Five to 10 per cent of people will suffer from posttraumatic stress disorder (PTSD) at some point in their lives.
The Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder provide information about the most effective treatments for PTSD. They are the first national Guidelines that provide guidance on the treatment of children and teenagers who experience PTSD.
The Guidelines aim to support high quality treatment of people with PTSD by providing a framework of best practice around which to structure treatment. While there has been growing consensus about the treatment of acute stress disorder and PTSD in recent years, approaches are varied and there is still a gap between evidence-based practice and routine clinical care.
Approved by the National Health and Medical Research Council (NHMRC), the Guidelines were developed by Phoenix Australia (formerly Australian Centre for Posttraumatic Mental Health) and a team of Australia’s leading trauma experts, in collaboration with representatives of the professional associations for psychiatrists, psychologists, general practitioners, social workers, occupational therapists, mental health nurses, school counsellors, and service users. Recommendations were based on best practice evidence found through a systematic review of the Australian and international trauma literature.
You can download the following PDF resources to suit your different needs at no charge
Printed copies of these publications (except the Appendices to the Guidelines) can be ordered from the Bookshop.
- The full Guidelines
- The complete appendices to the full Guidelines
- Guidelines Summary – incorporating a brief overview of ASD and PTSD and a full summary of the recommendations
- A Practitioner Guide to Treatment – a handy desktop guide for practitioners working with children & adolescents
Handouts of the Specific Populations and Trauma Types chapters in the Guidelines
- Aboriginal and Torres Strait Islander Peoples and PTSD
- Emergency services personnel and PTSD
- Military and ex-military personnel and PTSD
- Motor vehicle accident and other traumatic injury survivors
- Natural disasters and trauma reactions
- PTSD in older people
- Refugees, asylum seekers and PTSD
- Sexual assault and PTSD
- Terrorism and trauma reactions
- Victims of crime and PTSD
Resources for people affected by trauma
- Recovery after Trauma – A Guide for People with Posttraumatic Stress Disorder
- Joel and the Storm – A story for children who have experienced trauma
- What the? – A Guide for teenagers who have experienced trauma
- Helping my Children after Trauma – A Guide for Parents
For practitioners: screening, assessment and best practice treatments for PTSD
The Guidelines have been formulated with the assumption that treatment will be provided by qualified professionals who are skilled in the relevant psychosocial and medical interventions, as assessed against the prevailing professional standards. The Guidelines do not substitute for the knowledge and skill of competent individual practitioners. They should not be regarded as an inflexible prescription for the content or delivery of treatment, but interpreted and implemented in the context of good clinical judgement. They should not limit treatment innovation and development that is based upon scientific evidence, expert consensus, practitioner judgment of the needs of the person, and the person’s preferences. Practitioners should use their experience and expertise in applying these Guidelines in routine clinical practice and all clinical interventions should be provided with compassion and sensitivity. Whenever possible, decisions about treatment should be made collaboratively with the individual, their family, carers, and other professionals involved in their care.
Watch these two vodcasts in which trauma experts discuss “Best practice interventions for treating adults and children” and “The role of medication in helping people recover from PTSD”
In this vodcast, experts in early intervention and PTSD treatment discuss the recommendations for supporting people in the immediate aftermath of a traumatic event and for treating PTSD. The discussion focusses on research on what best promotes recovery following a traumatic incident, evidence-based psychological interventions for treating PTSD in both children and adults, and the role of psychosocial rehabilitation in treatment.
In this vodcast, experts in the treatment of PTSD present recommendations for using medication in the treatment of PTSD for both adults and children.
Exposure to a potentially traumatic event (PTE) is a common experience, with up to three quarters of the population likely to experience at least one during their lifetime. PTEs involve exposure to an event involving threat, actual or perceived, to the life or physical safety of the individual, their loved ones or those around them. They can be experienced on a single occasion or repeatedly.
A degree of psychological distress is very common in the early aftermath of traumatic exposure and can be considered a part of the normal response. When the individual’s psychological distress following exposure to a traumatic event persists, and is severe enough to interfere with important areas of psychosocial functioning, it can no longer be considered a normal response to traumatic exposure. The possibility of a posttraumatic mental health disorder such as PTSD should be considered.
For adults, adolescents, and children older than six, trauma exposure may occur through:
- Directly experiencing the event
- Witnessing the event as it occurred to others
- Learning that the event occurred to a close family member or close friend
- Experiencing repeated or extreme exposure to aversive details of the event
For children aged six years and younger, trauma exposure may occur through:
- Directly experiencing the event
- Witnessing the event as it occurred to others, especially primary caregivers
- Learning that the event occurred to a parent or caregiver
Adults, adolescents, and children older than six
A diagnosis of PTSD requires a number of criteria to be met:
- Presence of one or more intrusive symptoms – intrusive memories of the event; recurrent distressing dreams related to the event; dissociative reactions (e.g., flashbacks); psychological distress or physiological reactions to reminders of the event.
- Persistent avoidance of either internal (memories, thoughts, or feelings) or external (people, places, conversations, activities) reminders of the event.
- Presence of two or more symptoms of negative alterations in mood and cognitions – inability to remember an important part of the event; negative beliefs about oneself, others, or the world; distorted beliefs about the cause or consequences of the event; persistent negative emotional state; diminished interest in activities; feelings of detachment from others; inability to experience positive emotions.
- Presence of two or more arousal symptoms – irritable, angry, or aggressive behaviour; reckless or self-destructive behaviour; hypervigilance; exaggerated startle response; concentration problems; sleep disturbance.
These symptoms must be present for at least one month following trauma exposure.
Children aged six years and younger
In addition to trauma exposure, the following criteria must be met for at least one month for a diagnosis of PTSD:
- Presence of one or more intrusive symptoms –intrusive memories of the event (may be expressed as play re-enactment); distressing dreams; dissociative reactions (may be expressed as play re-enactment); psychological distress or physiological reactions to reminders of the event.
- Presence of one or more symptoms of avoidance or negative alterations in cognition – avoidance of activities, places or physical reminders of the event; avoidance of people, conversations, or interpersonal situations that arouse recollections of the event; increased frequency of negative emotions; diminished interest in activities, including constriction of play; socially withdrawn behaviour; reduction in expression of positive emotions.
- Presence of two or more arousal symptoms – irritable, angry, or aggressive behaviour (including extreme temper tantrums); hypervigilance; exaggerated startle response; concentration problems; sleep disturbance
It is estimated that between 5 and 10 percent of the general population will develop PTSD at some point in their lives. In those who have experienced trauma, the rate of PTSD differs according to the type of trauma experienced. As a general rule, higher rates of PTSD (up to 50%) are seen in survivors of intentional acts of violence or prolonged/repeated events than in survivors of non-intentional trauma such as natural disasters or accidents (around 10%).
Among children and adolescents, lifetime estimates of PTSD in the general population range from 1 to 6 percent. As with adults, the prevalence of PTSD among those exposed to trauma depends on the type of trauma experienced. Overall, approximately one third of trauma-exposed children and adolescents can be expected to develop PTSD.
Screening and assessment
People with ASD or PTSD will not necessarily express concern about a traumatic experience to their doctor or mental health professional in the first instance. They may present with any of a range of problems including mood disorders, anger, relationship problems, poor sleep, sexual dysfunction, or physical health complaints such as headaches, gastrointestinal problems, rheumatic pains, and skin disorders. In seeking to understand the origins of presenting problems, the practitioner should routinely enquire about any stressful or traumatic experiences, recently or in the past. If a traumatic experience is suspected, the practitioner may utilise a traumatic events checklist. If the person endorses any events on the checklist, then it is recommended that a brief PTSD screening tool be administered – Click here for a brief primary care screening tool to screen for PTSD.
Assessment should include a trauma history covering prior traumatic experiences as well as the ‘index’ traumatic event, the presence and course of posttraumatic symptoms, prior mental health problems, as well as broader quality of life indicators such as marital or family situation, and occupational, legal and financial status.
Comorbidity is common in PTSD: 86% of men and 77% of women with PTSD are likely to have another disorder such as depression, substance misuse or anxiety. Thus, assessment should go beyond PTSD, covering the broad range of potential mental health problems and their implications for treatment.
Children and adolescents
Clinicians should routinely ask children about exposure to commonly experienced traumatic events, even if trauma is not the reason for referral. If such exposure is endorsed, the child should be screened for the presence of PTSD symptoms.
Clinicians should gather information from both the parent and child, even if the child is preschool-aged. For very young children, assessment should include evaluation of behaviour in the context of developmental stage and attachment status.
In children of all ages, PTSD is commonly comorbid with other disorders, including behavioural and attentional problems, anxiety disorders, and affective disorders. In adolescents, suicidal ideation and substance dependence may also be present. Thus, assessment should go beyond PTSD to examine the child or adolescent’s mental health more broadly.
Generally speaking, although many of the clinical interviews require training and are quite time-intensive, a structured interview is regarded as a better assessment measure for diagnostic purposes than a questionnaire. Questionnaires, on the other hand, can be very useful for repeated assessments when monitoring treatment progress over time.
In the early aftermath of a traumatic event, routine psychological debriefing is not recommended. The best approach to helping people following a potentially traumatic experience is to offer practical and emotional support and encourage the use of helpful coping strategies and social supports. The goal here is to enhance the person’s natural resilience and coping ability in the face of trauma.
A stepped care model may be helpful, which recognises that not everyone who experiences a traumatic event will develop a diagnosable disorder. Many will experience only subthreshold symptoms and others will not experience significant symptomatology at all. Therefore, stepped care aims to ensure that people receive care according to their need. The approach involves ongoing monitoring of people who are more distressed and/or at heightened risk of poor psychological adjustment, with increasingly intensive interventions delivered as indicated.
Psychological interventions for adults with PTSD
- Adults with PTSD should be offered trauma-focussed psychological interventions (trauma-focussed cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR)).
Trauma-focussed cognitive behavioural therapy
TF-CBT is a short-term, structured psychological intervention that aims to address the emotional, cognitive and behavioural sequelae of exposure to traumatic events. Although it often includes additional interventions such as psychoeducation and symptom management strategies (notably arousal reduction), the two core interventions are:
- Exposure therapy – which involves confronting the memory of traumatic experiences in a controlled and safe environment (imaginal exposure), as well as confronting trauma-related avoided situations and activities through in vivo exposure
- Cognitive therapy – which helps the individual to identify, challenge and modify any biased or distorted thoughts and memories of their traumatic experience, as well as any subsequent maladaptive or unhelpful beliefs about themselves and the world that they may have developed
Cognitive processing therapy
CPT is a form of cognitive therapy developed specifically for the treatment of PTSD. It helps the person to identify unhelpful thoughts and beliefs (‘stuck points’), challenge them, and replace them with rational alternatives in an adaptation of standard cognitive therapy approaches. It has a smaller exposure component than traditional exposure therapy (restricted to writing an account of the experience) and is therefore potentially more acceptable to patients or practitioners seeking alternatives to purely exposure-focussed treatments.
Eye movement desensitisation and reprocessing
EMDR is based on the assumption that, during a traumatic event, overwhelming emotions or dissociative processes may interfere with information processing. This leads to the experience being stored in an ‘unprocessed’ way, disconnected from existing memory networks. In EMDR the person is asked to focus on trauma-related imagery, negative thoughts, emotions, and body sensations while simultaneously moving their eyes back and forth following the movement of the therapist’s fingers across their field of vision for 20–30 seconds or more. This process may be repeated many times. Over time, EMDR has increasingly included more treatment components that are comparable with cognitive behavioural therapy (CBT) interventions including cognitive interweaving (analogous to cognitive therapy), imaginal templating (rehearsal of mastery or coping responses to anticipated stressors), and standard in vivo exposure.
Pharmacological interventions for adults with PTSD
- Medication should not be used as a routine first line treatment in preference to trauma-focussed psychological therapy. Where medication is considered for the treatment of PTSD in adults, selective serotonin reuptake inhibitor (SSRI) antidepressants should be considered the first choice for practitioners.
Treating children with PTSD
- Trauma-focussed cognitive behavioural therapy is the treatment of choice for children and adolescents with PTSD. Developmentally appropriate treatment protocols are available and should be used in preference to modifying an adult treatment program.
- The effectiveness of eye movement desensitisation and reprocessing for PTSD in children is less well established.
- Parents and caregivers should be involved in treatment where possible.
- An integrated treatment model between education and health providers that facilitates appropriate support and referral is recommended.
- Medication should not be used routinely as either a primary or adjunct treatment for children with PTSD.