Transtorno do estresse pós-traumático

Principais recomendações do NICE sobre tratamento

Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.

This summary covers post-traumatic stress disorder in adults (aged 18 years and over).

Establish a risk management and safety plan as part of initial treatment planning if the person with PTSD is identified to be at a significant risk of harm to themselves or others.

Be aware of the risk of continued exposure to trauma-inducing environments. Avoid exposing people to triggers that could worsen symptoms or stop engagement with treatment (e.g., noisy or restricted environments, use of restraint).

Consider social or personal factors that may have a role in the development or maintenance of PTSD (e.g., childhood maltreatment, multiple traumatic events).

If multiple family members have PTSD after experiencing the same traumatic event, consider what aspects of treatment might be usefully provided together (e.g., psychoeducation), alongside individual treatments.

Consider active monitoring for people with subthreshold symptoms of PTSD within 1 month of a traumatic event. Arrange follow-up contact to take place within 1 month.

Psychological interventions for prevention and treatment of PTSD in adults

A choice of therapist should be offered, considering the person’s trauma experience (e.g., they may prefer a specific gender of therapist).

Do not offer psychologically-focused debriefing for the prevention or treatment of PTSD.

An individual trauma-focused cognitive behavioural therapy (CBT) intervention should be offered to prevent PTSD in adults who have acute stress disorder (i.e., a DSM-5 diagnosis that applies in the first month after a traumatic event, and requires symptoms to meet specified criteria) or clinically important symptoms of PTSD and have been exposed to 1 or more traumatic events within the last month. Individual trauma-focused CBT interventions include:

• Cognitive processing therapy

• Cognitive therapy for PTSD

• Narrative exposure therapy

• Prolonged exposure therapy.

An individual trauma-focused CBT intervention should be offered to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 1 month after a traumatic event.

Eye movement desensitisation and reprocessing (EMDR) should be considered for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3 months after a non-combat-related trauma if they have a preference for EMDR.

For adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event:

• EMDR should be offered if the trauma experienced was non-combat-related

• Supported trauma-focused computerised CBT should be considered if the person prefers it to face-to-face trauma-focused CBT or EMDR, as long as they do not have severe PTSD symptoms (in particular dissociative symptoms) and they are not at risk of harm to themselves or others

• CBT interventions targeted at specific symptoms (e.g., sleep disturbance or anger) should only be considered if the person is unable or unwilling to engage in a trauma-focused intervention or they have residual symptoms after a trauma-focused intervention.

Drug treatments for adults

Do not offer drug treatments (including benzodiazepines) to prevent PTSD in adults.

For adults with a diagnosis of PTSD, consider:

• Venlafaxine or a selective serotonin-reuptake inhibitor (e.g., sertraline) if the person has a preference for drug treatment. Review this treatment regularly

• Antipsychotics (e.g., risperidone) in addition to psychological therapies to manage disabling symptoms and behaviours (e.g., severe hyperarousal or psychotic symptoms) which have not responded to other drug or psychological treatments. Antipsychotic treatment should be started and reviewed regularly by a specialist.

Care for people with PTSD and complex needs

For people presenting with PTSD and depression, PTSD should usually be treated first because depression will often improve with successful PTSD treatment. However, depression should be treated first if it is severe enough to make psychological treatment of PTSD difficult, or if there is a risk of the person harming themselves or others.

Do not exclude people with PTSD from treatment based solely on comorbid drug or alcohol misuse.

For people with additional needs (including those with complex PTSD):

• Build in extra time to develop trust (e.g., increase duration/number of therapy sessions)

• Consider the safety and stability of their personal circumstances (e.g., housing), and how this might affect engagement and success of treatment

• Help them to manage barriers to engagement (e.g., substance misuse, dissociation, emotional dysregulation, interpersonal difficulties, negative self-perception)

• Plan ongoing support if needed (e.g., for residual PTSD symptoms or comorbidities).

© NICE (2018) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights . All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.