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A Guide to Delivering Evidence Based Psychological Therapies and Interventions in Scotland

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Post Traumatic Stress Disorder (PTSD)

Updated May 2023
PTSD

Post traumatic stress disorder (PTSD) is a diagnosis that relates to a series of symptoms which usually clusters around re-experiencing, avoidance and heightened perception of ongoing threat, that may develop following exposure to an extremely threatening or horrific event or series of events. It is characterised by all of the following: 1) re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. Re-experiencing may occur via one or multiple sensory modalities and is typically accompanied by strong or overwhelming emotions, particularly fear or horror and strong physical sensations; 2) avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event(s); and 3) persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. A description of the diagnosis can be found here (1).

The consequences to the individual of exposure to psychologically traumatic events vary widely. For most people there will be no lasting adverse impact on wellbeing, or any distress will be limited and resolve in the time following the event/s. In others it may cause or contribute to, a range of psychological disorders as well as social and physical problems. The nature and timing of the traumatic exposure may, in part, determine the individual’s response to it. Psychological disorders caused or contributed to by exposure to traumatic events include but not limited to: PTSD, Complex PTSD, depressive disorders, anxiety disorders, substance use disorders, somatic symptom disorders, psychosis and personality disorders. Co-occurring mental health difficulties are the norm for people presenting with PTSD (8).

Mental health clinicians should routinely explore for trauma history as part of their assessment and consider trauma history in their formulation of difficulties presented by the person accessing services.  A full and comprehensive assessment of mental health needs (undertaken by an individual who has the skills required to do so), is vital in order to determine the nature of an individual’s difficulties and needs, an assessment of risk, and co-produce an appropriate management plan.   

For adults in the UK who have lived through traumatic experiences, recent research suggests that 5.3% of people develop PTSD (2). One large survey of the general population in England found that 3 in 100 adults screened positive for PTSD. It is much more common in certain groups of people. Some studies have found that PTSD develops in about:

  • 10% rescue workers internationally (3)
  • 50% female rape victims (4)
  • 8-22% of veterans across their lifespan (5)

In the UK, in a recent study(6) just over 30% of young people experienced trauma and 8% developed post traumatic stress disorder (PTSD) by the age of 18 years. There is a greater likelihood of PTSD and Complex PTSD (CPTSD) (1) in ‘at risk’ child populations, i.e., those who had experienced certain adverse childhood experiences (highly stressful, potentially traumatic events) such as abuse or neglect. Rates of PTSD are also much higher in clinical services with ICD-11 PTSD prevalence rates at 24% in a clinical sample in Scotland(7).

This topic page covers therapies and interventions that can help prevent and treat post-traumatic stress disorder (PTSD) in children, young people and adults and while they may be effective for populations requiring specific consideration (e.g. people with Intellectual Disabilities or dementia), expert assessment is required to determine whether the approach is likely to be appropriate, taking into account available evidence base and preference of the person using services.

Full guidance on best practice in identifying, assessing and managing PTSD can be found in the NICE (2018) https://www.nice.org.uk/guidance/ng116 (8) and ISTSS guidance (https://istss.org/clinical-resources/treating-trauma/international-practice-guidelines-for-post-trauma).(9)

This topic does not cover Complex PTSD or the wider impact that stress of adverse life events can have.  However, guidance for CPTSD is available in the Matrix (2015) and this will be updated in due course.

Prevention and early treatment of Post Traumatic Stress Disorder (PTSD)

Research has focused on the impact of psychological interventions and therapies across a number of stages following a traumatic event.  This includes preventative approaches, early interventions following detection of PTSD symptoms, treatment of PTSD and treatment of chronic or complex PTSD.  This topic focuses primarily on early intervention and treatment of PTSD.

Preventing PTSD

People respond to traumatic events in different ways. The principles involved in preventing PTSD following a traumatic event include promoting natural recovery and support whilst monitoring any symptoms that may lead to clinical diagnosis.

All people presenting with symptoms within the first few months of traumatic events should be offered an assessment of mental health needs prior to being offered an intervention. A period of “watchful waiting” in the month following a traumatic event may be appropriate to see if symptoms naturally improve. It is recommended that people involved in traumatic events are offered support in an empathic trauma-informed and responsive manner with decisions about care being co-produced with the affected individual as aligned with the National Trauma Training Programme (10) and should be delivered in accordance with the principles of practical, pragmatic support in an empathic manner called psychological first aid https://learn.nes.nhs.scot/61302 . This should be in line with Preparing Scotland paper: responding to the psychosocial and mental health needs of people affected by emergencies (2013) (11)     

There is quality evidence (A) that a Stepped/Collaborative Care approach (which involves screening and direct assessment, followed by the provision of flexible and modular interventions based on an individual’s needs) can have some impact on symptoms (low efficacy).  Guidance on access and coordination of care can be found here (https://www.nice.org.uk/guidance/ng116/chapter/Recommendations)(8)

There is insufficient evidence to support any single universal intervention (one provided to everyone exposed) to prevent PTSD in the immediate aftermath of a traumatic event affecting a number of people. The National Institute for Health and Care Excellence (NICE) recommends against psychological debriefing.

Preventing PTSD in Children and Young People

Currently there is limited research informing early interventions to reduce traumatic stress symptoms in children and young people. In line with the NICE guidelines(8), we recommend against individual single session psychological debriefing based on 2 studies(12,13) which did not demonstrate any benefit in the reduction of PTSD symptoms and suggested that the intervention may slow recovery. One RCT identified a significant reduction in developing PTSD with a targeted family psychosocial intervention and this intervention is recommended(14).

In line with the National Trauma Training Programme, there are a number of pragmatic approaches that are likely to be helpful for infants, children and young people after a traumatic event (10). Key is the presence of a safe, predictable and emotionally available adult. Re-establishing routines around mealtimes and sleeping can be reassuring and provide a sense of stability and safety to a young person.  Encouraging social connections within family members and the extended family is important, as well as keeping connected to religious communities, school communities and youth groups. It is helpful to adopt an approach of active listening to a child or young person and to value a young person’s cultural identity as part of the healing process. A period of “active monitoring” in the first month may be appropriate to see if symptoms naturally improve and to allow professionals to target those children and young people with impairing traumatic symptoms to access targeted support(8).

Preventing PTSD in Adults

There is some limited evidence for interventions that treat early symptoms of PTSD or acute stress disorder and prevent further development of symptoms. The recommendation is to provide individual CBT with a trauma focus or an alternative evidence based psychological therapy such as EMDR (as per evidence table) as soon as symptoms of PTSD or acute stress disorder are identified.

https://www.gov.scot/publications/preparing-scotland-responding-psychosocial-mental-health-needs-people-affected-emergencies/pages/6/

Recommendation Who for? List of interventions Type of Psychological Practice Level of Evidence Level of Efficacy
Recommended intervention (if identified at risk of PTSD) Children and young people with early signs of PTSD. Family involvement Child and Family traumatic Stress Intervention (CFTSI)14 Enhanced /Specialist B Medium
Recommendation Who for? List of Interventions Type of psychological practice Level of Evidence Level of Efficacy
First line intervention Adults with symptoms of acute stress disorder or early signs of PTSD Individual CBT with a Trauma Focus for acute stress disorder and PTSD symptoms (8) Specialist A Medium
Alternative recommendation Adults with symptoms of acute stress disorder or early signs of PTSD which are not combat related EMDR for PTSD symptoms (8) Specialist B Medium

There is good evidence for the treatment of PTSD, in terms of both strength of evidence and efficacy. As outlined above, it can be argued that detecting and treating PTSD as early as possible is likely to represent a clinically and cost-effective use of available resources/services. The evidence, and detailed guidance on providing services for children, young people and adults with PTSD, is provided in https://www.nice.org.uk/guidance/ng116(8).

There are a wide range of different interventions that now have enough evidence to be included in the Tables with A or B level evidence. For adult populations, where there is the most amount of research, only those psychological interventions with A strength evidence of a medium or high level of efficacy have been included. This is to be consistent with the aim to focus on interventions with the highest levels of efficacy and the strongest levels of evidence where this exists. There is more variation in the evidence of interventions tailored to children and young people and this is reflected in the interventions included in that section.

Evidence Overview: Interventions PTSD in Children and Young People:

There is less evidence for the treatment of PTSD in children and young people than in adults, but a number of interventions with strong evidence in adult populations have been tested in an adapted format for children, young people and families. There are several effective psychological treatments for PTSD in children and young people, including TF-CBT, cognitive therapy for PTSD (CT-PTSD) and prolonged exposure therapy for adolescents (PE-A). There is a greater quantity of ‘grade A’ research indicating that TF-CBT is an effective treatment for PTSD in children and young people. NICE guidelines recommend EMDR as a second line intervention for children and young people with PTSD who have not responded to or engaged with TF-CBT(8). EMDR also achieves an A grade level of evidence due to the growing amount of research meeting the standard. A meta-analysis found TF-CBT marginally more effective in reducing Post traumatic stress symptoms post treatment than EMDR and, therefore, EMDR is graded as ‘medium to high’ for efficacy(15).

There is a lack of evidence for the treatment of Complex PTSD in children and young people. It is unclear if specific interventions are required to treat CPTSD as compared with PTSD in children and young people. It may be helpful to use the current recommended first line treatments for PTSD, whilst taking into account the disturbances in self-organisation which are a feature of CPTSD. That may result in longer courses of treatment being required(9). It may be helpful to consider the need for stabilisation work before recommending delivery of a trauma-focused intervention to a child or young person with CPTSD.  Please use in conjunction with the current recommendations in the 2014 matrix.

Evidence Overview: Interventions for PTSD (Adults):

As highlighted by the Table, five specific individual face to face therapies with a trauma focus have the highest levels of efficacy and these are recommended as first line interventions. Other psychological therapies with a trauma focus, namely Narrative Exposure Therapy (NET), have demonstrated a lower level of efficacy but may still have a role in the treatment of people with PTSD. Approaches that are non-trauma focused, or that focus on particular symptoms associated with the trauma, are particularly relevant for people with PTSD who are in unsafe situations (e.g., ongoing domestic violence) that mean trauma-focused work may be inappropriate, people with PTSD who do not want to engage in trauma-focused work, those who are unable to tolerate it or for those with residual symptoms following a trauma focused intervention.

There is also strong evidence of medium efficacy for Guided Internet-based CBT with a Trauma Focus for people with mild to moderate PTSD.  This provides a flexible approach that has the potential to increase choice and access for some people with PTSD.

The recommended therapies listed in the Table are indicated for people with PTSD as opposed to Complex PTSD. With the exception of Guided Internet-based CBT with a Trauma Focus, the listed therapies have been shown to be helpful to some people with more complex presentations of PTSD. The Table should help inform possible treatment approaches for complex PTSD and should be read alongside the guidance in the 2014 version of the Matrix, until the review of CPTSD is completed in the current Matrix. It may be important to consider the need for stabilisation work before recommending delivery of a trauma-focused intervention to someone with complex PTSD (some people with PTSD may also benefit from brief stabilisation work before trauma-focused treatment).  

This, and additional considerations, also applies to people with PTSD with significant co-morbidity. For example, in the case of co-morbid PTSD and substance use disorder, it can be helpful to consider ability to engage with and impact of substance use, before commencing trauma-focused treatment - with stabilisation of substance use being a helpful approach to enable optimal benefit of trauma focused treatment. In line with the Medication Assisted Treatment Standards(24), it is important that all people with co-occurring drug use and mental health difficulties can receive mental health care at the point of Medication Assisted Treatment delivery.

Recommendation Who for? List of Interventions Type of psychological practice Level of Evidence Level of Efficacy
First line recommendation CYP All severity TF-CBT with child, TF-CBT with child and parent/carer17,18 Specialist A High
First line recommendation CYP All severity EMDR*18-20 Specialist A Medium - high
Alternative (lower quality evidence) All severity D-CPT Developmentally adapted version of cognitive processing therapy21 Specialist B High
Alternative (lower quality evidence and efficacy) All severity Specific age ranges Pre-school TF-CBT; CT-PTSD22,23 Specialist B Medium

 

Recommendation Who for? List of Interventions Type of psychological practice Level of Evidence Efficacy
First line recommendation adults All severity Individual Trauma focused CBT (example models include: Cognitive Processing Therapy, Cognitive Therapy -PTSD, CBT -PTSD, Prolonged Exposure (PE) Specialist A High
First line recommendation All severity Non-combat related trauma EMDR* Specialist A High
Alternative(lower efficacy) All severity Narrative exposure therapy Enhanced/Specialist A Medium
Alternative(if person preferred and risk assessed) Mild/moderateLow risk Guided Internet-based CBT with a Trauma Focus Enhanced A Medium
Alternative(if non-trauma focus requested, to increase readiness for TF focus or for residual PTSD symptoms) All severitySpecific symptom targets e.g. anger, insomnia, substance use CBT for specific symptoms associated with trauma Specialist A Medium

* NICE recommend EMDR only after a non-combat-related trauma.  A marked difference in response to EMDR in adults exposed to combat-related trauma compared to non-combat-related trauma is not supported by practice-based evidence but more work is needed, and it is important that practitioners and people with PTSD are aware that the current, albeit limited, research evidence suggests that EMDR is not effective for combat-related trauma. 

With thanks to the Matrix Cymru team for sharing the results of their evidence review and associated guidance.

Advisory group: Shumela Ahmed, Dr Millia Begum, Dr Caroline Bruce, Dr Richard Cosway, Dr Paula Easton, Dr Sandra Ferguson, Claire Fyvie, Dr Alasdair Forrest, Alison Haustein Swain, Prof. Thanos Karatzias, Dr Nina Koruth, Linda Mitchell, Dr Leeanne Nicklas, Brodie Patterson, Prof. Kevin Power, Charlotte Strong.

Technical groups: Dr Millia Begum, Dr Paula Easton, Dr Regina Esiovwa, Dr Richard Cosway, Dr Sandra Ferguson, Prof. Thanos Karatzias, Dr Leeanne Nicklas, Dr Lisa Reynolds, Brodie Patterson.

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