CBT For Post Traumatic Stress Disorder (PTSD) Leslie Sokol, Ph.D.
Post-traumatic Stress Disorder (PTSD) The management of PTSD in adults and children in primary and...
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Transcript of Post-traumatic Stress Disorder (PTSD) The management of PTSD in adults and children in primary and...
Post-traumatic Stress Disorder(PTSD)
The management of PTSD in adults and children in primary and secondary care
Clinical GuidelinePublished: March 2005
Intro Clinical background Treatment Implementation
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Further Info
What is a NICE clinical guideline?
• Recommendations for good practice based on best available evidence
• DH ‘Standards for better health’ expects organisations to implement clinical guidelines
• Healthcare Commission monitors compliance with NICE guidance
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Intro Clinical background Treatment Implementation
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Further Info
What is PTSD?• A disorder that develops in response to a stressful event
or situation of exceptionally threatening or catastrophic nature e.g. assault, road accidents, disaster, rape
• Symptoms include:– re-experiencing symptoms (e.g. flashbacks,
nightmares)– avoidance of people or situations associated with the
event– emotional numbing – hyperarousal symptoms
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Intro Clinical background Treatment Implementation
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Further Info
How common is PTSD?
• Probability of developing PTSD after a traumatic event: – men 8 - 13% – women 20 - 30%
• Annual prevalence: – 1.5 - 3%
• Prevalence in PCT population of 170k: – 2.5k - 5k people
• Prevalence in GP practice of 5k:– 75 -150 people
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Intro Clinical background Treatment Implementation
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Further Info
Duration of symptoms for PTSD treated and untreated
0
0.2
0.4
0.6
0.8
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0 0.5 1 1.5 2 2.5 3.25 4 4.5 5.25 6 6.5 7.5
Duration of symptoms (years)
Pro
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Treatment
No treatment
What is the natural course of PTSD?
Usual onset of symptoms a few
days after the event
Many recover without treatment within months/years of event (50% natural remission by 2 years), but some may have
significant impairment of social and occupational functioning
Generally 33% remain symptomatic for 3 years or longer with greater risk of
secondary problems
Treatment means that about 20% more people with PTSD recover
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Intro Clinical background Treatment Implementation
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Further Info
What does the guideline cover?• The care provided by primary, secondary and
other healthcare professionals to:– recognise, screen and diagnose PTSD– assess and coordinate care– treat all people with PTSD, including children – support families and carers
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Intro Clinical background Treatment Implementation
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Further Info
What is not covered?
• Adjustment disorders: symptoms of significant trauma but doesn’t meet criteria for PTSD
• Disorders such as:– dissociative disorders – personality changes following trauma
(because of diagnostic uncertainty and lack of agreement)
• Note: many symptoms of these can be managed with interventions used in PTSD
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Intro Clinical background Treatment Implementation
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Further Info
How to treat PTSD: key messages
• Increased awareness and greater recognition of PTSD especially in primary care
• Increased provision of trauma focused psychological treatments
• Shift away from inappropriate use of medications and brief single session psychological treatments (debriefing)
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Intro Clinical background Treatment Implementation
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Further Info
Immediate management of PTSD• Psychological first aid
– Giving information and social support as soon as possible
• Avoid brief single session debriefing given to individuals alone following an event
• Watchful waiting if symptoms are moderate – assess whether natural recovery occurs, review at one month
• Screen at risk groups – Following disaster– Refugees and asylum seekers
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Intro Clinical background Treatment Implementation
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Further Info
Interventions for PTSD over time: Within 3 months of trauma• Treat PTSD within 1 month if symptoms are
severe• Introduce trauma focused CBT by first month if
symptoms persist
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Intro Clinical background Treatment Implementation
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Further Info
Interventions for PTSD over time: Beyond 3 months of trauma• Trauma-focused CBT or EMDR as first line
treatment for people with more than a 3 month history of symptoms
• Drug treatments should not be used in routine care in preference to a trauma focused psychological therapy
• Where drug treatments are used:– general use: paroxetine or mirtazapine– specialist use: amitriptyline or phenelzine
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Intro Clinical background Treatment Implementation
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Further Info
Psychological treatments
• Interventions need to be focused on the trauma and structured:– Trauma-focused CBT- therapist helps the
PTSD sufferer to:• Confront traumatic memories with less fear• Modify misinterpretations which
overestimate threat• Develop skills to cope with stress
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Intro Clinical background Treatment Implementation
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Further Info
Psychological treatments• Eye motion desensitisation and reprocessing
(EMDR) – a structured trauma-focused psychological intervention:– PTSD sufferer is asked to recall an
important aspect of the traumatic event – The sufferer follows repetitive side to side
movements, sounds or taps as the image is being focused on
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Intro Clinical background Treatment Implementation
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Further Info
Challenges in treating PTSD
• Management of ongoing trauma eg domestic violence– Ensure safety before starting treatment
• Comorbid drug and alcohol misuse:– If severe treat it first
• Severe depression:– Treat the depression first but most depression
will get better
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Intro Clinical background Treatment Implementation
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Further Info
Challenges in treating PTSD
• Ex-military personnel:– Be aware of possible increased risk in
some• Personality disorder:
– Can still treat PTSD but may need to extend sessions
• Traumatic bereavement– May complicate treatment
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Intro Clinical background Treatment Implementation
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Further Info
What special issues are there for children and young people?
• Diagnostic categories same as adult• Important to talk to children directly and not rely
solely on information from parents for diagnosis• Symptoms may differ in younger children (e.g. re-
enacting, repetitive play, emotional and behavioural disturbances)
• Offer trauma focused-CBT for children with PTSD• Drug treatments should not be routinely prescribed
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Intro Clinical background Treatment Implementation
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Further Info
What are the implementation actions for managers?• Improve access to trauma focused psychological
therapies– Focus on the time to treatment not first
assessment– Shift to primary care – Requires retraining some of the workforce– Don’t forget children
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Intro Clinical background Treatment Implementation
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Further Info
How is cost assessed locally?
• NICE has developed a costing tool for PTSD• A national costing report and local costing
templates are available on the NICE website at www.nice.org.uk/costimpact
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Intro Clinical background Treatment Implementation
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Further Info
What services are provided in your area?
• Primary care based mental health services• Psychological treatment services• Community Mental Health Teams• Traumatic stress services• Social services• Local authorities (occupational health)• Non-statutory and voluntary organisations
Create your own local services list!
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Intro Clinical background Treatment Implementation
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Further Info
Developing implementation plans• Prioritise recommendations locally• Involve stakeholders including service users • Assess current state compared to
recommendations using audits• Assess the impact of making the required
changes to fill the gap: cost, risk, resources• Identify strategies to achieve this and a timescale
to roll them out• Identify barriers to implementation• Evaluate implementation
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Intro Clinical background Treatment Implementation
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Further Info
What should be audited?
Key objectives:Patients involved in their careTreatment options are appropriateSO MEASURE…………..What isn’t recommended… Debriefing Ineffective psychological treatments Drug treatments NOT a first line treatmentWhat is recommended… Watchful waiting Trauma-focussed treatments (CBT and EMDR) for
adults and children
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Intro Clinical background Treatment Implementation
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Further Info
Where is the guideline available?• Quick reference guide: summary of recommendations for
health professionals:– www.nice.org.uk/cg026quickrefguide
• NICE guideline– www.nice.org.uk/cg026niceguideline
• Full guideline: all of the evidence and rationale behind the recommendations:– www.rcpsych.ac.uk/publications
• Information for the public: plain English version for sufferers, carers and the public
– www.nice.org.uk/cg026publicinfoenglish 22
Intro Clinical background Treatment Implementation
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Further Info
What other NICE guidance should be considered?Published:• Anxiety December 2004• Depression December 2004• Self Harm July 2004In development:• Depression in children September 2005• Antenatal & postnatal mental health
February 2007
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Intro Clinical background Treatment Implementation
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Further Info
www.nice.org.uk
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