Treatment

The National Institute for Clinical Excellence (NICE) recommends that all people with PTSD should be offered a course of trauma focussed psychological treatment; either trauma focussed cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR).

CBT has several components: providing information about the normal response to severe stress and the importance of confronting situations and memories related to the traumatic events; exposure to the situations that are being avoided; recall of the images of the traumatic events; discussion of assumptions about the traumatic events; anger management for people who still feel angry about the traumatic events.

EMDR consists of asking the person to concentrate on an image in their mind that is disturbing them and remember the way it makes them feel both emotionally and physically. The therapist asks them to hold the image in their head while he quickly moves his finger (or an object like a pen/pencil) side-to-side in front of the person’s eyes. The patient is asked to follow the movement of the therapist's finger. This may be repeated over several sessions.

Drug treatments are often used as a first line treatment as opposed to a trauma focussed psychological treatment, though the latter may be preferable. The antidepressants paroxetine, mirtazapine and amitriptylline (for general use) or phenelzine (under specialist mental health supervision) may be used in the following circumstances: if the person refuses to engage in or has received little or no benefit from a trauma focussed psychological treatment; in addition to trauma focussed psychological treatment where there is significant associated depression or severe hyperarousal that significantly affects the person’s ability to benefit from psychological treatment.

For sleep disturbance a hypnotic drug can be used short term or a suitable antidepressant can be used longer term.

When a person with PTSD responds to drug treatment it should be continued for at least 12 months before being gradually withdrawn.

If a person with PTSD does not respond to drug treatment, the dose should be increased to the maximum approved tolerated limits. Failure to respond should be treated by either changing the antidepressant or by the use of the antipsychotic drug, olanzapine.

Chronic disease management programmes should be considered for people with chronic PTSD who have not benefited from a number of courses of the above evidence based treatments.

Amended June 2008