PubMed Health. A service of the National Library of Medicine, National Institutes of Health.

National Collaborating Centre for Mental Health (UK). Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. Leicester (UK): Gaskell; 2005. (NICE Clinical Guidelines, No. 26.)

2Post-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, 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.

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. 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:

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: 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):

  1. The patient must have been exposed to a stressful event or situation (either short or long-lasting) of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone.
  2. 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.
  3. 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.
  4. 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:
      1. difficulty in falling or staying asleep
      2. irritability or outbursts of anger
      3. difficulty in concentrating
      4. hypervigilance
      5. exaggerated startle response.
  5. 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 re-experiencing 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 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:

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.

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]

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

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]

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]

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]

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]

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]

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).

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

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]

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]

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]

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
  • neurological damage due to injuries sustained during the event

Of course, PTSD may also exist comorbidly with many of the above disorders, in particular depression and anxiety disorders. 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:

  1. 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.
  2. 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.
  3. The personality change causes significant interference with personal or social functioning or significant distress.
  4. 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.
  5. 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. 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 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). 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. 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).

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.)

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]

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.

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.

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 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.

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]

Healthcare professionals should normally only consider providing trauma-focused psychological treatment when the sufferer considers it safe to proceed. [GPP]

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]

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]

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

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

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 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).

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 compensation-seeking (‘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–pituitaryadrenal (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.

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; 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.

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]

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.

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, man-made 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 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.

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 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.

Copyright © 2005, The Royal College of Psychiatrists & The British Psychological Society.

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.

Cover of Post-Traumatic Stress Disorder
Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care.
NICE Clinical Guidelines, No. 26.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): Gaskell; 2005.


NICE (National Institute for Health and Care Excellence)

PubMed Health Blog...

read all...

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...