General management and advice to patient and family
- Educate the patient and family about PTSD to help them understand the patientís altered attitude and behaviour.
- Most people find it helpful to discuss the event unhurriedly with sympathetic friends and family. Explain that avoidance of cues associated with the trauma strengthens and maintains fears and distress. Encourage the patient to face avoided activities and situations gradually (see Phobic disorders - F40).
- Ask about suicide risk (see Self-harm).
- Avoid using alcohol, tobacco or street drugs to cope with anxiety.
- Single session intervention is not needed for everyone after a trauma (ref 198).
- Provide a few sessions of cognitive behaviour therapy from about a month after the trauma benefit patients (ref 199-201)
- The evidence for a benefit from eye movement desensitization and reprocessing remains controversial (ref 202).
- Other psychological therapies, including group and psychodynamic therapies, are of unknown effectiveness (ref 203).
197 NICE will publish a guideline on the management of Post-traumatic stress disorder in January 2005.
198 Rose S, Bisson J, Wessley S. Psychological debriefing for preventing post traumatic stress disorder (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software. (AI). The routine use of single-session debriefing given to non-selected trauma victims cannot be recommended at present.
199 Bisson JI.Early interventions following traumatic events. Psychiatric Ann 2003, 33: 37-44. (BI) The authors review randomized controlled trials and conclude that the evidence base does not support routine early intervention but that multiple session cognitive behavioural early interventions might help.
200a Foa EB, Keane TM, Friedman MJ (eds.) Effective Treatments for PTSD. New York: Guildford Press, 2000. This work summarizes evidence for a wide variety of treatment approaches for Post-traumatic stress disorder. Cognitive therapy and exposure therapy emerge as the psychological treatments with the best evidence for efficacy.
200b Bisson JI., Andrew M. Psychological treatment of Post-traumatic stress disorder (PTSD) (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
201 Marks I, Lovell K, Noshirvani H et al. Treatment of Post-traumatic stress disorder by exposure and/or cognitive restructuring: a controlled study. Arch Gen Psychiatry 1998, 55: 317-25. (BII) This randomized control trial shows that exposure, cognitive restructuring, or both combined, were equally effective in Post-traumatic stress disorder and better than relaxation without exposure.
202 Shepherd J, Stein K, Milne R. Eye movement desensitization and reprocessing in the treatment of Posttraumatic stress disorder: a review of an emerging therapy. Psychol Med 2000, 30(4): 863-871. (AI) This is a systematic review of 16 studies. Eye movement desensitization and reprocessing might be as effective as imaginal exposure therapy and more effective than relaxation techniques in Post-traumatic stress disorder but it is unclear if it is the technique or the imaginal exposure component that is effective.
203 Stein DJ, Zungu-Dirwayi N, Van der Linden GJ, Seedat S. Pharmacotherapy for post-traumatic stress disorder (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software. (AI) Fifteen studies were examined. The research base is limited but there is increasing evidence that drugs can help in Post-traumatic stress disorder. Sertraline and paroxetine have been the most researched and have been shown to be effective. There is good evidence for the efficacy of fluoxetine and some evidence for tricyclic antidepressants and monoamine oxidase inhibitors.
Last edited: 26/1/2004
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