.
The antidepressants and sleeping tablets he has been taking for the past 3 years make him tired
and lethargic and his personality has changed from an outgoing, fun-to-be-with person to the
exact opposite. He very rarely socialises with anybody and doesn’t really want to.
My husband has seen various psychiatrists and psychologists, attended therapy groups and has
more recently tried behaviour therapy and a StressPac course. He has just begun a course of
EMDR [eye movement desensitisation and reprogramming]. I think my husband is willing to try
anything and everything to help himself, but given the nature of his police work he is very
sceptical, and the majority of treatments he has received only seem to help in the short term. He
feels he will be like this for the rest of his life because he has been suffering with these symptoms
for over 10 years.
Despite his having treatment over the past 2 years, I haven’t seen any improvement in him
really. My husband’s condition is in my view very debilitating for him and a strain on all of us,
especially where the kids are concerned because they don’t understand why he’s the way he
is.
3.4.2 Testimony two
When my husband joined the military he was army through and through and a secure,
compassionate kind of guy. But things started going wrong for us when he was still in the army.
He was diagnosed with PTSD, given a few brief counselling sessions at an army hospital in
Germany and medically discharged. I was not involved in the treatment except in driving him to
the hospital. Then we were out in the real world and neither of us had a clue of what was
coming or how it would affect us.
With my husband I got the impression that when he first had PTSD it developed quite slowly, but
that while he was fighting it, it crawled into all the nooks and crannies. It took him over, and
before he knew it he didn’t recognise himself (and neither did his loved ones nor his closest
friends). He became confused, distant and scared of what happened and is happening. All his
Carers’ testimonies
35
foundations that made him the person he was crumbled beneath his feet. The trust he had was
shaken first by the trauma he suffered, then by the army rejecting him, and then by his spirit
deserting him. He began to pull away from his closest family and friends, and became very
unsure and lacking in confidence – a shadow of his former self.
When my husband first showed serious signs of PTSD we were concerned, but reassured by him
that it was nothing. How ignorant we were! Then suddenly it changed my life, his and the
children’s lives. He left home and sent me a few messages saying that he didn’t know who he
was and where his life was going. He just walked away from our life without telling anyone, not
even his brother, who he was very close to. I knew without a doubt something was seriously
wrong because this was totally out of character.
I read what I could about PTSD in the library and on the internet but I really didn’t know where
to turn to for help, so I phoned the NHS helpline. The fellow who I spoke to was very nice and he
gave me the number for Combat Stress (he told me that he was a sufferer and that there was
light at the end of the tunnel). I phoned Combat Stress and was sent a standard information
pack with a form for my husband to fill out. But when I contacted my husband he admitted that
he was already in counselling via the SSAFA (Soldiers, Sailors, Airmen and Families Association –
this is a volunteer-led charity that helps ex-service personnel deal with problems that they cannot
cope with, among other things). This went on for 3 months.
Then my husband’s psychiatrist told him he would have to see his own GP to get a referral in his
local area, which he did, but the GP seemed more interested in starting him on a course of
Prozac [fluoxetine]. My husband is very wary of drugs and this was not the best course of action
for him. The GP did refer him but it took almost 2 months to get a reply from the local cognitive–
behavioural therapist. The waiting list was a further 3 months long! It was suggested that in the
meantime perhaps my husband would like to join a support group. I could not imagine my
husband even considering this advice, and I was right.
By this time various personal things had happened that made an already difficult situation almost
unbearable. My husband’s brother died, and he [my husband] took on an air of hopelessness and
refused help of any sort. This alienated him from me even further. All through this I was gently
trying to persuade him that he needed help, but it was a losing battle.
I went to my own doctor for help for myself and was put on antidepressants to control the
symptoms but was not offered counselling of any sort. I actually found counselling on my own
through Relate. I went in to talk about my husband’s PTSD and the breakdown of our marriage
and the various problems connected with that. I found I was helping the counsellor understand
PTSD because up till then she had never encountered a case like mine. I felt much better after
taking antidepressants for a little over a year.
PTSD not only affects the individual suffering, it can have dreadful consequences for those
nearest and dearest to the sufferer, breaking up marriages and affecting other close relationships.
Fortunately I am a very capable person and I have, myself, experienced trauma first-hand, so I
was able to realise that my husband was in trouble and phone anyone I could think of to help
him. I am still trying to get through that wall he has built to defend himself. I am also involved in
helping his parents understand what this is all about. I am still fighting to help my husband
despite lack of help from outside sources.
I am not trying to blame one specific individual in all of this. It has been a catalogue of errors
from the beginning and I do think that the military has a part to play in all of this. His treatment
while in the army seemed too short – longer, more intensive sessions over a period of months
rather than weeks might have been more beneficial. Discharging him did not help in any way – it
only served to reinforce his lack of self-worth.
Doctors should have a clearer understanding of PTSD and the way men experience it and describe
their feelings and reactions. Maybe they could include family members in the treatment sessions
so they can get a different point of view – it has been my experience that men with PTSD play
down what is actually happening because they are scared. I also think that things could improve
in other areas, such as reducing the amount of time PTSD sufferers have to wait for psychological
treatment. In addition, the family of the sufferer need help and information to understand PTSD
and to help the sufferer. They also need to be aware of what is required of them and to be
supported in their own right. Trying to help is much easier when you have a good support team
in the background.
36 Experiences of PTSD sufferers and carers
3.5 Understanding the impact of PTSD on carers
3.5.1 Emotional impact on carers
As both the above testimonies bear out, the experience of caring for someone with PTSD can be
lonely, frustrating and frightening. It is not uncommon for the sufferer to feel that the carer can never
truly understand the nature of the trauma, or to expect to know what the sufferer may be feeling.
This may mean that sufferers do not disclose the full nature of their disorder and treatment. This acts
to isolate the carers further, and make them feel unhelpful and helpless. Sometimes mood swings,
irritability and anger felt by the sufferer can be alienating and difficult for the carer to deal with. This
state of affairs can be exacerbated by a lack of professional help and support. Just as sufferers may
feel permanently altered by the trauma, so carers may find that their relationship with the sufferer
has changed irrevocably. It can take some time to adjust to this new situation. The diagnosis of PTSD
can be a relief to the carer as well as to the sufferer, although as the carer in the second testimony
suggests, coping with disorder on a day-to-day basis can still be very stressful and demanding.
3.5.2 Social implications of PTSD
As explained above, PTSD can have a profound effect on the sufferer’s familial and social
relationships. This can lead many carers to feel doubly isolated. The impact of the sufferer’s
difficulty in sustaining employment and social withdrawal can make family life difficult, as can
the unpredictable nature of the condition. It is not uncommon for marriages to be put under
considerable strain as a result of PTSD. However, with the right care and treatment both for the
sufferer and the carer, this situation may improve.
3.5.3 The carer’s experience of services and treatment
Because of the isolating effect of PTSD on carers and other family members, being able to access
appropriate help and support is vital. This may include written and verbal information about the
nature, course and treatment of PTSD, and information about voluntary organisations and
support groups. The carer or family member may also require some counselling and
pharmacological treatment.
3.6 Summary of carer needs
In many ways the need of family members and carers for care and support mirrors that of PTSD
sufferers, but it can only be met if this need is first recognised. This means that healthcare
professionals should be alert to the needs of families and carers and provide them with the right
information and education about the nature, course and treatment of PTSD. Family members and
carers bear the brunt of the impact of PTSD, but they also remain the most potent force for support
and care for sufferers. They should be given the correct advice about the part they can play in
supporting the family member with PTSD and support for themselves as carers, while also being
fully informed about the effects of PTSD upon family life. They should receive information about
possible treatment that they can themselves expect to receive, and details about support groups.
3.7 Clinical practice recommendations
Many of the recommendations in Chapter 2 reflect the concerns of both sufferers and carers as
expressed in the testimonies and should be seen in that context. However, other recommendations
that did not link clearly with the content of Chapter 2 or elsewhere in the guideline are included here.
3.7.1 PTSD sufferers
3.7.1.1
Healthcare professionals should treat PTSD sufferers with respect, trust and
understanding, and keep technical language to a minimum. GPP
Clinical practice recommendations 37
3.7.2 Relatives and carers
3.7.2.1
In addition to the provision of information, families and carers should be informed of
self-help and support groups and encouraged to participate in such groups where
they exist. GPP
38 Experiences of PTSD sufferers and carers
4 Methods used to develop this guideline
4.1 Overview
The development of this guideline drew upon methods outlined by the National Institute for
Clinical Excellence (2002; Eccles & Mason, 2001). A team of experts, professionals and PTSD
sufferers, known as the Guideline Development Group, with support from the NCCMH staff,
undertook the development of a PTSD sufferer-centred, evidence-based guideline. There are six
basic steps in the process of developing a guideline:
(a)
define the scope, which sets the parameters of the guideline and provides a focus and
steer for the development work
(b)
define clinical questions considered important for practitioners and PTSD sufferers
(c)
develop criteria for evidence searching, and search for evidence
(d)
design validated protocols for systematic review, and apply to the evidence recovered by
the search
(e)
synthesise and (meta-)analyse data retrieved, guided by the clinical questions, and produce
evidence statements
(f)
answer clinical questions with evidence-based recommendations for clinical practice.
The clinical practice recommendations made by the Guideline Development Group are therefore
derived from the most up-to-date and robust evidence base for the clinical and cost-effectiveness of
the treatments and services used in the management of PTSD. In addition, to ensure a sufferer and
carer focus, the concerns of PTSD sufferers and carers regarding clinical practice have been highlighted and addressed by good practice points and recommendations agreed by the whole Group.
The evidence-based recommendations and good practice points are the core of this guideline.
4.2 The Guideline Development Group
The Guideline Development Group consisted of professionals in psychiatry, clinical psychology,
nursing, social work and general practice; academic experts in psychiatry and psychology; and
PTSD sufferers. The guideline development process was supported by staff from the NCCMH, who
undertook the clinical and health economics literature searches, reviewed and presented the
evidence to the Group, managed the process, and contributed to the drafting of the guideline.
4.2.1 Guideline Development Group meetings
Seventeen Group meetings were held between February 2003 and June 2004. During each daylong meeting, in a plenary session, clinical questions and clinical evidence were reviewed and
assessed, statements developed and recommendations formulated. At each meeting all Group
members declared any potential conflict of interest, and PTSD sufferer and carer concerns were
routinely discussed as part of a standing agenda.
4.2.2 Topic leads
The Group divided its workload along clinically relevant lines to simplify the guideline
development process, and individual members took responsibility for advising on guideline work
for particular areas of clinical practice (psychological interventions, pharmacological
interventions, early intervention, risk factors and screening, and children).
4.2.3 PTSD sufferers and carers
Individuals with direct experience of services gave an integral PTSD sufferer focus to the Group and
to the guideline. The Group included two PTSD sufferers, both of whom had contact with other
39
PTSD sufferers and carers. They contributed as full Group members to writing the clinical questions,
helping to ensure that the evidence addressed their views and preferences, highlighting sensitive
issues and terminology associated with PTSD, and bringing PTSD sufferer research to the attention
of the Group. In drafting the guideline, they contributed to the editing of the introduction and
Chapter 3, and identified good practice points from the PTSD sufferer and carer perspectives.
4.2.4 Special advisers
Special advisers who had specific expertise in one or more aspects of treatment and management
relevant to the guideline assisted the Group, commenting on specific aspects of the developing
guideline and making presentations to the Group. The Acknowledgements section at the
beginning of this guideline lists those who agreed to act as special advisers.
4.2.5 National and international experts
National and international experts in the area under review were identified through the literature
search and through the experience of the Group members. These experts were contacted to
recommend unpublished or soon-to-be published studies in order to ensure up-to-date evidence
was included in the development of the guideline. They informed the group about completed
trials at the pre-publication stage, systematic reviews in the process of being published, studies
relating to the cost-effectiveness of treatment, and trial data if the Group could be provided with
full access to the complete trial report. Appendix 4 lists the researchers who were contacted.
4.3 Clinical questions
Clinical questions were used to guide the identification and interrogation of the evidence base
relevant to the topic of the guideline. The questions were developed using a modified nominal
group technique. The process began by asking each member of the Guideline Development
Group to submit as many questions as possible. The questions were then collated and refined by
the review team. At a subsequent meeting, the guideline chair facilitated a discussion to refine
the questions further. At this point, the Group members were asked to rate each question for
importance. The results of this process were then discussed and consensus reached about which
questions would be of primary importance and which would be secondary. The Group aimed to
address all primary questions; secondary questions would be covered only if time permitted.
Appendix 5 lists the clinical questions.
4.4 Systematic clinical literature review
The aim of the clinical literature review was to systematically identify and synthesise relevant
evidence from the literature in order to answer the specific clinical questions developed by the
Group. Thus, clinical practice recommendations are evidence-based, where possible, and if
evidence was not available, informal consensus methods were used (see section 4.4.10.1) and the
need for future research was specified.
4.4.1 Methodology
A stepwise, hierarchical approach was taken to locating and presenting evidence to the Group. The
NCCMH developed this process based on advice from the NICE National Guidelines Support and
Research Unit and after considering recommendations from a range of other sources. These included:
the Centre for Clinical Policy and Practice of the New South Wales Health Department
(Australia)
Clinical Evidence Online
Cochrane Collaboration
New Zealand Guideline Group
NHS Centre for Reviews and Dissemination
40 Methods used to develop this guideline
Oxford Centre for Evidence-Based Medicine
Scottish Intercollegiate Guidelines Network
United States Agency for Health Research and Quality
Oxford Systematic Review Development Programme.
4.4.2 The review process
A brief search of the major bibliographic databases for recent systematic reviews and existing
guidelines was first conducted to help inform the development of the scope. After the scope was
finalised, a more extensive search for systematic reviews was undertaken. At this point, the
review team, in conjunction with the Group, developed an evidence map that detailed all
comparisons necessary to answer the clinical questions. The initial approach taken to locating
primary-level studies depended on the type of clinical question and availability of evidence.
After consulting the Group, the review team decided which questions were likely to have a good
evidence base and which questions were likely to have little or no directly relevant evidence. For
questions in the latter category, a brief descriptive review was initially undertaken by a member
of the Group (see section 4.4.10). For questions with a good evidence base, the review process
depended on the type of clinical question.
4.4.2.1 Search process for questions concerning interventions
For questions related to interventions, the initial evidence base was formed from well-conducted
randomised controlled trials (RCTs) that addressed at least one of the clinical questions. Although
there are a number of difficulties with the use of RCTs in the evaluation of interventions in mental
health, the RCT remains the most important method for establishing treatment efficacy.
The initial search for RCTs involved searching the standard mental health bibliographic databases
(EMBASE, Medline, PsycINFO, Cochrane Library) for all RCTs potentially relevant to the guideline.
After the initial search results were scanned liberally to exclude irrelevant papers, the review team
used a purpose-built ‘study information’ database to manage both the included and the excluded
studies (eligibility criteria were developed after consultation with the Group). For questions
without good-quality evidence (after the initial search), a decision was made by the Group about
whether to repeat the search using subject-specific databases, such as CINAHL, the Allied and
Complementary Medicine Database (AMED), the System for Information on Grey Literature in
Europe (SIGLE) and the Publishers International Literature on Traumatic Stress (PILOTS); conduct a
new search for lower levels of evidence; or adopt a consensus process (see section 4.4.10.1).
Future guidelines will be able to update and extend the usable evidence base starting from the
evidence collected, synthesised and analysed for this guideline.
Data from unpublished pharmacological trials held by the Medical and Healthcare Products
Regulatory Agency were routinely requested, and where these data were available and could be
released they are considered within the review.
Recent high-quality English-language systematic reviews were used primarily as a source of RCTs
(see Appendix 7 for quality criteria). However, where existing data-sets were available from
appropriate reviews, they were cross-checked for accuracy before use. New RCTs meeting
inclusion criteria set by the Group were incorporated into the existing reviews and fresh analyses
performed. The review process is illustrated in Fig. 4.1.
Additional searches were made of the reference lists of all eligible systematic reviews and RCTs,
and the list of evidence submitted by stakeholders. Known experts in the field (see Appendix 2),
based both on the references identified in early steps and on advice from Group members, were
sent letters requesting systematic reviews or RCTs that were in the process of being published
(unpublished full trial reports were also accepted where sufficient information was available to
judge eligibility and quality). In addition, the standard mental health bibliographic databases
were periodically checked for relevant studies.
4.4.2.2 Search process for questions of screening and risk factors
For questions related to screening and risk factors, the search process was the same as described
above, except that the initial evidence base was formed by identifying recent high-quality
Systematic literature review
41
National Collaborating Centre for Mental
Health review team tasks
Draft clinical
questions with help
from GDG chair
Perform first scan; retrieve all eligible
papers for more detailed evaluation
Conduct systematic search for relevant
systematic reviews (initial 5-year limit)
Number of citations
excluded; number that
could not be located
Brief search for recent systematic reviews to
help inform the development of the scope
Clinical Guideline Development Group tasks
Number of citations
excluded
Begin developing clincial questions
based on draft questions and scope
Finalise clinical questions
Apply eligibility/quality criteria
to retrieved papers
Consult GDG about appropriate level
of evidence to begin search for
Consider known available evidence
for each question
Help produce evidence map
Produce evidence map with all comparisons
necessary to answer clinical questions
Conduct systematic search
for relevant levels of evidence
No
<5000 hits
Yes
Develop clincial question-specific search filters:
update existing high-quality systematic reviews;
run new filters only where necessary
Number of
citations excluded
Scan titles and abstracts, and apply eligibility
criteria liberally; cross-check excluded papers
Check systematic reviews
for additional evidence
Set up access database
according to evidence map
Enter study information into database
and apply eligibility/quality criteria
Update evidence map:
highlight areas without evidence
Consider known evidence
from randomised controlled trials
Consult GDG about likelihood
of lower levels of evidence
For questions unlikely to have lower levels
of evidence, begin consensus process
Fig. 4.1
For questions likely to have lower levels of
evidence, conduct new question-specific search
Guideline review process (GDG, Guideline Development Group)
42 Methods used to develop this guideline
systematic reviews and updating the searches for these systematic reviews. Additional searches
were run to cover aspects of screening and risk factors that the Group felt had not been
comprehensively covered by these earlier systematic reviews. (Separate searches were run for
screening tools and risk factors of injury, compensation and litigation, and all studies of risk
factors with a longitudinal prospective design.) In situations in which it was not possible to
identify a substantial body of appropriately designed studies that directly addressed each clinical
question, a consensus process was adopted (see section 4.4.10.1).
4.4.3 Search filters
Search filters developed by the review team consisted of a combination of subject heading and
free-text phrases. Specific filters were developed for the guideline topic, and where necessary, for
each clinical question. In addition, the review team used filters developed for systematic reviews,
RCTs and other appropriate research designs (Appendix 6).
4.4.4 Study selection
All primary-level studies included after the first scan of citations were acquired in full and reevaluated for eligibility at the time they were being entered into the study information database.
The inclusion criteria for RCTs are listed below (see section 4.4.8). For certain clinical questions
these inclusion criteria were amended (see Chapter 9). All eligible papers were then critically
appraised for methodological quality (see Appendix 8). The eligibility of each study was
confirmed by at least one member of the Group.
For some clinical questions, it was necessary to prioritise the evidence with respect to the UK
context. To make this process explicit, the Group took into account the following factors when
assessing the evidence:
participant factors (e.g. gender, age, ethnicity)
provider factors (e.g. model fidelity, the conditions under which the intervention was
performed, the availability of experienced staff to undertake the procedure)
cultural factors (e.g. differences in standard care, differences in the welfare system).
The Group decided which prioritisation factors were relevant to each clinical question in light of
the UK context, and then how they should modify the recommendations.
4.4.5 Synthesising the evidence
Where possible, outcome data were extracted directly from all eligible studies, which met the
quality criteria, into Review Manager 4.2 (Cochrane Collaboration, 2003). Meta-analysis was then
used, where appropriate, to synthesise the evidence using Review Manager. If necessary, reanalyses of the data or sensitivity analyses were used to answer clinical questions not addressed
in the original studies or reviews. For continuous outcomes, where more than 50% of the total
number randomised in a particular study were not accounted for, the data were excluded from
the analysis because of the risk of bias (as outlined within the inclusion criteria in section 4.4.8).
Included/excluded studies tables, generated automatically from the study information database,
were used to summarise general information about each study (see Appendix 14). Where metaanalysis was not appropriate and/or possible, the reported results from each primary-level study
were also presented in the included studies table.
Consultation was used to overcome difficulties with coding. Data from studies included in
existing systematic reviews were extracted independently by one reviewer directly into Review
Manager and cross-checked with the existing data-set. Two independent reviewers extracted data
from new studies, and disagreements were resolved with discussion. Where consensus could not
be reached, a third reviewer resolved the disagreement. Masked assessment (i.e. masked to the
journal from which the paper came, the authors, the institution and the magnitude of the effect)
was not used, since it is unclear that doing so reduces bias (Jadad et al, 1996; Berlin, 1997).
4.4.6 Presenting the data to the Guideline Development Group
Where possible, meta-analysis was used to synthesise data. If necessary, sub-analyses were used
to answer clinical questions not addressed in the original studies or reviews. The Group was given
Systematic literature review
43
a graphical presentation of the results using forest plots generated with the Review Manager
software. Each forest plot displayed the effect size and confidence interval (CI) for each study as
well as the overall summary statistic. The graphs were organised so that the display of data in the
area to the left of the ‘line of no effect’ indicated a ‘favourable’ outcome for the treatment in
question. Dichotomous outcomes were presented as relative risks (RR) with the associated 95% CI
(for an example, see Fig. 4.2). A relative risk (or risk ratio) is the ratio of the treatment event rate
to the control event rate. An RR of 1 indicates no difference between treatment and control. In
Figure 4.2, the overall RR of 0.73 indicates that the event rate (i.e. non-remission rate) associated
with intervention A is about three-quarters of that with the control intervention, or in other
words, the relative risk reduction is 27%.
The confidence interval shows with 95% certainty the range within which the true treatment
effect should lie and can be used to determine statistical significance. If the CI does not cross the
‘line of no effect’, the effect is statistically significant.
All dichotomous outcomes were calculated on an intention-to-treat basis (i.e. a ‘once randomised
always analyse’ basis). This assumes that participants who ceased to engage in the study – from
whatever group – had an unfavourable outcome (with the exception of the outcomes of death
and certain adverse events). Continuous outcomes were analysed as standardised mean
differences (SMDs) to allow for ease of comparison across studies (Fig. 4.3). If provided,
intention-to-treat data, using a method such as ‘last observation carried forward’, were preferred
over data from completers.
To check for heterogeneity between studies, both the I2 and χ2 tests of heterogeneity (P<0.10), as
well as visual inspection of the forest plots, were used. The I2 statistic describes the proportion of
total variation in study estimates that is due to heterogeneity (Higgins & Thompson, 2002). An I2
of less than 30% was taken to indicate mild heterogeneity and a fixed effects model was used to
synthesise the results. An I2 of more than 50% was taken as notable heterogeneity. In this case,
an attempt was made to explain the variation. If studies with heterogeneous results were found
to be comparable, a random effects model was used to summarise the results (DerSimonian &
Laird, 1986). In the random effects analysis, heterogeneity is accounted for both in the width of
CIs and in the estimate of the treatment effect. With decreasing heterogeneity the random effects
Review:
Comparison:
Outcome:
NCCMH clinical guideline review (Example)
01 Intervention A compared to a control group
01 Number of people who did not show remission
Study
or sub-category
Intervention A
n/N
Control
n/N
01 Intervention A vs. control
13/23
Griffiths1994
11/15
Lee1986
21/28
Treasure1994
45/66
Subtotal (95% CI)
Test for heterogeneity: Chi² = 2.83, df = 2 (P = 0.24), I² = 29.3%
Test for overall effect: Z = 3.37 (P = 0.0007)
RR (fixed)
95% CI
38.79
22.30
38.92
100.00
27/28
14/15
24/27
65/70
0.2
0.5
1
Favours intervention
Fig. 4.2
Review:
Comparison:
Outcome:
Study
or sub-category
2
RR (fixed)
95% CI
0.59
0.79
0.84
0.73
[0.41,
[0.56,
[0.66,
[0.61,
0.84]
1.10]
1.09]
0.88]
5
Favours control
Example of a forest plot displaying dichotomous data (RR, relative risk)
NCCMH clinical guideline review (Example)
01 Intervention A compared to a control group
03 Mean frequency (endpoint)
N
Intervention A
Mean (SD)
01 Intervention A vs. control
32
1.30(3.40)
Freeman1988
20
1.25(1.45)
Griffiths1994
14
3.70(4.00)
Lee1986
28
44.23(27.04)
Treasure1994
15
5.30(5.10)
Wolf1992
109
Subtotal (95% CI)
Test for heterogeneity: Chi² = 6.13, df = 4 (P = 0.19), I² = 34.8%
Test for overall effect: Z = 4.98 (P < 0.00001)
Control
Mean (SD)
N
20
22
14
24
11
91
SMD (fixed)
95% CI
Weight
%
25.91
17.83
15.08
27.28
13.90
100.00
3.70(3.60)
4.14(2.21)
10.10(17.50)
61.40(24.97)
7.10(4.60)
-4
-2
Favours intervention
Fig. 4.3
Weight
%
0
2
SMD (fixed)
95% CI
-0.68
-1.50
-0.49
-0.65
-0.36
-0.74
[-1.25,
[-2.20,
[-1.24,
[-1.21,
[-1.14,
[-1.04,
-0.10]
-0.81]
0.26]
-0.09]
0.43]
-0.45]
4
Favours control
Example of a forest plot displaying continuous data (SMD, standardised mean difference)
44 Methods used to develop this guideline
approach moves asymptotically towards a fixed effects model. An I2 of 30–50% was taken to
indicate moderate heterogeneity. In this case, both the χ2 test of heterogeneity and a visual
inspection of the forest plot were used to decide between a fixed and random effects model.
4.4.7 Forming and grading the statements and recommendations
The evidence tables and forest plots formed the basis for developing clinical statements and
recommendations.
4.4.7.1 Developing statements
For each outcome a clinical statement describing the evidence found was developed. To assess
clinical importance where a statistically significant summary was obtained (after controlling for
heterogeneity) the Group set thresholds for determining clinical importance, in addition to taking
into account the trial population and nature of the outcome.
Two separate thresholds for determining clinical importance were set. For comparisons of one
active treatment against waiting list or non-active interventions, a higher threshold was applied
than for comparisons of active treatments against one another.
For comparisons of one active treatment against another treatment the following thresholds
were applied: for dichotomous outcomes an RR of 0.80 or less was considered clinically
important and for continuous outcomes an effect size of approximately 0.5 (a ‘medium’ effect
size; Cohen, 1988) or less was considered clinically important.
For comparisons of active treatment against waiting list the following thresholds were applied:
for dichotomous outcomes a RR of 0.65 or less was considered clinically important and for
continuous outcomes an effect size of approximately 0.8 (a ‘large’ effect size; Cohen, 1988) or
less was considered clinically important.
In order to facilitate consistency in generating and drafting the clinical statements the Group
used a statement decision tree (Fig. 4.4). This flow chart was designed to assist with decisionmaking, not to replace clinical judgement. Using this procedure, the Group classified each effect
size as clinically important or not (i.e. whether or not the treatment is likely to benefit PTSD
sufferers), taking into account both the comparison group and the outcome.
Where heterogeneity between studies was judged problematic, in the first instance an attempt
was made to explain the cause of the heterogeneity (e.g. outliers were removed from the
analysis, or sub-analyses were conducted to examine the possibility of moderators). Where
homogeneity could not be achieved, a random effects model was used.
In cases where the point estimate of the effect was judged clinically important, a further
consideration was made about the precision of the evidence by examining the range of estimates
defined by the CI. For level I evidence, where the effect size was judged clinically important for
the full range of plausible estimates, the result was described as evidence favouring intervention
x over intervention y (i.e. statement 1, or S1). For non-level-I evidence or in situations where the
point estimate was clinically important but the CI included clinically unimportant effects, the
result was described as limited evidence favouring intervention x over intervention y (i.e. S2).
Where a point estimate was judged as not clinically important and the CI did not include any
clinically important effects, the result was described as unlikely to be clinically important (i.e. S3).
Alternatively, if the range of estimates defined by the CI included clinically important benefits as
well as no effect or harmful effects, the result was described as inconclusive (i.e. S4).
Where for a particular review very few trials meet the threshold for clinical importance, further
criteria are required to differentiate the relative efficacy of treatments considered. In this case
treatments are evaluated according to whether they are both statistically significant and
reasonably well tolerated. Specifically, the most effective treatments are identified as those for
which, for the principal outcome measures, the effect sizes are statistically significant (95% CI to
the left of the line of no effect).
4.4.7.2 Developing and grading the recommendations
Once all evidence statements relating to a particular clinical question were finalised and agreed
by the Group, the associated recommendations were produced and graded. Grading allowed
Systematic literature review
45
Is there a clinically important difference
between x and y
after controlling for heterogeneity?
Does the range of estimates defined
by the confidence interval include
only clinically important effects?
Yes
No
Yes
No
S1
There is evidence
favouring x over y on . . .
S2
There is limited evidence
favouring x over y on . . .
Does the range of estimates defined
by the confidence interval completely exclude
clinically important effects?
Fig. 4.4
Yes
No
S3
There is evidence suggesting
that there is unlikely to be a
clinically important difference
between x and y on . . .
S4
The evidence is inconclusive and so it
is not possible to determine whether
there is a clinically important difference
between x and y on . . .
Guideline statement decision tree
the Group to distinguish between the level of evidence and the strength of the associated
recommendation. This allowed the Group to moderate recommendations based on factors
other than the strength of evidence. Such considerations include the applicability of the
evidence to the people in question, economic considerations, values of the development group
and society, and the group’s awareness of practical issues (Eccles et al, 1998).
Each clinical evidence statement was classified according to a hierarchy. Recommendations were
then graded A to C based on the level of associated evidence (Table 4.1), or as a good practice
point (GPP). All evidence statements and associated forest plots are presented in Appendices 16
and 15 respectively, while a subset of the key evidence statements are presented in the relevant
chapters for ease of reference.
4.4.8 Inclusion criteria
The review used the following inclusion criteria:
the study used a randomised controlled design
at least 70% of participants needed to have a diagnosis of PTSD, other participants must
have PTSD symptoms following a traumatic event
the main target of treatment was PTSD
PTSD symptoms were measured
pre- and post-treatment data were reported
for continuous data at least 50% of the intent-to-treat sample were assessed at the
relevant time point
double-blind administration of treatment (for pharmacological treatments only).
46 Methods used to develop this guideline
Table 4.1
Hierarchy of evidence and recommendations grading scheme
Level Type of evidence
Grade
Evidence
I
Evidence obtained from a single
randomised controlled trial or a
meta-analysis of randomised
controlled trials
A
At least one randomised controlled trial
as part of a body of literature of overall
good quality and consistency addressing
the specific recommendation (evidence level
I) without extrapolation
IIa
Evidence obtained from at least
B
one well-designed controlled study
without randomisation
Well-conducted clinical studies but no
randomised clinical trial on the topic
of recommendation (evidence levels II or III);
or extrapolated from level I evidence
IIb
Evidence obtained from at least
one other well-designed
quasi-experimental study
III
Evidence obtained from
well-designed, non-experimental
descriptive studies, such as
comparative studies, correlation
studies and case studies
IV
Evidence obtained from expert
committee reports or opinions
and/or clinical experiences of
respected authorities
C
Expert committee reports or opinions
and/or clinical experiences of respected
authorities (evidence level IV) or extrapolated
from level I or II evidence. This grading
indicates that directly applicable clinical
studies of good quality are absent or not
readily available
GPP
Recommended good practice based on the
clinical experience of the Guideline
Development Group
Adapted from Eccles & Mason (2001); Department of Health (1996).
4.4.9 Measures of outcome
The main criterion for treatment effectiveness was its effect on PTSD symptoms. These were
assessed either by independent assessors or by self-report. The instruments included in the
analysis were as follows:
assessor-rated PTSD symptoms: the Clinician-Administered PTSD Scale for DSM–IV (CAPS),
the PTSD Symptom Scale – Interview Version (PSS–I), or the number of symptoms on the
Structured Clinical Interview for DSM–IV (SCID)
self-report instruments of PTSD symptoms: the Davidson Trauma Scale (DTS), or the Posttraumatic Diagnostic Scale (PDS), or the PTSD Checklist (PCL), or the Impact of Event Scale
(IES) or Impact of Event Scale – Revised (IES–R).
If more than one self-report scale (for example, PCL and IES) was used, the instrument that
mapped onto the DSM–IV criteria was included (in the example, PCL). Both continuous data
(outcome measures scores and changes) and dichotomous data (PTSD remission) based on these
scores were considered.
A number of scales have been developed for the measurement of PTSD and other outcomes for
children and young people and these are discussed in Chapter 9.
Systematic literature review
47
4.4.10 Method used to answer a clinical question in the absence
of appropriately designed, high-quality research
In the absence of level I evidence (or a level that is appropriate to the question), or where the
Group members were of the opinion (on the basis of previous searches or their knowledge of
the literature) that there was unlikely to be such evidence, either an informal or a formal
consensus process was adopted. This process focused on questions that the Group considered
a priority.
4.4.10.1 Informal consensus
The starting point for this process of informal consensus was that a member of the topic group
identified, with help from the systematic reviewer, a narrative review that most directly addressed
the clinical question. Where this was not possible, a brief review of the recent literature was
initiated. This existing narrative review (or new review) was used as a basis for beginning an
iterative process to identify lower levels of evidence relevant to the clinical question and to lead
to written statements for the guideline. The process involved a number of steps:
1
A description of what was known about the issues concerning the clinical question was
written by one of the topic group members.
2
Evidence from the existing review or new review was then presented in narrative form to
the Group and further comments were sought about the evidence and its perceived
relevance to the clinical question.
3
Based on the feedback from the Group, additional information was sought and added to
the information collected. This might include studies that did not directly address the
clinical question but were thought to contain relevant data.
4
If, during the course of preparing the report, a significant body of primary-level studies (of
appropriate design to answer the question) was identified, a full systematic review was
done.
5
At this time, subject possibly to further reviews of the evidence, a series of statements that
directly addressed the clinical question was developed.
6
Following this, on occasions and as deemed appropriate by the Guideline Development
Group, the report was then sent to appointed experts outside the Group for peer review
and comment. The information from this process was then fed back to the Group for
further discussion of the statements.
7
Recommendations were then developed and could also be sent for further external peer
review.
8
After this final stage of comment, the statements and recommendations were again
reviewed and agreed upon by the Group.
4.4.10.2 Primary care focus group
The Guideline Development Group (GDG) was concerned about the lack of primary care
representation among its members. Therefore, in an attempt to address this issue, a general
practitioner with extensive experience in primary-care service development in mental health and
experience of running focus groups was commissioned by the GDG to run a focus group on the
clinical practice recommendations developed for this guideline. A focus group, comprising six
general practitioners, two clinical psychologists and a primary-care-based nurse with special
experience in mental health, was recruited.
All the focus group members were supplied with the guideline introductory chapters and a
final draft of the short form of the NICE clinical guideline before they met. In addition, two
members of the GDG also attended the focus group to present relevant summaries of the
methods adopted by the GDG and the evidence underpinning the recommendations, and to
respond to any specific queries raised by the primary care practitioners. The specific aims of the
focus group were to review the appropriateness and wording of the clinical practice
recommendations for primary care. The discussions in the group were structured around
individual patient pathways. All discussions were recorded and summarised by the GDG project
manager; these were reviewed first by the general practitioner consultant and then by all focus
group members.
48 Methods used to develop this guideline
The general practitioner consultant then presented the outcome of the focus group to the GDG,
who used the presentation and subsequent discussion to amend the clinical practice
recommendations relevant to primary care.
4.5 Health economics review strategies
A systematic review for health economic evidence was conducted. The aim was threefold:
to identify all publications with information about the economic burden of PTSD in the UK
to identify existing economic evaluations of any psychological or pharmacological
interventions for the treatment of PTSD undertaken in the UK
to find studies with health state utility evidence generalisable to the UK context to facilitate
a possible cost–utility modelling process.
Although no attempt was made to review systematically studies with only resource use or cost
data, relevant UK-based information was extracted for future modelling exercises if it was
considered appropriate.
4.5.1 Search strategy
In January 2004, bibliographic electronic databases – Medline, PreMedline, EMBASE, CINAHL,
PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Cochrane Controlled Trials
Reports (CCTR), Database of Abstracts of Reviews of Effectiveness (DARE) and the NHS Health
Technology Assessment (HTA) – and specific health economic databases, the NHS Economic
Evaluation Database (NHS EED) and the Office of Health Economics Health Economic Evaluation
Database (OHE HEED), were searched for economic studies. For Medline, PreMedline, EMBASE,
CINAHL, PsycINFO, CDSR, CCTR and DARE, a combination of a specially developed health economics
search filter already tested in earlier NCCMH guidelines and a general filter for post-traumatic
stress disorder was used. A combination of subject headings and free-text searches was used. The
HTA, NHS EED and OHE HEED databases were searched using shorter, database-specific strategies.
In addition to searches of electronic databases, reference lists of eligible studies and relevant
reviews were searched by hand. Studies included in the clinical evidence review were also
screened for economic evidence.
4.5.2 Review process
The database searches for general health economic evidence for PTSD resulted in a total of 345
references. Of these, 27 were identified as potentially relevant. Secondary searches for additional
pharmaco-economic papers resulted in a further 46 references, of which 8 were initially
considered relevant to criteria for health economic appraisal. A further 6 potentially eligible
references were found by hand-searching. Full texts of all potentially eligible studies (including
those for which relevance or eligibility was not clear from the abstract) were obtained: a total of
41 papers. (At this stage inclusion was not limited to papers only from the UK.) These
publications were then assessed against a set of standard inclusion criteria by the health
economist, and papers eligible for inclusion as economic evaluations were subsequently assessed
for internal validity. The quality assessment was based on the 32-point checklist used by the
British Medical Journal to assist referees in appraising economic analyses (Drummond & Jefferson,
1996) (Appendix 12).
4.5.3 Selection criteria
Cost-of-illness/economic burden studies:
no restriction was placed on language or publication status of the papers
studies published between 1980 and 2003 were included (this date restriction was
imposed in order to obtain data relevant to current healthcare settings and costs)
only studies from the UK were included, as the aim of the review was to identify economic
burden information relevant to the national context
Health economics review strategies 49
selection criteria based on types of clinical conditions and patients were identical to the
clinical literature review (see Appendix 7)
studies were included provided sufficient details regarding methods and results were
available to enable the methodological quality of the study to be assessed and provided
the study’s data and results were extractable.
Economic evaluations:
studies were included provided they had used cost-minimisation analysis, cost-effectiveness
analysis, cost–utility analysis or cost–benefit analysis
only clinical evidence from a meta-analysis, a randomised controlled trial, a quasiexperimental trial or a cohort study was used
no restriction was placed on language or publication status of the papers
studies published between 1980 and 2003 were included (this date restriction was
imposed in order to obtain data relevant to current healthcare settings and costs)
only studies from the UK were considered, as the aim of the review was to identify
economic evaluation information relevant to the national context
selection criteria based on types of clinical conditions, patients, treatments and settings
were identical to the clinical literature review (see Appendix 7)
studies were included provided sufficient details regarding methods and results were
available to enable the methodological quality of the study to be assessed and provided
the study’s data and results were extractable.
Health state utility studies:
studies reporting health state utilities for PTSD were considered for inclusion
no restriction was placed on language or publication status of the papers
studies published between 1980 and 2003 were included
only studies from Organization for Economic Cooperation and Development countries were
considered, to assure the generalisability of the results to the UK context
selection criteria based on types of clinical conditions, patients, treatments and settings
were identical to the clinical literature review (see Appendix 7).
4.5.4 Data extraction
Data were extracted by the health economist. Masked assessment, whereby data extractors are
masked to the details of journal, authors and so on was not undertaken, because the evidence
does not support the claim that this minimises bias (Alderson et al, 2004).
4.6 Stakeholder contributions
Professionals, PTSD sufferers and companies have contributed to and commented on the
guideline at key stages in its development. Stakeholders for this guideline include:
PTSD sufferer/carer stakeholders: the national PTSD sufferer and carer organisations that
represent people whose care is described in this guideline
professional stakeholders: the national organisations that represent healthcare
professionals who are providing services to PTSD sufferers
commercial stakeholders: the companies that manufacture medicines used in the treatment
of PTSD
primary care trusts
Department of Health and Welsh Assembly Government.
Stakeholders have been involved in the guideline’s development at the following points:
commenting on the initial scope of the guideline and attending a briefing meeting held by
NICE
contributing lists of evidence to the Guideline Development Group
commenting on the first and second drafts of the guideline.
50 Methods used to develop this guideline
4.7 Validation of this guideline
This guideline has been validated through two consultation exercises. Drafts of the full and NICE
versions of the guideline were submitted to the NICE Guidelines Review Panel and posted on the
NICE website (http://www.nice.org.uk). Stakeholders and other reviewers nominated by the
Guideline Development Group were then informed that the documents were available.
The Group reviewed comments from stakeholders, the NICE Guidelines Review Panel, a number of
health authority and trust representatives and a wide range of national and international experts
from the first round of consultation. The Group then responded to all comments and prepared
final consultation drafts of all three versions of the guideline – the full guideline, the NICE
guideline, and the information for the public. These were made available on the NICE website,
and stakeholders were informed. Following consultation, the drafts were amended and responses
to any comments were made. The final drafts were then submitted to NICE to be signed off after
review by the Guidelines Review Panel.
Guideline validation
51
5 Psychological treatment of PTSD
in adults
5.1 Introduction
A range of psychological treatments is currently used in the NHS to treat PTSD sufferers. They
vary from generic psychological treatments, such as supportive and psychodynamic therapy, to
treatments that are specifically designed for PTSD, linked to specific theories or treatment
techniques. The focus of these guidelines is on those approaches for which there is some
evidence for efficacy from randomised controlled trials.
It is important to note that the term ‘psychological treatment’ is meant to define a group of
treatments that use psychological methods to help PTSD sufferers. The term is not meant to
denote the profession of the person delivering the treatment. However, this guideline considers it
necessary that mental health professionals who deliver these treatments receive appropriate
training and supervision. In the NHS and in the non-statutory sector, psychological treatments are
currently delivered by a range of mental health professionals, including clinical and counselling
psychologists, mental health nurses, occupational therapists, psychiatrists, psychotherapists,
counsellors and social workers.
5.2 Definitions
5.2.1 Cognitive–
– behavioural therapies
Cognitive–behavioural therapies (CBT) draw on psychological models describing the relationship
between thoughts, emotions and behaviour. Examples include learning theories that explain how
emotions, beliefs and behaviours are acquired and can be changed, and models of information
processing (for example, memory and attention). Cognitive–behavioural therapy employs a range
of therapeutic techniques that aim to change people’s distressing emotions by changing their
thoughts, beliefs and/or behaviour. These approaches have been shown to be effective for a
range of anxiety disorders (e.g. Barlow & Lehman, 1996), and in recent years specific
programmes for particular disorders have been developed.
All CBT programmes for PTSD include an element of psycho-education about common reactions
to trauma that normalises the PTSD sufferer’s symptoms, and a rationale for the interventions.
Cognitive–behavioural therapy programmes for PTSD include one or more of the following
groups of treatment techniques: exposure, cognitive therapy and stress management (see
sections 5.2.1.1 to 5.2.1.4).
5.2.1.1 Exposure
During exposure, the therapist helps PTSD sufferers to confront their trauma memories and
specific situations, people or objects that have become associated with the traumatic stressor and
evoke what is now an unrealistically intense emotional or physical response. Exposure is a
common therapeutic technique of effective behaviour therapies for anxiety disorders that have
been developed since the 1960s (e.g. Wolpe, 1958; Marks, 1969; Rachman, 1978; Rachman &
Hodgson, 1980). Keane (Keane & Kaloupek, 1982; Keane et al, 1989) and Foa (Foa et al, 1991)
were the first to develop exposure therapies for PTSD sufferers, and these approaches have since
been refined with a trend for increases in efficacy. A treatment manual for prolonged exposure,
the best-evaluated treatment programme for PTSD focusing on exposure, is available (Foa &
Rothbaum, 1998).
In the treatment of PTSD, exposure is usually done in two ways:
52 Psychological treatment of PTSD in adults
Imaginal exposure or narrative writing: the emotional and detailed recounting of the
traumatic memory in the temporal order in which the events unfolded, including one’s
thoughts and feelings, either in one’s imagination while giving a running commentary on
what one visualises, or in writing. This is usually repeated until the recounting no longer
evokes high levels of distress, and until the trauma memories are experienced as memories
rather than something happening all over again.
In vivo exposure: confrontation with now safe situations that the person avoids because
they are associated with the trauma and evoke strong emotions or physical reactions (e.g.
driving a car again after being involved in an accident; using lifts again after being assaulted
in a lift). Repeated exposures help the person realise that the feared situation is no longer
dangerous and that the anxiety about it does not persist for ever (Foa & Kozak, 1986).
5.2.1.2 Cognitive therapy
Cognitive therapy was developed by Beck (1976), originally with an emphasis on the treatment of
depression. Effective versions of cognitive therapy for a range of anxiety disorders have been
developed since the 1980s (e.g. Clark, 1999). In cognitive therapy, the therapist helps patients to
identify and modify their excessively negative cognitions (thoughts and beliefs) that lead to
disturbing emotions and impaired functioning. Cognitive treatments of anxiety disorders and
PTSD focus on the identification and modification of misinterpretations that lead the patient to
overestimate threat. In PTSD, this threat stems from interpretations of the trauma and its
aftermath. For example, PTSD sufferers may feel strong guilt or shame related to the trauma:
rape victims may blame themselves for the rape; war veterans may feel it was their fault that a
best friend was killed. Others overestimate the current danger they are encountering in everyday
life. Accident survivors may become convinced that they are at great risk of having a further
trauma. Others may take the intrusive re-experiencing symptoms as a sign that they are losing a
sense of reality.
By discussing the evidence for and against the interpretations, and by testing out the predictions
derived from the interpretations with the help of the therapist, the patient arrives at more
adaptive conclusions. The patient is encouraged to drop behaviours and cognitive strategies that
prevent a disconfirmation of the negative interpretations, e.g. excessive precautions to prevent
further trauma or excessive rumination about what one could have done differently during the
event.
Treatment manuals that describe the use of cognitive techniques in the treatment of PTSD include
those by Resick & Schnicke (1993), Blanchard & Hickling (2004) and Foa & Rothbaum (1998).
5.2.1.3 Stress management
Teaching people a set of skills that they can use to cope with stress has a long tradition in CBT.
Examples of the skills that help people manage their anxiety include:
relaxation training: teaching techniques for relaxation, for example, relaxing major muscle
groups, in a way that decreases anxiety
breathing retraining: teaching techniques of slow, abdominal breathing to avoid
hyperventilation and the unpleasant physical sensations that accompany it
positive thinking and self-talk: positive statements (e.g. ‘I did it before and I can do it again’)
are written on cards and rehearsed so that they can be used to replace the negative
thoughts that often occur during stressful experiences
assertiveness training: teaching the person how to express wishes, opinions and emotions
appropriately and without alienating others
thought stopping: teaching the person distraction techniques to overcome distressing
thoughts by inwardly shouting ‘stop’.
The most widely used stress management programme for trauma survivors is the stress
inoculation training developed by Meichenbaum (1985). It aims to provide patients with a sense
of mastery over their stress by teaching them a variety of coping skills and then providing an
opportunity to practise those skills in a graduated (‘inoculation’) fashion. It has been adapted for
the treatment of survivors of sexual assault by Kilpatrick and colleagues (e.g. Veronen &
Kilpatrick, 1983).
Definitions
53
5.2.1.4 Classification of CBT programmes for the meta-analysis
The CBT programmes tested in the available RCTs differ in several ways. First, whereas in most
studies treatment was on an individual basis, a few studies used group treatments. Group
cognitive–behavioural therapy was considered separately from individual therapies in the metaanalysis. The focus of the group treatment programmes that were tested in the RCTs was on
education about trauma reactions, exposure to reminders of the event, stress management and
problem-solving. Schnurr et al (2003) compared a trauma-focused group CBT programme with a
control group treatment that did not focus on the traumatic event. The latter included education
about trauma reactions and discussion of present difficulties with relationships or problem-solving.
Among the studies that delivered CBT on an individual basis, the main difference was the extent to
which the memory of the traumatic event and its meaning were the focus of treatment. In most
CBT studies, the focus was on the trauma. For the purpose of the meta-analysis, these treatment
programmes were labelled ‘trauma-focused CBT’. Programmes included in this category differ in
whether the emphasis in treatment techniques is on exposure or on cognitive interventions. Some
programmes place their main emphasis on exposure (e.g. Keane et al, 1989; Foa & Rothbaum,
1998), others on cognitive techniques (e.g. Resick & Schnicke, 1993; Kubany et al, 2003; Ehlers et
al, 2005), and most use a combination (e.g. Devilly & Spence, 1999; Fecteau & Nicki, 1999; Power
et al, 2002; Blanchard et al, 2003b). There is considerable overlap in the proposed mechanisms
underlying the effectiveness of the various versions of trauma-focused CBT. For example, a
prominent theory of exposure treatment (Foa & Kozak, 1986) suggests that exposure changes
problematic meanings. In the same vein, nearly all trauma-focused CBT treatments that include
cognitive therapy use some form of exposure (e.g. narrative writing, imaginal exposure) to access
problematic meanings. Two studies (Marks et al, 1998; Tarrier et al, 1999) included cognitive
therapy conditions without exposure. The following treatment programmes were included in the
category of trauma-focused CBT: prolonged exposure (Foa et al, 1991, 1999; Marks et al, 1998),
image habituation training (Vaughan et al, 1994), imaginal flooding (implosive flooding) therapy
(Keane et al, 1989), imaginal exposure and biofeedback-assisted desensitisation treatment (Peniston
& Kulkosky, 1991), cognitive reprocessing therapy (Resick et al, 2002), cognitive–behavioural
treatment (Fecteau & Nicki, 1999; Paunovic & Ost, 2001; Blanchard et al, 2003b), cognitive therapy
for PTSD (Ehlers et al, 2005), cognitive restructuring plus exposure (Marks et al, 1998; Bryant et al,
2003), cognitive restructuring (Marks et al, 1998; Tarrier et al, 1999), cognitive trauma therapy
(Kubany et al, 2003, 2004) and brief eclectic psychotherapy (Gersons et al, 2000). The last also
included some elements of psychodynamic therapy, but the main treatment components
overlapped with those of other trauma-focused cognitive–behavioural therapies.
Trauma-focused CBT was distinguished from CBT programmes that focus on stress management.
For the purposes of the meta-analysis, the following treatment programmes were grouped as
stress management: stress inoculation training (Foa et al, 1991, 1999) and progressive muscle
relaxation (Marks et al, 1998; Taylor et al, 2003).
There is some overlap in treatment techniques between trauma-focused CBT and stress
management. In trauma-focused CBT, patients with PTSD sometimes receive training in stress
management strategies, for example, breathing retraining or relaxation training to make
exposure to the trauma memory or reminders more tolerable. Similarly, the stress inoculation
training programme tested in the studies by Foa et al (1991, 1999) studies involved discussion of
the meaning of the traumatic event in the later sessions, overlapping with the cognitive elements
of trauma-focused CBT.
The relevant consideration for the classification was whether or not the treatment mainly focused
on the trauma memory and its meaning. Thus, the combination of prolonged exposure with
stress inoculation training was classified as ‘trauma-focused CBT’, whereas stress inoculation
training alone was classified as ‘stress management’.
In summary, the review classified CBT programmes into three groups:
trauma-focused CBT (individual treatment)
stress management (individual treatment)
group CBT.
A few recent RCTs investigated new forms of delivering CBT for PTSD, internet-based therapy
(Lange et al, 2003) and delivery through interpreters in refugee settlements (Neuner et al, 2004).
54 Psychological treatment of PTSD in adults
These could not be included in the meta-analysis because treatment setting and method of
delivery were too different from other studies. These studies are reviewed separately in section
5.6.2.
5.2.2 Eye movement desensitisation and reprocessing
Eye movement desensitisation and reprocessing (EMDR) was developed by Shapiro (1989). It is
based on a theoretical model which posits that the dysfunctional intrusions, emotions and
physical sensations experienced by trauma victims are due to the improper storage of the
traumatic event in implicit memory. The EMDR procedures are based on stimulating the patient’s
own information processing in order to help integrate the targeted event as an adaptive
contextualised memory (Shapiro, 2001).
Therapy with EMDR involves eliciting specific targets to represent the traumatic event, the current
triggers and future templates for appropriate future action. Standardised procedures are used to
process the targets to resolution. Patients are prepared to attend to the memory and associations
while their attention is also engaged by a bilateral physical stimulation (eye movements, taps or
tones). Each target is accessed individually according to procedures that bring together all the
relevant cognitive, emotional and sensory aspects of the traumatic memory. Then, the patient is
guided into a receptive state of awareness regarding aspects of the targeted event, and any
concomitant memory associations. Guided by standardised procedures, the clinician elicits sets of
dual attention stimuli, basing the length of the set and the focus of attention on the patient’s
response.
Desensitisation, de-arousal, insights and changes in belief are viewed as by-products of this direct
processing, which is posited to move the targeted event from implicit memory to explicit
memory, which no longer contains the disturbing affects, thoughts and sensations. It is
postulated, first, that what is useful is learned, stored with appropriate affects and is able to
guide the person in the future, and second, that what is not useful (the negative emotions,
thoughts and sensations) is progressively discarded as part of the transformation of the memory.
The EMDR procedures are also used to elicit and strengthen positive affects, cognitions and
future behaviours. The eye movement element of EMDR has attracted the most attention;
however, Shapiro has emphasised in her recent writing (e.g. Shapiro, 1996, 2001) that EMDR is a
multiple-stage therapy that is meant to be integrated into a comprehensive plan for the
treatment of trauma. Furthermore, eye movements are not the only treatment technique, and
others such as ‘sequential exposure, desensitisation, cognitive restructuring, and classical
conditioning’ (Shapiro, 1996: p. 209) are also used.
Many of the procedures used in EMDR overlap with those used in trauma-focused CBT; for
example, holding an image of the trauma in mind resembles imaginal exposure, although the
exposure is much briefer and the patient does not verbalise the content of the image.
Replacing negative cognitions associated with the trauma with positive cognitions overlaps
with cognitive interventions. The associative techniques resemble those used in psychodynamic
approaches. This has led several recent reviews to conclude that the effectiveness of EMDR may
be due to these common treatment components, rather than the eye movements (e.g.
Davidson & Parker, 2001). Several empirical studies have suggested that the eye movements
might not be necessary in producing the therapeutic effects observed with EMDR (reviewed by
Davidson & Parker, 2001). However, the treatment originator and other authors maintain that
rhythmic bilateral stimulation is an important therapeutic element (e.g. Shapiro, 1996; Welch &
Beere, 2002).
Despite the similarity in many treatment procedures, EMDR was considered separately from CBT
approaches for the purposes of the meta-analysis, as its originator considers it a distinct
treatment (Shapiro, 2001), and specific training programmes are required.
5.2.3 Other therapies
A range of other psychological treatments are currently used in the NHS to treat trauma
survivors. As the empirical evidence base for each of these treatments is sparse, they were
combined for the purposes of the review. It is important to note, however, that the different
treatments have different rationales and procedures.
Definitions
55
5.2.3.1Supportive therapy and non-directive counselling
Supportive therapy builds on the concept of client-centred therapy by Rogers (1951). It is defined
here as equivalent to non-directive counselling and as a way for the individual to explore how
they relate and respond to another person. In supportive therapy individuals are helped to focus
on their thoughts, feelings and behaviour; reach clearer self-understanding; and to find and use
their strengths so that they cope more effectively with their lives by making appropriate
decisions, or by taking relevant action. Essentially, supportive therapy is a purposeful relationship
in which one person helps another to help themselves.
Supportive therapy is primarily non-directive and non-advisory, but recognises that some
situations require positive guidance by means of information and advice (Hoxter, 1998, cited by
Bond, 2000). In the review, the RCTs of supportive therapy for PTSD included psycho-education
about stress reactions and the normalisation of PTSD symptoms. One RCT also encouraged
patients to explore coping strategies that they had used to cope with earlier life events
(Blanchard et al, 2003b).
5.2.3.2 Psychodynamic therapies
Psychodynamic therapies build on psychoanalytic theories of trauma (Breuer & Freud, 1895;
Janet, 1889; Freud, 1920; see also van der Hart et al, 1989). Several different forms of
psychodynamic treatments for PTSD have been described (see Garland, 1998; Kudler et al, 2000,
for an overview;). The emphasis in psychodynamic therapies lies on resolving the unconscious
conflicts provoked by the stressful event. ‘Psychodynamic treatment seeks to re-engage normal
mechanisms of adaptation by addressing what is unconscious, and in tolerable doses, making it
conscious’ (Kudler et al, 2000: p. 339). The goal of treatment is to understand the meaning of
the stressful event in the context of the individual’s personality, attitudes and early experiences
(Levy & Lemma, 2004). The psychological meaning of the event is explored by a range of
methods such as ‘sifting and sorting through wishes, fantasies, fears, and defences stirred up by
the event’ (Kudler et al, 2000: p. 339). Treatment strategies include exploratory insight-oriented,
supportive or directive activity. It may also include working with transference, but with the
therapist using a less strict technique than that used in psychoanalysis.
Despite the long history of psychodynamic therapies and numerous case reports of successful
treatments, the review only identified one RCT testing its efficacy in PTSD (BROM 1989) and one
trial using elements of psychodynamic therapy in combination with cognitive–behavioural
treatment (GERSONS 2000).
5.2.3.3 Hypnotherapy
Hypnotherapy involves giving the patient instructions (e.g. ‘focus on your right arm and on the
sensation that it is getting lighter and lighter’) to induce a state of highly focused attention, a
reduced awareness of peripheral stimuli and a heightened responsiveness to social cues
(suggestibility). The goal is to enhance control over trauma-related emotional distress and
hyperarousal symptoms and to facilitate the recollection of details of the traumatic event. It is
often considered as an adjunct to psychodynamic, cognitive–behavioural or other therapies
rather than as a therapy per se (see Cardeòa et al, 2000).
The meta-analysis only identified one RCT testing the efficacy of hypotherapy in PTSD (BROM
1989). Data from the hypnotherapy condition in this study were combined with data from
the psychodynamic therapy condition to form an ‘other therapies’ comparator in the metaanalysis.
5.2.4 Overview of classification of psychological treatments
In summary, the systematic review classified the psychological treatment programmes as follows.
Two of the treatment categories – trauma-focused CBT and EMDR – focus on the memory for the
traumatic event and its meaning; these are referred to as trauma-focused psychological
treatments throughout this guideline. Two other treatment categories do not place the main
focus of treatment on the trauma: these are stress management and relaxation, and other
therapies, including supportive therapy/non-directive counselling, psychodynamic therapies and
hypnotherapy. The above four categories refer to treatments that are delivered on an individual
basis; the final category was group cognitive–behavioural therapies.
56 Psychological treatment of PTSD in adults
5.3 Previous systematic reviews
Several previous systematic reviews of psychological treatments have been conducted. Van Etten
& Taylor (1998) concluded that cognitive–behavioural therapy and EMDR are both effective in the
treatment of PTSD. The practice guidelines from the International Society for Traumatic Stress
Studies (Foa et al, 2000) came to similar conclusions. Several systematic reviews highlight the
exposure to the memory of the traumatic event and reminders of the trauma as common
elements of effective trauma treatments (Paunovic, 1997; Rothbaum et al, 2000).
5.4 Studies considered for review
Previous meta-analyses included both controlled and uncontrolled studies. This review, in line
with the procedure set out in Chapter 4, only included RCTs.
5.4.1 Inclusion criteria
In addition to the generic inclusion criteria listed in Chapter 4, further inclusion criteria were that
the intervention did not occur less than 3 months after the trauma (earlier interventions are
considered in Chapter 7), and that treatment entailed more than one intervention session.
5.4.2 Measures of outcome
Unfortunately, for continuous measures of outcome such as the Clinician-Administered PTSD
Scale for DSM–IV, few studies reported intent-to-treat analyses (i.e. included all patients originally
assigned to the treatment condition). Therefore, the analysis of the continuous assessor-rated
and self-reported symptom scores is a completer analysis. This type of analysis may overestimate
treatment effectiveness, as one may expect that people who withdraw from treatment may on
average respond less well than those who complete the treatment.
To compensate for this potential bias, the percentage of people who still met diagnostic criteria
for PTSD at the end of treatment was calculated as an intent-to-treat analysis. This analysis made
the conservative assumption that people who did not complete the treatment still met diagnostic
criteria.
When making recommendations, we considered completer analyses for self-reported and
clinician-rated PTSD symptoms, and intent-to-treat analyses for the number of the people still
suffering from PTSD, together to form an overall estimate of treatment effectiveness.
Three further types of treatment outcome were considered as additional criteria. First, in order to
evaluate the acceptability of the treatments, the percentage of people who did not complete
treatment or any comparable active intervention was recorded. Second, we reviewed whether the
treatment of PTSD also led to significant improvement in symptoms of depression and anxiety.
The most commonly used standard measures were the Beck Depression Inventory (Beck et al,
1961) and the Beck Anxiety Inventory (Beck & Steer, 1993) or State–Trait Anxiety Inventory (STAI,
trait version; Spielberger et al, 1973). Last – but not least – we considered whether the
treatments had a measurable effect on the PTSD sufferer’s overall social and occupational
functioning and quality of life. Few studies included relevant measures such as the Sheehan
Disability Scale (American Psychiatric Association, 2000), the Global Assessment of Functioning
Scale (Endicott et al, 1976) or the Social Adjustment Scale (Weissman & Paykel, 1974). However,
in general, these measures focused on impairment in functioning rather than positive aspects of
quality of life.
5.5 Evidence statements
The review team conducted a new systematic research for RCTs of each of the five therapy
groupings outlined above (trauma-focused CBT, EMDR, stress management, group CBT and other
therapies) that compared these treatments against waiting list or usual care or against another
Evidence statements
57
psychological treatment. The following studies were identified by the Guideline Development
Group as meeting the inclusion criteria. (Full details of the search strategy for this and other
reviews of the guideline are given in Appendix 6. Information about each study along with an
assessment of methodological quality is given in Appendix 14, which also contains a list of
excluded studies with reasons for exclusions.)
24 studies compared trauma-focused CBT with waiting list or other psychological
interventions (BLANCHARD 2003, BROM 1989, BRYANT 2003A, CLOITRE 2002, COOPER
1989, DEVILLY 1999, ECHEBURUA 1997, EHLERS, FECTEAU 1999, FOA 1991, FOA 1999,
GERSONS 2000, IRONSON 2002, KEANE 1989, KUBANY 2003, KUBANY 2004, LEE 2002B ,
MARKS 1998, PAUNOVIC 2001, PENISTON 1991, POWER 2002, RESICK 2002, TAYLOR 2003,
VAUGHAN 1994)
11 studies compared EMDR with waiting list or other psychological interventions (CARLSON
1998, DEVILLY 1999, IRONSON 2002, JENSEN 1994, LEE 2002B, MARCUS 1997, POWER
2002, ROTHBAUM 1997, SCHECK 1998, TAYLOR 2003, VAUGHAN 1994)
7 studies compared stress management with waiting list or other psychological
interventions (CARLSON 1998, ECHEBURUA 1997, FOA 1991, FOA 1999, MARKS 1998,
TAYLOR 2003, VAUGHAN 1994)
6 studies compared other therapies with waiting list or other psychological interventions
(BLANCHARD 2003, BROM 1989, BRYANT 2003A, FOA 1991, MARCUS 1997, SCHECK 1998)
4 studies compared group CBT with waiting list or other psychological interventions
(CLASSEN 2001, KRAKOW 2001, SCHNURR 2003, ZLOTNICK 1997).
Two additional RCTs met inclusion criteria, but differed in mode of delivery and are discussed
separately in section 5.6.2 (LANGE 2003, NEUNER 2004). One further RCT compared two versions
of trauma-focused CBT (exposure and cognitive therapy) with each other (data for this RCT are
reported in two papers: TARRIER 1999 and TARRIER 1999B).
5.5.1 Comparing intervention against waiting list
The comparisons against waiting list are summarised in the following order: trauma-focused CBT,
EMDR, stress management, other therapies and group CBT. The full list of evidence statements is
given in Appendix 16.
5.5.1.1 Trauma-focused CBT versus waiting list
There is evidence favouring trauma-focused CBT over waiting list on reducing the likelihood of
having a PTSD diagnosis after treatment (k=14; n=716; RR=0.47, 95% CI 0.37 to 0.59). I
There is evidence favouring trauma-focused CBT over waiting list on reducing the severity of PTSD
symptoms (self-report measures) (k=8; n=388; SMD=–1.7, 95% CI –2.21 to –1.18). I
There is evidence favouring trauma-focused CBT over waiting list on reducing the severity of PTSD
symptoms (clinician-rated measures) (k=13; n=609; SMD=–1.36, 95% CI –1.88 to –0.84). I
There is limited evidence favouring trauma-focused CBT over waiting list on reducing depression
symptoms (k=13; n=585; SMD=–1.2, 95% CI –1.65 to –0.75). I
There is limited evidence favouring trauma-focused CBT over waiting list on reducing anxiety
symptoms (self-report measures) (k=10; n=375; SMD=–0.94; 95% CI –1.16 to –0.72). I
5.5.1.2 EMDR versus waiting list
There is limited evidence favouring EMDR over waiting list on reducing the likelihood of having a
PTSD diagnosis after treatment (k=5; n=169; RR= 0.51; 95% CI 0.28 to 0.95). I
There is limited evidence favouring EMDR over waiting list on reducing the severity of PTSD
symptoms (self-report measures) (k=4; n=116; SMD=–1.1; 95% CI –2.42 to 0.23). I
There is evidence favouring EMDR over waiting list on reducing the severity of PTSD symptoms
(clinician-rated measures) (k=4; n=122; SMD=–1.54, 95% CI, –1.96 to –1.12). I
There is evidence favouring EMDR over waiting list on reducing depression symptoms (k=4;
n=120; SMD=–1.67, 95% CI –2.1 to –1.25). I
58 Psychological treatment of PTSD in adults
There is limited evidence favouring EMDR over waiting list on reducing anxiety symptoms (k=4;
n=116; SMD=–1.18, 95% CI –1.58 to –0.78). I
5.5.1.3 Stress management versus waiting list
There is limited evidence favouring stress management therapy over waiting list on reducing the
likelihood of having a PTSD diagnosis after treatment (k=4; n=121; RR=0.64, 95% CI 0.47 to
0.87). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between stress management therapy and waiting list on reducing the severity of PTSD
symptoms (self-report measures) (k=1; n=24; SMD=0.33, 95% CI –0.47 to 1.14). I
There is limited evidence favouring stress management therapy over waiting list on reducing the
severity of PTSD symptoms (clinician-rated measures) (k=3; n=86; SMD=–1.14, 95% CI –1.62 to
–0.67). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between stress management therapy and waiting list on reducing depression
symptoms (k=4; n=109; SMD=–0.73, 95% CI –1.12 to –0.33). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between stress management therapy and waiting list on reducing anxiety symptoms
(k=3; n=82; SMD=–0.77, 95% CI –1.23 to –0.32). I
5.5.1.4 Other therapies versus waiting list
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between other therapies and waiting list on reducing the likelihood of having a PTSD
diagnosis after treatment (k=2; n=85; RR=0.79, 95% CI 0.53 to 1.18). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between other therapies and waiting list on reducing the severity of PTSD symptoms
(self-report measures) (k=2; n=132; SMD=–0.61, 95% CI –0.98 to –0.24). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between other therapies and waiting list on reducing the severity of PTSD symptoms
(clinician-rated measures) (k=2; n=72; SMD=–0.43, 95% CI –0.9 to 0.04). I
There is evidence suggesting there is unlikely to be a clinically important difference between
other therapies and waiting list on reducing depression symptoms (k=2; n=72; SMD=–0.25,
95% CI –0.71 to 0.22). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between other therapies and waiting list on reducing anxiety symptoms (k=3; n=153;
SMD=–0.48, 95% CI –0.82 to –0.14). I
5.5.1.5 Group CBT versus waiting list
The full range of outcome measures was not provided in the three studies of group CBT.
There is limited evidence favouring group CBT over waiting list on reducing the likelihood of
having a PTSD diagnosis after treatment (k=1; n=48; RR=0.56, 95% CI 0.31 to 1.01). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between group CBT and waiting list/usual care on reducing the severity of PTSD
symptoms (self-report measures) (k=2; n=71; SMD=–0.71, 95% CI –1.2 to –0.22). I
5.5.2 Intervention versus intervention
Although many of the included studies compared active treatments against waiting list, there
were fewer studies available for direct comparisons of each of the active treatments against one
another. The comparisons are set out in the following order. Each treatment is considered in turn
in the same order as in the preceding section (trauma-focused CBT, EMDR, stress management
and other therapies). So the first treatment considered in the review, trauma-focused CBT, is
Evidence statements
59
compared against each of the other classifications of treatments in turn (except group CBT, for
which no study provided a direct comparison). Next, EMDR is compared against each of the
remaining treatments for which a direct comparison has not already been provided (therefore the
comparison against trauma-focused CBT is not repeated). Hence for stress management only one
comparison is listed directly (against other therapies), as all other comparisons have already been
listed. Where available, three outcome measures are reported for each comparison in the
following section: a self-report measure of the severity of PTSD symptoms (or where this is not
reported, the clinician-rated measure), likelihood of having a PTSD diagnosis, and leaving
treatment early. The full list of evidence statements is given in Appendix 16.
5.5.2.1 Trauma-focused CBT versus EMDR
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between EMDR and trauma-focused CBT on reducing the likelihood of having a PTSD
diagnosis after treatment (k=6; n=220; RR=1.03, 95% CI 0.64 to 1.66). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between EMDR and trauma-focused CBT on reducing the severity of PTSD symptoms
(self-report) (k=6; n=166; SMD=–0.31, 95% CI –0.62 to 0). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between EMDR and trauma-focused CBT on reducing the likelihood of leaving
treatment early for any reason (k=7; n=240; RR=0.83, 95% CI 0.54 to 1.27). I
5.5.2.2 Trauma-focused CBT versus stress management therapies
There is limited evidence favouring trauma-focused CBT over stress management therapy on
reducing the likelihood of having a PTSD diagnosis after treatment (k=6; n=284; RR=0.78, 95%
CI 0.61 to 0.99). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between trauma-focused CBT and stress management therapy on reducing the severity
of PTSD symptoms (self-report measures) (k=3; n=127; SMD=–0.37, 95% CI –0.74 to 0.01). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically
important difference between trauma-focused CBT and stress management therapy on
reducing the likelihood of leaving treatment early for any reason (k=6; n=284; RR=1.17,
95% CI 0.69 to 2). I
5.5.2.3 Trauma-focused CBT versus other therapies
There is limited evidence favouring trauma-focused CBT over other therapies on reducing the
likelihood of having a PTSD diagnosis after treatment (k=5; n=286; RR=0.71, 95% CI 0.56 to
0.89). I
There is limited evidence favouring trauma-focused CBT over other therapies on reducing the
severity of PTSD symptoms (self-report measures) (k=3; n=176; SMD=–1.18, 95% CI –2.32 to –
0.03). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between trauma-focused CBT and other therapies on reducing the likelihood of leaving
treatment early for any reason (k=5; n=290; RR=1.14, 95% CI 0.68 to 1.9). I
5.5.2.4 EMDR versus stress management therapies
There is limited evidence favouring EMDR over stress management on reducing the likelihood of
having a PTSD diagnosis after treatment (k=3; n=84; RR=0.69, 95% CI 0.46 to 1.04). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between EMDR and stress management therapy on reducing the severity of PTSD
symptoms (self-report measures) (k=3; n=75; SMD=–0.4, 95% CI –0.86 to 0.06). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between EMDR and stress management therapy on reducing the likelihood of leaving
treatment early for any reason (k=3; n=84; RR=1.03, 95% CI 0.37 to 2.88). I
60 Psychological treatment of PTSD in adults
5.5.2.5 EMDR versus other therapies
There is limited evidence favouring EMDR over other therapies on reducing the likelihood of
having a PTSD diagnosis after treatment (k=1; n=67; RR=0.4, 95% CI 0.19 to 0.84). I
There is limited evidence favouring EMDR over other therapies on reducing the severity of PTSD
symptoms (self-report measures) (k=2; n=124; SMD=–0.84, 95% CI –1.21 to –0.47). I
There is limited evidence favouring other therapies over EMDR on reducing the likelihood of
leaving treatment early for any reason (k=2; n=127; RR=1.48, 95% CI 0.26 to 8.54). I
5.5.2.6 Stress management versus other therapies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between stress management therapy and other therapies on reducing the likelihood of
having a PTSD diagnosis after treatment (k=1; n=31; RR=0.58, 95% CI 0.3 to 1.11). I
There is limited evidence favouring stress management therapy over other therapies on reducing
the severity of PTSD symptoms (clinician-rated measures) (k=1; n=25; SMD=–1.22, 95% CI –2.09
to –0.35). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between stress management therapy and other therapies on reducing the likelihood of
leaving treatment early for any reason (k=1; n=31; RR=0.82, 95% CI 0.2 to 3.46). I
5.5.2.7 Group CBT (trauma-focused) versus group CBT (non-trauma-focused)
There is evidence suggesting there is unlikely to be a clinically important difference between
group CBT (trauma-focused) and group CBT (non-trauma-focused) on reducing the likelihood of
having a PTSD diagnosis after treatment (k=1; n=360; RR=0.98, 95% CI 0.83 to 1.16). I
There is evidence suggesting there is unlikely to be a clinically important difference between
group CBT (trauma-focused) and group CBT (non-trauma-focused) on reducing the severity of
PTSD symptoms (k=1; n=325; SMD=0.12, 95% CI –0.34 to 0.1). I
There is limited evidence suggesting a difference favouring group CBT (non-trauma-focused) over
group CBT (trauma-focused) on reducing the likelihood of leaving treatment early for any reason
(k=1; n=360; RR=1.38, 95% CI 1 to 1.9). I
5.6 Clinical summary for psychological treatments
5.6.1 Summary of meta-analysis
Trauma-focused CBT showed clinically important benefits over waiting list on all measures of
PTSD symptoms. In addition, there was limited evidence that this therapy also has clinically
important effects on depression and anxiety. Trauma-focused CBT had the largest empirical
database (16 RCTs with 857 participants compared trauma-focused CBT with waiting lists). The
studies included survivors of a range of different traumas, including accidents, assault, sexual
assault (including childhood sexual assault), domestic violence, military combat, ‘mixed’ trauma
groups and refugees with multiple traumatic events. Treatment duration ranged between 4 and
18 sessions, and the duration of sessions was between 50 min and 120 min. Furthermore, there
was limited evidence that trauma-focused CBT was superior to supportive/non-directive therapies,
hence it is highly unlikely that the effectiveness of this group of treatments is due to non-specific
factors such as attention.
The effectiveness of EMDR was also generally supported by the meta-analysis, but the evidence
base was not as strong as that for trauma-focused CBT, both in terms of the number of RCTs
available and the certainty with which clinical benefit was established. The EMDR treatments
showed clinically important benefits on clinician-rated PTSD symptom criteria compared with
waiting lists, and there was limited evidence for its effectiveness in self-report measures of PTSD
symptoms and PTSD diagnosis (5 studies, n=169). In addition, there was evidence or limited
evidence for clinically important effects on anxiety and depression. There was limited evidence
that EMDR was superior to supportive/non-directive therapy, suggesting that it is unlikely that its
Clinical summary for psychological treatments
61
effectiveness is due to non-specific factors such as attention. The studies included survivors of a
range of different traumas, including accidents, sexual assault (including childhood sexual
assault) and military combat, and ‘mixed’ trauma groups. Treatment duration ranged between 2
and 12 sessions, and the duration of sessions was between 50 min and 97 min.
The treatments supported by the review (trauma-focused CBT and EMDR) are both traumafocused psychological treatments that specifically address the PTSD sufferers’ troubling memories
of the traumatic event and the personal meanings of the event and its consequences. Direct
comparisons of these two approaches did not reveal any significant advantages for one over the
other, with respect to either treatment outcome or the speed of therapeutic change (Taylor et al,
2001). Similarly, studies comparing different versions of trauma-focused CBT did not find
differences (MARKS 1998; TARRIER 1999; RESICK 2002).
Other therapies (supportive/non-directive therapy, psychodynamic therapies and hypnotherapies)
that focus on current or past aspects of the patient’s life other than the trauma or general
support did not show clinically important effects on PTSD symptoms, depression or anxiety.
However, there were very few studies of the latter two approaches. Thus the review did not find
support for any clinically important benefits of these treatments, although this does not mean
that these treatments were shown to be ineffective.
For stress management and relaxation there was limited evidence for clinical effects on some
measures when compared with waiting lists, but no consistent differences in effectiveness
compared with other treatments. This may be due to the overlap of stress inoculation training
with the cognitive components of trauma-focused CBT. The RCTs that compared trauma-focused
CBT or EMDR with relaxation training only, found clearer differences favouring the traumafocused psychological treatments (VAUGHAN 1994; CARLSON 1998; MARKS 1998; TAYLOR 2003).
Psychological group treatments have rarely been investigated. Three RCTs compared group CBT
with waiting lists (n=271) and did not find convincing evidence for its effectiveness, in contrast
to clinically important effects observed with individual trauma-focused CBT. Similarly, a large RCT
(n=360) did not find that trauma-focused group CBT had larger clinical benefits than non-trauma
focused group treatment in US military veterans, using the strict intent-to-treat analyses which
included everyone who was randomised (SCHNURR 2003). However, a sub-analysis of participants
who received an adequate amount of therapy showed some evidence that trauma-focused group
CBT had advantages over non-trauma-focused group treatment.
5.6.2 Delivering effective treatments
Considerable concern is often expressed about whether the results of clinical trials can generalise
to routine clinical practice in the NHS. Two aspects of RCTs are often highlighted in this
discussion, specifically that therapists in RCTs usually have considerable expertise in delivering the
respective treatments, and that patients are not representative because they have to meet certain
inclusion and exclusion criteria for the trial. It is therefore encouraging to note that two recent
studies demonstrated that treatment effects comparable with those found in RCTs of cognitive
therapy for PTSD (EHLERS 2005), and of prolonged exposure (FOA 1991; FOA 1999; Foa &
Rothbaum, 1998), can be achieved by training and providing regular supervision to healthcare
professionals who are not experts in CBT or to individuals working in the non-statutory sector
(Gillespie et al, 2002; Cahill et al, 2005) and under routine NHS conditions without any exclusion
criteria (Gillespie et al, 2002).
A further problem with the generalisability of RCTs of psychological treatments for PTSD is that
not all PTSD sufferers are able to attend treatment in the usual clinical settings. It is therefore
encouraging that several groups have presented treatment innovations that may help deliver
effective PTSD treatments to PTSD sufferers in remote locations. This includes studies in
traumatised communities affected by disaster (Basoglu et al, 2003, 2005) and studies in nonWestern societies (NEUNER 2004). These innovations build on trauma-focused CBT programmes.
Neuner (NEUNER 2004) developed ‘narrative exposure therapy’ for traumatised survivors of war
or torture. The four-session programme builds on exposure therapy and testimony therapy. With
the help of interpreters, PTSD sufferers are asked to give a narrative account of their lives with
special emphasis on a detailed description of traumatic events. They are asked to relive the
emotions they experienced during the traumatic events while reporting them. The narratives are
read back to the sufferer repeatedly and details are added. Neuner and colleagues randomly
62 Psychological treatment of PTSD in adults
assigned 43 Sudanese refugees who lived in a refugee settlement to one of the following:
narrative exposure therapy, supportive therapy or psychoeducation. At 12-month follow-up, but
not at the post-treatment assessment, there was limited evidence for clinically important benefits
of narrative exposure therapy compared with both supportive therapy and psychoeducation on
measures of PTSD symptoms (NEUNER 2004).
Lange (LANGE 2003) developed and tested ‘interapy’, a form of therapy delivered over the
internet. It involves writing about the traumatic event, similar to some trauma-focused CBT
programmes (e.g. BLANCHARD 2003; RESICK 2002). An RCT involving 101 trauma survivors
showed clinically important effects of the internet therapy on self-reported PTSD symptoms
compared with a waiting list, and limited evidence for effect on depression and anxiety.
Basoglu et al (2003, 2005) developed a short, trauma-focused cognitive–behavioural treatment
for earthquake survivors. The main emphasis of the treatment was on encouraging selfexposure to reminders of the traumatic event. The treatment rationale emphasised the
enhancement of a sense of control over one’s fear. An open trial of 231 earthquake survivors
with chronic PTSD (Basoglu et al, 2003) found that the majority of participants experienced a
reduction in PTSD symptoms after one or two sessions. In an RCT (Basoglu et al, 2005), 53
earthquake survivors with PTSD were identified among a community sample and randomly
assigned to either treatment (1 hour, plus 30 min follow-up) or waiting list. (Participants who
did not attend the post-treatment assessment were replaced by other participants.) The
treatment group showed greater changes on measures of PTSD symptoms and depression than
the waiting list group.
5.6.3 Predictors of response to trauma-focused psychological treatment
A number of studies have investigated whether response to trauma-focused CBT can be predicted
from patient or trauma characteristics. Overall, few predictors have been found. Some clinically
important findings from these analyses were:
The time that had passed since the trauma was not related to treatment effectiveness
(Gillespie et al, 2002; RESICK 2002; EHLERS 2005).
Comorbidity was not associated with outcome, but patients with comorbid disorders
needed more treatment sessions (Gillespie et al, 2002).
People who were physically injured during the trauma had poorer outcome than those
without physical injuries (Gillespie et al, 2002). The same applied to people with chronic
pain as a result of the trauma (Taylor et al, 2001).
People with greater PTSD symptom severity at the beginning of treatment have greater
symptom severity at the end of treatment (van Minnen et al, 2002; Blanchard et al, 2003b),
but the degree of improvement does not differ (EHLERS 2005).
Pitman et al (1991) presented a case series suggesting that exposure treatment may not be
suitable for perpetrators of harm, especially those in whom guilt is the primary emotion.
However, for other PTSD sufferers the presence of guilt does not seem to predict response to
exposure (van Minnen et al, 2002).
5.7 Recommendations for psychological treatments
for chronic PTSD
5.7.1.1
All PTSD sufferers should be offered a course of trauma-focused psychological
treatment (trauma-focused cognitive–behavioural therapy or eye movement
desensitisation and reprocessing). These treatments should normally be provided on
an individual out-patient basis. A
5.7.1.2
Trauma-focused psychological treatment should be offered to PTSD sufferers
regardless of the time that has elapsed since the trauma. B
5.7.1.3
The duration of trauma-focused psychological treatment should normally be 8–12
sessions when the PTSD results from a single event. When the trauma is discussed in
the treatment session, longer sessions than usual are generally necessary (for example
Recommendations for psychological treatments for chronic PTSD 63
90 min). Treatment should be regular and continuous (usually at least once a week)
and should be delivered by the same person. B
5.7.1.4
Healthcare professionals should consider extending the duration of treatment beyond
12 sessions if several problems need to be addressed in the treatment of PTSD
sufferers, particularly after multiple traumatic events, traumatic bereavement or where
chronic disability resulting from the trauma, significant comorbid disorders or social
problems are present. Trauma-focused treatment needs to be integrated into an
overall plan of care. C
5.7.1.5
Treatment should be delivered by competent individuals who have received
appropriate training. These individuals should receive appropriate supervision. C
5.7.1.6
Some PTSD sufferers may initially find it difficult and overwhelming to disclose details
of their traumatic events. In these cases, healthcare professionals should consider
devoting several sessions to establishing a trusting therapeutic relationship and
emotional stabilisation before addressing the traumatic event. C
5.7.1.7
When PTSD sufferers request other forms of psychological treatment (for example,
supportive therapy/non-directive therapy, hypnotherapy, psychodynamic therapy or
systemic psychotherapy), they should be informed that there is as yet no convincing
evidence for a clinically important effect of these treatments on PTSD. GPP
5.7.1.8
Non-trauma-focused interventions such as relaxation or non-directive therapy, which
do not address traumatic memories, should not routinely be offered to people who
present with chronic PTSD. B
5.7.1.9
For PTSD sufferers who have no or only limited improvement with a specific traumafocused psychological treatment, healthcare professionals should consider the
following options:
an alternative form of trauma-focused psychological treatment
the augmentation of trauma-focused psychological treatment with a course of
pharmacological treatment. C
5.8 Research recommendations
5.8.1 Guided self-help
5.8.1.1
A randomised controlled trial, using newly developed guided self-help materials based
on trauma-focused psychological interventions, should be conducted to assess the
efficacy and cost-effectiveness of guided self-help compared with trauma-focused
psychological interventions for mild and moderate PTSD.
Rationale
Post-traumatic stress disorder is a common and potentially disabling condition; it has a 1-month
prevalence of between 1.5% and 3% (Stein et al, 1997; Andrews et al, 1999). Many individuals
may recover without specific intervention, but a significant proportion go on to develop a chronic
disorder with associated psychological and social handicaps (Kessler et al, 1995). Trauma-focused
psychological interventions are generally effective for the treatment of PTSD, with brief
interventions appearing to be effective for acute PTSD (Van Etten & Taylor, 1998). In contrast to
many other anxiety and depressive disorders, where there is good evidence for the efficacy of
self-help-based interventions (Lewis et al, 2003), no such evidence exists for PTSD and to date
only one trial of guided self-help has been conducted, which failed to show any benefit from this
intervention (Ehlers et al, 2003). However, if the benefits that have been demonstrated in other
anxiety and depressive disorders were to be demonstrated in PTSD, it would offer the possibility
of increasing the availability of cost-effective treatments and reducing the burden of illness
through speeding the process of recovery. The research programme would first need to develop a
suitable guided self-help programme in a series of smaller-scale pilot studies. The final
programme would then need to be tested in an RCT.
64 Psychological treatment of PTSD in adults
5.8.2 Trauma-focused psychological interventions in adults
5.8.2.1
Adequately powered effectiveness trials of trauma-focused psychological interventions
for the treatment of PTSD (trauma-focused CBT and EMDR) should be conducted. They
should provide evidence on the comparative effectiveness and cost-effectiveness of
these interventions and consider the format of treatment (type and duration) and the
specific populations who might benefit.
Rationale
Post-traumatic stress disorder is a common and potentially disabling condition; it has a 1-month
prevalence of between 1.5% and 3% (Stein et al, 1997; Andrews et al, 1999). Many individuals
may recover without specific intervention, but a significant proportion go on to develop a chronic
disorder with associated psychological and social handicaps (Kessler et al, 1995). Good evidence
for the efficacy of trauma-focused psychological interventions is available (Van Etten & Taylor,
1998), but less is known about the effectiveness of these treatments in routine practice, although
some recent trials suggest that it may be possible to replicate the findings of RCTs in more
routine clinical settings (e.g. Gillespie et al, 2002). Effectiveness trials should use established
measures of PTSD severity and quality of life, and also provide information not only about the
value of such interventions in routine clinical practice but also about the type and duration of
intervention (CBT or EMDR) and the training requirements of the different types of intervention.
Particular populations may also derive differential benefit from different interventions in routine
clinical practice, and the characteristics of those who do and do not respond to the interventions
should be a focus of these trials (e.g. Taylor et al, 2001; Gillespie et al, 2002).
Research recommendations
65
6 Pharmacological and physical
interventions for PTSD in adults
6.1 Introduction
Drug treatments currently have an important place in the management of PTSD. This is
supported by reviews, which suggest that they are effective (e.g. Van Etten & Taylor, 1998;
Friedman et al, 2000). Drug treatments have been shown to achieve statistically significant
(positive) effects on each of the three main elements of PTSD (re-experiencing, avoidance and
hyperarousal). However, other reviews, for example Stein et al (2004), have suggested that
the efficacy of drug treatments may be less strong (they estimated an SMD for drug
treatments against placebo of –0.46 (k=4; n=327; 95% CI –0.71 to –0.2). This more modest
view was based on a rigorous systematic review of relevant studies, including only
randomised controlled trials and applying more strenuous inclusion criteria (in particular
those for trial quality). As with this review, Stein et al (2004) used between-group rather than
within-group effect sizes, thereby reducing the likelihood of artificially inflating the effect
size (as is acknowledged by Van Etten & Taylor, 1998).
Given issues concerning the lack of wide-scale availability of psychological interventions and
the desire to provide increased patient choice, it is important to establish the relative efficacy
of drug treatments in PTSD. If there are drugs with comparable efficacies to the psychological
treatments, for which there is currently the strongest evidence base (see Chapter 5), these
would allow rapid access to an effective intervention, especially in primary care settings. They
would be available as adjunctive or alternative treatments in case of treatment failure and
would allow individuals with PTSD to make a choice as to the approach they favour. Even if
the efficacy were less good, these drugs would still be available as a second-line intervention.
In the UK, only two drugs are currently licensed for the treatment of PTSD, paroxetine and
sertraline (the latter being licensed only for women). However, other drugs that are not
licensed for use in the UK have been subjected to randomised clinical trial for the treatment
of PTSD and are considered within this review.
6.2 Current clinical practice
Robust evidence on the pattern of drug usage for the treatment of PTSD in the UK is not
available. However, it is widely accepted that many patients in the UK are treated with drugs:
predominantly selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants,
although to a lesser extent tricyclic antidepressants and atypical antipsychotic agents are also
prescribed. The major uses of these drugs are for the treatment of PTSD symptoms, related
sleep disturbance and agitation and comorbid depression. Low-dose amitriptyline may also
be used in the treatment of chronic pain syndromes. In one major UK centre for the
treatment of PTSD it was estimated that around 30% of patients at point of assessment are
taking some form of psychotropic medication and a further 30% are prescribed medication
during their attendance at the clinic (C. Freeman, 2004, personal communication).
Mellman et al (2003) have reported on a survey of drug treatments in the USA in a communitybased sample of mental health clinic attenders with PTSD. They compared drug prescribing for
patients with PTSD alone, depression alone and PTSD comorbid with depression. Of the PTSD
alone group, 77% were prescribed medication, compared with 89% of the comorbid group and
82% of the depression alone group. Patients with PTSD alone were prescribed a range of
antidepressant medication, but 17% were taking atypical antipsychotics and 41% were taking
benzodiazepines and related drugs. Mellman et al (2003) point out that the use of the latter
two drug types is likely not to conform to international guidelines (Friedman et al, 2000).
66 Pharmacological and physical interventions for PTSD in adults
6.3 Limitations of the literature:
comparing RCTs of pharmacological and psychological
treatment
There are some important differences between drug treatment and psychological treatment
clinical trials. Drug trials use a double-blind method, often with a placebo arm. What this
means is that the effect of the drug treatment can, in principle, be separated from the nonspecific effects of being in a trial. There are a number of non-specific effects that may occur.
The most prominent of these is the placebo effect, which can account for a significant
component of a drug treatment effect, and in the case of mild depression this may be as
much as 80% (Kirsch, 2000). In addition, in any trial – and in particular in drug trials – much
attention is paid to measurement, and the assessment interviews are likely to be mutative
(i.e. they may in themselves have a therapeutic effect). It is therefore no surprise to find that
the total effect of drug intervention is greater than the chemical effect of the drug treatment
alone.
In trials of active drug versus placebo, the control for non-specific attentional effects is
greater than is the case in a psychological therapy trial when a waiting list control is used
(see intervention v. waiting list comparisons in Chapter 5), as opposed to a trial in which
some form of attentional control has been used (see intervention v. intervention comparisons
in Chapter 5). Further, in drug trials, researchers are masked to the treatments being
evaluated. In psychological therapy trials there is greater potential for the degree of
enthusiasm of the researcher for a particular treatment to affect the outcomes. There may
therefore be both a less effective control for the placebo effect and also the potential for
inflation of the estimated active treatment effect. What this means is that when comparing
the results of meta-analyses of drug treatment and psychological treatment trials (particularly
where these are intervention v. waiting list comparisons) caution is required, especially in
drawing conclusions from simple comparisons of effect sizes. The design of the drug trial
may lead to a lower effect size for the active drug than for an equivalent psychological
therapy when a comparison is made against no other active intervention. Unfortunately,
direct comparisons between pharmacological and psychological treatments are largely
lacking.
We have attempted to respond to this problem in comparability by assuming that the
placebo arm of a drug trial, with its significant clinical input and enhanced measurement
strategies, constitutes an active intervention and therefore we have adopted the lower of the
two thresholds for effect size used in the psychological treatment comparisons. This means
that we have regarded, on a priori grounds, a standardised mean difference (SMD) of –0.5 as
indicative of a clinically meaningful difference between active drug and placebo. It may be
helpful at this point to explain this process in more detail. What we set out to achieve was a
recommendation based not on statistical difference alone but on the sort of change in
symptom score likely to be experienced as beneficial by clinicians and PTSD sufferers.
Selecting an SMD of –0.5 was a decision taken before the statistical analyses were
undertaken. The evidence statements derive not only from the SMD but also from the
confidence intervals in the meta-analysis (see Chapter 4).
We have been faced with data from smaller, older trials and larger, more recent trials. There
are some limitations that should be pointed out in any comparison of these studies, because
the more recent trials have tended to be more robust, using intention-to-treat analyses. They
may also have included more patients in primary care, who would have been less severely
affected. These differences might have influenced the effect sizes found in the different
studies, to the disadvantage of some of the newer drugs.
Before leaving the general issue of differences between study designs, there is another factor
to take into account. In drug treatment trials it is common to offer a flexible dosage regimen.
This allows the clinician (masked to the allocation of placebo and active drug) to increase the
number of tablets taken within an approved range. Trial designs may therefore encourage
early increases in dosage in the absence of a marked treatment response. This may lead to
somewhat elevated mean dosages in drug treatment trials as opposed to clinical practice,
where experience suggests a more cautious use of dosage escalation.
Limitations of the literature
67
6.4 Issues and topics covered by this review
In broad terms we have tried to address the issues of comparative efficacy, acceptability and
tolerability of pharmacological treatments most commonly prescribed in the UK both for
acute phase treatment and continuation/relapse prevention treatments in adults. (There is a
separate review of treatments of all types in children and young people.)
For the purposes of this review the following drug treatments were considered: paroxetine
and sertraline (the only two drugs licensed in the UK for PTSD), including a small comparison
trial of paroxetine versus trauma-focused CBT, fluoxetine (another SSRI antidepressant),
amitriptyline, imipramine (a tricyclic antidepressant), phenelzine and brofaromine
(monoamine oxidase inhibitors), mirtazapine and venlafaxine (other antidepressants),
olanzapine and risperidone (atypical antipsychotics) and combined drug and therapy
interventions (phenelzine and psychotherapy, and imipramine and psychotherapy). There are
a number of other drugs that are not licensed for the treatment of PTSD in the UK but may
be prescribed with some frequency for this condition (based on advice from the Guideline
Development Group). These include the SSRIs citalopram, escitalopram and fluvoxamine, the
atypical antipsychotic quetiapine and the reversible monoamine oxidase inhibitor
moclobemide. However, for these latter drugs no study met the inclusion criteria, and so
these drugs could not be assessed within the meta-analysis.
Finally, we have included one non-pharmacological but biological intervention (repetitive
transcranial magnetic stimulation of the right dorsolateral prefrontal cortex) in this
chapter.
6.4.1 Measures of outcome
When making recommendations, two primary outcomes were considered: completer data for
self-reported symptoms and completer data for clinician-rated PTSD symptoms. In contrast to
the reviews of psychological interventions, for this review of drug treatments few studies
reported data for PTSD diagnosis and so this outcome measure was of less use in forming an
overall assessment of effectiveness.
6.5 Studies included
Full details of the search strategy for this and other reviews in the guideline are given in
Appendix 6. From the main search for RCTs, 26 separate studies were identified by the
Guideline Development Group as meeting the inclusion criteria. These include 23 studies of
drug treatments against placebo (BRADY 2000A, BUTTERFIELD 2001, CONNOR 1999B,
DAVIDSON 1990, DAVIDSON 2001, DAVIDSON 2001C, DAVIDSON 2003, DAVIDSON 2004,
DAVIDSON, ELI LILLY, HERTZBERG 2000, KATZ 1994, KOSTEN 1991, MARSHALL 2001,
MARTENYI 2002, MARTENYI 2002A, PFIZER 588, PFIZER 589, SKB 627, SKB 650, STEIN 2002,
TUCKER 2001, ZOHAR 2002) and three studies of combined drug and or therapy interventions
(FROMMBERGER 2004, HAMNER 2003A, KOSTEN 1992). (References given in shortened
format are listed in Appendix 14.) In addition, one study of repeated transcranial magnetic
stimulation (rTMS) against placebo (sham treatment) was identified (COHEN 2004B). The
report by SAYGIN 2002 is not considered further in this review, because one of the drugs
involved has now been withdrawn in the UK. (Details of the search for RCT studies are given
in Appendix 6 and summary characteristics of individual included trials are given in Appendix
14.)
In the meta-analysis, a number of crossover studies were excluded owing to the nonavailability of pre-crossover point data. (In crossover trials all participants receive all
interventions (or control or other non-active intervention) in sequence and hence participants
act as their own control. At present, methods for interpreting and using crossover data are
not sufficiently developed to allow integration of complete (post-crossover point) data from
such trials with standard RCT trials within the same meta-analysis.)
68 Pharmacological and physical interventions for PTSD in adults
6.6 Study characteristics
In contrast to the reports of psychological interventions, the studies included did not typically
provide data on remission of PTSD diagnosis, but instead reported response rate in terms of a
percentage decrease in symptoms from baseline score. Response rate data were not used
within the meta-analysis because of the inconsistency in reporting (thresholds for reported
response rates typically vary from 30% to 50%). This decision was taken because it is known
that relatively small differences in mean scores (which are not clinically significant) between
two comparison groups can produce statistically significant differences when presented as
response rates (Kirsch et al, 2002). Remission rates have the advantage of being clinically
determined in advance (diagnosis v. no diagnosis). Recent research in depression suggests that
remission is a more reliable indicator of a stable return to normal mood states than response
rates (Keller, 2003). The most consistent evidence reported for tolerability was the number of
participants leaving the treatment early and this is reported within the review.
6.6.1 SSRI drugs
Before proceeding to review the SSRI drugs individually, we wish to draw attention to the
recent guidance issued by the Committee on Safety of Medicines concerning the use of these
drugs in people of all ages, but especially in children and young adults (Committee on Safety
of Medicines, 2004). This draws attention to the increased risks of self-harm and suicidal
thoughts in children and young people. In the treatment of children and young people under
the age of 18 years with depression, the balance of risks and benefits is favourable only for
fluoxetine on current data. Careful and frequent monitoring is also important in the use of
SSRIs in young adults of 18 years of age or over, all adults in the early stages of treatment
(particularly if they experience a worsening or new symptoms after starting treatment), and
at the time of dosage changes. If a PTSD sufferer is not doing well after starting treatment,
the possibility of an adverse reaction to the drug should be considered. For the majority of
SSRIs in the treatment of depressive illness, clinical trial data do not show an increasing
benefit from increasing the dosage above the recommended daily amount. Increasing the
dosage in the presence of agitation or restlessness, particularly at the beginning of
treatment, may be detrimental. To minimise withdrawal reactions on stopping SSRIs, the
dosage should be tapered gradually over a period of several weeks. This guidance is regularly
updated and practitioners are advised to consult the Department of Health website (http://
www.dh.gov.uk) for further developments.
6.6.2 Paroxetine
Four studies of paroxetine were identified that met the inclusion criteria (MARSHALL 2001,
SKB 627, SKB 650, TUCKER 2001) and this included one continuation/relapse prevention
study. In these trials patients with depression were admitted provided PTSD was considered
to be the primary diagnosis. All four trials were of mixed-trauma populations.
6.6.2.1 Paroxetine versus placebo (acute phase)
Efficacy of treatment
There is evidence suggesting there is unlikely to be a clinically important difference between
paroxetine and placebo on reducing the severity of PTSD symptoms as measured by the Davidson
Trauma Scale (self-report measure) (k=3; n=1065; SMD=–0.37, 95% CI –0.49 to –0.24) I
The evidence is inconclusive and so it is not possible to determine if there is a clinically
important difference between paroxetine and placebo on reducing the severity of PTSD
symptoms as measured by CAPS (clinician-rated measure) (k=3; n=1070; SMD=–0.42, 95%
CI –0.55 to –0.3) I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between paroxetine and placebo on reducing depression symptoms as measured by
the Montgomery–Åsberg Depression Rating Scale (MADRS) (clinician-rated measure) (k=3;
n=1069; SMD=–0.34, 95% CI
–0.61 to –0.07). I
Study characteristics 69
Tolerability of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between paroxetine and placebo on reducing the likelihood of leaving treatment early
(k=3; n=1196; RR=0.95, 95% CI 0.79 to 1.15). I
6.6.2.2 Paroxetine versus placebo (continuation/relapse prevention)
Efficacy of treatment
There are some continuation/relapse prevention data for paroxetine from an unpublished trial
(SKB 650). This trial consisted of 12 weeks of single-blind acute phase treatment, followed by a
further 24 weeks of double-blind administered treatment for those assessed as having responded
to treatment within the acute phase. In the continuation phase responders were allocated either
to placebo or paroxetine (dose range 20–50 mg).
There is evidence suggesting there is unlikely to be a clinically important difference between
paroxetine and placebo on reducing the severity of PTSD symptoms as measured by the Davidson
Trauma Scale (self-report measure) for continuation/relapse prevention treatments (k=1; n=127;
SMD=0.06, 95% CI –0.28 to 0.41). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between paroxetine and placebo on reducing the severity of PTSD symptoms as
measured by CAPS (clinician-rated measure) for continuation/relapse prevention treatments (k=1;
n=129; SMD=0.19, 95% CI –0.15 to 0.54). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between paroxetine and placebo on reducing the likelihood of having a diagnosis of PTSD
for continuation/relapse prevention treatments (k=1; n=173; RR=0.81, 95% CI 0.55 to 1.19). I
Tolerability of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between paroxetine and placebo on reducing the likelihood of leaving treatment early
for continuation/relapse prevention treatments (k=1; n=176; RR=0.84, 95% CI 0.51 to 1.38). I
6.6.2.3 Dosage levels
There is one study comparing paroxetine at dosages of 20 mg and 40 mg. There was no difference
between these groups (MARSHALL 2001), suggesting that in general the dosage of 20 mg is
appropriate.
6.6.2.4 Paroxetine 20 mg versus paroxetine 40 mg (acute phase)
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between paroxetine (20 mg) and paroxetine (40 mg) on reducing the severity of PTSD symptoms as measured by the Davidson Trauma Scale (k=1; n=365; SMD=–0.08, 95% CI –0.29 to 1.2). I
6.6.2.5 Paroxetine versus trauma-focused CBT
Efficacy of treatment
One small study (FROMMBERGER 2004) compared 12 weeks of paroxetine (10–50 mg) with 12
weekly sessions of trauma-focused CBT. In studies comprising both drug and psychological
intervention treatment arms individuals are not masked to treatment allocation, and in this study
neither were the rating assessors. Further, given the lack of placebo control it is not possible to
isolate specific effects. It is noteworthy that the measures that provide limited evidence favouring
CBT are based on self-ratings. These effects were not replicated in the clinician ratings. The
withdrawal rates were also based on a very small difference (early withdrawal of 3 of 11 in the
paroxetine group versus 2 of 11 in the trauma-focused CBT group). This study is the only one to
compare directly drug and psychological interventions, but it should be interpreted cautiously.
There is limited evidence favouring trauma-focused CBT over paroxetine on reducing PTSD severity
as measured by the Posttraumatic Stress Scale (self-rated measure) post-treatment (k=1; n=16;
SMD=1.06, 95% CI –0.01 to 2.13). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between paroxetine and trauma-focused CBT on reducing PTSD severity as measured by
CAPS (clinician-rated measure) post-treatment (k=1; n=16; SMD=0.09, 95% CI –0.89 to 1.07). I
There is limited evidence favouring trauma-focused CBT over paroxetine on reducing depression
symptoms post-treatment as measured by the Beck Depression Inventory (self-rated measure)
(k=1; n=16; SMD=0.55, 95% CI –0.46 to 1.55). I
70 Pharmacological and physical interventions for PTSD in adults
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between paroxetine and trauma-focused CBT on reducing post-treatment depression
symptoms as measured by the MADRS (clinician-rated measure) (k=1; n=16; SMD=–0.37, 95%
CI –1.36 to 0.62). I
Tolerability of treatment
There is limited evidence favouring trauma-focused CBT over paroxetine on reducing the
likelihood of leaving the study early due to any reason prior to treatment end-point (k=1; n=21;
RR=1.36, 95% CI 0.28 to 6.56). I
6.6.3 Sertraline
Six published studies of sertraline were identified for this review as meeting the inclusion criteria
(BRADY 2000A, DAVIDSON 2001, DAVIDSON 2001C, DAVIDSON 2004, DAVIDSON and ZOHAR
2002), one of which (DAVIDSON 2001) was a continuation/relapse prevention study covering the
same population as DAVIDSON 2001C. Four trials were of mixed trauma populations and one was
of military veterans. Full data for two large unpublished trials (PFIZER 588, PFIZER 589) held by
the manufacturers were unavailable (n=166 for a trial with combat veterans, n=188 for a mixed
trauma population trial) despite repeated requests to the manufacturer. In order to incorporate
these substantial trials within the meta-analysis, estimates for missing standard deviation data
are included (standard deviations were estimated as the highest standard deviation for each
outcome measure as derived from the other published drug trials).
6.6.3.1 Sertraline versus placebo (acute phase)
Efficacy of treatment
There is evidence suggesting there is unlikely to be a clinically important difference between
sertraline and placebo on PTSD diagnosis (k=2; n=747; RR=0.91, 95% CI 0.85 to 0.98). I
There is evidence suggesting there is unlikely to be a clinically important difference between
sertraline and placebo on reducing the severity of PTSD symptoms as measured by the Davidson
Trauma Scale (self-report measure) (k=5; n=1091; SMD=–0.18, 95% CI –0.41 to 0.06). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between sertraline and placebo on reducing the severity of PTSD symptoms as
measured by CAPS (clinician-rated measure) k=6; n=1123; SMD=–0.26, 95% CI –0.51 to 0.00). I
There is evidence suggesting there is unlikely to be a clinically important difference between
sertraline and placebo on reducing the severity of PTSD symptoms as measured by the Impact of
Event Scale (self-report measure) (k=4; n=739; SMD=–0.06, 95% CI –0.39 to 0.26). I
There is evidence suggesting there is unlikely to be a clinically important difference between
sertraline and placebo on reducing the severity of depression as measured by pooled clinicianrated measures (k=3; n=417; SMD=–0.27, 95% CI –0.46 to –0.07). I
Tolerability of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between sertraline and placebo on reducing the likelihood of leaving treatment early
(k=6; n=1148; RR=1.10, 95% CI 0.90 to 1.33). I
6.6.3.2 Sertraline versus placebo (continuation/relapse prevention)
Efficacy of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between sertraline and placebo on reducing the severity of PTSD symptoms as
measured by CAPS (clinician-rated measure) for continuation/relapse prevention treatments (k=1;
n=42; SMD=–0.14, 95% CI –0.75 to 0.47). I
6.6.4 Fluoxetine
Five studies of fluoxetine met the inclusion criteria (CONNOR 1999B, ELI LILLY, HERTZBERG 2000,
MARTENYI 2002, MARTENYI 2002A), one of which was a continuation/relapse prevention study.
The studies were of mixed trauma populations with the exception of one small study (HERTZBERG
2000) of male military veterans.
Study characteristics 71
6.6.4.1 Fluoxetine versus placebo (acute phase)
Efficacy of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between fluoxetine and placebo on reducing the severity of PTSD symptoms as
measured by the Davidson Trauma Scale (self-report measure) (k=3; n=363; SMD=–0.41, 95% CI
–0.98 to 0.15). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between fluoxetine and placebo on reducing the severity of PTSD symptoms as
measured by CAPS (clinician-rated measure) (k=1; n=301; SMD=–0.28, 95% CI –0.54 to –0.02). I
There is evidence suggesting there is unlikely to be a clinically important difference between
fluoxetine and placebo on reducing the severity of PTSD symptoms as measured by the 8-item
Treatment Outcome PTSD Scale (TOP8) (self-report measure) (k=1; n=411, SMD=0.02, 95% CI
–0.21 to 0.26). I
There is limited evidence favouring fluoxetine over placebo on enhancing quality of life (k=2;
n=61; SMD=–0.62, 95% CI –1.13 to –0.1). I
Tolerability of treatment
There is limited evidence favouring fluoxetine over placebo on reducing the likelihood of leaving
treatment early (k=2; n=66; RR=0.6, 95% CI 0.28 to 1.3). I
6.6.4.2 Fluoxetine versus placebo (continuation/relapse prevention)
Efficacy of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between fluoxetine and placebo on reducing the severity of PTSD symptoms as
measured by the Davidson Trauma Scale (self-report measure) (k=1; n=98; SMD=–0.19, 95% CI
–0.59 to 0.21). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between fluoxetine and placebo on reducing the severity of PTSD symptoms as
measured by CAPS (clinician-rated measure) (k=1; n=98; SMD=–0.28, 95% CI –0.68 to 0.12). I
Tolerability of treatment
There is limited evidence favouring fluoxetine over placebo on reducing the likelihood of leaving
treatment early (k=1; n=131; RR=0.51, 95% CI 0.28 to 0.96). I
6.6.5 Tricyclic antidepressants
Although they are not licensed for PTSD, tricyclic antidepressants have been in use for much
longer than the SSRI drugs. The trials of tricyclic antidepressants are of older design and this
needs to be borne in mind as these results are considered.
6.6.5.1 Amitriptyline versus placebo (acute phase)
One trial (in combat veterans) of amitriptyline met the study criteria (DAVIDSON 1990).
Efficacy of treatment
There is limited evidence favouring amitriptyline over placebo on reducing the severity of PTSD
symptoms as measured by the Impact of Event Scale (self-report measure) (k=1; n=33;
SMD=–0.90, 95% CI –1.62 to –0.18). I
There is limited evidence favouring amitriptyline over placebo on reducing depression symptoms
as measured by the Hamilton Rating Scale for Depression (k=1; n=33; SMD=–1.16, 95% CI –1.90
to –0.41). I
There is limited evidence favouring amitriptyline over placebo on reducing anxiety symptoms as
measured by the Hamilton Rating Scale for Anxiety (k=1; n=33; SMD=–0.99, 95% CI –1.72 to
–0.26). I
Tolerability of treatment
There is limited evidence favouring placebo over amitriptyline on reducing the likelihood of
leaving treatment early (k=1; n=46; RR=1.34, 95% CI 0.52 to 3.49). I
72 Pharmacological and physical interventions for PTSD in adults
6.6.5.2 Imipramine versus placebo (acute phase)
Two trials (both in combat veterans) of imipramine met the inclusion criteria – one of imipramine
alone (KOSTEN 1991) and one of combined imipramine and psychodynamic therapy (KOSTEN
1992).
Efficacy of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between imipramine and placebo on reducing the severity of PTSD symptoms as
measured by the Impact of Event Scale (self-report measure) (k=1; n=41; SMD=–0.24, 95% CI
–0.86 to 0.38). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between imipramine and placebo on reducing depression symptoms as measured by
the Hamilton Rating Scale for Depression (k=1; n=41; SMD=–0.22, 95% CI –0.84 to 0.40). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between imipramine and placebo on reducing anxiety symptoms as measured by Covi
Anxiety (k=1; n=41; SMD=–0.46, 95% CI –1.08 to 0.17). I
Tolerability of treatment
There is limited evidence favouring imipramine over placebo on reducing the likelihood of leaving
treatment early (k=1; n=41; RR=0.78, 95% CI 0.47 to 1.3). I
6.6.5.3 Imipramine and psychodynamic therapy versus placebo (acute phase)
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between imipramine and psychodynamic therapy and placebo on reducing the severity
of PTSD symptoms as measured by Impact of Event Scale (self-report) (k=1; n=39; SMD=–0.16,
95% CI –0.8 to 0.48). I
6.6.6 Monoamine oxidase inhibitors
The use of traditional monoamine oxidase inhibitors (MAOIs) such as phenelzine has been limited
by the need to impose dietary restrictions. However, there has been research into this group of
drugs in PTSD with trials of phenelzine and brofaromine.
6.6.6.1 Brofaromine versus placebo (acute phase)
Brofaromine is a reversible MAOI with fewer side-effects than the more traditional MAOIs;
although investigated for the treatment of depression, it has never been marketed in the UK. One
trial (in a mixed trauma population) met the inclusion criteria (KATZ 1994).
Efficacy of treatment
There is limited evidence favouring brofaromine over placebo on reducing the severity of PTSD
symptoms as measured by CAPS (clinician-rated measure) (k=1; n=45; SMD=–0.58, 95% CI
–1.18 to 0.02). I
Tolerability of treatment
There is limited evidence favouring placebo over brofaromine on reducing the likelihood of
leaving treatment early (k=1; n=66; RR=1.44, 95% CI 0.69 to 3.01). I
6.6.6.2 Phenelzine versus placebo (acute phase)
A trial of phenelzine alone (KOSTEN 1991) and a trial of combined phenelzine and psychodynamic
therapy (KOSTEN 1992) met the inclusion criteria. Both trials were in combat veterans.
Efficacy of treatment
There is limited evidence favouring phenelzine over placebo on reducing the severity of PTSD
symptoms as measured by the Impact of Event Scale (self-report measure) (k=1; n=37;
SMD=–1.06, 95% CI –1.75 to –0.36). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between phenelzine and placebo on reducing depression symptoms as measured by
the Hamilton Rating Scale for Depression (k=1; n=37; SMD=–0.4, 95% CI –1.06 to 0.25). I
Study characteristics 73
Tolerability of treatment
There is evidence favouring phenelzine over placebo on reducing the likelihood of leaving
treatment early (k=1; n=37; RR=0.32, 95% CI 0.12 to 0.80). I
6.6.6.3 Phenelzine and psychodynamic therapy versus placebo (acute phase)
There is limited evidence favouring phenelzine and psychodynamic therapy over placebo on
reducing the severity of PTSD symptoms as measured by the Impact of Event Scale (k=1; n=34;
SMD=–1.01, 95% CI –1.73 to –0.29). I
6.6.7 Mirtazapine
One study of mirtazapine (DAVIDSON 2003) for a mixed trauma population met the inclusion
criteria.
6.6.7.1 Mirtazapine versus placebo (acute phase)
Efficacy of treatment
There is evidence favouring mirtazapine over placebo on reducing the severity of PTSD symptoms
as measured by the Structured Interview for PTSD (k=1; n=21; SMD=–1.89, 95% CI –3 to –0.78).
I
There is limited evidence favouring mirtazapine over placebo on reducing the severity of PTSD
symptoms as measured by the Davidson Trauma Scale (k=1; n=26; SMD=–0.76, 95% CI –1.6 to
0.08). I
There is limited evidence favouring mirtazapine over placebo on reducing depression symptoms
as measured by the depression sub-scale of the Hospital Anxiety and Depression Scale (k=1;
n=25; SMD=–0.92, 95% CI –1.81 to –0.04). I
There is limited evidence favouring mirtazapine over placebo on reducing anxiety symptoms as
measured by the anxiety sub-scale of the Hospital Anxiety and Depression Scale (k=1; n=25;
SMD=–0.88, 95% CI –1.77 to 0). I
Tolerability of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between mirtazapine and placebo on reducing the likelihood of leaving treatment
early (k=1; n=29; RR=0.9, 95% CI 0.29 to 2.82). I
6.6.8 Venlafaxine
The Committee on Safety of Medicines has recently recommended that treatment with
venlafaxine should only be initiated by mental health specialists because of concerns about
cardiotoxicity and toxicity in overdose (Committee on Safety of Medicines, 2004).
There is one unpublished study of venlafaxine that met the inclusion criteria (DAVIDSON); the
trauma population was unspecified.
6.6.8.1 Venlafaxine versus placebo (acute phase)
Efficacy of treatment
There is evidence suggesting there is unlikely to be a clinically important difference between
venlafaxine and placebo on reducing the severity of PTSD symptoms as measured by the
Davidson Trauma Scale (k=1; n=358; SMD=–0.19, 95% CI –0.4 to 0.01). I
There is evidence suggesting there is unlikely to be a clinically important difference between
venlafaxine and placebo on reducing the severity of PTSD symptoms as measured by CAPS (k=1;
n=358; SMD=–0.14, 95% CI –0.35 to 0.06). I
Tolerability of treatment
There is evidence suggesting there is unlikely to be a clinically important difference between
venlafaxine and placebo on increasing the likelihood of leaving treatment early (k=1; n=358;
RR=0.83, 95% CI 0.62 to 1.12). I
74 Pharmacological and physical interventions for PTSD in adults
6.6.9 Olanzapine
Two trials met the inclusion criteria. One study (BUTTERFIELD 2001) was of olanzapine alone
versus placebo for a mixed-trauma population (predominantly female rape victims). There was
one study (STEIN 2002) of adjunctive olanzapine (taken in conjunction with SSRIs) for male
combat veterans.
6.6.9.1 Olanzapine versus placebo (acute phase)
Efficacy of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between olanzapine and placebo on reducing the severity of PTSD symptoms as
measured by the Davidson Trauma Scale (self-report measure) (k=1; n=11; SMD=0.04, 95% CI
–1.19 to 1.26). I
Tolerability of treatment
There is limited evidence favouring placebo over olanzapine on the likelihood of leaving
treatment early (k=1; n=15; RR=1.5, 95% CI 0.2 to 11). I
6.6.9.2 Adjunctive olanzapine (acute phase)
One study (STEIN 2002) examined the efficacy of olanzapine for people already receiving but not
responsive to SSRI treatment within the first 12 weeks of SSRI treatment. During the trial, of the
total of 19 participants 5 were taking fluoxetine, 7 were taking paroxetine and 7 were taking
sertraline.
Efficacy of treatment
There is limited evidence favouring adjunctive olanzapine (to SSRI) over placebo on reducing the
severity of PTSD symptoms (clinician-rated measure) (k=1; n=19; SMD=–0.92, 95% CI –1.88 to
0.04). I
There is limited evidence favouring adjunctive olanzapine (to SSRI) over placebo on reducing
depression symptoms (k=1; n=19; SMD=–1.2, 95% CI –2.2 to –0.21). I
6.6.10 Risperidone
One study of adjunctive risperidone (HAMNER 2003A) met the inclusion criteria. In this study,
participants (all combat veterans) continued taking their previously prescribed antipsychotic,
antidepressant, benzodiazepine or sleep medications. Given the variability in the other (nonrisperidone) medications being taken by participants, some caution is required in interpreting the
effect sizes from the review of this study.
6.6.10.1 Adjunctive risperidone (acute phase)
Efficacy of treatment
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between adjunctive risperidone (combined with miscellaneous medication) and
placebo on reducing the severity of PTSD symptoms as measured by CAPS (k=1; n=37;
SMD=0.1, 95% CI –0.55 to 0.74). I
Tolerability of treatment
There is limited evidence favouring adjunctive risperidone (combined with miscellaneous
medication) over placebo on reducing the likelihood of leaving treatment early (k=1; n=40;
RR=0.5, 95% CI 0.05 to 5.08). I
6.7 General issues arising in the management
of antidepressant medication
This guideline has been developed in parallel with a set of guidelines applicable to the treatment of
depressive disorders. There is a certain amount of common ground arising from the use of
General issues 75
antidepressant drugs in both settings. This section draws heavily on the forthcoming NICE guideline
on the treatment of depression (National Collaborating Centre for Mental Health, 2005).
Common concerns in PTSD sufferers about taking medication, such as fears of addiction or that
taking medication will be seen as a weakness, should be addressed in an early discussion about
prescribing options. Discontinuation/withdrawal symptoms can occur after stopping many drugs
(that are not drugs of dependence), including antidepressants, and may be explained in the
context of ‘receptor rebound’: for example, an antidepressant with potent anticholinergic sideeffects may be associated with diarrhoea on withdrawal. Discontinuation/withdrawal symptoms
may be new or hard to distinguish from some of the original symptoms of the underlying illness.
They are experienced by at least a third of patients (Lejoyeux et al, 1996).
All patients who are prescribed antidepressants should be informed, at the time that treatment is
initiated, of potential side-effects and of the risk of discontinuation/withdrawal symptoms (particularly with paroxetine and venlafaxine). Patients started on antidepressants should be informed
about the delay in onset of effect, the time course of treatment and the need to take medication as
prescribed. Written information appropriate to the patient’s needs should be made available.
The onset of discontinuation/withdrawal symptoms is usually within 5 days of stopping
treatment, or occasionally during taper or after missed doses (Rosenbaum et al, 1998; Michelson
et al, 2000). Symptoms can vary in form and intensity and occur in any combination.
Discontinuation/withdrawal symptoms may be mistaken for a relapse of illness or the emergence
of a new physical illness (Haddad, 2001), leading to unnecessary investigations or reintroduction
of the antidepressant. It is important to counsel patients before, during and after antidepressant
therapy about the nature of this syndrome.
Generally, the antidepressant drugs recommended for use in PTSD should be discontinued over at
least a 4-week period (Rosenbaum et al, 1998). (A shorter period may be appropriate for
fluoxetine because of its long half-life.) The end of the taper may need to be slower as symptoms
may not appear until the reduction in the total daily dosage of the antidepressant is substantial.
If discontinuation/withdrawal symptoms do emerge and are mild, the clinician may reassure the patient
that these symptoms are not uncommon after discontinuing an antidepressant and will pass in a few
days. If symptoms are severe, reintroduction of the original antidepressant (or another with a longer
half-life from the same class) and gradual tapering are advised (Lejoyeux & Ades, 1997; Haddad, 2001).
During treatment with antidepressant medication, it is important to consider the risk of selfharm. Adult PTSD sufferers started on antidepressants who are considered to present an
increased suicide risk, and all those aged 18–29 years (because of the potentially increased risk of
suicidal thoughts associated with the use of antidepressants in this age group), should normally
be seen after 1 week and frequently thereafter until the risk is no longer considered significant.
For PTSD sufferers at high risk of suicide, consideration should be given to prescribing an
appropriate quantity of antidepressants and providing additional support for administering
medication. Toxicity in overdose should also be considered when choosing an antidepressant for
patients at significant risk of suicide. Practitioners should be aware that SSRIs and mirtazapine
are safer in overdose than other tricyclic antidepressants.
Patients with PTSD started on antidepressants who are not considered to be at increased risk of
suicide should normally be seen after 2 weeks and thereafter on an appropriate and regular
basis: for example, at intervals of 2–4 weeks in the first 3 months, and at greater intervals
thereafter if response is good.
There are specific issues relating to the use of SSRI medication. Particularly in the initial stages of
SSRI treatment, healthcare professionals should actively seek out signs of akathisia, suicidal ideation
and increased anxiety and agitation. They should also advise PTSD sufferers of the risk of these
symptoms in the early stages of treatment and advise them to seek help promptly if these are at all
distressing. If a PTSD sufferer develops marked and/or prolonged akathisia while taking an
antidepressant, the use of the drug should be reviewed. In the treatment of PTSD, where this is not
an uncommon issue anyway, it is also important to consider the impact of sexual side-effects.
Similarly, there are specific issues relating to the use of the monoamine oxidase inhibitor
phenelzine. All patients receiving phenelzine require careful monitoring (including blood pressure
measurement) and advice on interactions with other medicines and foodstuffs, and should have
their attention drawn to the product information leaflet.
76 Pharmacological and physical interventions for PTSD in adults
Administration of some drugs to nursing mothers may lead to effects in the infant if the drug
passes into breast milk. It is therefore important to exercise additional care. In any individual
case, a decision to prescribe should only be made after full and open discussion with the PTSD
sufferer, reference to the appendix on breast-feeding in the British National Formulary and full
consideration of the risks and benefit of this action. In general, this is likely to be an additional
factor pointing strongly to the advantages of a psychological treatment.
It is likely that guidance on the use of antidepressant drugs will be further updated during the
life of this guideline and practitioners should maintain an awareness of current guidance set out
by the Committee on Safety of Medicines and available on the Department of Health website
(http://www.info.doh.gov.uk/doh/embroadcast.nsf/vwDiscussionAll/
9AA9EC56B07B3B4F80256F61004BAA88).
6.8 Repetitive transcranial magnetic stimulation
Repetitive transcranial magnetic stimulation (rTMS) is a new technique under investigation in a
range of conditions, such as depression and stroke. It involves placing an electromagnetic coil on
the scalp and rapidly turning on and off a high-intensity current through the discharge of a
capacitor. The magnetic pulse induces electrical effects in the underlying brain cortex. These
pulses vary in frequency. If the stimulation occurs faster than once per second (1 Hz), it is referred
to as fast or high-frequency rTMS and may result in excitatory physiological changes. On the
other hand, low-frequency or slow rTMS may have an inhibitory effect on brain excitability. There
is a low risk of seizure and certain exclusion criteria apply. In the study by Cohen (COHEN 2004)
investigators administered rTMS over the right dorsolateral prefrontal cortex of the brain for 20
min per day over 10 working days. The sham treatment group also underwent the same
procedure but the positioning of the coil was such that it did not have an effect (it was held
vertically to the scalp rather than being placed on the scalp). There were two treatment groups:
one receiving fast rTMS (10 Hz) and the other slow rTMS (1 Hz).
6.8.1 High-frequency rTMS versus control
Efficacy of treatment
There is limited evidence favouring high-frequency rTMS over control on reducing the severity of
PTSD symptoms as measured by clinician-rated CAPS at 14 days’ follow-up (k=1; n=16; SMD=–
0.72, 95% CI –1.77 to 0.33). I
There is limited evidence favouring high-frequency rTMS over control on reducing the severity of
PTSD symptoms at 14 days’ follow-up as measured by self-report PTSD checklist (k=1; n=16;
SMD=–0.68, 95% CI –1.73 to 0.36). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between high-frequency rTMS and control on reducing depression symptoms at 14
days’ follow-up as measured by the clinician-rated Hamilton Rating Scale for Depression (k=1;
n=16; SMD=–0.13, 95% CI –1.14 to 0.89). I
Tolerability of treatment
There is limited evidence favouring high-frequency rTMS over control on reducing the likelihood
of leaving the study early for any reason prior to 14 days’ follow-up (k=1; n=19; RR=0.36, 95%
CI 0.04 to 3.35). I
6.8.2 Low-frequency rTMS versus control
Efficacy of treatment
There is limited evidence favouring control over low-frequency rTMS on reducing the severity of
PTSD symptoms as measured by CAPS (clinician-rated measure) at 14 days’ follow-up (k=1;
n=14; SMD=0.82, 95% CI –0.25 to 1.88). I
There is limited evidence favouring control over low-frequency rTMS on reducing the severity of
PTSD symptoms at 14 days’ follow-up as measured by the PTSD Checklist (self-report measure)
(k=1; n=14; SMD=0.67, 95% CI –0.43 to 1.77). I
Repetitive transcranial magnetic stimulation
77
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between low-frequency rTMS and control on reducing depression symptoms at 14
days’ follow-up as measured by the Hamilton Rating Scale for Depression (clinician-rated
measure) (k=1; n=14; SMD=0.36, 95% CI –0.71 to 1.43). I
Tolerability of treatment
There is limited evidence favouring low-frequency rTMS over control on reducing the likelihood of
leaving the study early for any reason prior to 14 days’ follow-up (k=1; n=18; RR=0.8, 95% CI
0.14 to 4.49). I
6.9 Clinical summary
We have drawn attention to the important difficulties of comparing drug treatment trials with
psychological therapy trials. The tough design of the drug trial is likely to produce a lower effect
size than a comparable psychological treatment trial.
However, using an a priori criterion for a clinically important effect, the drug treatments were
disappointing. For paroxetine, there is a reliable, positive but small effect, which (although
statistically significant) fell short of the target effect size of 0.5 for a clinically important
intervention. Once we included additional unpublished data, we were able to demonstrate
neither clinically important nor statistically significant effects in the meta-analysis for sertraline,
the other drug licensed in the UK.
There are a number of other randomised controlled trials that met the inclusion criteria, although
these tended to be based on relatively small samples and therefore need to be interpreted with
some caution. These suggest that there may be a clinically important effect for mirtazapine,
amitriptyline and the MAOI antidepressants phenelzine and brofaromine.
The difficulties arising from simple comparisons of recent large trials and older small trials have
already been identified. It would be incorrect to conclude that an older drug with an apparently
larger effect size in a small trial is preferable. It is likely that none of the drug treatments has a
very large effect size using current robust trial methodology. Current policy is to favour the use of
licensed drugs in preference to unlicensed drugs. However, prescribers should be aware of other
positive trial data in reaching a clinical decision. The use of unlicensed drugs is the responsibility
of the prescriber.
This review includes one RCT using a non-pharmacological treatment (rTMS). This report is
encouraging (for high-frequency rTMS) but further research is required to determine the place of
interventions like this in the management of PTSD.
In the event that few trials for a review had effect sizes that met the thresholds for clinical
significance, as was the case for this review of drug treatments, statistical significance in the
meta-analysis was also taken into account in reaching a recommendation (see Chapter 4).
A specific drug is recommended here if it meets the threshold for clinical effect as outlined above
and is currently available in the UK. Thus, mirtazapine, amitriptyline and phenelzine have been
included (brofaromine not being currently available), although we do recognise that in each case,
this recommendation is made on the basis of data from single trials.
We have concluded that we should recommend paroxetine on the basis of its robust
statistically significant effect based on large-trial data, even though it did not meet the
threshold for a clinically significant effect as we have defined it in the list of recommended
drugs. This is the only drug in the list of recommendations with a current UK product licence
for PTSD.
We have also made a recommendation about the use of adjunctive olanzapine in people who are
non-responsive to initial drug treatment. In this case, the recommendation is based on limited
evidence of a clinically important effect on comorbid depression symptoms. Although the metaanalysis shows a limited evidence of effect on PTSD symptoms as well, this does not reach
statistical significance and needs to be interpreted with caution.
We have also examined tolerability data and side-effect profiles. On this basis, we recommend
that paroxetine and mirtazapine should be the drugs of choice for use in primary care.
78 Pharmacological and physical interventions for PTSD in adults
Phenelzine, amitriptyline (and adjunctive olanzapine) should be recommended as additional drug
treatments for use under supervision of mental health specialists.
6.10 Clinical practice recommendations
6.10.1 Recommendations specific to PTSD
6.10.1.1
Drug treatments for PTSD should not be used as a routine first-line treatment for
adults (in general use or by specialist mental health professionals) in preference to a
trauma-focused psychological therapy. A
6.10.1.2
Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or
phenelzine for initiation only by mental health specialists) should be considered for
the treatment of PTSD in adults when a sufferer expresses a preference not to engage
in a trauma-focused psychological treatment. B
6.10.1.3
Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or
phenelzine for initiation only by mental health specialists) should be offered to adult
PTSD sufferers who cannot start a psychological therapy because of serious ongoing
threat of further trauma (for example, where there is ongoing domestic violence). C
6.10.1.4
Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or
phenelzine for initiation only by mental health specialists) should be considered for
adult PTSD sufferers who have gained little or no benefit from a course of traumafocused psychological treatment. C
6.10.1.5
Where sleep is a major problem for an adult PTSD sufferer, hypnotic medication may
be appropriate for short-term use but, if longer-term drug treatment is required,
consideration should also be given to the use of suitable antidepressants at an early
stage in order to reduce the later risk of dependence. C
6.10.1.6
Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or
phenelzine for initiation only by mental health specialists) for PTSD should be
considered as an adjunct to psychological treatment in adults when there is significant
comorbid depression or severe hyperarousal that significantly impacts on a sufferer’s
ability to benefit from psychological treatment. C
6.10.1.7
When an adult sufferer with PTSD has not responded to a drug treatment,
consideration should be given to increasing the dosage within approved limits. If
further drug treatment is considered, this should generally be with a different class of
antidepressant or involve the use of adjunctive olanzapine. C
6.10.1.8
When an adult sufferer with PTSD has responded to drug treatment, it should be
continued for at least 12 months before gradual withdrawal. C
6.10.2 General recommendations
6.10.2.1
All PTSD sufferers who are prescribed antidepressants should be informed, at the time
that treatment is initiated, of potential side-effects and of the risk of discontinuation/
withdrawal symptoms (particularly with paroxetine). C
6.10.2.2.
Discontinuation/withdrawal symptoms are usually mild and self-limiting but
occasionally can be severe. Prescribers should normally gradually reduce the doses of
antidepressants over a 4-week period, although some people may require longer
periods. C
6.10.2.3
If discontinuation/withdrawal symptoms are mild, practitioners should reassure the
PTSD sufferer and arrange for monitoring. If symptoms are severe, the practitioner
should consider reintroducing the original antidepressant (or another with a longer
half-life from the same class) and reducing it gradually while monitoring symptoms. C
6.10.2.4
Adult PTSD sufferers started on antidepressants who are considered to present an
increased suicide risk and all patients aged between 18 and 29 years (because of the
Clinical practice recommendations 79
potential increased risk of suicidal thoughts associated with the use of antidepressants
in this age group) should normally be seen after 1 week and frequently thereafter
until the risk is no longer considered significant. GPP
6.10.2.5
Particularly in the initial stages of SSRI treatment, practitioners should actively seek
out signs of akathisia, suicidal ideation and increased anxiety and agitation. They
should also advise PTSD sufferers of the risk of these symptoms in the early stages of
treatment and advise them to seek help promptly if these are at all distressing. GPP
6.10.2.6
If a PTSD sufferer develops marked and/or prolonged akathisia while taking an
antidepressant, the use of the drug should be reviewed. GPP
6.10.2.7
Adult PTSD sufferers started on antidepressants who are not considered to be at
increased risk of suicide should normally be seen after 2 weeks and thereafter on an
appropriate and regular basis, for example, at intervals of 2–4 weeks in the first 3
months, and at greater intervals thereafter, if response is good. GPP
6.11 Research recommendations
6.11.1 Trauma-focused psychological treatment versus pharmacological
treatment
6.11.1.1
Adequately powered, appropriately designed trials should be conducted to determine
if trauma-focused psychological treatments are superior in terms of efficacy and costeffectiveness to pharmacological treatments in the treatment of PTSD and whether
they are efficacious and cost-effective in combination.
Rationale
Post-traumatic stress disorder is a common and potentially disabling condition. It has been
shown that trauma-focused psychological treatments are effective for this disorder (Van Etten &
Taylor, 1998). At the moment, these interventions (done properly) are often hard to access. Drug
treatments have the advantage of accessibility, although the evidence for the efficacy of
pharmacological treatment is less strong (Stein et al, 2004). Currently there is no large, welldesigned trial that directly compares these two approaches (Stein et al, 2004). There is one small
trial comparing paroxetine and cognitive–behavioural therapy (Frommberger et al, 2004), but this
lacks adequate power. Therefore, the only real comparison between these two approaches relies
on indirect methods of limited validity, further hampered by high withdrawal rates in many trials.
Large, well-designed trials would allow direct comparisons and should help to determine the
relative places of trauma-focused psychological treatment and pharmacological treatment in
PTSD, both individually and in combination. There is also an opportunity for the NHS to use this
as a case example for forging a real partnership between itself, the pharmaceutical industry and
other major research funders in undertaking this investigation.
80 Pharmacological and physical interventions for PTSD in adults
7 Early interventions for PTSD in adults
7.1 Introduction
The incentive to identify and develop effective early interventions for post-traumatic stress
disorder comes from three sources. First, PTSD is a distressing and disabling condition from
which a great number of sufferers do not spontaneously recover. Therefore, early and effective
treatment might reduce the burden of PTSD on both the individual and society. Second, now that
studies have identified the post-incident prevalence rates of PTSD from large-scale disasters and
combat, there is concern to ameliorate the impact of PTSD by responding in the early days and
weeks following such incidents. Third, occupational groups such as firefighters have campaigned
to have the psychological impact of their work recognised and support services delivered as part
of their conditions of employment. In addition, in military organisations, there exists a specific
drive to early interventions – that of enabling traumatised combatants to return to front-line
duties as soon as possible.
However, given that the prevalence of initial distress following a traumatic event is far greater
than that of either acute stress disorder or PTSD, the potential exists to deliver interventions to
people whose problems would spontaneously remit. As well as the time commitment required of
the traumatised individual, interventions for traumatic stress generally involve confronting
aspects of distressing experiences, the emotional cost of which might not warrant early
intervention. This potential for diluting the cost-effectiveness of early interventions is a significant
factor in service planning, particularly disaster planning and employee support. There is a
vigorous debate between those who would provide some intervention for all victims and
survivors of traumatic incidents, and those who advocate waiting and targeting interventions at
people likely to develop the disabling symptoms of chronic PTSD (Litz et al, 2002).
7.2 Current practice
Several interventions often referred to generically as ‘debriefing’, such as crisis intervention
(Raphael, 1986) and critical incident stress debriefing (CISD; Mitchell, 1983), have been
developed since the 1980s to help deal with the immediate psychological aftermath of severe
trauma. In particular, CISD – defined as a meeting of those involved in a traumatic event, which
aims to diminish the impact of the event by promoting support and encouraging processing of
traumatic experiences in a group setting (Richards, 2001) – gained widespread initial popularity.
Subsequently, Mitchell & Everly (1997) coined the term ‘critical incident stress management’
(CISM) to differentiate the single-session, stand-alone debriefing meeting from a broader,
multicomponent programme including pre-trauma training, CISD, follow-up and case
management. Both CISD and CISM were designed to try to accelerate recovery before harmful
stress reactions have had a chance to damage the performance, career, health and families of
victims. However, there is no agreement on the best way to deliver early interventions or indeed
whether it is possible to reduce the incidence of PTSD through this route (Litz et al, 2002).
Indeed, the area is hotly contested. The efficacy of debriefing has been called into question in
systematic reviews (e.g. van Emmerik et al, 2002; Rose et al, 2004), which have suggested that
single-session CISD produced either no improvement compared with controls or had the
potential to cause significant harm to those debriefed. It has been suggested that single-session
debriefing might sensitise traumatised individuals further or might persuade people not to use
the necessary natural social support networks likely to assist with recovery (van Emmerik et al,
2002). These studies led to claims that CISD was an ineffective technique and that it should not
be routinely used in supporting people after traumatic incidents (Avery & Orner, 1998; Wessely et
al, 1998). Other reviews, however, came to the conclusion that CISD is a useful technique as part
of an overall CISM programme (Everly et al, 1999) and that the studies included in the negative
reviews sacrifice internal validity for experimental control, use self-selected participants, misapply
these techniques to individuals rather than to the groups for which they were originally designed,
81
use CISD outside the time scale recommended and have debriefers who appear inadequately
trained (Mitchell & Everly, 1997). Indeed, negative reviews such as that by van Emmerick et al
(2002) do include the caveat that CISD was never designed to be a stand-alone intervention.
Some have suggested that early intervention and debriefing should be directed at community or
group support rather than individual treatment and have called for new research methods to
investigate this approach (British Psychological Society, 2002).
Indeed, the lack of non-intervention controls in studies of ‘pure’ debriefing is a problem for
clinicians and policy-makers alike, a problem compounded by the ethical difficulty of designing
non-intervention conditions in sensitive post-incident or workplace environments where offering no
support may be unacceptable to employees and employers alike. The provision of psychological
debriefing as a community support and cohesion strategy (British Psychological Society, 2002)
rather than a treatment intervention to prevent PTSD is beyond the scope of this guidance.
More recently, there has been significant interest in replicating some of the findings from the
treatment of chronic PTSD in an early intervention format with populations identified as at risk of
developing chronic PTSD. The belief that cognitive–behavioural therapy is effective for PTSD, the
disquiet over debriefing and the desire referred to earlier to limit the duration of disability for
sufferers has led to either the adaptation of routine CBT into shorter variants delivered close to
the time of the incident or the application of more standard CBT within a few months of the
incident. Given that the efficacy of CBT for PTSD was only established in the late 1990s, early
interventions of this kind are a new development and have only recently been the subject of
research.
7.3 Studies included
The review team conducted a new systematic search for RCTs that assessed the efficacy of
treatments delivered in any of the two areas described above. From the main search for RCTs (see
Appendix 6), 21 studies in all were identified that met the inclusion criteria. The retrieved studies
were divided into three groups:
treatment for all – studies that investigated treatments delivered to all traumatic incident
survivors, normally within the first month after the incident
early psychological interventions for acute PTSD and acute stress disorder – studies that
investigated treatments delivered to people who were assessed as having a high risk of
chronic PTSD, initiated within 3 months of the incident
early pharmacological interventions – studies using drug treatments for people in the acute
phase of the disorder.
Ten studies were identified as falling within the ‘treatment for all’ category: BISSON 1997, BROM
1993, CAMPFIELD 2001, CONLON 1999, DOLAN, HOBBS 1996, LEE 1996, MAYOU 2000, ROSE 1999
and ZATZICK 2001. Nine studies, comprising five different types of intervention, were identified as
falling within the category of early interventions for acute PTSD and acute stress disorder: BISSON
2004, BRYANT 1998, BRYANT 1999, BRYANT 2003, BRYANT A, BRYANT B, ECHEBURA 1996, EHLERS
2003A and OST 2003. (In EHLERS 2003A the self-monitoring period was taken to be part of the
active intervention and as occurring within 3 months of the trauma.) Two studies were identified as
falling in the pharmacological category: PITMAN 2002 and SCHELLING 2001. References given in
shortened format and summary characteristics of individual included trials are given in Appendix 14.
7.4 Treatment for all
Four different types of early intervention for all were identified in the RCTs that met the inclusion
criteria. These were education, collaborative care, trauma-focused counselling and debriefing.
7.4.1 Education
One study (ROSE 1999, n=157) included a 30 min educational intervention in its randomised
design, comparing it with debriefing and an assessment-only control group. Individuals were
82 Early interventions for PTSD in adults
assault victims and the intervention was delivered to them 9–31 days after the assault. Education
consisted of a 30 min session related to the individual’s experiences and information on when
and where to find help, and included a specially written leaflet. Education was delivered by a
therapist whose qualifications were not described. Outcomes were reported at 6 months postintervention.
7.4.1.1 Education versus control
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between education and control on reducing the likelihood of having a PTSD diagnosis
at 6 months’ follow-up (k=1; n=103; RR=0.69, 95% CI 0.37 to 1.3). I
There is evidence suggesting there is unlikely to be a clinically important difference between
education and control on reducing the severity of PTSD symptoms (self-reported) at 6 months’
follow-up (k=1; n=91; SMD=–0.18, 95% CI –0.59 to 0.24). I
7.4.2 Collaborative care
One study (ZATZICK 2001, n=34) compared a collaborative care programme delivered by a
trauma support specialist for road traffic accident survivors with usual care. Collaborative care
involved eliciting and monitoring patients’ post-traumatic concerns and joint provider–patient
treatment planning. Monitoring was undertaken by consultation liaison psychiatrists and a
trauma clinical nurse specialist. The intervention was delivered from 1 month after the accident
for 4 months and involved trauma support specialists monitoring psychological health, reviewing
the traumatic event, providing education on coping strategies, jointly developing problem
definitions and plans with individuals, and liaison with a multidisciplinary trauma team.
Outcomes were reported at 4 months post-intervention.
7.4.2.1 Collaborative care versus control
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between collaborative care and control on reducing the severity of PTSD symptoms
(self-report measures) at 1 month’s follow-up (k=1; n=29; SMD=–0.5, 95% CI –1.24 to 0.24). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between collaborative care and control in severity of PTSD symptoms (self-report
measures) at 4 months’ follow-up (k=1; n=26; SMD=0.4, 95% CI –0.38 to 1.18). I
7.4.3 Trauma-focused counselling
One study (BROM 1993, n=151) compared a three- to six-session counselling programme with a
monitoring control. Counselling was delivered 1–3 months after the traumatic incident to road
traffic accident survivors. Counselling included practical help, education, support, reality testing
and confrontation with the traumatic experience. Outcomes were reported at 6 months following
the accident.
7.4.3.1 Trauma-focused counselling versus control
There is evidence suggesting there is unlikely to be a clinically important difference between
trauma-focused counselling and control on reducing the severity of PTSD symptoms (self-report
measures) at 6 months’ follow-up (k=1; n=151; SMD=0.17, 95% CI –0.15 to 0.49). I
7.4.4 Debriefing
Seven RCTs of individual psychological debriefing were identified: BISSON 1997, CONLON 1999,
DOLAN, HOBBS 1996, LEE 1996, MAYOU 2000 and ROSE 1999; n=629. Studies involved
individuals who had experienced a range of traumatic events including road traffic incidents,
assaults, miscarriages, fires and unspecified other incidents. Psychological debriefing was
delivered between 10 hours and 31 days after the incident, with a duration of 30–120 min. Five
studies were of individual treatment only, one study included some debriefing of groups of two
to five PTSD sufferers and another included family members in some debriefing sessions. All
debriefing interventions were single sessions and included education about traumatic stress,
Treatment for all
83
expression of emotions and planning for the future. Debriefing was delivered by a range of
professionals, including nurses, mental health nurses, psychiatrists and psychologists. The
training and qualifications of the debriefers was not comprehensively described in any of the
studies. Five studies reported post-intervention outcomes up to 4 months; three studies reported
outcomes from 6 months to 13 months and one study reported outcomes to 3 years. There was
no randomised study of critical incident debriefing, the group-focused approach advocated by
Mitchell & Everly (1997), in contrast to the single-session, typically individually focused debriefing
interventions considered in this section.
7.4.4.1 Delayed versus immediate debriefing
One study of delayed versus immediate debriefing for victims of robbery was included
(CAMPFIELD 2001). Debriefing lasted 1–2 hours and was conducted individually or in small
groups. There was evidence favouring immediate debriefing (occurring within 10 hours of the
trauma) to delayed debriefing (occurring within 48 hours of the trauma) for reducing PTSD
severity at 2 weeks post-trauma. However, the study provided no data to indicate how sustained
this relative improvement was, and in the absence of a control group it is not possible to
determine whether both treatments led to an improvement relative to natural recovery at 2
weeks.
7.4.4.2 Debriefing versus control
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between debriefing and control on reducing the likelihood of having a PTSD diagnosis
at 3–6 months’ follow-up (k=2; n=238; RR=1.2, 95% CI 0.84 to 1.71). I
There is limited evidence suggesting a difference favouring control over debriefing on reducing
the likelihood of having a PTSD diagnosis at 13 months’ follow-up (k=1; n=133; RR=1.87, 95%
CI 1.12 to 3.12). I
There is evidence suggesting there is unlikely to be a clinically important difference between
debriefing and control on reducing the severity of PTSD symptoms (self-report measures) at 1–4
months’ follow-up (k= 5; n=356; SMD=0.11, 95% CI –0.1 to 0.32). I
There is evidence suggesting there is unlikely to be a clinically important difference between
debriefing and control on reducing depression symptoms at 1–4 months’ follow-up (k= 3;
n=225; SMD=0, 95% CI –0.27 to 0.26). I
7.5 Treatment for all – clinical summary
When brief, single-session interventions of debriefing or education are offered as an individually
structured intervention to any person involved in a traumatic incident, there is evidence
suggesting that there is unlikely to be a clinically important effect on subsequent PTSD and across
a range of self-report measures. However, one study (BISSON 1997) suggested that there is
limited evidence of harmful effects of debriefing at 13 months’ post-injury for PTSD diagnosis. On
current evidence, therefore, single-session debriefing may be at best ineffective.
An important reservation in interpreting the evidence for early interventions for all is that all the
studies were of survivors who had experienced individual traumas and who in the main received
an individual intervention. No trial on critical incident stress debriefing as it was originally
conceived by Mitchell and colleagues (i.e. as a group intervention for teams of emergency
workers, military personnel or others who are used to working together) or critical incident stress
management (i.e. a multicomponent programme of debriefing, follow-up and case management)
met our methodological inclusion criteria. As a consequence we have a lack of evidence for
practice in these situations. Furthermore, there is a paucity of methodologically sound early
intervention studies, containing detailed descriptions of training and fidelity checks on
interventions used.
Notwithstanding these methodological reservations, given the evidence that there is unlikely to
be a clinically important effect on subsequent PTSD, we do not recommend that systematic, brief,
single-session interventions focusing on the traumatic incident are provided individually to
84 Early interventions for PTSD in adults
everyone who has been exposed to such an incident. However, we do recommend the good
practice of providing general practical and social support and guidance to anyone following a
traumatic incident. Acknowledgement of the psychological impact of traumatic incidents should
be part of healthcare and social service workers’ responses to incidents. Support and guidance
are likely to cover reassurance about immediate distress, information about the likely course of
symptoms, and practical and emotional support in the first month after the incident.
7.6 Early psychological interventions for acute PTSD
and acute stress disorder
Five different types of early intervention for all were identified in the RCTs that met the inclusion
criteria: trauma-focused cognitive–behavioural therapy (as defined in Chapter 5), trauma-focused
CBT supplemented with hypnosis or anxiety management, relaxation techniques and a self-help
booklet.
7.6.1 Cognitive–
– behavioural therapy
All nine studies identified for ‘early intervention for acute PTSD’ had one treatment group that
underwent some form of CBT (see Chapter 5 for descriptions of the treatments that fall within
this category): BISSON 2004, BRYANT 1998, BRYANT 1999, BRYANT 2003, BRYANT A, BRYANT B,
ECHEBURA 1996, EHLERS 2003A and OST 2003; n=491 (one of these studies, BRYANT 2003, was
a 4-year follow-up to BRYANT 1998 and BRYANT 1999). These studies involved individuals who
had experienced accidents or physical and sexual assaults. In six studies, individuals were
identified within 1 month of the trauma occurring and treatment was continued into the period
1–6 months after the trauma. In the other three studies, PTSD sufferers were identified within 3
months and treatment was completed within 6 months. All individuals were included in the
studies on the basis of symptomatic criteria, but these varied. Four studies required survivors to
have a diagnosis of acute stress disorder; two others required survivors to meet symptomatic
diagnostic criteria for PTSD; another two studies required individuals to meet PTSD symptomatic
diagnostic criteria and, in addition, to exceed cut-off scores on screening tools; and a final study
included individuals on the basis of exceeding cut-off scores on screening tools only. Treatment
was delivered to individuals rather than in groups and ranged from 4 sessions to 16 sessions of
1–2 hours’ duration, a total time ranging from 4 hours to almost 17 hours of therapy. Treatment
also included varied combinations of education, relaxation, imaginal exposure, image habituation
training, thought stopping, distraction, cognitive restructuring and in vivo exposure. Postintervention outcomes were reported in four studies at 6 months and in another five studies at
9–13 months. One study reported a further follow-up at 4 years.
7.6.1.1 Trauma-focused CBT versus control
There is limited evidence suggesting a difference favouring trauma-focused CBT over waiting list
(random effects) on reducing the likelihood of having a PTSD diagnosis post-treatment (k=3;
n=252; RR=0.4, 95% CI 0.16 to 1.02). I
There is limited evidence suggesting a difference favouring trauma-focused CBT over waiting list
(random effects) on reducing the likelihood of having a PTSD diagnosis at 9–13 months’ followup (k=2; n=209; RR=0.41, 95% CI 0.11 to 1.45). I
There is limited evidence suggesting a difference favouring trauma-focused CBT over waiting list
(random effects) on reducing the severity of PTSD symptoms (self-report measures) (k=3; n=224;
SMD=–0.98, 95% CI –1.81 to –0.14). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between trauma-focused CBT and waiting list (random effects) on reducing the
severity of PTSD symptoms (self-report measures) at 9–13 months’ follow-up (k=2; n=171;
SMD=–0.68, 95% CI –1.23 to –0.12). I
There is limited evidence suggesting a difference favouring trauma-focused CBT over waiting list
(random effects) on reducing the severity of PTSD symptoms (clinician-rated measures) (k=3;
n=224; SMD=–0.88, 95% CI –1.72 to –0.04). I
Early psychological interventions 85
There is evidence suggesting there is unlikely to be a clinically important difference between
trauma-focused CBT and waiting list (fixed effects) on reducing the severity of PTSD symptoms
(clinician-rated measures) at 9–13 months’ follow-up (k=2; n=171; SMD=–0.45, 95% CI –0.75 to
–0.14). I
7.6.2 Prolonged exposure with anxiety management
One study (BRYANT 1999, n=36) compared the effectiveness of prolonged exposure and anxiety
management techniques against prolonged exposure. Prolonged exposure entailed a minimum of
four 50 min sessions of imaginal exposure to the traumatic memories as part of the five 90 min
treatment sessions. Anxiety management included breathing retraining, self-talk and progressive
muscular relaxation exercises. Individuals had all experienced road traffic accidents or non-sexual
assaults and outcomes were reported at 6 months post-intervention.
There is limited evidence suggesting a difference favouring prolonged exposure over prolonged
exposure with anxiety management on reducing the likelihood of having a PTSD diagnosis posttreatment (k=1; n=38; RR=0.58, 95% CI 0.3 to 1.15). I
There is limited evidence suggesting a difference favouring prolonged exposure over prolonged
exposure with anxiety management on reducing the likelihood of having a PTSD diagnosis as
observed at 6 months’ follow-up (k=1; n=38; RR=0.64, 95% CI 0.37 to 1.11). I
7.6.3 Trauma-focused CBT and hypnotherapy
One study (BRYANT B, n=63) compared the effectiveness of trauma-focused CBT versus traumafocused CBT with an additional element of hypnotherapy in the form of a 15 min hypnotic
induction audiotape recording, for individuals who had experienced road traffic accidents or nonsexual assaults. Outcomes were reported to 6 months post-intervention.
7.6.3.1 Trauma-focused CBT versus trauma-focused CBT and hypnotherapy
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between trauma-focused CBT and trauma-focused CBT with hypnotherapy on reducing
the likelihood of having a PTSD diagnosis post-treatment (k=1; n=63; RR=1.21, 95% CI 0.6 to
2.46). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between trauma-focused CBT and trauma-focused CBT with hypnotherapy on reducing
the likelihood of having a PTSD diagnosis as observed at 6 months’ follow-up (k=1; n=63;
RR=1.06, 95% CI 0.59 to 1.92). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between trauma-focused CBT and trauma-focused CBT with hypnotherapy on reducing
the severity of PTSD symptoms (self-report measures) (k=1; n=47; SMD=0.13, 95% CI –0.45 to
0.7). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between trauma-focused CBT and trauma-focused CBT with hypnotherapy on reducing
the severity of PTSD symptoms (self-report measures) as observed at 6 months’ follow-up (k=1;
n=47; SMD=0.07, 95% CI –0.5 to 0.64). I
7.6.4 Relaxation
One study of trauma-focused CBT (ECHEBURA 1996, n=20) used relaxation alone as a
comparator condition with a group of female survivors of sexual assault. Relaxation was
progressive muscle relaxation training and was delivered in five hour-long sessions. Postintervention outcomes were reported to 12 months.
7.6.4.1 Trauma-focused CBT versus relaxation
There is limited evidence suggesting a difference favouring trauma-focused CBT over progressive
muscular relaxation training on reducing the likelihood of having a PTSD diagnosis posttreatment (k=1; n=20; RR=0.4, 95% CI 0.1 to 1.6). I
86 Early interventions for PTSD in adults
There is limited evidence suggesting a difference favouring trauma-focused CBT over progressive
muscular relaxation training on reducing the likelihood of having a PTSD diagnosis at 12 months’
follow-up (k=1; n=20; RR=0.2, 95% CI 0.01 to 3.7). I
7.6.5 Supportive psychotherapy
Five studies (BRYANT 1998, BRYANT 1999, BRYANT 2003, BRYANT A and BRYANT B; n=191)
involved a comparison of ‘supportive psychotherapy’ against other treatments. Across the
studies, the researchers defined supportive psychotherapy to include active listening, education,
problem-solving and unconditional support to individuals.
7.6.5.1 Trauma-focused CBT versus supportive psychotherapy
There is evidence suggesting a difference favouring trauma-focused CBT over supportive
psychotherapy on reducing the likelihood of having a PTSD diagnosis at 6 months’ follow-up
(k=3; n=105; RR=0.51, 95% CI 0.32 to 0.8). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between trauma-focused CBT and supportive psychotherapy on reducing the likelihood
of having a PTSD diagnosis at 4 years’ follow-up (k=1; n=80; RR=0.9, 95% CI 0.61 to 1.33). I
There is evidence suggesting a difference favouring trauma-focused CBT over supportive
psychotherapy on reducing the severity of PTSD symptoms (self-report measures) (k=3; n=94;
SMD=–1.11, 95% CI –1.55 to –0.67). I
There is limited evidence suggesting a difference favouring trauma-focused CBT over supportive
psychotherapy on reducing the severity of PTSD symptoms (self-report measures) at 6 months’
follow-up (k=3; n=94; SMD=–0.8, 95% CI –1.22 to –0.37). I
7.6.6 Self-help
One study of trauma-focused CBT (EHLERS 2003A, n=85) used self-help as a comparator
condition for individuals who had experienced road traffic accidents or physical assault. Self-help
patients were given a 64-page booklet based on CBT principles, accompanied by one 40 min
session with a therapist at the beginning of treatment to explain the book and its content. Postintervention outcomes were reported to 9 months.
For self-help booklet intervention delivered 1–6 months after the incident, the evidence varies
from suggesting that there is not a clinically important difference between the intervention and
control, to being inconclusive across the different measures of outcome.
7.6.6.1 Self-help booklet versus control
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between self-help booklet and waiting list on reducing the likelihood of having a PTSD
diagnosis post-treatment (k=1; n=57; RR=1.09, 95% CI 0.81 to 1.46). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between self-help booklet and waiting list on reducing the likelihood of having a PTSD
diagnosis at 9 months’ follow-up (k=1; n=57; RR=1.1, 95% CI 0.71 to 1.71). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between self-help booklet and waiting list on reducing the severity of PTSD symptoms
(self-report measures) (k=1; n=52; SMD=–0.27, 95% CI –0.81 to 0.28). I
There is evidence suggesting there is unlikely to be a clinically important difference between selfhelp booklet and waiting list on reducing the severity of PTSD symptoms (clinician-rated
measures) at 9 months’ follow-up (k=1; n=52; SMD=0.07, 95% CI –0.47 to 0.62). I
7.7 Clinical summary of early psychological interventions
When trauma-focused CBT is delivered between 1 month and 6 months after the incident, there
is evidence suggesting that it is effective for people at risk of developing chronic PTSD, compared
Clinical summary of early psychological interventions 87
with the effect of being on a waiting list, for PTSD diagnosis post-treatment and at 9–13
months’ follow-up, as well as a number of other outcomes assessed post-treatment, which
included self-report measures of PTSD severity, anxiety and quality of life and clinician-assessed
PTSD severity. However, the evidence is inconclusive for a number of outcomes assessed at 9–13
months’ follow-up (self-report measures of PTSD severity, anxiety and quality of life) and the
evidence suggests that there is no clinically important difference for clinician-assessed PTSD
severity at 9–13 months.
Trauma-focused CBT delivered between 1 month and 6 months after the incident is also more
effective for people at risk of developing chronic PTSD compared with being on a waiting list or
receiving non-trauma-focused interventions such as self-help booklets, relaxation or general
supportive counselling.
Although trauma-focused CBT is effective for people at risk of developing chronic PTSD, there is
great variation in the dimensions of delivery. The variable response rates in different studies are
unexplained and may be due to differences in the PTSD sufferer intake variables (for example,
symptomatic PTSD criteria versus diagnoses of acute stress disorder), number of treatment sessions,
the expertise of the therapists or the length of individual therapy sessions. The interaction and
predictive effects of symptom severity and the duration and number of sessions in trauma-focused
CBT are likely to be highly important but have not been systematically varied in controlled trials.
7.8 Early intervention drug treatments for PTSD
There are few trials of early intervention drug treatments and only two studies met the inclusion
criteria. The results of the review of these studies are summarised below. For further information
on the differences between drug trials and trials of other interventions, see Chapter 6.
7.8.1 Propranolol versus placebo
One study (PITMAN 2002) compared propranolol and placebo. Propranolol is a betaadrenoceptor blocker and crosses the blood–brain barrier. This trial was based on a priori
hypotheses about the role of the amygdala in the development of PTSD. Participants were
administered propranolol (40 mg four times a day) or placebo, beginning within 6 hours of the
traumatic event.
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between propranolol and placebo on reducing the likelihood of having a PTSD
diagnosis at 1 month (k=1; n=41; RR=1.14, 95% CI 0.55 to 2.35). I
There is limited evidence suggesting a difference favouring placebo over propranolol on reducing
the likelihood of having a PTSD diagnosis at 3 months’ follow-up (k=1; n=41; RR=1.28, 95% CI
0.69 to 2.38). I
7.8.2 Hydrocortisone versus placebo
One study (SCHELLING 2001, n=20) explored the effect of hydrocortisone (a corticosteroid) and
placebo on the reactions to the intense physical and psychological stress during septic shock in
the intensive care environment. Studies of hydrocortisone are of particular interest given the
evidence of disturbance in the HPA axis in PTSD.
There is limited evidence suggesting a difference favouring hydrocortisone over placebo on
reducing the likelihood of having a PTSD diagnosis at approximately 31 months after treatment
(k=1; n=20; RR=0.17, 95% CI 0.03 to 1.17). I
7.9 Clinical summary of early intervention drug treatments
Given the small number and scale of studies of early intervention drug treatments, it is not
possible to draw strong conclusions. At present there is no conclusive evidence that any drug
88 Early interventions for PTSD in adults
treatment helps as an early intervention for the treatment of PTSD-specific symptoms. However,
for sufferers who are acutely distressed, and may in particular be experiencing significant sleep
problems, consideration may be given to the use of medication.
7.10 Economic evaluation of early versus later delivery
of psychological treatment
7.10.1 Introduction
The phenomenon of spontaneous or natural remission has both health and economic
consequences in PTSD as in other conditions. The proposition is that where treatments are given
to patients who would otherwise naturally recover, resources could be better spent on patients
who need them. The difference between natural remission and treatment-related recovery is
critical, and this difference may change with time elapsed since the traumatic event. A large
number of mental health economic studies have been conducted generally (see McCrone &
Weich, 2001), but none has addressed the incremental costs of alternative interventions, nor the
cost-effectiveness of early versus late delivery of cognitive–behavioural therapy, in particular for
PTSD. Moreover, few studies have presented a decay curve showing the changing slope of natural
remission over time. For example, to examine this phenomenon, Richards (2005) presented
‘caseness’ data for PTSD, using a General Health Questionnaire (GHQ). At 3 days post-trauma,
60% of the patients who were directly involved in a raid suffered from PTSD symptoms. However,
this figure nearly halved to 31% by 2 weeks post-trauma, and again to 17% by 1 month posttrauma (Fig. 7.1, Table 7.1).
7.10.2 Method
For this guideline, all psychological interventions and different service provision options for the
treatment of PTSD were briefly reviewed from a health economics perspective. The Guideline
Development Group decided to focus on the question of the appropriate time at which to
initiate treatment: that is, were there significant additional costs associated with intervening
early or later in the course of PTSD? An economic evaluation was therefore undertaken using
data from published sources (Bryant et al, 1998; Ehlers et al, 2003), along with a costeffectiveness analysis in accordance with the NICE guideline development recommendations
(National Institute for Clinical Excellence, 2004). The cost-effectiveness was evaluated to
determine the consequences of moving patients from one treatment category to an
incrementally earlier treatment category. The NHS perspective was adopted, with only direct
staffing costs included in the analysis.
Component costs were measured from the health services perspective based upon 2002–3 prices,
and estimated as hours of treatment multiplied by the hourly wage of a clinical psychologist
according to the 2002–3 Unit Costs of Health and Social Care manual (Netten & Curtis, 2003).
According to these estimates, the average annual wage of a clinical psychologist is £33 193 per
year and requires £3775 in on-costs, £4230 in direct revenue overheads and £1713 in capital
overheads. This translates into £66 per hour of client contact, including these additional expenses.
Using data from Bryant et al (1998), total cost was estimated in the instance of early intervention
from five 1.5-hour sessions. These earlier timed interventions were evaluated alongside longerterm data from Ehlers et al (2003), where total cost was estimated from [(5 x 1.5 h) + (5 x 1 h)]
sessions, using the above per-hour costing estimates. Total cost reflected treatment-related
recoveries as well as recoveries that might otherwise have occurred naturally in patients who
received CBT.
Types of trauma comprised motor vehicle accidents (Ehlers et al, 2003) and motor vehicle
accidents or industrial accidents (Bryant et al, 1998). Treatment-related recoveries were calculated
separately for each study by calculating total number of recoveries in the CBT group minus the
natural recoveries estimated to arise from the supportive counselling or control groups. Costeffectiveness ratios comparing treatments of various lengths at 2 weeks versus 12 weeks were
estimated and presented as incremental cost per additional treatment-related recovery. Follow-up
times ranged from 3 months to 12 months post-trauma.
Economic evaluation of early versus later treatment 89
70
PTSD caseness (%)
50
40
30
20
10
Regression
estimation
Observed caseness
for PTSD
Table 7.1 Data corresponding to decay
curve in Figure 7.1
Weeks post-trauma (raid)
0
0
GHQ (>3) caseness rates
for PTSD
60
10
20
30
40
50
60
Time elapsed since trauma (weeks)
Fig. 7.1 Post-traumatic stress disorder (PTSD)
‘caseness’ of patients directly involved in a raid
(x, weeks post-trauma; y, PTSD % caseness).
Data from Richards (1997).
0
60
1
51
2
31
4
17
13
8
26
12
52
8
GHQ, General Health Questionnaire.
Adapted from Richards (1997).
In this analysis, cost was calculated as cost-of-treatment multiplied by the number of sessions,
and effectiveness the number of patients who would not otherwise naturally recover (e.g. chronic
PTSD sufferers). Uncertainty was estimated in a sensitivity analysis in which the stochastic and
deterministic data were varied over plausible ranges.
Incremental cost-effectiveness was determined by dividing the difference between the total costs
(TC) of programme 1 and programme 2 by the difference in numbers of treatment-related
recoveries (TR) for each programme, to give the incremental cost-effectiveness ratio (ICER):
(TC2 – TC1)/(TR2 – TR1) = ICER
This ratio indicates the cost-effectiveness of each timing of programme. In comparing two points
in time post-trauma, the ICER indicates the marginal cost necessary to achieve an additional
treatment-related recovery. Where the cost is negative, this indicates a reduction in cost per
additional treatment-related recovery, relative to the comparator.
Costs and health outcomes were discounted at 3.5%. Discounting is a technique that assumes
individuals prefer to delay costs rather than incur them in the present, and forego future benefits
in exchange for gaining some benefit in the present. The choice of a discount rate is a disputed
issue, however. Although the most common recommendation in health economics literature is
that costs and health outcomes should be discounted at the same rate, there is considerable
variation in practice, with some studies failing to discount health effects at all, and others citing
that different age-groups will discount costs and benefits differently. For instance, younger
individuals may be at a disadvantage with respect to the terms on which they can borrow money
(i.e. money allocated today is worth far more than it is anticipated to be in the future), and older
people or individuals with comorbid conditions that impinge on their quality of life are more
aware of their own mortality and therefore may discount benefits more heavily (i.e. an
intervention today is worth more than in the future).
Although the effect of discounting was small in this study, the choice to include this method
followed NICE recommendations (NICE, 2004) and is common practice in health economic
evaluations. Discounting reduced the total cost by £231 in the case of treatment at 12 weeks and
by £8 in the case of treatment at 2 weeks post-trauma. Discounting the benefits had no effect on
the whole number of treatment-related recoveries on which the cost-effectiveness analyses were
based.
7.10.3 Results
The results of this illustrative analysis are presented in Tables 7.2 and 7.3.
90 Early interventions for PTSD in adults
Table 7.2
Weeks
post-trauma
Frequency of recovery and costs at various treatment times
Patients
treated (n)
Recoveries
(n)
Not
remitted (n)
Natural
remission rate
TreatmentTreatment
related
cost (£ per
recoveries (n) patient
2
12
10
2
0.33
7
495 1
12
28
25
3
0.42
14
825
Total
cost (£)
5932
22 869
1. Equivalent to five 1.5 h sessions.
Sources – first row: Bryant et al (1998); second row: Ehlers et al (2003).
Table 7.3
Results of the cost-effectiveness analysis of early versus late intervention
Weeks post-trauma
Treatment recoveries (n)
Total cost (£)
2
7
5932
12
14
22 869
Incremental cost 2>12
Incremental recoveries 2>12
ICER 2>12
16 937
7
2420 (cost per additional treatment-related recovery
in treating at 12 instead of 2 weeks post-trauma)
ICER, incremental cost-effectiveness ratio, calculated by dividing the difference in total cost by the difference in
number of recoveries.
7.10.4 Summary
Assuming a remission is worth more than £2420, then cognitive–behavioural therapy at 12 weeks
is the most cost-effective option. Achieving faster recoveries by treating early, however, may
provide intangible benefits to those who suffer severe initial PTSD symptoms, particularly by
preventing the conditions from becoming chronic. Future early versus late intervention studies
should include a waiting list control in order to reduce the uncertainty associated with similar
treatments (e.g. psychological debriefing, cognitive–behavioural therapies, self-help booklets and
repeated assessments).
7.10.5 Conclusions
The findings of this study strengthen the impression that treating patients with cognitive–
behavioural therapy at 12 weeks after the traumatic event is cost-effective, assuming a
willngness-to-pay threshold of £2420 per additional treatment-related remission. Of course,
caution must be exercised, because the estimates are based on small sample sizes and a select
range of traumas. Indeed, the indirect and social costs of treating patients later may present
hidden costs that are not included in this analysis (see section 2.7). Further research is needed to
evaluate the cost of investing in early PTSD screening and prevention methods compared with the
cost of treating PTSD at a later stage. This should be trial-based, where all costing and
effectiveness parameters are estimated from data prospectively collected within an RCT. Rigorous
health economic evaluations are needed to ensure interventions are cost-effective and equitable
in preventing relapses across a wide range of the population.
This analysis does not account for fluctuations in treatment and/or behavioural effects between
the two referenced studies. A sensitivity analysis demonstrated that a 10% increase or decrease in
caseness, treatment-related recoveries or cost of treatment did not alter the conclusions.
Nevertheless, there are certain confounding variables that may limit economic evaluations of the
existing samples. These include the type and subtype of trauma; gender, age and other sociodemographic variables; differential study retention and withdrawal rates; differential inclusion
criteria; comorbidity factors; time from trauma to presentation and treatment; type of treatment
Economic evaluation of early versus later treatment 91
and skill of the person delivering treatment; number and length of sessions; the possibility that
some or all of the chronic cases in the 12 week cohort might have recovered equally if given only
the number of treatments as in the 2 week cohort; and the fact that patients needed to agree to
randomisation. More importantly, this economic evaluation included neither the intangible cost
of suffering nor the added financial cost to the patient in terms of work absence and lost
opportunities as a consequence.
7.11 Clinical practice recommendations
7.11.1 Immediate interventions for all survivors of traumatic incidents
7.11.1.1
All health and social care workers should be aware of the psychological impact of
traumatic incidents in their immediate post-incident care of survivors and offer
practical, social and emotional support to those involved. GPP
7.11.1.2
For individuals who have experienced a traumatic event, the systematic provision to
that individual alone of brief, single-session interventions (often referred to as
debriefing) that focus on the traumatic incident should not be routine practice when
delivering services. A
7.11.1.3
Drug treatment may be considered in the acute phase of PTSD for the management of
sleep disturbance. In this case, hypnotic medication may be appropriate for short-term
use but if longer-term drug treatment is required, consideration should also be given
to the use of suitable antidepressants at an early stage in order to reduce the later risk
of dependence. C
7.11.2 Early interventions for acute PTSD
7.11.2.1
Trauma-focused cognitive–behavioural therapy should be offered to those with severe
post-traumatic symptoms or with severe PTSD in the first month after the traumatic
event. These treatments should normally be provided on an individual out-patient
basis. B
7.11.2.2
Trauma-focused cognitive–behavioural therapy should be offered to people who
present with PTSD within 3 months of a traumatic event. A
7.11.2.3
The duration of the trauma-focused cognitive–behavioural therapy should normally be
8–12 sessions, but if the treatment starts in the first month after the event, fewer
sessions (about 5) may be sufficient. When the trauma is discussed in the treatment
session, longer sessions (for example, 90 min) are usually necessary. Treatment should
be regular and continuous (usually at least once a week) and should be delivered by
the same person. B
7.11.2.4
Non-trauma-focused interventions such as relaxation or non-directive therapy, which
do not address traumatic memories, should not routinely be offered to people who
present with PTSD symptoms within 3 months of a traumatic event. B
92 Early interventions for PTSD in adults
8 Predictors of PTSD and screening
for the disorder
8.1 Introduction
Various factors have been considered as potentially predictive of the development of PTSD and
instruments have been developed to screen for it. The benefits of being able to predict accurately
those who will develop or have PTSD include the opportunity to focus on individuals at high risk
and to contribute to the development of specific interventions.
Screening typically involves testing large numbers of individuals for the presence or absence of a
particular condition. Usually a screening test is not diagnostic, but it will detect people at high
risk of having the condition under consideration; an example would be mammography to screen
for breast cancer. Screening can also be used to identify people at high risk of developing PTSD at
a later date, who will perhaps require closer monitoring; this is more comparable to screening for
cervical cancer, in which cervical smears identify pre-cancerous changes. In order to be of value, a
screening test should be reasonably simple to administer and interpret, and be efficient in
discriminating between people with and without the condition under consideration. Brief
screening instruments are widely used in other mental health areas, for example the four ‘CAGE’
questions (Ewing, 1984) and the Alcohol Use Disorders Identification Test (AUDIT) questionnaire
(Babor et al, 1992) in the detection of problem drinkers.
The National Screening Committee has set 22 criteria for appraising the viability, effectiveness
and appropriateness of a programme for large population screening (http://www.nsc.nhs.uk/pdfs/
criteria.pdf). These include: the need for a simple, safe, precise and validated screening test; an
agreed policy on the further evaluation of individuals with a positive test result; the availability of
an effective intervention for those identified through early detection, with evidence of early
treatment leading to better outcomes than late treatment; adequate resources available prior to
commencement; and acceptability to the population. It is important that the majority of these
criteria are satisfied before a screening programme is adopted, not least because screening can
cause adverse effects, including distress secondary to asking specific questions, raising concerns
and raising expectations of cure.
Three high-quality systematic reviews have been conducted in this area (Brewin et al, 2000; Ozer
et al, 2003; Brewin, 2005). The results of these studies, supplemented by further searches, are
discussed below. The search strategies that were used to identify these reviews and subsequent
individual studies are described in Chapter 4.
8.2 Risk factors
To determine if any factors or variables predict the development or chronicity of PTSD, large,
prospective longitudinal studies are required. Unfortunately no such study has been done and
therefore the evidence base is limited and must be interpreted with caution. A number of studies
have looked for associations between various factors and the presence or development of PTSD.
Although these studies are important, their design does not allow determination of the exact
nature of any association with PTSD, for example whether factors are causative of development
or chronicity.
Two major systematic reviews of predictors of PTSD have been published (Brewin et al, 2000;
Ozer et al, 2003). The main outcome measure considered in the reviews was effect size calculated
for the different factors. Effect sizes give an indication of the magnitude of the associations
found. A commonly used guideline for interpreting effect sizes is that of Cohen (1988), by which
an effect size of 0.25 is considered small, 0.5 is considered medium and 0.8 is considered large
(see Chapter 4).
93
The systematic reviews did not consider all potential predictors of PTSD and only included studies
published by the year 2000. Additional factors that have been suggested to have an association
with PTSD and key studies published after 2000 are also discussed.
8.2.1 Review by Brewin et al (2000)
The review by Brewin et al (2000) included studies published in English that were designed to
detect risk factors for PTSD in populations exposed to trauma in adulthood; there were also ten
large epidemiological studies that allowed the trauma to have occurred at any age.
Relevant databases, journals and other sources (for example book chapters) were systematically
reviewed using standard methodology. Seventy-seven articles were included, containing a total of
85 data-sets. Potential risk factors were limited to those that had been assessed in at least four of
the studies. Fourteen potential risk factors were considered: gender, age at trauma, socioeconomic status, education, intelligence, ethnicity, previous psychiatric history, reported abuse in
childhood, reported other previous traumatisation, reported other adverse childhood factors
(excluding abuse), family history of psychiatric disorder, trauma severity, post-trauma life stress
and post-trauma social support. After identification of the factors, all the statistics were
converted to obtain a common measure of effect size.
In addition to the risk factors, Brewin et al (2000) considered individual study characteristics and
performed analyses to determine if these made a difference to the outcome. The study
characteristics considered were: military versus civilian trauma; gender of participants;
retrospective versus prospective design; analyses based on presence or absence of diagnosis
versus continuous symptom scores; PTSD assessed with interview or questionnaire; traumas that
might have occurred in childhood and/or adulthood.
Results
The sample size in the studies ranged from 25 to 4127 with a median of 119. Twenty-eight
articles considered service personnel and the trauma was defined as active service. The remaining
49 articles considered civilian trauma victims (13 crime victims, 9 disaster victims, 4 motor vehicle
accident victims, 6 burns victims, 7 other specific groups, e.g. terrorist attack victims, and 10
victims of mixed traumas). Fifty-nine articles were retrospective and 18 at least partly
longitudinal. The authors produced a combined effect size for all the variables considered (Table
8.1). There was variation between effect sizes for different factors. All were relatively small but
strongly statistically significantly associated with PTSD. The factors most associated with PTSD
were the three peri-traumatic and post-traumatic ones (greater trauma severity, lack of social
support and more subsequent life stress). There was considerable heterogeneity of effect sizes for
individual factors, which complicates interpretation. The most homogeneous effect sizes across
studies were found for psychiatric history, childhood abuse and family psychiatric history.
With regard to the specific study factors, the greatest number of differences occurred between
civilian and military population studies. Female gender was less important in military samples,
whereas younger age at trauma, lack of education, ethnicity, childhood adversity, trauma severity
and lack of social support were all significantly more important. Younger age at trauma, lower
socio-economic status and ethnicity had significantly greater effect sizes among males.
Retrospective design was associated with a weaker gender effect but a stronger effect for
younger age at trauma and for trauma severity. Continuous measure studies had a weaker female
gender effect size but stronger effect sizes for younger age at trauma, lack of education, previous
trauma, childhood adversity and trauma severity. Interview PTSD assessment was associated with
stronger effect sizes for female gender, younger age at trauma and trauma severity, whereas
questionnaire assessment was associated with a stronger effect size for previous trauma. The
studies that included trauma at any age found a stronger female gender effect, but weaker
effects for lack of education, previous psychiatric history, previous trauma, childhood adversity
and trauma severity.
8.2.2 Review by Ozer et al (2003)
The review by Ozer et al (2003) focused on two types of predictor, which the authors labelled as
personal characteristics salient for psychological processing and functioning, and aspects of the
traumatic event or its sequelae. These were subdivided into seven different factors: a history of at
94 Predictors of PTSD and screening for the disorder
Table 8.1
Summary of factors considered in the study by Brewin et al (2000)
Risk factor
No. of studies
Population size (n)
Range of effect
size r
Weighted average
effect size r1
95% CI
Gender (female)
25
11 261
–0.04 to 0.31
0.13
0.11 to 0.15
Younger age
29
7 207
–0.38 to 0.28
0.06
0.04 to 0.08
Low socio-economic status 18
5957
0.01 to 0.38
0.14
0.12 to 0.16
29
11 047
–0.11 to 0.37
0.10
0.8 to 0.12
6
1149
0.08 to 0.38
0.18
0.12 to 0.24
Race (minority status)
22
8165
–0.27 to 0.39
0.05
0.03 to 0.07
Psychiatric history
22
7307
0.00 to 0.29
0.11
0.09 to 0.13
Childhood abuse
9
1746
0.07 to 0.30
0.14
0.09 to 0.19
Other previous trauma
14
5147
–0.05 to 0.36
0.12
0.09 to 0.15
Other adverse childhood
14
6969
0.09 to 0.60
0.19
0.17 to 0.21
Family psychiatric history
11
4792
0.07 to 0.28
0.13
0.10 to 0.16
Trauma severity
49
13 653
–0.14 to 0.76
0.23
0.21 to 0.25
Lack of social support
11
3276
–0.02 to 0.54
0.40
0.37 to 0.43
8
2804
0.26 to 0.54
0.32
0.29 to 0.35
Lack of education
Low intelligence
Life stress
1. All these values are statistically significant at P<0.001.
From Brewin, C. R., Andrews, B. & Valentine, J. D. (2000) Meta-analysis of risk factors for post-traumatic stress
disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748–766. Copyright © 2000 by
the American Psychological Association. Adapted with permission.
least one other trauma prior to the traumatic event, psychological adjustment prior to the
traumatic event, family history of psychopathology, perceived life threat during the traumatic
event, perceived social support following the traumatic event, peri-traumatic emotionality and
peri-traumatic dissociation.
Standard systematic review methods were used to search various databases, journals and other
sources such as reference lists. Sixty-eight studies were included and effect size estimates
determined for all the factors included. The effect size representing the assessment of PTSD
symptoms closest to the time of the traumatic event but after 1 month was included for studies
with assessments at multiple time points. The authors also considered the influence of four study
factors on outcome: sample type (community, medical patients, or individuals seeking mental
health services), length of time between traumatic event and assessment, type of trauma studied
as the target incident, and the method used to assess PTSD.
Results
Table 8.2 shows the summary of the effect sizes. All seven risk factors were associated with
higher levels of PTSD. Peri-traumatic dissociation was the most strongly associated, closely
followed by perceived support and perceived life threat. Pre-trauma factors were also associated
with PTSD and the prior trauma and prior adjustment factors included more studies and had
tighter 95% confidence intervals than the other factors considered. Whether prior trauma
occurred in childhood or in adult life made no difference. However, having a prior trauma was
more strongly related to PTSD when the traumatic experience involved non-combat interpersonal
violence than when the traumatic experience resulted from combat exposure or an accident.
The prior adjustment grouping included various factors such as previous mental health
treatment, previous emotional problems and antisocial personality disorder prior to military
service. When the authors considered the four studies that examined pre-trauma depression as a
risk factor, this was found to be more strongly associated with PTSD than the other measures of
prior adjustment. Having a family history of psychopathology was more significant when the
traumatic experience involved non-combat interpersonal violence than when the traumatic
experience was combat exposure. Perceived life threat was more associated when assessment
was further away from the traumatic event and in non-combat interpersonal violence than in
Risk factors 95
accidents. Perceived social support was also more significant in studies that assessed individuals
further away from the time of the traumatic event. Peri-traumatic dissociation was most
significantly associated with PTSD in samples seeking mental health treatment, when the
assessment time frame was 6 months to 3 years post-trauma and when self-assessment versus
interview measures were used.
8.2.3 Comment on the Brewin and Ozer studies
Although the two reviews used a similar design, there are several differences between them. Both
reviewed studies published between 1980 and 2000, but Brewin et al (2000) included 77 trials,
whereas Ozer et al (2003) included 68 studies. Nineteen of the studies reviewed by Ozer et al
(2003) were not reviewed by Brewin et al (2000); this might be partly accounted for by the
former study not including the demographic factors included by Brewin et al such as gender,
ethnicity, education and socio-economic status, but it is also likely to reflect more subtle
differences in methodology.
Most of the studies included in both reviews used methods by which individuals were asked
about potential risk factors after they had developed PTSD or post-traumatic stress symptoms.
This design can lead to over-reporting of certain factors and attributions, perhaps particularly of
peri- and post-traumatic factors. The review by Brewin et al (2000) did not include early
emotional symptoms or dissociation. Neither review included other potentially important factors
such as the receipt of intervention, comorbidity, physical difficulties, coping strategies and the
presence or absence of a compensation claim. Despite these issues the reviews are of high-quality
methodologically and seem likely to provide a representative picture of research published
between 1980 and 2000.
Reassuringly, there was some consistency in the results of the two reviews. All the factors
considered showed relatively small associations with PTSD. Pre-traumatic factors appeared less
associated with outcome than peri- and post-traumatic factors, although there was greater
homogeneity among the results of the pre-traumatic factors. Of the overlapping factors
considered, family psychiatric history was weakly associated with PTSD in both reviews, as was
prior psychiatric history (included in prior adjustment in Ozer et al, 2003) and prior trauma
(considered as three separate factors in Brewin et al, 2000). Similar results were obtained for
trauma severity (Brewin et al, 2000) and perceived life threat (Ozer et al, 2003). Reported lack of
social support after the traumatic event had the strongest association with PTSD (0.4) in the
review by Brewin et al (2000) and the second strongest (0.28) in the review by Ozer et al (2003).
The other measures employed in the two studies did not overlap.
8.2.4 Post-2000 research on risk factors
There have been a few more recent studies of the same risk factors considered by Brewin et al
(2000) and Ozer et al (2003). Holbrook et al (2001) diagnosed 261 (32%) of 824 individuals as
Table 8.2
Summary of factors considered in the study by Ozer et al (2003)
Risk factor
No. of studies
Population size (n)
Weighted average
effect size r
95% CI
Prior trauma
23
5308
0.17
0.11 to 0.22
Prior adjustment
23
6797
0.17
0.10 to 0.23
9
667
0.17
0.04 to 0.29
Perceived life threat
12
3524
0.26
0.18 to 0.34
Perceived support
11
3537
–0.28
–0.40 to –0.15
5
1755
0.26
0.08 to 0.42
16
3534
0.35
0.16 to 0.52
Family history of psychopathology
Peri-traumatic emotions
Peri-traumatic dissociation
From Ozer, E. J., Best, S. R., Lipsey, T. L. & Weiss, D. S. (2003) Predictors of post-traumatic stress disorder and
symptoms in adults: a meta-analysis. Psychological Bulletin, 129, 52–73. Copyright © 2003 by the American
Psychological Association. Adapted with permission.
96 Predictors of PTSD and screening for the disorder
having PTSD 6 months after major physical trauma. Factors associated with a PTSD diagnosis
included perceived threat to life, female gender, younger age and lower income. Mayou et al
(2002) reported a 3-year follow-up of 546 individuals involved in road traffic accidents: factors
associated with increased risk of PTSD at 3 years included female gender, and perceived threat
and dissociation during the accident. Van Loey et al (2003) found that PTSD symptoms in 301
burn trauma victims were predicted by female gender.
8.2.5 Other factors
In addition to the factors identified in the reviews described above, the Guideline Development
Group also considered a number of other factors as being of potential importance. Three of these
(the nature of the intervention, comorbidity and cognitive factors) are dealt with elsewhere in the
guideline. The fourth and fifth factors – compensation and physical injury – are considered below.
8.2.5.1 Compensation
Compensation issues have been much discussed as a possible maintaining factor for PTSD.
However, compensation clearly illustrates why caution is required in suggesting a causative effect
of an associated factor. Individuals claiming compensation are presumably more likely to have a
psychiatric injury, as this would appropriately be part of the basis of their claim. It has also been
argued that individuals claiming compensation are more likely to report higher levels of distress
through some manipulation of their symptoms. Additionally, the compensation process often
involves regular reminders such as correspondence from lawyers and medico-legal assessments
which may re-traumatise individuals.
The concept of ‘compensation neurosis’ has been challenged by several authors and involves the
use of the word ‘neurosis’ inappropriately and pejoratively. Mendelson (1995) described it as
‘simplistic and false’ as a result of his follow-up study of 760 litigants and argued that its
continued use reflected more on the attitudes and biases of those who used it than on the
individuals who were labelled with it. He found that 396 of the 760 litigants he studied had
returned to work prior to settlement of the claim. Of the remaining litigants, 99 could not be
traced at follow-up, a mean of 23 months post-settlement. Of the 264 who were traced, 198
were still not working; of those who had returned to work the mean time to this was 12.5
months post-settlement. Fontana & Rosenheck (1998) studied 1008 war veterans with PTSD and
found no compensation-seeking effect in outcome among out-patients but a significant effect
among some in-patients, particularly those on longer-stay units. The reason for this was not clear,
but the authors argued that overstatement of symptoms was the most likely explanation. Franklin
et al (2003) interviewed 204 compensation-seeking US military veterans using the Minnesota
Multiphasic Personality Inventory. A large number (84%) had elevated results on at least one scale
used to identify overreporting, but Franklin et al concluded that the scales appeared to identify
both overreporting and extreme pathology. They argued that a majority of compensation-seeking
veterans did not overreport their symptoms.
Bryant & Harvey (1995) and Ehlers et al (1998) in their studies of motor vehicle accident survivors,
and Bisson et al (1997) in a study of burns victims, found an association between PTSD and
compensation. Mayou et al (2002) found that planned or initiated claims at 1 year following road
traffic accidents and unsettled claims at 3 years were associated with the presence of PTSD at 3
years. Bryant & Harvey (2003) reported a prospective study of 171 motor vehicle accident
survivors, of whom 20 had initiated compensation within 6 months but had settled by 2 years,
73 had initiated claims by 6 months that were ongoing at 2 years, and 13 had not initiated a
compensation claim. Post-traumatic stress disorder was less prevalent in those who had never
initiated a claim. The majority returned to work within 6 months of the accident irrespective of
compensation status. More individuals with settled claims entered psychotherapy than those with
unsettled claims. The authors argued that their findings suggested that settlement of
compensation claims did not influence reported PTSD.
The studies discussed above support an association between compensation and symptoms of
PTSD, but there is a lack of evidence to substantiate the concept of ‘compensation neurosis’.
Indeed, there appears to be some evidence to support the notion that compensation is not
directly causative of chronic PTSD, but the exact nature and direction of the association remains
to be determined and may well be heterogeneous. For example, there may be a factor such as
anger with others that is related to both PTSD and claiming compensation.
Risk factors 97
8.2.5.1.1
Healthcare professionals should not delay or withhold treatment for PTSD because of
court proceedings or applications for compensation. C
8.2.5.2 Physical injury
Ehlers et al (1998) and Mayou et al (2002) found that persistent medical problems were
associated with PTSD and its severity at 1 year and 3 years after road traffic accidents. Whether
or not an individual was admitted to hospital as a result of physical injuries had a smaller
association with poorer outcome. Bownes et al (1990) found that physical injury was
associated with higher rates of PTSD in rape victims. Considerable work has been done in this
area with burns trauma victims. There are some conflicting results but overall there appears to
be an association between severity of burn and psychological distress, although this association
seems unlikely to be a strong one. Of 23 studies identified in one review (Bisson, 2000), one
found a relationship between percentage burn and a positive psychological outcome, sixteen
found no association and six found an association with increased psychological sequelae.
Involvement of hands or face was considered in nine studies, with an association with negative
outcome in four and no relationship in five. Van Loey et al (2003) found that percentage burn,
length of hospital stay and involvement of hands were associated with PTSD symptoms.
The influence of a head injury on outcome is perhaps more contentious. Some studies have
suggested that individuals who lost consciousness around the time of a trauma were less likely
to develop psychological sequelae (e.g. Adler, 1943). However, more recent studies have
challenged this. Chemtob et al (1998), in a study of male combat veterans, found that 36
(61%) of those who reported a history of head injury had PTSD compared with 11 (41%) of
those who did not. Almost half of those who reported a head injury also reported loss of
consciousness. Bryant & Harvey (1998) found that 19 (24%) of 79 consecutive adult patients
who sustained a mild traumatic brain injury following a motor vehicle accident satisfied criteria
for PTSD at 6 months’ follow-up. In a study of 125 male veterans with spinal cord injury,
Radnitz et al (1998) found that head injury at the time predicted current PTSD symptom
severity but not diagnosis or lifetime diagnosis and that loss of consciousness was not
consistently associated with PTSD symptom severity or diagnosis. Mayou et al (2000) found
that PTSD was more commonly found in road traffic accident victims who were rendered
unconscious, at both 3 months and 1 year, compared with those who were not. Klein et al
(2003) reviewed the literature on traumatic brain injury and PTSD, found conflicting evidence
but concluded that when traumatic brain injury caused impaired memory of the traumatic
event it might protect against the development of PTSD.
8.2.5.2.1
Post-traumatic stress disorder may present with a range of symptoms (including reexperiencing, avoidance, hyperarousal, depression, emotional numbing and anger)
and therefore when assessing for PTSD, members of secondary care medical teams
should ask in a sensitive manner whether or not patients with such symptoms have
suffered a traumatic experience and give specific examples of traumatic events (for
example, assaults, rape, road traffic accidents, childhood sexual abuse and traumatic
childbirth). GPP
8.3 Screening
In practice, PTSD screening is only likely to be done when someone is felt to be at higher than
usual risk of suffering from the disorder. Common reasons for this are known involvement in a
major traumatic event, being from a higher-risk group (e.g. refugees, asylum seekers, military/
ex-military and emergency services personnel, the bereaved, prison officers and journalists) or
the presence of some symptoms of PTSD.
The key measures of effectiveness of a PTSD screening instrument are generally considered to
be sensitivity (the probability that someone with a PTSD diagnosis will have tested positive),
specificity (the probability that someone without a PTSD diagnosis will have tested negative),
the positive predictive power (the probability that someone with a positive test result will
receive a diagnosis of PTSD), the negative predictive power (the probability that someone with
a negative test result will not receive a PTSD diagnosis) and overall efficiency (percentage of
cases correctly classified by the test as having or not having PTSD). A good test will have good
98 Predictors of PTSD and screening for the disorder
results on all these different measures. The relative value placed on each measure in
determining which test to use is dependent on several factors, including the prevalence of the
disorder among the group being considered and the risks of missing a diagnosis. It can be
argued that the positive predictive value is of particular importance. As the prevalence of a
condition reduces, so does the positive predictive value, i.e. there are more individuals who
have screened positive but do not have the condition (false positives). This has major
implications in terms of screening for PTSD, which will usually be expected to occur at a
prevalence of less than 50%. One way of addressing this issue would be to screen only
populations who are likely to have a high prevalence of PTSD, i.e. targeted screening as
opposed to large population screening.
8.3.1 Screening for individuals who may develop PTSD
There has been some interest in determining if the later development of PTSD can be predicted
by screening individuals shortly after a traumatic event. One of the major benefits of this would
be to allow the identification of high-risk individuals who might benefit from evidence-based
brief early interventions such as those discussed in Chapter 7. Most screening instruments have
focused on the detection of early psychological distress shortly after the traumatic event rather
than the other factors associated with PTSD discussed above.
Perhaps the most studied screening approach to date is that of diagnosing acute stress disorder
(ASD) within 1 month of the traumatic event. In the study of 79 consecutive adult patients who
sustained a mild traumatic brain injury following a motor vehicle accident (Bryant & Harvey,
1998), ASD was diagnosed in 11 patients within 1 month of the trauma, and at 6 months’
follow-up 19 satisfied criteria for PTSD. The latter disorder was diagnosed in 9 (82%) of the
patients who had been diagnosed with ASD and in 7 (11%) of those who had not.
Bryant (2003) subsequently reviewed ten prospective studies of ASD to determine if it was
predictive of chronic PTSD. The proportion who went on to develop PTSD ranged from 30% to
83% at 6 months, and the proportion of PTSD sufferers at 6 months who had suffered from ASD
ranged from 10% to 61%. He concluded that the ASD diagnosis did not have adequate predictive
power and postulated that biological and cognitive factors occurring in the acute post-traumatic
phase might provide more accurate means of predicting chronic PTSD. Creamer et al (2004)
found ASD to have low sensitivity in predicting PTSD among 307 consecutive admissions to a
critical care unit following severe physical injury. Only 3 (1%) individuals satisfied the criteria for
ASD, 29 (9%) suffered from PTSD at 3 months and 32 (10%) at 1 year. Dissociative symptoms
were found to be rarely endorsed and therefore particularly unhelpful in predicting PTSD.
Shalev et al (1997) interviewed the victims of various traumas who presented to an emergency
unit with physical injuries. Of the 239 participants, 191 completed questionnaires and were
interviewed at 1 week, 1 month and 4 months after the traumatic event. The study found no
significant loss of power between 1 week and 1 month in predicting the presence of PTSD at 4
months. There was no difference in the efficiency of the specific traumatic stress symptom
measures used (the Impact of Event Scale and the Mississippi Rating Scale for Combat Related
PTSD – Civilian Trauma Version) and the non-specific ones (the State–Trait Anxiety Scale and the
Peritraumatic Experiences Scale). The performance of the instruments was considered using
various cut-off values. Table 8.3 displays the results obtained by Shalev et al using cut-off values
that gave a balance between sensitivity and specificity and highlights the limited overall
efficiency. The authors concluded that the instruments were better at predicting recovery than
predicting individuals who would go on to develop PTSD.
Unfortunately the results of the currently available research on predictive screening are
disappointing. No accurate way of screening for the later development of PTSD has been
identified. All the instruments considered suffer from limited overall efficiency.
8.3.2 Screening for the presence of PTSD
Several screening instruments, mainly questionnaires containing traumatic stress symptoms, have
been developed to detect the presence of PTSD. These may be of potential use for screening
programmes following major traumatic events and for use in primary and secondary care within
the NHS, when usually individuals with PTSD will first present to someone other than a mental
health professional, such as a primary care worker or an emergency unit worker.
Screening
99
Table 8.3
PTSD
Sensitivity, specificity and power of questionnaires to predict the development of
Scale
Cut-off
Sensitivity
Specificity
PPV
NPV
Impact of Event Scale
35
0.72
0.67
0.31
0.36
55
0.66
0.65
0.28
0.38
85
0.78
0.69
0.34
0.35
51
0.74
0.86
0.52
0.15
State–Trait Anxiety Scale
Mississippi Rating Scale for Combat Related PTSD
Clinician-Administered PTSD Scale
1
After Shalev et al, 1997.
NPV, negative predictive value; PPV, positive predictive value.
1. Civilian Trauma version.
8.3.2.1 Screening questionnaires
The only systematic review of screening questionnaires for the presence of PTSD is by Brewin
(2005), who performed a systematic search of various databases and hand-searched journals,
books and reference lists to identify studies that had attempted to validate self-completed
questionnaires. Only general questionnaires (as opposed to ones of specific populations) of
fewer than 30 items, validated against a structured interview that yielded a diagnosis of PTSD,
were included. Twenty-two different data-sets from the 13 instruments listed below were
identified.
11
The Impact of Event Scale (IES; Horowitz et al, 1979) contains 15 questions about intrusion
and avoidance relative to a specified event, which are answered on a four-point scale.
12
The PTSD Checklist – Civilian version (PCL–C; Weathers et al, 1991; Weathers & Ford, 1996)
contains the 17 DSM–IV PTSD symptoms, which are rated on a scale ranging from 1 (‘not
at all’) to 5 (‘extremely’).
13
The Posttraumatic Stress Symptom Scale – Self-Report version (PSS–SR) and Post-traumatic
Diagnostic Scale (PDS) (Foa et al, 1993). Developed from the 17 DSM–III–R PTSD symptoms
to the DSM–IV ones rated on a four-point scale. The PDS includes 12 preliminary items
inquiring about the occurrence of specific traumatic experiences and a further 9 questions
assessing impairment.
14
The Davidson Trauma Scale (DTS; Davidson et al, 1997) consists of 17 items corresponding
to each of the DSM–IV symptoms scored for both frequency and severity during the
previous week on scales of 0–4.
15
The SPAN test (Meltzer-Brody et al, 1999) comprises the ‘startle’, ‘physiological upset on
reminders’, ‘anger’ and ‘numbness’ questions derived from the DTS, scored for both
frequency and severity during the previous week on scales of 0–4.
16
The Self-Rating Scale for Post-traumatic Stress Disorder (SRS–PTSD; Carlier et al, 1998)
contains 17 items corresponding to the DSM–III–R symptoms of PTSD using a three-point
scale.
17
The Brief DSMPTSD–III–R (Ursano et al, 1995) and DSMPTSD–IV (BPTSD–6; Fullerton et al,
2000) are based on the IES and the Symptom Checklist (SCL–90–R; Derogatis, 1983) as core
instruments, supplemented by 12 PTSD-specific items scored on a five-point scale. Fullerton
et al (2000) reported on the use of these 12 items alone in screening for PTSD.
18
The Screen for Post-traumatic Stress Symptoms (SPTSS; Carlson, 2001) is not tied to a
single traumatic event and covers the 17 DSM–IV items using an 11-point scale.
19
The Post-traumatic Stress Disorder Questionnaire (PTSD–Q; Cross & McCanne, 2001) has the
17 DSM–IV symptoms and uses a seven-point scale.
10
The Penn Inventory (Hammarberg, 1992) has questions with options of four sentences,
modelled on the Beck Depression Inventory (Beck et al, 1961), which measure the presence
or absence of PTSD symptoms as well as their degree, frequency or intensity.
11
The Trauma Screening Questionnaire (TSQ; Brewin et al, 2002) consists of the ten reexperiencing and arousal items from the PSS–SR (Foa et al, 1993), modified to provide only
two response options. Respondents indicate whether or not they have experienced each
symptom at least twice in the past week.
100
Predictors of PTSD and screening for the disorder
12
13
The Disaster-Related Psychological Screening Test (DRPST; Chou et al, 2003) consists of
seven items (three re-experiencing symptoms, three arousal symptoms, and one arousal
symptom answered present or absent) derived from the 17 PTSD symptoms and nine
symptoms of major depression.
The Self-Rating Inventory for Post-traumatic Stress Disorder (SRIP; Hovens et al, 2002)
consists of 22 items based on DSM–IV symptoms using a four-point intensity scale.
The results of the various screening instruments used were impressive, with an overall mean
diagnostic efficiency of 86.5%. Given the relatively uniform results obtained across the
instruments it seems appropriate to follow Brewin’s advice in determining which instruments to
recommend in routine practice. He argued that the ideal instrument would have fewer items,
simpler response scales, simple scoring methods and perform as well if not better than longer
and more complex measures. Such instruments are likely to be more acceptable and provide less
scope for error or uncertainty in terms of answering the questions. Another important
consideration on which we have little information is their acceptability to individuals with and
without PTSD who are asked to complete them.
The questionnaires that appear to have the greatest potential for routine use in primary care are
the Trauma Screening Questionnaire and the SPAN, although both have their limitations. The TSQ
has ten questions requiring yes/no answers, which, for example, may be considered too many in
a busy primary care setting. The SPAN has only four questions but the nature of the SPAN
symptoms (e.g. numbing) is not so straightforward, and the response scales (0–4 ratings for both
frequency and severity) and scoring are more complicated than is the case for the TSQ. The other
instrument that performed well was the Impact of Event Scale. Many individuals will be familiar
with this scale and, like the TSQ, it has the advantage of having been validated on independent
samples and within 1 year of a traumatic event. Table 8.4 lists the relative efficiencies of the IES,
SPAN and TSQ. Unfortunately, several studies determined the cut-off point post hoc, i.e. they
determined the ‘best fit‘ with the results they obtained rather than stating a priori what the cutoff value was to be; this potentially reduced the reliability of the results and increased the
apparent efficiency of the scale.
8.3.2.2 Other studies
Screening for psychological illness, including PTSD, has been evaluated in the British army (Rona
et al, 2004a). In this study 314 service personnel completed a 17-item PTSD checklist as part of a
longer screening document that covered other psychological and physical symptoms as well as
alcohol use. The participants were subsequently assessed by a medical officer masked to the
screening results, who determined if further help was required. The positive predictive value for
the PTSD checklist was 67%, somewhat better than the performance of the other screening
measures. However, the screening programme did not appear to be acceptable to service
personnel. Less than 30% of individuals invited to attend a medical centre for further evaluation
after screening attended. It was noted that those who screened positive for PTSD were less likely
to attend than controls (Rona et al, 2004b).
8.3.2.3 Conclusions
So far there is no sound evidence to support a national or large population screening programme
for PTSD. None of the screening questionnaires considered would fulfil all of the relevant
National Screening Committee criteria. There is evidence that several measures can aid the
detection of PTSD, but they require refinement and crucially integration into a screening
programme with appropriate follow-up before routine, large-scale administration can be
seriously considered. Indeed, the National Steering Committee guidelines state that no such
screening programme will be implemented in the NHS without evidence from a properly
conducted, randomised controlled trial.
This raises important questions as to how proactive to be in trying to identify individuals with
PTSD following traumatic events. The case for screening in large populations where a low
prevalence or rapidly decreasing prevalence of PTSD is expected is weak, not least because of the
large number of ‘false positives’ that would be generated. A stronger case can be made to
consider targeted screening when high prevalence rates are expected, for example for those
directly involved in the heart of an extremely traumatic event. The strength of the case will also
depend on various factors including the simplicity of administration of the screening tool,
Screening 101
102
Predictors of PTSD and screening for the disorder
Table 8.4
Sensitivity, specificity and predictive power of screening tests for PTSD
Reference
Instrument
Number
of items
Sample
Neal et al (1994)
IES/cut-off 351
15
15
Wohlfarth et al (2003)
IES/cut-off 35
1
Prevalence Sensitivity
of PTSD (%)
Specificity
Positive
predictive
power
Negative
predictive
power
Overall efficiency
Mixed trauma (n=70)
51
0.89
0.88
0.89
0.88
0.89
2
13
0.89
0.94
0.67
0.99
0.94
0.88
Crime victims (n=79)
4
Mixed trauma (n=121)
46
0.84
0.91
0.89
0.87
Meltzer-Brody et al (1999) SPAN/cut-off 5
4
Mixed trauma (n=122)
51
0.77
0.82
0.81
0.78
0.80
Brewin et al (2002)
TSQ/cut-off 61
10
Rail crash survivors (n=41)2
34
0.86
0.93
0.86
0.93
0.90
Brewin et al (2002)
TSQ/cut-off 6
10
Crime victims (n=157)2
27
0.76
0.97
0.91
0.92
0.92
0.83
0.85
0.70
0.90
0.86
Meltzer-Brody et al (1999) SPAN/cut-off 5
Mean performance of all measures
IES, Impact of Event Scale; SPAN, Startle, Physiological arousal, Anger and Numbness items from the Davidson Trauma Scale; TSQ, Trauma Screening Questionnaire.
1. Cut-off value determined post hoc.
2. Administered within 1 year of trauma.
cultural validity and acceptability to the population being considered, and the existence of easily
accessible full assessment and effective management options for those who screen positive.
It can be argued that until a screening programme has been shown to be effective, resources
should first be focused on raising awareness. This would involve the provision of information to
those affected and their families, and the education of those most likely to be confronted by
individuals with symptoms, such as general practitioners and employers.
8.4 Clinical practice recommendations
8.4.1 Individuals at high risk
8.4.1.1
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. C
8.4.1.2
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. C
8.5 Research recommendations
8.5.1 Screening
8.5.1.1
An appropriately designed longitudinal study should be conducted to determine if a
simple screening instrument, acceptable to those receiving it, can identify individuals
who develop PTSD after traumatic events and can be used as part of a screening
programme to ensure individuals with PTSD receive effective interventions.
Rationale
Post-traumatic stress disorder is a common and potentially disabling condition. It has been
shown that some individuals are more likely to develop PTSD following traumatic events than
others (e.g. Brewin et al, 2000) and that individuals with acute PTSD respond to trauma-focused
psychological interventions (e.g. Bryant et al, 1998; Ehlers et al, 2003). Interventions for everyone
following a traumatic event have not been shown to be effective (Rose et al, 2004). It has
therefore been argued that a standard response following a traumatic event should be to detect
individuals who develop PTSD and offer them trauma-focused psychological interventions (e.g.
Bisson et al, 2003). Trials of screening programmes should determine if this approach is feasible
and effective and is consistent with the criteria for such screening programmes developed by the
National Screening Committee (2003).
Clinical practice recommendations 103
9 Children and young people with PTSD
9.1 Introduction
When the diagnosis of PTSD was first formulated in 1980 (American Psychiatric Association,
1980) it was initially believed that it would not be relevant to children and young people. This
was soon demonstrated to be false and it is now accepted that children and young people can
develop PTSD following traumatic events. For the purposes of this guideline, ‘children’ refers to
ages 2–12 years and ‘young people’ (adolescents) to ages 13–18 years.
9.2 Developmental differences
9.2.1 Post-traumatic stress reactions in children
The broad categories of PTSD symptoms (re-experiencing, avoidance/numbing and increased
arousal) are present in children as well as in adults. The requirements of DSM criteria for the
diagnosis of PTSD in children are that children must exhibit at least one re-experiencing
symptom, three avoidance/numbing symptoms and two increased arousal symptoms. From the
age of 8–10 years, following traumatic events, children display reactions closely similar to those
manifested by adults. Below 8 years of age, and in particular below the age of 5 years, there is
less agreement as to the range and severity of the reactions. Scheeringa et al (1995) have
suggested an alternative set of criteria for the diagnosis of PTSD in children, placing more
emphasis on regressive behaviours and new fears, but these have yet to be fully validated.
Traumatic reactions in children have been less extensively studied than in adults and there are
few naturalistic, longitudinal studies mapping the natural history of these reactions. It has long
been recognised (Eth, 2001) that it is much more difficult to elicit evidence of emotional
numbing in young children. Other items indicating avoidance reactions in children simply are not
relevant, thereby making it difficult for children to meet DSM criteria for that part of the
diagnostic algorithm (although this does not apply to the ICD diagnosis).
In general, it is agreed that children display a wide range of stress reactions. To some extent these
vary with age, with younger children displaying more overt aggression and destructiveness. They
may also show more repetitive play about the traumatic event, and this may even be reflected in
repetitive drawing.
9.2.2 Family influences
As with other anxiety disorders, children’s reactions are influenced by parental reactions. In
addition to modelling on their parents’ reactions (social influence) there are probably also
inherited dispositions to react adversely to traumatic events (genetic influence). This has not been
adequately studied in relation to PTSD in children.
What is clinically described and widely accepted is that children are very sensitive to their parents’
reactions – both to the event itself and to talking about it afterwards. Children often say that
they choose not to discuss a traumatic event and/or their reactions to it with their parents, as
they do not wish to upset the parents further. This is, in part, one of the reasons for the finding
that even more than with other anxiety disorders, parents grossly underestimate the degree of
stress reactions experienced by their children. Thus, one cannot rely solely on parental report
when making diagnoses or estimating prevalence. A study by McFarlane (1987) suggested that in
an Australian bush fire, the children’s reactions to the event were fully accounted for by the
mothers’ own mental health, rather than by the exposure to the fire. However, as mothers had
rated both their own adjustment and that of their children, this finding was suspect. Subsequent
studies (for example Smith et al, 2001) have found that direct exposure is usually a stronger
determinant of child reaction, with maternal reactions being important modifying influences.
104
Children and young people with PTSD
It is important therefore always to consider the nature and extent of a child’s exposure to a
traumatic event.
9.2.3 Multiple versus single trauma
Many children presenting with symptoms of PTSD may have been subjected to multiple traumas
such as childhood sexual abuse or domestic violence. The most common form of multiple trauma
for children that has been studied and investigated is childhood sexual abuse, which often occurs
in secret and is repeated over a long period. The traumatic reactions associated with such
multiple trauma can be usefully construed as similar to those that follow from single traumas,
although issues of abuse of power, loss of trust and so on do make them different. Although
there is evidence that the social circumstances and events surrounding multiple traumas for
children may have consequences for their future management (Ramchandani & Jones, 2003), the
evidence does not support the idea that multiple traumas are associated with significantly
different outcomes or that the treatment required for PTSD is significantly different when
compared with single traumas.
9.3 Incidence, prevalence and natural history
9.3.1 Prevalence
Most epidemiological studies have been of older young people and adults. Giaconia et al
(1995) reported a lifetime prevalence of 6% in a community sample of older young people.
Kessler et al (1995) reported a lifetime prevalence of 10% using data collected from older
young people and adults in the US National Comorbidity Survey. In contrast, the British
National Survey of Mental Health of over 10 000 children and young people (Meltzer et al,
2000) reported that 0.4% of children aged 11–15 years were diagnosed with PTSD, with girls
showing twice the rate of boys. Below the age of 10 years, PTSD was scarcely registered. This
lower rate is, of course, a point prevalence estimate and is bound to be lower than a lifetime
prevalence estimate. Moreover, the screening instrument employed was not specifically
developed to screen for PTSD.
9.3.2 Incidence
Estimates of the incidence of PTSD are more frequently reported after various natural and other
disasters. Rates vary enormously, partly as a result of different methodologies and partly as a
result of different types of traumatic event. In various studies of the effects of road traffic
accidents (not resulting in an overnight stay in hospital) rates of 25–30% are reported. The
study of 200 young survivors of the sinking of the cruise ship Jupiter (Yule et al, 2000) reported
an incidence of PTSD of 51%. Most cases manifested within the first few weeks, with delayed
onset being rare. Other disorders such as anxiety and depression were common as well. Studies
of the mental health of child refugees from war-torn countries find the incidence to be close to
67% (W. Yule, personal communication, 2004). Therefore, significantly increased demands may
be made at all levels of primary and secondary child and adolescent mental health services
following traumatic events.
The implication of this for the NHS is that while the numbers of children and young people
experiencing PTSD at any one point in time may be approaching 1% and represents a
significant level of morbidity in any community, by way of comparison, in adults PTSD has a
point prevalence of 1.5–3%, and schizophrenia in adults has a prevalence of 1%.
9.3.3 Natural history
The follow-up study of young people who survived the sinking of the Jupiter found that 15% still
met criteria for PTSD 5–7 years after the event. More recently, a 33-year follow-up of the children
who survived the Aberfan landslide disaster found that 29% of those traced and interviewed still
met criteria for PTSD (Morgan et al, 2003). In other words, in the absence of effective therapy,
the long-term effects of life-threatening, traumatic events in childhood can be severe.
Incidence, prevalence and natural history
105
9.4 Diagnostic and assessment measures
9.4.1 Children over 7 years old
More is known about screening, assessment and diagnosis in children over the age of 7 years
because above that age many children can read independently and can complete self-rating
scales. It is much more time-consuming and expensive to conduct standardised clinical interviews
with both parent and child to establish a diagnosis in large groups of children.
9.4.1.1 Self-completed PTSD scales
The most widely used self-report scales in research and clinical settings are the Children’s Impact
of Event Scale, the Child Post Traumatic Stress Reaction Index and the Child PTSD Symptom Scale.
For a detailed recent review of self-completed scales, see Ohan et al (2002).
The Children’s Impact of Event Scale was developed from the widely used adult self-report PTSD
measure, the Impact of Event Scale (Horowitz et al, 1979). The adult version has been used with
children and young people in its original 15-item version. Following two large principal
component analyses, a briefer eight-item version was developed for children (Yule, 1997) and
subsequently expanded to a 13-item version to include five items attempting to measure arousal
(see http://www.childrenandwar.org).
The Child Post Traumatic Stress Reaction Index (CPTS–RI) was originally rated following interview
by a clinician with the carer and sometimes the child. More recently it has been modified to be a
self-report instrument (Pynoos et al, 1987; Pynoos, 2002).
The Child PTSD Symptom Scale (CPSS; Foa et al, 2001) is a 17-item scale used both in initial
diagnosis and in monitoring progress. It contains a brief functional impairment rating.
9.4.1.2 Structured interviews for PTSD in children and young people
Structured interviews for children are not well developed; three of the more commonly used
scales are described below.
The Clinician-Administered PTSD Scale for Children and Adolescents for DSM–IV (CAPS–CA;
Nader et al, 2002) is modelled on the adult CAPS and is widely regarded as the gold
standard measure to diagnose DSM–IV PTSD in children.
The Anxiety Disorders Interview Schedule for Children for DSM–IV (ADIS–C; Silverman &
Albano, 1996) can be used to diagnose a range of anxiety disorders and has a specific
module for PTSD symptoms.
The Schedule for Affective Disorders and Schizophrenia for School Age Children (K–SADS;
Kaufman et al, 1997) can be used to diagnose a range of anxiety disorders and has specific
supplementary questions for measuring PTSD symptoms. Both the parent and the child are
interviewed.
Trauma-specific PTSD measures
The Children’s Impact of Traumatic Events Scale – Revised (CITES–R; Wolfe et al, 1991) is a
measure of PTSD symptoms arising from sexual abuse and measures aspects such as social
reactions to disclosure, eroticism and abuse-related attributions in addition to non-traumaspecific PTSD symptoms.
9.4.2 Children aged 7 years or younger
No consensus has emerged as to how to measure PTSD symptoms in children aged 7 years or
younger. In the recent past a range of scales measuring behavioural problems have been adopted
such as the Child Behaviour Checklist (CBCL; Achenbach & Edelbrock, 1983) and, for children who
have suffered sexual abuse, the Child Sexual Behaviour Inventory (CSBI; Friedrich et al, 1992).
9.4.2.1 Measures of outcome for children within this review
Given the lack of consensus about the measurement of PTSD for younger children, a range of
child-specific measures were included in this review (Table 9.1).
106
Children and young people with PTSD
Table 9.1
Measures of PTSD in children
Scale
Age range
No. of items
and score range
Self-report/interview
Notes
Children’s Impact
of Event Scale
8–18 years
15–13 items depending
Self-report
on version, 4-point range
Child Post Traumatic
Stress Reaction Index
(CPTS–RI)
8–18 years
20 items, 5-point range
Clinician-rated and
self-report versions
Child PTSD Symptom
Scale (CPSS)
8–15 years
24 items, 4-point range
Self-report
Clinician-Administered PTSD
Scale for Children and
Adolescents for DSM–IV
(CAPS–CA)
8–18 years
32 items, 5-point range
Clinician-rated
Anxiety Disorders
Interview Schedule
for Children (ADIS–C)
(PTSD module)
Not specified
(PTSD module only)
24 items, scale
‘yes’/’no’/’other’
Clinician-rated (child
and parent/caretaker
interviewed)
Schedule for Affective
Disorders and Schizophrenia
for School-Age Children
(K–SADS; K–SADS–E;
K–SADS–PL) (PTSD
supplement)
6–18 years
Variable, approximately
17 items with varying
scales, typically
a 4-point scale
Clinician-rated (child PL, Present and
and parent/caretaker Lifetime version;
interviewed)
E, Epidemiological
version
Children’s Impact
of Traumatic Events
Scale – Revised
8–16 years
78 items, 3-point scale
Clinician-rated
Trauma-specific
(sexual abuse)
Child Behavior Checklist
(CBCL) parent version
2–16 years
113 items, 3-point
scale
Parent-rated
Measures adaptive
competencies and
behavioural
problems
Child Sexual Behavior
Inventory (CSBI)
Not specified
42 items, 4-point scale
Parent-rated
Measures sexual
behaviours
Child Report of PTSD
Symptoms (CROPS)1
7–17 years
24 items
Self-report
Parent Report of PTSD
Symptoms (PROPS)1
7–17 years
28 items
Parent-rated
Designed to be
used as companion
instrument to CROPS
1. Greenwald & Rubin, 1999.
In addition to PTSD scales, a range of child measures of depression, anxiety and quality of life
were included within the review.
9.4.2.2 Measures of exposure to traumatic events
The structured interviews indicate the most likely adverse life events that may result in PTSD in
children and young people, but they do not constitute formal measures. General practitioners,
paediatricians and child mental health workers who see a child presenting with a sudden change
in sleep pattern, nightmares and jumpiness should enquire about intrusive images and then ask
whether the child has experienced any threatening life event such as a bad accident, natural
disaster, or physical or sexual abuse.
9.4.2.3 Measures of process and related aspects
Increasing attention is being paid to cognitive factors such as the way in which children attribute
blame for an event or the extent to which they erroneously believe that they might have died in
the accident. The effective social support that is available to the child is also likely to be a key
determinant of whether the child continues to respond adversely (Joseph et al, 1993). Standard
measures of these aspects are still being developed.
Diagnostic and assessment measures 107
9.5 Psychological interventions
Early intervention would be attractive if it could be shown that it prevented later development of
PTSD or other disorders, but, as with adult studies, there have been few properly controlled trials
of any early intervention. The only one known is that of Stallard et al (2005), which is discussed
below.
Ramchandani & Jones (2003) reported a systematic review of RCTs treating a range of
psychological symptoms in sexually abused children. They identified 12 RCTs: three investigating
group CBT; six investigating individual CBT; one of adding group therapy to a family therapy
intervention; and two comparing individual (non-CBT) therapy with group therapy. However, the
dependent (outcome) measures were very varied, and only five studies looked at recognised,
specific measures of PTSD.
9.5.1 Studies included
The inclusion criteria that 70% of participants within a study have a PTSD diagnosis was not applied
for the review of children and young people because, as discussed above, diagnosis of child and
adolescent PTSD is still evolving and is relatively undeveloped for younger children. Otherwise the
inclusion criteria were identical to those for adults (see Chapter 4). However, all studies had to
include a measure of the child’s PTSD symptoms, although as discussed above (see section 9.4.5) a
wider range of measures was deemed more acceptable than for adult PTSD scales.
From the main search for RCTs (see Appendix 6), 11 studies of psychological interventions were
identified by the Guideline Development Group as meeting the inclusion criteria: CELANO 1996,
COHEN 1996, COHEN 1997 (COHEN 1997 is a follow-up study to COHEN 1996), COHEN 1998,
COHEN 2004, DEBLINGER 1999, JABERGHADERI1, KING 2000, STALLARD, STEIN 2003 and
TROWELL 2002. References given in shortened format and summary characteristics of individual
included trials are given in Appendix 14.
9.5.1.1 Interventions considered
Broadly, four different psychological interventions were covered within the included studies: one
early intervention treatment (debriefing), cognitive–behavioural therapy, eye movement
desensitisation and reprocessing (EMDR) and supportive therapy (fuller definitions of these
treatment classifications, as they apply to adults, are given in Chapter 5).
Within these broad categories of treatments there was considerable variation in how treatments
were delivered, with many studies allowing for some part of treatment being delivered to the
caretaker as well as the child, either individually or in sessions for both the child and the
caretaker. Two studies involved treatment arms that consisted of treatments delivered to groups
of children (STEIN 2003, TROWELL 2002). Given the many different formats in which the four
treatments were delivered, it was not possible to combine many of the studies for the purpose of
this review. Table 9.2 provides a summary of the range of interventions and delivery formats
(treatment delivered to both the caretaker/parent and the child, to the child individually, etc.) for
which eligible studies were available.
9.5.1.2 Populations – childhood sexual abuse and other traumas
Nine of the studies related to childhood sexual abuse and were analysed separately from the
remaining studies, which covered a range of traumatic events including witnessing violence,
natural disaster, war and burns.
9.5.2 Childhood sexual abuse
Trials comparing different forms of CBT with waiting list or supportive therapy
Seven of the trials covering childhood sexual abuse compared different forms of CBT therapies
against waiting list, supportive therapy or another mode of delivering CBT (CELANO 1996,
COHEN 1996, COHEN 1997, COHEN 1998, COHEN 2004, DEBLINGER 1999, KING 2000).
1. Data from this study have now been published as Jaberghaderi et al (2004).
108
Children and young people with PTSD
Table 9.2
Interventions for which eligible studies were available
Intervention
Debriefing
Supportive
therapy
STALLARD
(age 7–18, n=158)1
EMDR
CBT (child and
carer)
CBT (child only)
CBT (mother only)
CBT (for carer
and child)
Community
care
DEBLINGER 1999
(CSA, age 7–13,
n=50)
DEBLINGER 1999
(CSA, age 7–13,
n=50)
DEBLINGER 1999
(CSA, age 7–13,
n=50)
Waiting list
KING 2000 (CSA,
age 5–17, n=24)
CBT (child only but Individual
group format)
psychotherapy
CELANO 1996,
COHEN 2004 (CSA,
age 8–16, n=276)
COHEN 1998 (CSA,
age 7–14, n=82)
COHEN1996/7
(CSA, age 2–7
approx., n=86)
CBT (child only)
Psychological interventions 109
Group psychotherapy
JABER-GHADERI
(CSA, age 12–13,
n=14)
KING 2000 (CSA,
age 5–17, n=24)
STEIN 2003 (age
about 10–12,
n= 126)
KING 2000 (CSA,
age 5–17, n=24)
TROWELL 2002
(CSA, age 6–14,
n=71)
CBT, cognitive–behavioural therapy; CSA, childhood sexual abuse (where not specified, participants had experienced a range of other traumas); EMDR, eye movement desensitisation and
reprocessing.
1. Note: n denotes number of participants in the intent-to-treat sample (those randomised to a treatment condition whether or not they completed any treatment sessions).
9.5.2.1 Child and carer CBT versus supportive therapy
Children over 7 years old
One large study (COHEN 2004) compared trauma-focused CBT with supportive therapy for
children aged 8–14 years and a parent. Each treatment arm consisted of 12 weekly sessions of 45
min for the child individually and 45 min for the parent, although three of the weekly sessions
involved 30 min of joint parent–child therapy. Supportive therapy was child- and parent-centred,
allowing the child or parent to guide the structure and content of the treatment, supplemented
by the provision of written psychoeducational information. Trauma-focused therapy worked on
expression of feelings, coping skills and gradual exposure, whereby the children were assisted in
developing their own trauma narrative as well as some psychoeducation. An earlier smaller study
by COHEN 1998 of CBT versus supportive therapy for children aged 7–14 years compared similar
interventions but used a behavioural-based measure to assess PTSD symptoms. Each treatment
arm consisted of 12 individual treatment sessions of 90 min (45 min for the child individually and
45 min for the parent individually). Another study (CELANO 1996) compared developmentally
appropriate cognitive–behavioural techniques and metaphoric techniques with supportive
therapy for girls aged 8–13 years and their carers. Each treatment arm consisted of eight 1-hour
weekly sessions. Sessions were split with 30 min of treatment each for the child and the carer
individually, although two or three sessions included some joint work. For this review the COHEN
1998, COHEN 2004 and CELANO 1996 studies were combined.
There was limited evidence that CBT for children over 7 years old and their carers was better than
supportive therapy in reducing the severity of PTSD symptoms post-treatment. For the other
outcome measures post-treatment, the evidence was either inconclusive (child-rated depression,
parent-rated internalising and externalising behaviours, sexualised behaviours and likelihood of
leaving the study early) or indicated that there was unlikely to be a clinically important difference
(child-rated anxiety). Unfortunately we do not know how sustained these improvements are
because no follow-up data are currently available.
There is limited evidence favouring CBT for children over 7 years old and their parents/carers over
supportive therapy on reducing the severity of PTSD symptoms (k=2; n=212; SMD=–0.55, 95%
CI –0.83 to –0.28). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between CBT for children over 7 years old and their parents/carers and supportive
therapy on reducing self-rated post-treatment depression symptoms as measured by the Child
Depression Inventory (k=2; n=232; SMD=–0.44, 95% CI –0.7 to –0.18). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between CBT for children over 7 years old and their parents/carers and supportive
therapy on reducing the likelihood of leaving the study early for any reason (k=2; n=276;
RR=1.18, 95% CI 0.77 to 1.82). I
Children under 7 years old
The study by COHEN 1996 and its follow-up study (COHEN 1997) compared CBT with supportive
therapy for children under 7 years old. Each treatment arm consisted of 12 weekly sessions of 50
min for the parent individually and 30–40 min for the child. Measurement of PTSD symptoms in
very young children is still evolving, and for this study there was no direct measure of PTSD but
rather a range of behavioural measures such as CBCL and CSBI. There is limited evidence
favouring CBT over supportive therapy for reducing parent-rated externalising symptoms and
sexualised behaviour both post-treatment and at 1-year follow-up.
There is limited evidence favouring CBT for children under 7 years old and their parents/carers
over supportive therapy on reducing parent-rated externalising behaviours post-treatment as
measured by the CBCL (k=1; n=67; SMD=–0.79, 95% CI –1.29 to –0.28). I
There is limited evidence favouring CBT for children under 7 years old and their parents/carers
over supportive therapy on reducing parent-rated externalising behaviours at 1-year follow-up as
measured by the CBCL (k=1; n=43; SMD=–0.53, 95% CI –1.17 to 0.11). I
9.5.2.2 Child only, mother only and mother and child CBT versus community care
One study (DEBLINGER 1999) compared CBT treatments with community care. Community care
consisted of support from child protection workers and victim witness advocates and
110
Children and young people with PTSD
encouragement to seek therapists within the local community, and was treated as an active
intervention for this review. There were three CBT treatment arms comprising CBT for the child
only, CBT for the mother only and CBT for child and mother. Individual treatment consisted of 12
treatment sessions of 45 min. The joint treatment condition comprised 12 sessions of 90 min
with individual sessions for the child and mother and some joint sessions. Children ranged in age
from 7 years to 13 years.
CBT for the child versus community care
On the clinician-rated K–SADS–E, there is limited evidence favouring CBT for the child only over
community care on reducing the severity of PTSD symptoms both immediately post-treatment
and 6 months post-treatment. However, by the 2-year follow-up the difference between the
groups had diminished. There are similar results for the CDI (self-report) measure of depression,
and the advantage of CBT for child only is present at the end of treatment and at the 6-month
and 2-year post-treatment evaluations. Given the nature of the community care, evidence on
tolerability (leaving the study early) is difficult to interpret.
There is limited evidence favouring CBT for the child only over community care on reducing the
severity of PTSD symptoms post-treatment as measured by K–SADS–E (clinician-rated measure)
(k=1; n=35; SMD=–0.96, 95% CI –1.68 to –0.24). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between CBT for the child only and community care on reducing the severity of PTSD
symptoms at 2 years post-treatment as measured by K–SADS–E (clinician-rated measure) (k=1;
n=35; SMD=–0.45, 95% CI –1.14 to 0.24). I
CBT for the mother only versus community care
Cognitive–behavioural therapy with the mother alone does not appear to have any advantage
over community treatment as far as the severity of PTSD symptoms as measured by the K–SADS–E
is concerned, either immediately post-treatment or at 6 months. However, somewhat surprisingly,
at 2 years’ follow-up the reduction in the severity of PTSD symptoms was clinically significant. For
children’s self-report depression symptoms the pattern is similar, with clinically significant effects
occurring at 2 years’ follow-up but not for earlier assessments.
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between CBT for the mother only and community care on reducing the severity of
PTSD symptoms post-treatment as measured by K–SADS–E (clinician-rated measure) (k=1; n=34;
SMD=–0.43, 95% CI –1.13 to 0.26). I
There is limited evidence favouring CBT for the mother only over community care on reducing the
severity of PTSD symptoms at 2 years post-treatment as measured by K–SADS–E (clinician-rated
measure) (k=1; n=34; SMD=–0.77, 95% CI –1.48 to –0.06). I
Mother and child CBT versus community care
On the clinician-rated K–SADS–E there is limited evidence favouring CBT for the child and mother
over community care on reducing the severity of PTSD symptoms both immediately posttreatment and at 6 months’ follow-up, and this improvement was quite well sustained at 2 years’
follow-up. The results for depression (child-rated) showed clinically significant improvement at
the post-treatment and 2-year follow-up assessments but did not reach the threshold for clinical
significance at the intervening assessments.
There is limited evidence suggesting a difference favouring mother and child CBT over community
care on reducing the severity of PTSD symptoms post-treatment as measured by K–SADS–E
(clinician-rated measure) (k=1; n=33; SMD=–0.86, 95% CI –1.58 to –0.13). I
There is limited evidence suggesting a difference favouring mother and child CBT over community
care on reducing the severity of PTSD symptoms at 2 years post-treatment as measured by K–
SADS–E (clinician-rated measure) (k=1; n=33; SMD=–0.64, 95% CI –1.35 to 0.07). I
9.5.2.3 Child only and child and mother CBT versus waiting list
One study (KING 2000) compared CBT intervention for the child individually with CBT for the
child and mother jointly. The interventions consisted of 20 weekly sessions of 50 min; however,
the child and mother joint intervention arm consisted of a further 20 weekly 50 min sessions of
training for the parents in child behaviour management skills. Children ranged in age from 5
years to 17 years.
Psychological interventions 111
Individual child CBT versus waiting list
There was limited evidence of a clinically important improvement for PTSD severity, although this
was not sustained at 3 months’ follow-up. Effect sizes for depression and anxiety did not reach
the threshold for clinical importance.
There is limited evidence suggesting a difference favouring child CBT over waiting list on reducing
the severity of PTSD symptoms post-treatment as measured by the ADIS–C (clinician-rated
measure) (k=1; n=24; SMD=–1.05, 95% CI –1.92 to –0.19). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between child CBT and waiting list on reducing depression symptoms as measured by
the CDI (k=1; n=24; SMD=–0.29, 95% CI –1.1 to 0.51). I
Child and mother CBT versus waiting list
The results were similar to those for individual child CBT versus waiting list, with limited evidence
of a clinically important improvement for PTSD severity, although this was not sustained at 3
months’ follow-up. Effect sizes for depression and anxiety did not reach the threshold for clinical
importance.
There is limited evidence suggesting a difference favouring child and mother CBT over waiting list
on reducing the severity of PTSD symptoms post-treatment as measured by the ADIS–C (clinicianrated measure) (k=1; n=24; SMD=–1.19, 95% CI –2.08 to –0.31). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between child and mother CBT and waiting list on reducing depression symptoms
post-treatment as measured by the CDI (k=1; n=24; SMD=–0.28, 95% CI –1.09 to 0.52). I
Individual child CBT versus child and mother CBT
Direct comparison of individual child CBT versus CBT for the child and mother did not yield
evidence of clinically important differences between the two treatment conditions for PTSD
severity, depression, anxiety or tolerability (leaving the study early).
9.5.2.4 Individual versus group psychotherapy for children
One study (TROWELL 2002) compared group psychotherapy with individual psychotherapy for
sexually abused girls aged 6–14 years. Individual psychotherapy entailed up to 30 weekly
sessions, compared with up to 18 sessions for those completing group psychotherapy.
Unfortunately data were not available for total PTSD symptoms (arousal symptoms data were not
reported). There was limited evidence that individual therapy was better than the group delivery
in terms of reducing re-experiencing and avoidance symptoms at 12 months and 24 months
post-therapy, although effect sizes were borderline for clinical importance. The evidence suggests
that neither treatment was substantially better tolerated than the other.
There is limited evidence suggesting a difference favouring individual psychotherapy over group
psychotherapy on reducing re-experiencing and avoidance symptoms at 12 months using the K–
SADS-based Orvaschel scale (Orvaschel, 1989) (k=1; n=56; SMD=–0.49, 95% CI –1.02 to 0.05). I
9.5.2.5 Comparing EMDR with other treatment (CBT)
One unpublished study (JABERGHADERI) compared EMDR with CBT. Each treatment arm entailed
up to 12 sessions (duration not specified) and CBT incorporated a degree of exposure work. The
evidence was inconclusive for both child-reported and parent-reported PTSD severity, using the
Child Report and the Parent Report of PTSD Symptoms, respectively (Greenwald & Rubin, 1999),
and there was no evidence that one treatment was better tolerated.
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between EMDR and CBT on reducing child self-report PTSD severity as measured by
CROPS (k=1; n=14; SMD=–0.49, 95% CI –1.55 to 0.58). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between EMDR and CBT on reducing parent-rated PTSD severity as measured by PROPS
(k=1; n=14; SMD=–0.18, 95% CI –1.23 to 0.87). I
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Children and young people with PTSD
9.5.3 Other trauma
9.5.3.1 Debriefing
One unpublished study (STALLARD) compared single-session debriefing with a generally
supportive talk to children aged 7–18 years who had been involved in road traffic accidents,
within approximately 2 weeks of the accident occurring. The interventions were of approximately
equal duration (68 min). The evidence suggested that there is unlikely to be a clinically important
difference at 8 months’ follow-up between single-session debriefing and supportive talk for selfrated measures of PTSD severity, depression and anxiety. The evidence was inconclusive for PTSD
diagnosis and tolerability.
There is evidence suggesting there is unlikely to be a clinically important difference between
structured debriefing and attention control on reducing child self-rated PTSD severity at 8
months’ follow-up (k=1; n=132; SMD=–0.05, 95% CI –0.39 to 0.3). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between structured debriefing and attention control on reducing PTSD diagnosis at 8
months’ follow-up (k=1; n=158; RR=0.97, 95% CI 0.58 to 1.62). I
9.5.3.2 CBT interventions
One study (STEIN 2003) compared group CBT against waiting list (delayed intervention) for
children who had been exposed to violence. The intervention consisted of ten group sessions and
was delivered in a school mental health clinic. The children were approximately 10–12 years old.
Group CBT versus waiting list
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between group CBT and waiting list on reducing the severity of PTSD symptoms posttreatment as measured by CPSS (self-report) (k=1; n=117; SMD=–0.71, 95% CI –1.08 to –0.33). I
The evidence is inconclusive and so it is not possible to determine if there is a clinically important
difference between group CBT and waiting list on depressive symptoms as measured by CDI
(k=1; n=117; SMD=–0.38, 95% CI –0.74 to –0.01). I
9.6 Clinical summary of psychological interventions
The above evidence suggests that psychological interventions, specifically trauma-focused
cognitive–behavioural psychotherapy, can be effective for the treatment of post-traumatic stress
symptoms in children and young people who have been sexually abused.
In contrast, there is very little evidence from RCTs for the efficacy of any psychological
interventions for children or young people who suffer from PTSD arising from other forms of
trauma. This reflects not the inconclusive nature of the evidence but rather the lack of RCTs. This
means that conclusions about the effectiveness of psychological interventions for this group are
reliant on extrapolation from other areas, principally work on PTSD with sexually abused children
and psychological interventions for adults. Considerable caution is therefore required in drawing
conclusions, particularly when drawing on downward extension of results from work with adults.
Nevertheless, the limited psychological trials available suggest that trauma-focused CBT, whether
delivered to children and young people with PTSD or to children who have developed PTSD in the
context of childhood sexual abuse, may be of value.
Some of the trials involving children who have suffered sexual abuse included in this review
specifically considered to whom and in what combination treatment should be given. For
children over 7 years old who have suffered sexual abuse, treatment of the mother alone seems
to be ineffective when compared with treatment of the child alone. Indeed, delivering CBT to the
mother as well as the child does not of itself seem to confer much advantage over treatment of
the child alone on PTSD symptoms. The lack of clinically important effects for trauma-focused
CBT treatments delivered to the child and non-abusing parent or caretaker are particularly
striking, given that for DEBLINGER 1999 and KING 2000 the ‘joint’ treatment condition essentially
entails additional therapeutic time for the parent/caretaker.
Clinical summary of psychological interventions 113
No other psychological intervention has yet established a comparable evidence base, but other
interventions such as EMDR show some promise, for example in the study by Chemtob et al
(2002), which we were unable to include in the review owing to insufficient data being available
for the control group, as well as in a number of non-randomised studies. The single study
providing a comparison of EMDR against trauma-focused CBT (JABERGHADERI) suffered from the
use of a non-standard PTSD measure. The single psychotherapy trial (TROWELL 2002) also used
non-standard measures, which, combined with the lack of a waiting list or attention control,
made drawing any significant clinical conclusions very difficult.
The evidence base from which to draw conclusions about the treatment of children under 7 years
old suffering from PTSD is sparse. The lack of agreement on and use of a common set of measures
is particularly of concern for studies of PTSD in very young children, and adds to the difficulties of
interpreting an extremely limited data-set. All treatments need to be adapted to accommodate
young children’s less mature ways of thinking about their world, and often clinicians will use play
materials and drawings to help children focus on what happened to them and how they feel.
However, there is a lack of high-quality (randomised controlled trial) evidence that specific types of
play therapy or art therapy have therapeutic value in treating PTSD in young children.
The evidence does not support the use of single-session debriefing for children of any age.
9.7 Pharmacological interventions
Although the use of some psychotropic drugs has increased since the 1990s (Riddle et al, 2001;
Bramble, 2003; Wolraich, 2003), and there is belief in their efficacy, much of the increase is
accounted for by prescribing by doctors who are not child mental health experts. Although drugs
are prescribed less often for childhood disorders in the UK than in the USA, there is none the less
a considerable rate of prescribing psychotropic drugs for children by general practitioners in the
UK (Montoliu & Crawford, 2002).
Few psychotropic medicines are licensed for use with children. Thus, many prescriptions have to
be made ‘off licence’ on a named patient basis. The Royal College of Paediatrics and Child Health
(2000) states that:
‘The use of unlicensed medicines or licensed medicines for unlicensed applications is
necessary in paediatric practice where there is no suitable alternative. Such uses are
informed and guided by a respectable and responsible body of professional opinion’.
This advice was given prior to the Medicines Control Agency advising against the use of all but
one SSRI for the treatment of major depression in young people, following the discovery that
reports of adverse reactions indicating an increased risk of self-harm had been suppressed.
There are major difficulties in conducting adequate drug trials with children and young people,
but these need to be undertaken responsibly if potentially useful help is to be made available, if
only while awaiting the application of more powerful treatments that are less available.
From the main search for randomised controlled trials (see Appendix 6), no study of drug
treatments was identified by the Guideline Development Group as meeting the inclusion criteria.
Only one RCT (Robert et al, 1999) was identified, which compared imipramine with chloral
hydrate for 25 child burns victims aged 2–19 years for 1 week of treatment. However, this study
did not meet the inclusion criteria as outcomes were recorded in the form of remission rates
across a range of symptoms rather than a specific measure of PTSD. Open-label trials suggest
that propranolol (Famularo et al, 1988), clonidine (Perry, 1994; Harmon & Riggs, 1996; Horrigan,
1996) and carbamazepine (Loof et al, 1995) resulted in symptomatic improvement, but no
comparison group was studied.
9.8 Clinical summary of pharmacological interventions
At present there is too little evidence from RCTs, controlled trials, open-label studies or case–control
studies to recommend the use of any psychotropic medication to treat PTSD in children or young
people.
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Children and young people with PTSD
9.9 Clinical practice recommendations
9.9.1 Assessment
9.9.1.1
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. GPP
9.9.1.2
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 general practitioner if the symptoms persist beyond 1 month.
GPP
9.9.2 Early intervention
9.9.2.1
Trauma-focused cognitive–behavioural therapy should be offered to older children
with severe post-traumatic symptoms or with severe PTSD in the first month after the
traumatic event. C
9.9.3 Chronic PTSD
9.9.3.1
Children and young people with PTSD, including those who have been sexually
abused, should be offered a course of trauma-focused cognitive–behavioural
therapy adapted appropriately to suit their age, circumstances and level of
development. B
9.9.3.2
Where appropriate, families should be involved in the treatment of PTSD in children
and young people. However, treatment programmes for PTSD in children and young
people that consist of parental involvement alone are unlikely to be of any benefit for
PTSD symptoms. C
9.9.3.3
The duration of trauma-focused psychological treatment for children and young
people with chronic PTSD should normally be 8–12 sessions when the PTSD results
from a single event. When the trauma is discussed in the treatment session, longer
sessions than usual are usually necessary (for example, 90 min). Treatment should be
regular and continuous (usually at least once a week) and should be delivered by the
same person. C
9.9.3.4
Drug treatments should not be routinely prescribed for children and young people
with PTSD. C
9.9.3.5
When considering treatments for PTSD, parents and, where appropriate, children
and young people should be informed that, apart from trauma-focused
psychological interventions, there is at present no good evidence for the efficacy of
widely used forms of treatment of PTSD such as play therapy, art therapy or family
therapy. C
9.10 Research recommendations
9.10.1 Trauma-focused psychological intervention for children
9.10.1.1
Randomised controlled trials for children of all ages should be conducted to assess the
efficacy and cost-effectiveness of trauma-focused psychological treatments
(specifically CBT and EMDR). These trials should identify the relative efficacy of
different trauma-focused psychological interventions and provide information on the
differential effects, if any, arising from the age of the children or the nature of the
trauma experienced.
Research recommendations 115
Rationale
Post-traumatic stress disorder is a common and potentially disabling condition in children as well
as adults (Giaconia et al, 1995). Although up to 50% of children may develop PTSD following a
traumatic event (Yule et al, 2000), many individuals recover without specific intervention;
however, a significant proportion of individuals, perhaps more than 30% of victims of major
disasters, go on to develop a chronic disorder with associated psychological and social handicaps
(Morgan et al, 2003). Trauma-focused psychological interventions are generally effective for the
treatment of PTSD in adults but only a limited evidence base exists for children and young people
(Cohen et al, 2000). In addition, much of the evidence is drawn from work with children who
have experienced childhood sexual abuse as well as developing PTSD (Ramchandani & Jones,
2003) and therefore the evidence base for interventions for PTSD arising from other traumas is
weaker. For children aged under 7 years who develop PTSD there are virtually no formal RCTs of
appropriate psychological interventions. A number of non-controlled trials suggest that
treatments (specifically CBT and EMDR) are efficacious, but these have not been formally tested
(Cohen et al, 2000).
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Children and young people with PTSD
10 Special considerations
10.1 Introduction
This guideline is concerned with the treatment of PTSD within the National Health Service.
However, certain groups such as ex-military personnel, survivors of major disasters and many
refugees and asylum seekers typically have some key aspects of their care delivered outside the
NHS. In developing guidelines for the NHS it is therefore essential to give special consideration to
the role and links with other organisations that play a key part in delivering care (particularly in
the immediate aftermath of traumatic events) for those at risk of PTSD within specific
populations of ex-military personnel, refugees and survivors of disasters.
10.2 Disaster planning
Health and social services have specific responsibilities for making arrangements for the
appropriate social and psychological support of survivors, relatives and other affected individuals
following disasters. In order for their input to be effective this support should be evidence based
and delivered in a pre-planned, coordinated manner that is integrated into the central disaster
plan. Multi-agency social and psychological care steering groups should be part of every area’s
Disaster Management System with a responsibility to meet regularly, develop and maintain the
psychosocial care plan, and have authority to decide on provision. The membership of these
groups should include representatives from primary care, adult mental health services, child and
adolescent mental health services, social services, non-statutory organisations and the local
emergency planning officer.
Social and psychological care ranges from providing immediate comfort and practical help
through to longer-term psychological support, which may need to be provided for 18–24 months
or even longer. Those involved should not feel rushed to ‘restore normality’. Any formal response
should be non-intrusive and non-judgemental, and designed to complement and mobilise the
excellent support many people will receive from their family and friends. The exact nature of a
response will vary in terms of size, management and the extent to which it will be proactive or
reactive, depending on the specific circumstances of the disaster. An early meeting of the
psychosocial steering group should be held following a disaster to determine the level of input.
The response should then be closely monitored to ensure that the planned service is being
delivered and to make changes as necessary.
Individuals involved in psychosocial care following disasters should usually have been selected for
specific roles and have received appropriate training prior to the event in order to allow rapid
deployment of a coordinated, planned response. This may require the release of individuals
involved from routine activities and for this workload to be covered by others, possibly on a
medium- to long-term basis. Support from senior management in both the planning and
operational phases is therefore essential. During the response it is vital to involve sufficient
numbers of staff to enable regular rotation to ensure that individuals do not work for excessive
periods. Those managing the psychological response need to use their professional judgement to
determine what is reasonable. The arrangement of adequate supervision for all personnel will be
a key role of the social and psychological care steering group.
It is likely that specific local individuals not already mentioned will be important in a particular
response, for example local community leaders, religious leaders and local primary care teams.
Social and psychological care steering group representatives should liaise with these individuals,
incorporate their skills into the planned response and cater for their training and supervision
needs.
Social services will have the overall lead role in the initial psychosocial response, but it is vital that
mental health professionals liaise with social services and provide supervision and support. There
will be specific roles and responsibilities for healthcare staff and these should be identified clearly
117
in the disaster plan. Typically, healthcare staff will only become directly involved in the initial
phase if individuals develop extreme responses that are felt to be unmanageable or present with
specific needs. The initial focus is likely to be on immediate practical help, including housing,
food, drink, financial issues, providing comfort, helping people to get home, obtaining and
providing accurate and timely information, establishing clear communication channels, providing
space and privacy for those involved, specialist care of elderly people and children, and support
to relatives. In addition it is important to record personal details and create a database of
individuals involved (including health and social care staff, emergency services and volunteers as
well as the victims of the disaster).
Early interventions should be provided in an empathic manner, but formal counselling or
psychological intervention is usually inappropriate at this time (see Chapter 7). Information about
the availability of help should be widely circulated and this can be done through distributing
leaflets that describe some of the feelings commonly experienced by those involved in disasters
and give basic advice and contact numbers for those seeking help. Leaflets should be on each
local authority’s computer system in readiness for contact telephone numbers to be added on the
day and for distribution from day one.
As time progresses, the focus of the response will change and key tasks will include education
and reassurance about normal emotional reactions, listening to and absorbing people’s accounts
of the incident if they want to talk about it, as well as helping them to piece together their
experience of the disaster. Those involved (and their families and friends) should be provided with
help and information on how to deal with problems arising from the disaster, e.g. family
difficulties, insomnia, work problems, working with grief and emotional issues. This should
include a role in facilitating individuals to make choices on various issues, including access to the
dead, visiting the disaster site and memorials. Additional support may be required for any legal
proceedings, inquiries and inquests. The creation of an emotional support telephone helpline
should be considered along with the identification of those at highest risk (see Chapter 8) and
assessment of their need for more formal intervention. Evidence-based interventions (see Chapter
7) should be offered to those with specific needs through adequately trained and supervised
counsellors and clinicians. Mutual support groups and self-help work can be facilitated and the
longer-term provision should be planned.
Educational psychology services in conjunction with child and adolescent mental health services
(CAMHS), social services and education are likely to coordinate the provision of social and
psychological care to children. The model used will be similar to the adult model, with an initial
focus on providing emotional and practical support. School nurses can play an important role in
this area under the supervision of the educational psychologists and CAMHS. It is often necessary
to provide input to whole families.
The disaster plan should also consider and plan for the needs of special groups, such as those
with sensory impairments, those who are mentally ill, and frail elderly people.
10.3 Ex-military personnel
The NHS has responsibility for the ongoing healthcare of ex-military personnel as soon as they
leave the armed forces. It is also responsible for the healthcare of families of serving military
personnel when they live in the UK. When experienced by ex-military personnel, PTSD is
frequently comorbid with other disorders (Kulka et al, 1990) and there are often other important
psychosocial issues that need to be addressed (including the impact of being discharged from the
armed services and all that that entails). The adjustment from military to civilian life can be
difficult; problematic social circumstances can occur and these may result in housing problems
and financial hardship. These factors and the often prolonged and intense nature of traumatic
exposure can result in a complex PTSD presentation that is potentially difficult to treat.
It is vital that primary and secondary health services in the UK are familiar with the specific needs
of ex-military personnel and their families, and are equipped to deal with them. Ideally every local
mental health service should be able to offer evidence-based treatments to ex-military personnel
with PTSD. It is likely that this will require increased education and liaison between the military
and the NHS. It is hoped that the new Department of Defence Mental Health in London will
provide a focus for this.
118
Special considerations
When an individual is discharged from the military it is the military health service’s responsibility
to ensure that appropriate aftercare has been arranged. For individuals with PTSD this should
involve close liaison with the local NHS service and a comprehensive handover. Many ex-service
personnel report feeling better understood by healthcare professionals who are ex-military
themselves. This probably mainly relates to difficulty in trusting someone who does not seem to
understand the military way of life, and can usually be overcome by improved knowledge and a
willingness to deal with issues relating to the individual’s military background.
Primary and secondary care practitioners should be aware that ex-military personnel are at higher
risk of having or developing PTSD (and other mental health problems) than most civilian
populations and should consider assessing for this when they present with other problems (see
Chapter 2). It is also important that local mental health services are aware of national bodies that
can help ex-military personnel. In addition to the Department of Defence Mental Health, Combat
Stress is a charity that was created to help ex-military personnel with mental health difficulties
(http://www.combatstress.com). There are also other charities and former military personnel with
personal experience of PTSD and difficulties accessing appropriate help who can be contacted for
advice (see http://www.ptsd.org.uk for further information).
10.4 Phased interventions in settings of continuing threat
There are situations in which people do not experience a neat termination of a traumatic
experience. Here, a phased intervention is appropriate. This has been well described by Herman
(1997), especially for women who have been subjected to domestic violence and may experience
further risk as long as they stay with their abusive partner.
Where there is ongoing violence at home, the first step of the practitioner is to deal with the dual
issues of safety from further harm and trust in the therapist. Typically, achieving safety requires
that the victim of violence has to make tough choices – including separation from the perpetrator
– and so the task is to help such people to clarify their own wishes, free from external pressures.
To negotiate this stage is hard and it does require a trusting, therapeutic and non-judgemental
relationship. Although it may be hard to trust a stranger, there are cues that may help. Making it
obvious that the therapist has experience of work with other survivors of violence – usually
through the use of non-verbal behaviour or choice of questions – is almost always important. A
common barrier to trust is a sense of alienation from others. Appropriate use of empathy can be
a powerful means of demonstrating understanding. If appropriate, an explicit commitment to the
rights of women – perhaps by undertaking work in a refuge setting – can also be helpful.
If the person decides to stay in a situation where violence will continue, then the aims of any
further psychological intervention are limited. It is generally not possible to process fully the
emotional consequences of a past event if it continues to recur. It may be possible to help to
stabilise the psychological symptoms and, of course, to hold open the door for return and reengagement. To achieve a more fundamental resolution, however, will require the person to take
steps to reduce the risk of further violence. This is a crucial phase of any intervention and is often
not given enough attention.
Only after this stage has been successfully negotiated can active psychological treatment (seeking
fundamental change) really take place. This is when the specific interventions become
appropriate. These may take a number of forms. These are the subject of scientific enquiry
(efficacy trials) and may appear to carry greater respectability than a consideration of therapeutic
process. However, realistically, they can only be approached if the first stage has been successfully
negotiated. They have been summarised in other parts of this guideline.
The final phase of treatment is concerned with (re)integration or adaptation to what has
happened. The process of therapeutic change does not end, therefore, until the individual is back
in the world and can function as an effective agent again.
It has been suggested that the phased approach goes back to the days of Pierre Janet (van der
Hart et al, 1989). Herman herself attributes some of her thinking to Janet, although she has
certainly enhanced and enlarged on this early thinking. Janet’s work on dissociation not only
helps explain crucial elements of the dissociative trauma response, it also paved the way for a
phased model of intervention, with three phases:
Phased interventions 119
stabilisation, symptom-oriented treatment
exploration of traumatic memories
personality reintegration and rehabilitation (Janet, 1889, cited by Herman, 1997).
A staged model has formed the basis of most treatments for complex trauma reactions, such as
Linehan’s dialectical behaviour therapy (DBT) model (Linehan, 1993). Similarly, in settings where
there is a risk of child abuse, the first step is to achieve safety and then consideration can be
given to the processes of treatment and recovery.
10.5 Working with refugees and asylum seekers
Refugees and asylum seekers often present another example of a complex problem. Being a
refugee is not a diagnosis, and refugees may present with any of the psychiatric disorders or
none at all. Some may develop other specific responses, such as ‘enduring personality change
after catastrophic experience’, and may require long-term treatments, but to discuss these would
go beyond the scope of this guideline. There is an important need to ensure a comprehensive
assessment and to plan treatment with the refugee or asylum seeker in the light of that
assessment.
By virtue of their experiences (e.g. war, imprisonment and torture), these people are more likely
to experience PTSD than the general population. Often this is comorbid with depression (Turner
et al, 2003; Turner, 2004). The expression of emotional disturbance may be modified by cultural
and linguistic factors, as well as by the beliefs of the sufferer concerning health services and their
willingness to work across cultures.
This is another situation in which a phased model may be appropriate (although there is no trial
evidence to support this contention and it therefore reflects a pragmatic approach). Typically, the
first need is to achieve safety from further persecution. This may not be possible until the person
has legal status – and this may take a long time to obtain. Clinicians working with refugees
should not only have knowledge of the complexity of the emotional reaction that many
experience (going well beyond PTSD in many cases), but should also have an awareness of
immigration law, welfare rights and cultural and political diversities. Until there is safety from
further persecution, there may be a limit to the depth of therapeutic work that can be delivered.
It can be hard to confront trauma memories anyway, but if the PTSD sufferer faces a realistic
prospect of being returned to face more trauma, then it can be impossible. As asylum seekers
who flee civil war in their own country often do not meet the criteria for refugee status (although
they are not, as often portrayed in the media, ‘bogus’), this is a realistic possibility for some.
In the first phase, primary needs are often focused on accommodation, benefits and continued
family separation. These are phase one problems. At this stage, it is typically inappropriate and
ineffective to attempt a trauma-focused therapy. (This is something to be considered once the
individual has achieved a sufficient sense of stability and security, and this is a subjective state
that will vary from person to person.) Interventions in phase one are likely to be practical,
supportive, involve medication (see Chapter 6) to help with emotional stabilisation, and may
involve psychoeducation (possibly in a group format). A priority is to support the development of
a trusting relationship that can help in the provision of other phases of the intervention.
The phase two interventions are similar to those described elsewhere in this review. There has
long been interest in the use of narrative approaches (‘testimony’, e.g. Cienfuegos & Monelli,
1983), although in the context of the evidence statements made earlier about psychological
treatments, these can be construed as including important elements of trauma-focused CBT with
exposure and cognitive restructuring. There are few good efficacy trials applying treatments to
refugee populations. Neuner et al (2004) have reported encouraging data in a trial of ‘narrative
exposure therapy’ (similar to testimony); this is discussed in Chapter 5. Often, in the context of a
phase two treatment, a crisis will emerge and it will be necessary to return to phase one
stabilisation and crisis management work. In this phase, issues concerning loss and bereavement
are also often encountered.
With refugees, it is not a question of reintegration in phase three so much as integration into a
new community, but this, too, is an important element of the therapeutic approach and should
120
Special considerations
not be neglected. Some refugees later have the option to return to their own country and they
may have reintegration needs to deal with there as well.
There are some subgroups with special needs. Head injuries are common and some refugee PTSD
sufferers also present with subtle cognitive impairment as a consequence. There may be other
physical handicaps as a result of injury. Where there is a history of sexual assault, a PTSD with
predominant shame may be found. It has been demonstrated that both men and women with
histories of sexual assault present with marked avoidance responses – in contrast to survivors of
physical torture, which is associated with high intrusion scores (van Velsen et al, 1996). This
means that people often present a history of rape late and it is appropriate to maintain an open
mind in therapy about this possibility.
Work with survivors of torture (and other forms of malicious abuse) reminds us of the need for
an ethical base to all our practice in this field. It is appropriate to declare a commitment to
human rights. The approach should be focused on the refugee rather than on the service and this
may mean trying to offer an integrated physical, psychosocial and legal approach within one
setting. Finally, there is an overriding need to respect those aspects of the individual that
demonstrate these people’s resilience and strengths (Schlapobersky, 1990).
10.6 Role of the non-statutory sector
The non-statutory sector and associated community organisations have long played an important
part in the treatment and management of trauma. The contributions of the non-statutory sector
have been apparent in a number of distinct ways. First, there has been a long-standing tradition
of the provision of bereavement counselling and related services which, despite not having a
specialist remit for trauma victims, provide services for a number of people who have experienced
a range of traumatic events, including (but not restricted to) traumatic bereavements. Second, a
number of services in the non-statutory sector have developed specifically in response to the
needs of particular traumatised groups. These have included victims of domestic violence and
rape, victims of crime, childhood sexual abuse and torture, refugees and individuals who have
been involved in large-scale natural or other disasters. These groups may have developed
specifically to meet the needs of identified groups of traumatised individuals or may have
emerged from existing groups as their remit changed in order to meet a new need.
The range of services provided within the non-statutory sector is considerable and diverse, with a
very varied distribution across England and Wales. Many services will provide some form of
psychological intervention; often in the early days of such services this was non-directive
counselling, but increasingly these services are providing a range of psychological interventions
with a stronger evidence base for the treatment of PTSD. The provision of such services may
complement or supplement that provided by the NHS; the degree to which this takes place will
vary with the availability of local services and the variation in demand – for example, large-scale
disasters often place considerable strain on statutory services and it is in such cases that the nonstatutory sector may have a vital role.
In addition to the direct provision of psychological interventions, the non-statutory sector can
provide several other key services. Many non-statutory organisations provide immediate practical
and emotional support for victims of trauma, both individual and large-scale, which builds on
and enhances the support available for local communities. Again, this complements the work of
the statutory services and in many regions non-statutory organisations will take the lead for local
communities in this area of work. Such work will often provide not just valuable immediate
support but also the basis for a better-informed group of trauma sufferers: this has been done
both at a local level and at national level, for example through the provision of internet-based
information about PTSD. Many non-statutory organisations also take on an advocacy role for
PTSD sufferers, working to obtain effective treatment and social and practical support; for some
organisations this will be a primary focus of their work. Finally, non-statutory organisations are
often the focus for a number of self-help or support groups for PTSD sufferers or their families or
carers, which can play a vital part in overcoming the impact of severe trauma.
Non-statutory sector services therefore can make a significant contribution to the care and
management of people with PTSD. Given this, it is essential that NHS and related statutory
Role of the non-statutory sector
121
services are aware of the specific contribution that is made in this area by their local non-statutory
services. This should then allow for a more integrated approach to the care of PTSD sufferers. As
is apparent from this guideline, the effective treatment of many PTSD sufferers depends on their
living in a safe and supportive environment, and the non-statutory sector can contribute
significantly to this. The NHS services caring for PTSD sufferers should seek to develop effective
working links with all relevant non-statutory sector services, which should seek to identify
complementary elements of the respective services. The NHS should also support, where
appropriate, non-statutory sector services in the provision of effective interventions for PTSD
sufferers through educational and training initiatives. An example of this approach can be seen in
the Women’s Mental Health Strategy recently published by the Department of Health (NIMHE,
2003).
10.7 Recommendations
10.7.1 Disaster planning
10.7.1.1
122
All disaster plans should make provision for a fully coordinated psychosocial response
to the disaster. Those responsible for developing the psychosocial aspect of a disaster
plan should ensure it contains the following: provision for immediate practical help,
means to support the affected communities in caring for those involved in the disaster
and the provision of specialist mental health, evidence-based assessment and
treatment services. All healthcare workers involved in a disaster plan, should have
clear roles and responsibilities, which should be agreed in advance. GPP
Special considerations
11 Summary of recommendations
11.1 Key recommendations for implementation
11.1.1 Initial response to trauma
For individuals who have experienced a traumatic event, the systematic provision to that
individual alone of brief, single-session interventions (often referred to as debriefing) that focus
on the traumatic incident should not be routine practice when delivering services.
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 people with PTSD, should be
considered. A follow-up contact should be arranged within 1 month.
11.1.2 Trauma-focused psychological treatment
Trauma-focused cognitive–behavioural therapy should be offered to those with severe posttraumatic symptoms or with severe post-traumatic stress disorder in the first month after the
traumatic event. These treatments should normally be provided on an individual out-patient
basis.
All people with PTSD should be offered a course of trauma-focused psychological treatment
(trauma-focused CBT or eye movement desensitisation and reprocessing). These treatments
should normally be provided on an individual out-patient basis.
11.1.3 Children and young people
Trauma-focused CBT should be offered to older children with severe post-traumatic symptoms or
with severe PTSD in the first month after the traumatic event.
Children and young people with PTSD, including those who have been sexually abused, should be
offered a course of trauma-focused CBT adapted appropriately to suit their age, circumstances
and level of development.
11.1.4 Drug treatments for adults
Drug treatments for PTSD should not be used as a routine first-line treatment for adults (in
general use or by specialist mental health professionals) in preference to a trauma-focused
psychological therapy.
Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for
initiation only by mental health specialists) should be considered for the treatment of PTSD in
adults who express a preference not to engage in trauma-focused psychological treatment.
11.1.5 Screening for PTSD
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.
11.2 Guidance
The following guidance is evidence-based. The grading scheme used for the recommendations (A,
B, C) or good practice point (GPP) is described in Chapter 4. A summary of the evidence on which
the guidance is based is provided in the full guideline (see Chapters 5–10).
123
11.3 Recognition of PTSD
Effective treatment of PTSD can only take place if the disorder is recognised. In some cases, for
example following a major disaster, specific arrangements to screen people at risk may be
considered. For the vast majority of people with PTSD, opportunities for recognition and
identification come as part of routine healthcare interventions, for example, following an assault
or an accident for which physical treatment is required, or when a person discloses domestic
violence or a history of childhood sexual abuse. Identification of PTSD in children presents
particular problems but is improved if children are asked directly about their experiences.
11.3.1 Recognition in primary care
PTSD can present with a range of symptoms, which in most adults are most commonly in the
form of very vivid, distressing memories of the event or flashbacks (otherwise known as intrusive
or re-experiencing symptoms). However, at times the most prominent symptoms may be
avoidance of trauma-related situations or general social contacts. It is important when
recognising and identifying PTSD to ask specific questions in a sensitive manner about both the
symptoms and traumatic experiences. A number of problems such as depression are often
comorbid with PTSD. Often these problems will improve with the treatment of the PTSD, but
where this does not happen or the comorbid disorder impedes the effective treatment of the
PTSD, it may be appropriate to consider providing specific treatment for that disorder.
11.3.1.1
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). GPP
11.3.1.2
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 and childhood sexual abuse.
GPP
11.3.1.3
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, childhood sexual
abuse and traumatic childbirth). GPP
11.3.1.4
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. C
11.3.2 Recognition in general hospital settings
Many people attending for medical services in a general hospital setting may have experienced
traumatic events. This may be particularly so in emergency departments and in orthopaedic and
plastic surgery clinics. For some people with PTSD, this may be the main point of contact with the
healthcare system and the opportunity that this presents for the recognition and identification of
PTSD should be taken.
11.3.2.1
124
PTSD may present with a range of symptoms (including re-experiencing, avoidance,
hyperarousal, depression, emotional numbing and anger) and therefore when
assessing for PTSD, members of secondary care medical teams should ask in a
sensitive manner whether or not patients with such symptoms have suffered a
traumatic experience and give specific examples of traumatic events (for example,
assaults, rape, road traffic accidents, childhood sexual abuse and traumatic
childbirth). GPP
Summary of recommendations
11.3.3 Screening of individuals involved in a major disaster, programme
refugees and asylum seekers
Many individuals involved in a major disaster will suffer both short- and long-term consequences
of their involvement. Although the development of single-session debriefing is not
recommended, screening of all individuals should be considered by the authorities responsible for
developing the local disaster plan. Similarly, the vast majority of programme refugees (people
who are brought to the UK from a conflict zone through a programme organised by an agency
such as the United Nations High Commission for Refugees) will have experienced major trauma
and may benefit from a screening programme.
11.2.3.1
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. C
11.2.3.2
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. C
11.3.4 Specific recognition issues for children
Children, particularly those aged under 8 years, may not complain directly of PTSD symptoms
such as re-experiencing or avoidance. Instead, children may complain of sleeping problems. It is
therefore vital that all opportunities for identifying PTSD in children should be taken. Questioning
the children as well as parents or guardians will also improve the recognition of PTSD. PTSD is
common (up to 30%) in children following attendance at emergency departments for a traumatic
injury. Emergency department staff should inform parents or guardians of the risk of their child
developing PTSD following emergency attendance for a traumatic injury and advise them on
what action to take if symptoms develop.
11.3.4.1
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. GPP
11.3.4.2
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 general practitioner if the symptoms persist beyond 1 month. GPP
11.4 Assessment and coordination of care
11.4.1 Recommendations
11.4.1.1
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. C
11.4.1.2
Assessment of PTSD sufferers should be conducted by competent individuals and be comprehensive, including physical, psychological and social needs and a risk assessment. GPP
11.4.1.3
Patient preference should be an important determinant of the choice among effective
treatments. PTSD sufferers should be given sufficient information about the nature of
these treatments to make an informed choice. C
11.4.1.4
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) and should be shared with the
patient and, where appropriate, their family and carers. C
Assessment and coordination of care 125
11.5 Support for families and carers
11.5.1 Recommendations
Families and carers have a central role in supporting people with PTSD. However, depending on
the nature of the trauma and its consequences, many families may also need support for
themselves. Healthcare professionals should be aware of the impact of PTSD on the whole family.
11.5.1.1
In all cases of PTSD, healthcare professionals should consider the impact of the
traumatic event on all family members and, when appropriate, assess this impact and
consider providing appropriate support. GPP
11.5.1.2
Healthcare professionals should ensure, where appropriate and with the consent of
the PTSD sufferer where necessary, that the families of PTSD sufferers are fully
informed about common reactions to traumatic events, including the symptoms of
PTSD and its course and treatment. GPP
11.5.1.3
In addition to the provision of information, families and carers should be informed of
self-help groups and support groups and encouraged to participate in such groups
where they exist. GPP
11.5.1.4
When a family is affected by a traumatic event, more than one family member may
suffer from PTSD. If this is the case, healthcare professionals should ensure that the
treatment of all family members is effectively coordinated. GPP
11.6 Practical support and social factors
Practical and social support can play an important part in facilitating a person’s recovery from
PTSD, particularly immediately after the trauma. Healthcare professionals should be aware of this
and advocate for such support when people present with PTSD.
11.6.1 Recommendations
11.6.1.1
Healthcare professionals should identify the need for appropriate information about
the range of emotional responses that may develop and provide practical advice on
how to access appropriate services for these problems. They should also identify the
need for social support and advocate the meeting of this need. GPP
11.6.1.2
Healthcare professionals should consider offering help or advice to PTSD sufferers or
relevant others on how continuing threats related to the traumatic event may be
alleviated or removed. GPP
11.7 Language and culture
People with PTSD treated in the NHS come from diverse cultural and ethnic backgrounds and
some have no or limited English, but all should be offered the opportunity to benefit from
psychological interventions. This can be achieved by the use of interpreters and bicultural
therapists. In all cases, healthcare professionals must familiarise themselves with the cultural
background of the sufferer.
11.7.1 Recommendations
11.7.1.1
Where a PTSD sufferer has a different cultural or ethnic background from that of the
healthcare professionals who are providing care, the healthcare professionals should
familiarise themselves with the cultural background of the PTSD sufferer. GPP
11.7.1.2
Where differences of language or culture exist between healthcare professionals and
PTSD sufferers, this should not be an obstacle to the provision of effective traumafocused psychological interventions. GPP
126
Summary of recommendations
11.7.1.3
Where language or culture differences present challenges to the use of traumafocused psychological interventions in PTSD, healthcare professionals should consider
the use of interpreters and bicultural therapists. GPP
11.7.1.4
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. GPP
11.8 Care for all people with PTSD
PTSD responds to a variety of effective treatments. All treatment should be supported by
appropriate information to sufferers about the likely course of such treatment. A number of
factors, which are described below, may modify the nature, timing and course of treatment.
11.8.1 Care across all conditions
11.8.1.1
When developing and agreeing a treatment plan with a PTSD sufferer, healthcare
professionals should ensure that sufferers receive information about common
reactions to traumatic events, including the symptoms of PTSD and its course and
treatment. GPP
11.8.1.2
Healthcare professionals should not delay or withhold treatment for PTSD because of
court proceedings or applications for compensation. C
11.8.1.3
Healthcare professionals should be aware that many PTSD sufferers are anxious about
and can avoid engaging in treatment. Healthcare professionals should also recognise
the challenges that this presents and respond appropriately, for example by following
up PTSD sufferers who miss scheduled appointments. C
11.8.1.4
Healthcare professionals should treat PTSD sufferers with respect, trust and
understanding, and keep technical language to a minimum. GPP
11.8.1.5
Healthcare professionals should normally only consider providing trauma-focused
psychological treatment when the sufferer considers it safe to proceed. GPP
11.8.1.6
Treatment should be delivered by competent individuals who have received
appropriate training. These individuals should receive appropriate supervision. C
11.8.2 Comorbidities
11.8.2.1
When a patient presents with PTSD and depression, healthcare professionals should
consider treating the PTSD first, as the depression will often improve with successful
treatment of the PTSD. C
11.8.2.2
For PTSD sufferers whose assessment identifies a high risk of suicide or harm to
others, healthcare professionals should first concentrate on management of this risk.
C
11.8.2.3
For PTSD sufferers who are so severely depressed that this makes initial psychological
treatment of PTSD very difficult (for example, as evidenced by extreme lack of energy
and concentration, inactivity, or high suicide risk), healthcare professionals should
treat the depression first. C
11.8.2.4
For PTSD sufferers with drug or alcohol dependence or in whom alcohol or drug use
may significantly interfere with effective treatment, healthcare professionals should
treat the drug or alcohol problem first. C
11.7.2.5
When offering trauma-focused psychological interventions to PTSD sufferers with
comorbid personality disorder, healthcare professionals should consider extending the
duration of treatment. C
11.7.2.6
People who have lost a close friend or relative due to an unnatural or sudden death
should be assessed for PTSD and traumatic grief. In most cases, healthcare
professionals should treat the PTSD first without avoiding discussion of the grief. C
Care for all people with PTSD
127
11.9 Treatment of PTSD
11.9.1 Early interventions
A number of sufferers with PTSD may recover with no or limited interventions. However, without
effective treatment, many people may develop chronic problems over many years. The 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.
Watchful waiting
11.9.1.1
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 sufferers, should be considered by healthcare professionals. A follow-up
contact should be arranged within 1 month. C
Immediate psychological interventions for all
As described in this guideline, practical support delivered in an empathetic manner is important
in promoting recovery for PTSD, but it is unlikely that a single session of a psychological
intervention will be helpful.
11.9.1.2
All health and social care workers should be aware of the psychological impact of
traumatic incidents in their immediate post-incident care of survivors and offer
practical, social and emotional support to those involved. GPP
11.9.1.3
For individuals who have experienced a traumatic event, the systematic provision to that
individual alone of brief, single-session interventions (often referred to as debriefing) that
focus on the traumatic incident should not be routine practice when delivering services. A
PTSD where symptoms are present within 3 months of a trauma
Brief psychological interventions (five sessions) may be effective if treatment starts within the first
month after the traumatic event. Beyond the first month, the duration of treatment is similar to
that for chronic PTSD.
11.9.1.4
Trauma-focused cognitive–behavioural therapy should be offered to those with severe
post-traumatic symptoms or with severe PTSD in the first month after the traumatic event.
These treatments should normally be provided on an individual out-patient basis. B
11.9.1.5
Trauma-focused CBT should be offered to people who present with PTSD within 3
months of a traumatic event. A
11.9.1.6
The duration of the trauma-focused CBT should normally be 8–12 sessions, but if the
treatment starts in the first month after the event, fewer sessions (about 5) may be
sufficient. When the trauma is discussed in the treatment session, longer sessions (for
example, 90 min) are usually necessary. Treatment should be regular and continuous
(usually at least once a week) and should be delivered by the same person. B
11.9.1.7
Drug treatment may be considered in the acute phase of PTSD for the management of
sleep disturbance. In this case, hypnotic medication may be appropriate for short-term
use but, if longer-term drug treatment is required, consideration should also be given
to the use of suitable antidepressants at an early stage in order to reduce the later risk
of dependence. C
11.9.1.8
Non-trauma-focused interventions such as relaxation or non-directive therapy, which
do not address traumatic memories, should not routinely be offered to people who
present with PTSD symptoms within 3 months of a traumatic event. B
11.9.2 PTSD where symptoms have been present for more than 3 months
after a trauma
Most patients presenting with PTSD have had the problem for many months, if not years. The
interventions outlined below are effective in treating such individuals and duration of the
128
Summary of recommendations
disorder does not itself seem an impediment to benefiting from effective treatment provided by
competent healthcare professionals.
Psychological interventions
11.9.2.1
All PTSD sufferers should be offered a course of trauma-focused psychological
treatment (trauma-focused CBT or eye movement desensitisation and reprocessing).
These treatments should normally be provided on an individual out-patient basis. A
11.9.2.2
Trauma-focused psychological treatment should be offered to PTSD sufferers
regardless of the time that has elapsed since the trauma. B
11.9.2.3
The duration of trauma-focused psychological treatment should normally be 8–12
sessions when the PTSD results from a single event. When the trauma is discussed in
the treatment session, longer sessions than usual are generally necessary (for example,
90 min). Treatment should be regular and continuous (usually at least once a week)
and should be delivered by the same person. B
11.9.2.4
Healthcare professionals should consider extending the duration of treatment beyond 12
sessions if several problems need to be addressed in the treatment of PTSD sufferers,
particularly after multiple traumatic events, traumatic bereavement or where chronic
disability resulting from the trauma, significant comorbid disorders or social problems are
present. Trauma-focused treatment needs to be integrated into an overall plan of care. C
11.9.2.5
For some PTSD sufferers it may initially be very difficult and overwhelming to disclose
details of their traumatic events. In these cases, healthcare professionals should
consider devoting several sessions to establishing a trusting therapeutic relationship
and emotional stabilisation before addressing the traumatic event. C
11.9.2.6
Non-trauma-focused interventions such as relaxation or non-directive therapy, which
do not address traumatic memories, should not routinely be offered to people who
present with chronic PTSD. B
11.9.2.7
For PTSD sufferers who have no or only limited improvement with a specific traumafocused psychological treatment, healthcare professionals should consider the
following options:
an alternative form of trauma-focused psychological treatment
the augmentation of trauma-focused psychological treatment with a course of
pharmacological treatment. C
11.9.2.8
When PTSD sufferers request other forms of psychological treatment (for example,
supportive therapy/non-directive therapy, hypnotherapy, psychodynamic therapy or
systemic psychotherapy), they should be informed that there is as yet no convincing
evidence for a clinically important effect of these treatments on PTSD. GPP
11.9.3 Drug treatment
The evidence base for drug treatments in PTSD is limited. There is evidence of clinically significant
benefits for mirtazapine, amitriptyline and phenelzine. (Dietary guidance is required with
phenelzine.) For paroxetine there were statistically but not clinically significant benefits on the
main outcome variables. Nevertheless, this drug has also been included in the list of
recommended drugs. This is the only drug in the list of recommendations with a current UK
product licence for PTSD.
11.9.3.1
Drug treatments for PTSD should not be used as a routine first-line treatment for
adults (in general use or by specialist mental health professionals) in preference to a
trauma-focused psychological therapy. A
11.9.3.2
Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or
phenelzine for initiation only by mental health specialists) should be considered for
the treatment of PTSD in adults where a sufferer expresses a preference not to engage
in a trauma-focused psychological treatment. B
11.9.3.3
Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or
phenelzine for initiation only by mental health specialists) should be offered to
Treatment of PTSD
129
adult PTSD sufferers who cannot start a psychological therapy because of serious
ongoing threat of further trauma (for example, where there is ongoing domestic
violence). C
11.9.3.4
Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or
phenelzine for initiation only by mental health specialists) should be considered for
adult PTSD sufferers who have gained little or no benefit from a course of traumafocused psychological treatment. C
11.9.3.5
Where sleep is a major problem for an adult PTSD sufferer, hypnotic medication may
be appropriate for short-term use but, if longer-term drug treatment is required,
consideration should also be given to the use of suitable antidepressants at an early
stage in order to reduce the later risk of dependence. C
11.9.3.6
Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or
phenelzine for initiation only by mental health specialists) for PTSD should be
considered as an adjunct to psychological treatment in adults where there is
significant comorbid depression or severe hyperarousal that significantly impacts on a
sufferer’s ability to benefit from psychological treatment. C
11.9.3.7
When an adult sufferer with PTSD has not responded to a drug treatment,
consideration should be given to increasing the dosage within approved limits. If
further drug treatment is considered, this should generally be with a different class of
antidepressant or involve the use of adjunctive olanzapine. C
11.9.3.8
When an adult sufferer with PTSD has responded to drug treatment, it should be
continued for at least 12 months before gradual withdrawal. C
General recommendations regarding drug treatment
11.9.3.9
All PTSD sufferers who are prescribed antidepressants should be informed, at the time
that treatment is initiated, of potential side-effects and discontinuation/withdrawal
symptoms (particularly with paroxetine). C
11.9.3.10 Adult PTSD sufferers started on antidepressants who are considered to have an
increased suicide risk and all patients aged between 18 and 29 years (because of the
potential increased risk of suicidal thoughts associated with the use of antidepressants
in this age group) should normally be seen after 1 week and frequently thereafter
until the risk is no longer considered significant. GPP
11.9.3.11 Particularly in the initial stages of SSRI treatment, practitioners should actively seek
out signs of akathisia, suicidal ideation and increased anxiety and agitation. They
should also advise PTSD sufferers of the risk of these symptoms in the early stages of
treatment and advise them to seek help promptly if these are at all distressing. GPP
11.9.3.12 If a PTSD sufferer develops marked and/or prolonged akathisia while taking an
antidepressant, the use of the drug should be reviewed. GPP
11.9.3.13 Adult PTSD sufferers started on antidepressants who are not considered to be at
increased risk of suicide should normally be seen after 2 weeks and thereafter on an
appropriate and regular basis, for example, at intervals of 2–4 weeks in the first 3
months, and at greater intervals thereafter, if response is good. GPP
Recommendations regarding discontinuation/withdrawal symptoms
11.9.3.14 Discontinuation/withdrawal symptoms are usually mild and self-limiting but
occasionally can be severe. Prescribers should normally gradually reduce the dosage of
antidepressants over a 4-week period, although some people may require longer
periods. C
11.9.3.15 If discontinuation/withdrawal symptoms are mild, practitioners should reassure
the PTSD sufferer and arrange for monitoring. If symptoms are severe, the
practitioner should consider reintroducing the original antidepressant (or another
with a longer half-life from the same class) and reduce gradually while monitoring
symptoms. C
130
Summary of recommendations
11.9.4 Chronic disease management
11.9.4.1
Chronic disease management models should be considered for the management of
people with chronic PTSD who have not benefited from a number of courses of
evidence-based treatment. C
11.9.5 Children
It is particularly difficult to identify PTSD in children (see section 11.3.4). The treatments for
children with PTSD are less developed but emerging evidence provides an indication for
effective interventions.
Early intervention
11.9.5.1
Trauma-focused CBT should be offered to older children with severe posttraumatic symptoms or with severe PTSD in the first month after the traumatic
event. B
PTSD where symptoms have been present for more than 3 months after a trauma
11.9.5.2
Children and young people with PTSD, including those who have been sexually
abused, should be offered a course of trauma-focused CBT adapted appropriately
to suit their age, circumstances and level of development. B
11.9.5.3
The duration of trauma-focused psychological treatment for children and young
people with chronic PTSD should normally be 8–12 sessions when the PTSD results
from a single event. When the trauma is discussed in the treatment session, longer
sessions than usual are usually necessary (for example, 90 min). Treatment should
be regular and continuous (usually at least once a week) and should be delivered
by the same person. C
11.9.5.4
Drug treatments should not be routinely prescribed for children and young people
with PTSD. C
11.9.5.5
Where appropriate, families should be involved in the treatment of PTSD in
children and young people. However, treatment programmes for PTSD in children
and young people that consist of parental involvement alone are unlikely to be of
any benefit for PTSD symptoms. C
11.9.5.6
When considering treatments for PTSD, parents and, where appropriate, children
and young people should be informed that, apart from trauma-focused
psychological interventions, there is at present no good evidence for the efficacy
of widely used forms of treatment of PTSD such as play therapy, art therapy or
family therapy. C
11.10 Disaster planning
Both health and social services have a role in organising the appropriate social and psychological
support for those affected by disasters.
11.10.1 Recommendations
11.10.1.1 Disaster plans should include provision for a fully coordinated psychosocial
response to the disaster. Those responsible for developing the psychosocial aspect
of a disaster plan should ensure it contains the following: provision for immediate
practical help, means to support the affected communities in caring for those
involved in the disaster and the provision of specialist mental health, evidencebased assessment and treatment services. All healthcare workers involved in a
disaster plan should have clear roles and responsibilities, which should be agreed
in advance. GPP
Disaster planning 131
11.11 Research recommendations
11.11.1 Guided self-help
11.11.1.1 A randomised controlled trial, using newly developed guided self-help materials based
on trauma-focused psychological interventions, should be conducted to assess the
efficacy and cost-effectiveness of guided self-help compared with trauma-focused
psychological interventionse for mild and moderate PTSD.
11.11.2 Children and young people
11.11.2.1 Randomised controlled trials for children of all ages should be conducted to assess the
efficacy and cost-effectiveness of trauma-focused psychological treatments
(specifically CBT and EMDR). These trials should identify the relative efficacy of
different trauma-focused psychological interventions and provide information on the
differential effects, if any, arising from the age of the children or the nature of the
trauma experienced.
11.11.3 Trauma-focused psychological interventions in adults
11.11.3.1 Adequately powered effectiveness trials of trauma-focused psychological interventions
for the treatment of PTSD (trauma-focused cognitive–behavioural therapy and eye
movement desensitisation and reprocessing) should be conducted. They should
provide evidence on the comparative effectiveness and cost-effectiveness of these
interventions and consider the format of treatment (type and duration) and the
specific populations who might benefit.
11.11.4 Screening programme
11.11.4.1 An appropriately designed longitudinal study should be conducted to determine if a
simple screening instrument, which is acceptable to those receiving it, can identify
individuals who develop PTSD after traumatic events and can be used as part of a
screening programme to ensure individuals with PTSD receive effective interventions.
11.11.5 Trauma-focused psychological treatment versus pharmacological
treatment
11.11.5.1 Adequately powered, appropriately designed trials should be conducted to determine
if trauma-focused psychological treatments are superior in terms of efficacy and costeffectiveness to pharmacological treatments in the treatment of PTSD and whether
they are efficacious and cost-effective in combination.
132
Summary of recommendations
Appendices
Appendix 1:
Scope for the development of a clinical guideline on the management
of post-traumatic stress disorder
Appendix 2:
Stakeholders who responded to early requests for evidence
Appendix 3:
Stakeholders and experts who responded to the first consultation draft
of the guideline
Appendix 4:
Researchers contacted to request information about unpublished
or soon-to-be published studies
Appendix 5:
Clinical questions
Appendix 6:
Search strategies for the identification of clinical studies
Appendix 7:
Systematic review quality checklist
Appendix 8:
Randomised controlled trial methodological quality checklist
Appendix 9:
Clinical study data extraction form
Appendix 10:
Methods for calculating means and standard deviations for pooled
treatment groups
Appendix 11:
Search strategies for the identification of health economics studies
Appendix 12:
Quality checklists for economic studies
Appendix 13:
Diagnostic criteria
Appendix 14:
Evidence tables for clinical studies
Appendix 15a–d: Forest plots
Appendix 16a–d: Evidence statements
134
137
138
140
141
143
145
146
147
148
149
151
153
on CD
on CD
on CD
133
Appendix 1: Scope for the development
of a clinical guideline on the management
of post-traumatic stress disorder
1 Guideline title
Post-traumatic stress disorder: the management of PTSD in adults and children in primary and
secondary care
2 Short title
PTSD
3 Background
The National Institute for Clinical Excellence (‘NICE’ or ‘the Institute’) has commissioned the
National Collaborating Centre for Mental Health to develop a clinical guideline on the
management of anxiety disorders for use in the National Health Service (NHS) in England and
Wales. This follows referral of the topic of anxiety disorders, by the Department of Health and
Welsh Assembly Government. This document provides further detail on the specific issues relating
to PTSD and is a development of the original scope agreed for the anxiety disorders. The
guideline will provide recommendations for good practice that are based on the best available
evidence of clinical and cost effectiveness.
The Institute’s clinical guidelines will support the implementation of National Service Frameworks
(NSFs) in those aspects of care where a Framework has been published. The statements in each
NSF reflect the evidence that was used at the time the Framework was prepared. The clinical
guidelines and technology appraisals published by the Institute after an NSF has been issued will
have the effect of updating the Framework.
4 Clinical need for the guideline
Community-based studies in the USA reveal a lifetime prevalence for PTSD of approximately 8%
of the adult population. The disorder can occur at any age, including during childhood, with
symptoms usually beginning within the first 3 months after the trauma. However, there may be a
delay of months or years before symptoms start to appear.
PTSD presents in a range of populations, including those who have been exposed to or witnessed
severe accidents, assault, deliberate acts of torture, disaster or military action; members of the
emergency services; and other special populations.
People with post-traumatic stress and related disorders are currently treated in a range of
NHS settings, including primary care, general mental health services and specialist secondary
care mental health services. The provision and uptake of such services varies across England
and Wales and reflects the demands of particular populations (for example refugees or war
veterans) and the presence or absence of specialist services. The decade since 1995 has seen
a significant expansion of special services, but the provision is still subject to considerable
local variation.
134
Appendices
A number of guidelines, consensus statements and local protocols exist. This guideline will review
evidence of clinical and cost-effective practice, together with current guidelines, and will offer
guidance on best practice.
5 The guideline
The guideline development process is described in detail in three booklets that are available from
the NICE website (see paragraph 11). The Guideline Development Process – Information for
Stakeholders describes how organisations can become involved in the development of a
guideline.
This document is the scope. It defines exactly what this guideline will (and will not) examine, and
what the guideline developers will consider. The scope is based on the referral from the
Department of Health and Welsh Assembly Government; these organisations asked the Institute:
to prepare a clinical guideline and audit tool for the NHS in England and Wales for ‘talking’
therapies, drug treatments and prescribing for anxiety and related common mental
disorders, including generalised anxiety disorder (GAD), panic disorder (with or without
agoraphobia), post-traumatic stress disorder, and obsessive–compulsive disorder (OCD).
The audit tool should include a dataset, database and audit methodology.
The areas that will be addressed by the guideline are described in the following sections.
6 Population
The recommendations made in the guideline will cover management of the following groups:
Adults and children of all ages who meet or are at risk of PTSD.
The guideline developers will be sensitive to the different approaches to PTSD of different races
and cultures, and be aware of the issues of both internal and external social exclusion.
Traumatic experiences can affect the whole family and often the community. The guideline will
recognise the role of both in the treatment and support of people with PTSD.
The primary focus of the guideline will be PTSD; however, comorbid factors such as drug misuse
and alcoholism, pain disorders, major depression and developmental issues including personality
disorder will also be considered.
7 Healthcare setting
The guideline will cover the care provided by primary, secondary and other healthcare
professionals who have direct contact with, and make decisions concerning the care of, people
with PTSD.
The guideline will also be relevant to the work, but will not cover the practice, of those in:
occupational health services
social services
the independent sector.
8 Clinical management: areas that will be covered
The guideline will cover the following areas of clinical practice.
Diagnostic criteria currently in use for PTSD and the diagnostic factors that trigger the use of this
guideline. The definition of the condition in relation to other anxiety disorders will be precise.
Appendix 1: Scope for guideline development 135
The guideline will address the issues of diagnosis, detection and the use of screening techniques
in high-risk situations and include advice on the appropriate use of early intervention
(psychological and pharmacological).
Pharmacological interventions for PTSD (those available in the UK according to the British
National Formulary). When referring to pharmacological treatments, the guideline will whenever
possible recommend within the licensed indications. However, where the evidence clearly
supports it, recommendations for use outside the licensed indications may be made in
exceptional circumstances. The guideline will expect that prescribers will use the Summary of
Product Characteristics to inform their prescribing decisions for individual patients.
The guideline will include advice on the appropriate use of psychological interventions including
type, modality, frequency and duration.
The guideline will include the appropriate use of combined pharmacological and psychological
interventions.
The guideline will consider the side-effects, toxicity, acceptability and other disbenefits of
treatments.
The guideline will recognise the need for people with PTSD to have information and opportunities
to discuss with clinicians the advantages, disadvantages and potential side-effects of treatment,
so that they can make informed choices about care options.
9 Clinical management: areas that will not be covered
The guideline will not cover treatments that are not normally available on the NHS.
10 Audit support within guideline
The guideline will include key review criteria for audit, which will enable objective measurements
to be made of the extent and nature of local implementation of this guidance, particularly its
impact upon practice and outcomes for people with PTSD.
11 Status
This is the final version of the scope. It has been derived from the scope on generalised anxiety
which formerly included PTSD and which was subject to a 4-week period of consultation with
stakeholders and review by the Guidelines Advisory Committee. As a result of that consultation, a
decision was taken to prepare a separate guideline for PTSD and this separate scope was drafted
and submitted to the Institute’s Guideline Programme Director and Executive Lead for approval.
The development of the guideline recommendations began in spring 2003.
Further information on the guideline development process is provided in:
The Guideline Development Process – Information for the Public and the NHS
The Guideline Development Process – Information for Stakeholders
The Guideline Development Process – Information for National Collaborating Centres and
Guideline Development Groups.
These booklets are available as PDF files from the NICE website (www.nice.org.uk). Information
on the progress of the guideline will also be available from the website.
136
Appendices
Appendix 2: Stakeholders who responded
to early requests for evidence
ASSIST (Assistance, Support and Self-Help in Surviving Trauma) Trauma Care
British Association for Counselling and Psychotherapy
British Geriatrics Society
College of Occupational Therapists
Eli Lilly
GlaxoSmithKline UK
Inner Cities Mental Health Group
NHS Quality Improvement Scotland
Pfizer
Royal College of Nursing
Solvay Healthcare Limited
Victim Support
Wyeth Laboratories
137
Appendix 3: Stakeholders and experts
who responded to the first consultation
draft of the guideline
Stakeholders
ASSIST (Assistance, Support and Self-Help in Surviving Trauma) Trauma Care
Association for Improvements in Maternity Services
Association of the British Pharmaceuticals Industry
Birth Trauma Association
Bolton Salford & Trafford Mental Health
British Association for Behavioural and Cognitive Psychotherapies
British Association for Counselling and Psychotherapy
British Association for Psychopharmacology
British Association of Art Therapists
British Psychological Society
Camden & Islington Mental Health and Social Care Trust
Centre for Trauma Studies/Traumatic Stress Services
Chartered Society of Physiotherapy
Cheshire & Wirral Partnership NHS Trust
CIS’ters
College of Occupational Therapists
Cornwall Partnership Trust
Counselling and Psychotherapy Trust
Department of Health
First Person Plural
GlaxoSmithKline UK
Hampshire Partnership NHS Trust
Human Givens Institute
Institute of Psychotrauma
Janssen-Cilag Ltd
London Ambulance Services NHS Trust
Moving Minds Ltd
National Childbirth Trust
National Mental Health Partnership
North Staffordshire Combined Healthcare NHS Trust
Oxfordshire Mental Health Care NHS Trust
Patient Involvement Unit for NICE
138
Appendices
Royal College of Midwives
Royal College of Nursing
Royal College of Paediatrics and Child Health
Survivors Trust
Tavistock and Portman NHS Trust
UK Council for Psychotherapy
UK Society for the Study of Dissociation
Victim Support
West London Mental Health NHS Trust
WISH – Women in Secure Hospitals
Wyeth Laboratories
Experts
Mr Paul Atkinson
Dr Sandra Buck
Dr Judith Cohen
Dr Stephen Davies
Defence Medical Services
Dr Edna Foa
Dr Berthold Gersons
Dr Ben Green
Dr Rahul Kacker
Dr Blanaid Kelly
Dr Mark Mayal
Mr Peter McDermott
Dr Paul Rogers
Dr Barbara Rothbaum
Ms Sue Richardson
Dr Josef Ruzek
Dr Francine Shapiro
Dr Simon Wessely
Appendix 3: Stakeholders and experts who responded to first consultation draft
139
Appendix 4: Researchers contacted
to request information about unpublished
or soon-to-be published studies
Arnoud Arntz
Charles Marmar
Richard Bryant
Sandy McFarlane
Willi Butollo
Thomas Mellman
Claude Chemtob
Lars-Gõran Öst
Judith Cohen
Michael Otto
Mark Creamer
Roger Pitman
Jonathan Davidson
Mark Pollack
Enrique Echeburua
Patti Resick
Paul Emmelkamp
David Riggs
Edna Foa
Sue Rose
Chris Freeman
Barbara Rothbaum
Matt Friedman
Joe Ruzek
Berthold Gersons
Paula Schnurr
Louise Humphreys
Arieh Shalev
Terry Keane
Dan Stein
Dean Kilpatrick
Nick Tarrier
Merel Kindt
Agnes van der Minnen
Edward Kubany
Simon Wessely
Brett Litz
Patricia White
Andreas Maercker
Rachel Yehuda
140
Appendices
Appendix 5: Clinical questions
Psychology
1
2
3
4
For people with PTSD, do psychological treatments improve patient outcomes compared
with no treatment?
For people with PTSD, does any psychological treatment confer any advantage over any
other psychological treatment?
For people exposed to trauma, do early psychological interventions improve patient
outcomes compared with no intervention?
For people exposed to trauma, does any early psychological intervention confer any
advantage compared with other psychological intervention?
Pharmacology
1
2
3
4
For people with PTSD, do pharmacological interventions improve patient outcomes
compared with placebo?
For people with PTSD, do any pharmacological interventions confer any advantage over any
other pharmacological interventions?
For people exposed to trauma, do early pharmacological interventions improve patient
outcomes compared with placebo?
For people exposed to trauma, do any early pharmacological interventions confer any
advantage over any other pharmacological interventions?
Psychology and pharmacology
1
2
For people with PTSD, do combinations of pharmacological and psychological interventions
improve outcomes over no treatment/placebo?
For people with PTSD, do combinations of pharmacological and psychological interventions
improve outcomes over psychological or pharmacological treatment alone?
Response to treatment
1
2
For adults with PTSD, do factors such as traumatic grief, depression, personality disorders,
pain and drug and alcohol misuse predict response to treatment?
For children with PTSD, do factors such as parental involvement in the traumatic event
predict response to treatment?
Screening and diagnosis
1
2
Are there routine screening methods that may be valuable in predicting who will develop
PTSD?
Are there routine methods that may be valuable in confirming a clinical diagnosis of PTSD?
141
Risk factors
1
2
Do any factors or variables predict the development of PTSD?
Do any factors or variables predict the chronicity of PTSD?
Health economics
1
142
Initiation of treatment: are there significant additional costs associated with intervening
early or later in the course of PTSD?
Appendices
Appendix 6: Search strategies for the
identification of clinical studies
General search filters
Medline, EMBASE, PsycINFO, CINAHL–OVID interface
A general search was conducted to extract randomised controlled trials and systematic reviews of
randomised controlled trials, from which relevant papers were identified for each of the main
chapters within this guideline (psychological interventions, pharmacological interventions,
children and early interventions).
11
Stress Disorders, Traumatic/ or Combat Disorders/ or Stress Disorders, Post-Traumatic,
Acute/ or Stress Disorders, Post-Traumatic/ or Stress, Psychological/
12
Stress, Psychological/ or Critical Incident Stress/ or Stress Disorders, Post-Traumatic/
13
Posttraumatic Stress Disorder/ or Emotional Trauma/ or Traumatic Neurosis/
14
Posttraumatic Stress Disorder/ or Psychotrauma/
15
(post?traumatic$ or post-traumatic$ or stress disorder$ or acute stress or PTSD or ASD or
DESNOS).tw.
16
(combat neuros$ or combat syndrome or concentration camp syndrome or extreme stress
or flash?back$ or flash-back$ or hypervigilan$ or hypervigilen$ or psych$ stress or psych$
trauma$ or psycho?trauma$ or psycho-trauma$).tw.
17
(railway spine or (rape adj2 trauma$) or re?experienc$ or re-experienc$ or torture
syndrome or traumatic neuros$ or traumatic stress).tw.
18
(trauma$ and (avoidance or grief or horror or death$ or night?mare$ or night-mare$ or
emotion$)).tw.
19
or/1–8
10
exp clinical trials/ or cross-over studies/ or random allocation/ or double-blind method/ or
single-blind method/
11
random$.pt.
12
exp clinical trial/ or crossover procedure/ or double blind procedure/ or single blind
procedure/ or randomization/
13
exp clinical trials/ or crossover design/ or random assignment/
14
exp clinical trials/ or double blind method/ or random allocation/
15
random$.mp.
16
(cross-over or cross?over or (clinical adj2 trial$) or single-blind$ or single?blind$ or doubleblind or double?blind$ or triple-blind or triple?blind).tw.
17
or/10–16
18
animals/ not (animals/ and human$.mp.)
19
animal$/ not (animal$/ and human$/)
20
meta-analysis/
21
meta-analysis.pt.
22
systematic review/
23
or/18–22
24
17 not 23
25
9 and 24
26
or/1–5
27
or/6–8
28
26 and 24
29
27 and 24
30
remove duplicates from 29
31
remove duplicates from 28
143
32
30 or 31
33
remove duplicates from 32
In addition, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register
and the Database of Reviews of Effectiveness of the Cochrane Library were searched.
Narrative review search filters
Medline, EMBASE, PsycINFO–Dialog DataStar interface
Separate searches were conducted to cover narrative reviews for screening and risk factors.
The following search was used to update the systematic review undertaken by Brewin et al (2000)
for longitudinal prospective studies.
1
#5 #3 and #4
2
#4 cohort* or longitudinal or prospective or case control*
3
#3 #1 and #2 and (PY=2000-2004)
4
#2 risk or predictor or prediction or predisposition
5
#1 post traumatic or posttraumatic or ptsd
Additional searches were conducted for specific risk factors such as injury, compensation and
litigation and prospective screening tools. These search filters are available on request.
144
Appendices
Appendix 7: Systematic review quality
checklist
Checklist completed by:
Report reference ID:
SECTION 1: VALIDITY
Evaluation criteria
Notes for reviewer
1.1 Does the review address Unless a clear and well-defined question is specified, it will be
an appropriate and
difficult to assess how well the study has met its objectives or
clearly focused question? how relevant it is to the question you are trying to answer on
the basis of its conclusions.
1.2 Does the review include a A systematic review should include a detailed description of
description of the
the methods used to identify and evaluate individual studies. If
methodology used?
this description is not present, it is not possible to make a
thorough evaluation of the quality of the review, and it should
be rejected as a source of Level I evidence (although it may be
useable as Level IV evidence, if no better evidence can be found.
1.3 Was the literature search
sufficiently rigorous to
identify all relevant
studies?
Consider whether the review used an electronic search of at
least one bibliographic database (searching for studies dating
at least 10 years before publication of the review). Any
indication that hand-searching of key journals or follow-up of
reference lists of included studies was done in addition to
electronic database searches can normally be taken as
evidence of a well-conducted review.
1.4 Was study quality
assessed and taken
into account?
A well-conducted systematic review should have used clear
criteria to assess whether individual studies had been well
conducted before deciding whether to include or exclude
them. At a minimum, the authors should have checked that
there was adequate concealment of allocation, that the rate of
withdrawal from the study was minimised, and that the results
were analysed on an intention-to-treat basis. If there is no
indication of such an assessment, the review should be rejected
as a source of Level I evidence. If details of the assessment are
poor, or the methods considered to be inadequate, the quality
of the review should be downgraded.
SECTION 2: OVERALL
ASSESSMENT
Comments
Code
2.1 Low risk of bias
Moderate risk of bias
High risk of bias
All or most criteria met
Most criteria partly met
Few or no criteria met
A
B
C
145
Appendix 8: Randomised controlled trial
methodological quality checklist
Checklist completed by:
Report reference ID:
SECTION 1: INTERNAL VALIDITY
Evaluation criteria
Notes for reviewer
1.1 Was the assignment of
If there is no indication of randomisation, the study should
participants to treatment be rejected. If the description of randomisation is poor, or the
groups randomised?
process used is not truly random (e.g. allocation by date,
alternating between one group and another) or can otherwise
be seen as flawed, the study should be given a lower quality
rating.
1.2 Was an adequate
concealment method
used?
Centralised allocation, computerised allocation systems or the
use of coded identical containers would all be regarded as
adequate methods of concealment, and may be taken as
indicators of a well-conducted study. If the method of
concealment used is regarded as poor or relatively easy to
subvert, the study must be given a lower quality rating, and
can be rejected if the concealment method is seen as
inadequate.
SECTION 2: OVERALL
ASSESSMENT
Comments
Code
2.1 Low risk of bias
Moderate risk of bias
High risk of bias
Both criteria met
One or more criteria partly met
One or more criteria not met
A
B
C
146
Appendices
Appendix 9: Clinical study data
extraction form
147
Appendix 10: Methods for calculating
means and standard deviations for pooled
treatment groups
For a number of the analyses of psychological interventions, treatment groups within a study
were combined for a particular comparison.
Where ni is the sample size of treatment group i, mi is the mean of treatment group i and sdi is
the standard deviation of treatment group i, the mean of the combined treatment group is
estimated as
Σ i n i m i / Σ ni
and the standard deviation of the combined treatment group is estimated as
√ [Σi (ni – 1) (sdi)2 / ((Σi ni) – T)]
where T is the number of treatment groups (all summations from 1 to T).
148
Appendices
Appendix 11: Search strategies for the
identification of health economics studies
General search filters
Medline, EMBASE, PsycINFO, CINAHL–OVID interface
A general search was conducted to extract randomised controlled trials and systematic reviews of
randomised controlled trials, from which relevant papers were identified for each of the main
chapters within this guideline (psychological interventions, pharmacological interventions,
children and early interventions).
11
Stress Disorders, Traumatic/ or Combat Disorders/ or Stress Disorders, Post-Traumatic,
Acute/ or Stress Disorders, Post-Traumatic/ or Stress, Psychological/
12
Stress, Psychological/ or Critical Incident Stress/ or Stress Disorders, Post-Traumatic/
13
Posttraumatic Stress Disorder/ or Emotional Trauma/ or Traumatic Neurosis/
14
Posttraumatic Stress Disorder/ or Psychotrauma/
15
(post?traumatic$ or post-traumatic$ or stress disorder$ or acute stress or PTSD or ASD or
DESNOS).tw.
16
(combat neuros$ or combat syndrome or concentration camp syndrome or extreme stress
or flash?back$ or flash-back$ or hypervigilan$ or hypervigilen$ or psych$ stress or psych$
trauma$ or psycho?trauma$ or psycho-trauma$).tw.
17
(railway spine or (rape adj2 trauma$) or re?experienc$ or re-experienc$ or torture
syndrome or traumatic neuros$ or traumatic stress).tw.
18
(trauma$ and (avoidance or grief or horror or death$ or night?mare$ or night-mare$ or
emotion$)).tw.
19
or/1–8
10
exp clinical trials/ or cross-over studies/ or random allocation/ or double-blind method/ or
single-blind method/
11
random$.pt.
12
exp clinical trial/ or crossover procedure/ or double blind procedure/ or single blind
procedure/ or randomization/
13
exp clinical trials/ or crossover design/ or random assignment/
14
exp clinical trials/ or double blind method/ or random allocation/
15
random$.mp.
16
(cross-over or cross?over or (clinical adj2 trial$) or single-blind$ or single?blind$ or doubleblind or double?blind$ or triple-blind or triple?blind).tw.
17
or/10–16
18
animals/ not (animals/ and human$.mp.)
19
animal$/ not (animal$/ and human$/)
20
meta-analysis/
21
meta-analysis.pt.
22
systematic review/
23
or/18–22
24
17 not 23
25
9 and 24
26
or/1–5
27
or/6–8
28
26 and 24
29
27 and 24
30
remove duplicates from 29
31
remove duplicates from 28
149
32
30 or 31
33
remove duplicates from 32
In addition, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register
and the Database of Reviews of Effectiveness of the Cochrane Library were searched.
Narrative review search filters
Medline, EMBASE, PsycINFO–Dialog DataStar interface
Separate searches were conducted to cover narrative reviews for screening and risk factors.
The following search was used to update the systematic review undertaken by Brewin et al (2000)
for longitudinal prospective studies.
1
#5 #3 and #4
2
#4 cohort* or longitudinal or prospective or case control*
3
#3 #1 and #2 and (PY=2000–2004)
4
#2 risk or predictor or prediction or predisposition
5
#1 post traumatic or posttraumatic or ptsd
Additional searches were conducted for specific risk factors such as injury, compensation and
litigation and prospective screening tools. These search filters are available on request.
Health economics search filters
PTSD – General +
11
12
13
14
15
16
17
18
19
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(burden adj2 illness).mp.
(burden adj2 disease).mp.
(cost$ adj2 evaluat$).mp.
(cost$ adj2 benefit$).mp.
(cost$ adj2 utilit$).mp.
(cost$ adj2 minimi$).mp.
(cost$ adj2 illness).mp.
(cost$ adj2 disease).mp.
(cost$ adj2 analys$).mp.
(cost$ adj2 assess$).mp.
(cost$ adj2 study).mp.
(cost$ adj2 studies).mp.
(cost$ adj2 allocation).mp.
(cost$ adj2 outcome$).mp.
(cost$ adj2 consequence$).mp.
(cost$ adj2 effect$).mp.
(cost$ adj2 treatment$).mp.
(economic adj2 evaluat$).mp.
(economic adj2 analysis$).mp.
(economic adj2 study).mp.
(economic adj2 studies).mp.
(economic adj2 assess$).mp.
(economic adj2 consequence$).mp.
(economic adj2 outcome$).mp.
(resource$ adj2 allocation$).mp.
(resource$ adj2 utili$).mp.
expenditure$.mp.
exp economics/
exp “costs and cost analysis”/
exp “health economics”/
or/1-30
150
Appendices
Appendix 12: Quality checklists
for economic studies
Full economic evaluations
Author:
Date:
Title:
Yes
No
NA
Study design
11
12
13
14
15
16
Data
11
12
13
14
15
16
17
18
19
10
11
12
The research question is stated
The viewpoint(s) of the analysis are clearly stated
The alternatives being compared are relevant
The rationale for choosing the alternative programmes
or interventions compared is stated
The alternatives being compared are clearly described
The form of economic evaluation used is justified in relation
to the question addressed
collection
The source of effectiveness data used is stated
Details of the design and results of effectiveness study are given
The primary outcome measure(s) for the economic
evaluation are clearly stated
Methods to value health states and other benefits are stated
Details of the subjects from whom valuations were
obtained are given
Indirect costs (if included) are reported separately
Quantities of resources are reported separately from their
unit costs
Methods for the estimation of quantities and unit costs are
described
Currency and price data are recorded
Details of currency of price adjustments for inflation or
currency conversion are given
Details of any model used are given
The choice of model used and the key parameters on which
it is based are justified
Analysis and interpretation of results
11
Time horizon of costs and benefits is stated
12
The discount rate(s) is stated
13
The choice of rate(s) is justified
14
An explanation is given if costs or benefits are not discounted
15
Details of statistical tests and confidence intervals are given
for stochastic data
16
The approach to sensitivity analysis is given
17
The choice of variables for sensitivity analysis is given
18
The ranges over which the variables are varied are stated
19
Relevant alternatives are compared
10
Incremental analysis is reported
11
Major outcomes are presented in a disaggregated as well
as aggregated form
12
The answer to the study question is given
13
Conclusions follow from the data reported
14
Conclusions are accompanied by the appropriate caveats
151
Partial economic evaluations
Author:
Date:
Title:
Yes
No
NA
Study design
11
12
The research question is stated
The viewpoint(s) of the analysis are clearly stated and justified
Data collection
11
Details of the subjects from whom valuations were
obtained are given
12
Indirect costs (if included) are reported separately
13
Quantities of resources are reported separately from their
unit costs
14
Methods for the estimation of quantities and unit costs are
described
15
Currency and price data are recorded
16
Details of currency of price adjustments for inflation or
currency conversion are given
17
Details of any model used are given
18
The choice of model used and the key parameters on which
it is based are justified
Analysis and interpretation of results
11
Time horizon of costs is stated
12
The discount rate(s) is stated
13
Details of statistical tests and confidence intervals are given
for stochastic data
14
The choice of variables for sensitivity analysis is given
15
Appropriate sensitivity analysis is performed
16
The answer to the study question is given
17
Conclusions follow from the data reported
18
Conclusions are accompanied by the appropriate caveats
152
Appendices
Stressor criterion
1 Event or situation of exceptionally threatening
or catastrophic nature
A1 Event or situation of exceptionally threatening
or catastrophic nature
2 Likely to cause pervasive distress in almost anyone
2 Likely to cause pervasive distress in almost anyone
A1 The person experienced, witnessed, or was
confronted with an event or events that involved actual
or threatened death or serious injury, or a threat to the
physical integrity of self or others
2 The person’s response involved intense fear, helplessness,
or horror (or disorganized or agitated behaviour in children)
Symptom criterion
Necessary symptom
1 Repetitive intrusive recollection or re-enactment of
the event in memories, daytime imagery, or dreams
Other typical symptoms
2 Sense of ‘numbness’ and emotional blunting,
detachment from others, unresponsiveness to
surroundings, anhedonia
3 Avoidance of activities and situations reminiscent
of trauma
Common symptoms
4 Autonomic hyperarousal with hypervigilance,
enhanced startle reaction, insomnia
5 Anxiety and depression
Rare symptoms
6 Dramatic acute bursts of fear, panic, or aggression
triggered by reminders
Necessary symptoms
B Persistent remembering or ‘reliving’ of the stressor in
intrusive ‘flashbacks’, vivid memories, or recurring
dreams, and in experiencing distress when exposed to
circumstances resembling or associated with the stressor
C Actual or preferred avoidance of circumstances
resembling or associated with the stressor which was
not present before exposure to the stressor
D1 Inability to recall, either partially or completely,
some important aspects or the period of exposure
to the stressor
OR
2 Persistent symptoms of increased psychological
sensitivity and arousal (not present before exposure
to the stressor), shown by any two of the following
(a) Difficulty in falling or staying asleep
(b) Irritability or outbursts of anger
(c) Difficulty in concentrating
(d) Hypervigilance
(e) Exaggerated startle response
Necessary symptoms
B The traumatic event is persistently re-experienced in one (or
more) of the following ways
1 Recurrent and intrusive distressing recollections of the
event, including images, thoughts, or perceptions (or
repetitive play in which the themes or aspects of the trauma
are expressed in children)
2 Recurrent distressing dreams of the event (or frightening
dreams without recognizable content in children)
3 Acting or feeling as if the traumatic event were
recurring (or trauma-specific re-enactment in children)
4 Intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
5 Physiological reactivity at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic
event
C Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present before
trauma), as indicated by three (or more) of the following
1 Efforts to avoid thoughts, feelings, or conversations
associated with the trauma
2 Efforts to avoid activities, places, or people that arouse
recollections of the trauma
3 Inability to recall an important aspect of the trauma
4 Markedly diminished interest or participation in
significant activities
5 Feeling of detachment or estrangement from others
6 Restricted range of affect
7 Sense of foreshortened future
153
D Persistent symptoms of increased arousal (not present before
the trauma), as indicated by two (or more) of the following
1 Difficulty falling or staying asleep
2 Irritability or outbursts of anger
3 Difficulty concentrating
4 Hypervigilance
5 Exaggerated startle response
Appendix 13: Diagnostic criteria
DSM–IV criteria
Diagnostic criteria for post-traumatic stress disorder in ICD–10 and DSM–IV
ICD–10 research diagnostic criteria
Diagnostic criteria for post-traumatic stress disorder in ICD–10 and DSM–IV
(contd…)
ICD–10 diagnostic guidelines
154
Appendices
ICD–10 diagnostic guidelines (contd…)
ICD–10 research diagnostic criteria (contd…)
DSM–IV criteria (contd…)
Time frame
Symptoms should usually arise within 6 months of
traumatic event
Symptoms should usually arise within 6 months of
the traumatic event
Symptoms present for at least 1 month
Disability criterion
NA
NA
The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning
Same as ICD–10 diagnostic guidelines
1 Acute stress disorder (duration of up to 4 weeks)
2 Adjustment disorder (less severe stressor or different
symptom pattern)
3 Mood disorder or other anxiety disorder (symptoms of
avoidance, numbing or hyperarousal present before
exposure to the stressor)
4 Other disorders with intrusive thoughts or perceptual
disturbances (e.g. obsessive–compulsive disorder,
schizophrenia, other psychotic disorders, substance-induced
disorders)
Differential diagnosis
1 Acute stress reaction (F43.0) (immediate reaction
in the first 3 days after event)
2 Enduring personality change after a catastrophic
experience (F62.0) (present for at least 2 years, only
after extreme and prolonged stress)
3 Adjustment disorder (less severe stressor or
different symptom pattern)
4 Other anxiety or depressive disorders (absence of
traumatic stressor or symptoms precede stressor)
Adapted from Ehlers, A. (2000) Post-traumatic stress disorder (Table 1). In New Oxford Textbook of Psychiatry, Vol. 1 (eds M. G. Gelder, J. J. Lopez-Ibor & N. Andreasen), pp. 758–771.
Oxford: Oxford University Press. Reproduced by permission of Oxford University Press.
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