New guidelines for psychologists
The past two years have been challenging for us all and traumatic for many. The COVID-19 pandemic and its associated hardships, combined with other recent disasters such as drought and bushfires, have led to significant levels of psychological distress across the country. Exposure to the potentially stressful social, family, economic and health sequelae associated with COVID-19 may directly cause PTSD or exacerbate existing PTSD symptoms. The impact of traumatic experiences associated with bushfires, drought and/or domestic violence can add to this load. While some people have been directly impacted by COVID-19 and disaster, we are also witnessing a range of stress and trauma-related reactions across the Australian community among those who have not been directly exposed.
The types of events that are more commonly associated with the development of PTSD – such as witnessing someone being injured or killed, motor vehicle accidents and sexual assault – unfortunately persist. It has never been more important for psychologists to know how to assess stress- and trauma-related conditions, and provide best-practice treatment and care. The recent release of the updated NHMRC Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD (The PTSD Treatment Guidelines; Phoenix Australia, 2020) could not have come at a better time.
Trauma and post-traumatic mental health problems
Between 50 to 70 per cent of Australians are exposed to at least one potentially traumatic event in their lives. Potentially traumatic events include any event that involves threat, actual or perceived, to the life or physical safety of the individual, their loved ones or those around them. Examples include, but are not limited to, war; torture; sexual assault; physical assault; natural disasters such as floods, drought and bushfires; accidents and terrorism. Exposure to a potentially traumatic event may be direct (e.g., actually experienced or witnessed), or indirect (e.g., confronted with or learnt about), and may be experienced on a single occasion, or repeatedly. A degree of psychological distress can be expected in the first week or so following trauma, but when an individual’s distress is severe, persists and/or interferes with their ability to maintain usual roles and routines, they should be assessed for a post-traumatic mental health disorder. In any 12-month period, 4.4 per cent or more than one million Australians will have PTSD. This makes it the second most common mental health condition next to depression. PTSD can have a profound impact not only on the individual but also on their family and friends.
Acute stress disorder, PTSD and complex PTSD
Acute stress disorder and PTSD are both included in the trauma- and stressor-related disorders category in the DSM-5 (American Psychiatric Association, 2013), with the key distinguishing feature between the two being the duration of symptoms. Acute stress disorder (ASD) is diagnosed between two days and one month following the traumatic event, while PTSD requires that the symptoms be present for at least one month following the traumatic event.
In addition to meeting the Criterion A definition of exposure to a traumatic event, the diagnosis of PTSD requires one of five symptoms of re-experiencing, one of two symptoms of avoidance, two of seven symptoms of negative alterations in cognition and mood, and two of six symptoms of hyperarousal. PTSD can be specified as the dissociative subtype (if the individual reports experiences of depersonalisation or derealisation) and/or with delayed expression (with onset at least six months after the trauma) (American Psychiatric Association, 2013).
While complex PTSD is not included in the DSM-5, the ICD-11 (WHO, 2018) formally recognises complex PTSD under a general parent category of Disorders Specifically Related to Stress. PTSD is defined more narrowly than in the DSM-5 as comprising three symptom clusters including: (1) re-experiencing of the trauma; (2) avoidance of traumatic reminders; and (3) a persistent sense of current threat that is manifested by exaggerated startle and hypervigilance. Complex PTSD includes the three PTSD clusters and three additional clusters that reflect “disturbances in self-organisation” (DSO): problems in emotional regulation, self-concept and disturbances in relationships. Those presenting with complex PTSD have commonly experienced events of an interpersonal, prolonged and repeated nature such as childhood sexual abuse, imprisonment or torture.
Screening, assessment and diagnosis
When someone has been through a particularly stressful or traumatic experience, they may be reluctant to talk about what has occurred. As a result, people with ASD or PTSD may not initially talk about their trauma but instead present with a range of problems including depression, anger, sleep, relationship issues or physical health complaints. It can be useful to routinely enquire about any recent and past stressful or traumatic experiences. A traumatic events checklist such as the Life Events Checklist for DSM-5 (Weathers et al., 2013) may assist to elicit such experiences. If the person indicates that they have experienced trauma, the next step should be to screen for PTSD. The Primary Care PTSD Screen for DSM-5 (Prins et al., 2016) is a quick and easy five-item screening tool. A comprehensive diagnostic assessment of PTSD usually involves a combination of a clinical interview and self-report measures. The 20-item PTSD Checklist (Weathers et al., 2013) is widely used in the assessment of PTSD, and is available for use by clinicians at no cost. A new measure, The International Trauma Questionnaire (Cloitre et al., 2018), has been developed as a self-report measure of ICD-11 PTSD and complex PTSD.
PTSD is commonly comorbid with other mental health conditions, primarily depression, substance use disorder and anxiety disorders. While the focus of this article is on ASD and PTSD, it is important for psychologists to be mindful that people can develop a range of conditions after trauma, with mood, substance use and anxiety disorders also common (Bryant et al., 2010). Psychologists should assess for comorbidity and plan interventions accordingly.
About the PTSD Treatment Guidelines
The PTSD Treatment Guidelines were developed by Phoenix Australia – Centre for Posttraumatic Mental Health in collaboration with a Guideline Development Group including Australia’s leading trauma experts, specialist practitioners working with people affected by trauma and individuals with lived experience of trauma. The PTSD Treatment Guidelines have been approved by the National Health and Medical Research Council (NHMRC) and endorsed by the Australian Psychological Society (APS), the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Royal Australian College of General Practitioners (RACGP). These guidelines and the evidence review that supports them are available online (bit.ly/3wTVrfw). They have been developed as a living guideline, meaning the recommendations can be updated as new evidence becomes available, ensuring they remain current. The PTSD Treatment Guidelines are intended to guide the care of all Australians who have been impacted by trauma, and familiarity with them will benefit psychologists who provide trauma treatments.
Key treatment recommendations
Although many adults with PTSD are prescribed medication, there is more evidence for the effectiveness of psychological treatments and so these should be considered first-line treatment. The cornerstone of psychological treatment involves helping the person to confront the memory of the traumatic event in order to come to terms with the experience. The previous guidelines recommended trauma-focused cognitive behavioural therapy (TF-CBT) or eye movement desensitisation and reprocessing (EMDR) as having the best evidence. There is now enough evidence to recommend independently several variants of TF-CBT. As a result, for the treatment of adults with PTSD, the new PTSD Treatment Guidelines recommend TF-CBT generally then more specifically cognitive processing therapy (CPT), cognitive therapy (CT) and prolonged exposure (PE), as well as EMDR.
If none of these interventions are available or acceptable to the individual, a small number of second-line psychological treatments can be considered. These include guided internet-based TF-CBT (importantly, internet-based TF-CBT must involve therapist support), present-centred therapy (a non-trauma-focused manualised intervention designed to target daily challenges encountered by people with PTSD), stress inoculation training (an anxiety management program including relaxation, thought stopping, cognitive restructuring and role play) and group TF-CBT (which includes the key elements of TF-CBT of engagement with the traumatic memory in some way, cognitive restructuring and tackling avoidance). Similarly, the PTSD Treatment Guidelines make a conditional recommendation for narrative exposure therapy (NET) in cases where trauma is linked to genocide, civil conflict, torture, political detention or displacement. NET allows people with PTSD to describe and develop a coherent, chronological, autobiographical narrative of their life that includes their traumatic experiences (a testimony).
While medication should not be used in preference to psychological therapy, it can play an important role for many adults with PTSD (noting that medication is not recommended for children). Medication can be useful when the person is not ready or willing to engage in trauma-focused therapy, or is unable to access it. It should also be considered when the individual has additional mental health problems such as depression, or has not benefited from trauma-focused therapy. Medications that receive a conditional recommendation (not in preference to psychological treatment but to be considered in the circumstances described above) include selective serotonin reuptake inhibitors (SSRIs) or venlafaxine, a serotonin noradrenaline reuptake inhibitor (SNRI).
For children and adolescents with PTSD, TF-CBT tailored to the developmental stage of the individual is recommended. This can be delivered either working with the child alone or together with a caregiver. Even if the TF-CBT is provided to the child or adolescent alone, it is important to engage with caregivers in assessment and treatment, taking into consideration the whole system of which the child is a part. The evidence is less certain for the effectiveness of EMDR in children or adolescents, so EMDR is only recommended if TF-CBT is unavailable or unacceptable to the child or adolescent and their caregiver.
The PTSD Treatment Guidelines also offer guidance to psychologists on early intervention; care of people who have been exposed to a potentially traumatic event, and those who have early symptoms of PTSD. Routine psychological debriefing, in which the individual is encouraged to talk in detail about their traumatic experience, is no longer recommended for either adults or children/adolescents. Instead, the best approach to helping people following a potentially traumatic experience is to offer information, emotional support and practical assistance, consistent with the set of interventions collectively referred to as ‘psychological first aid’.
For adults with PTSD symptoms within the first three months of a traumatic event, there is a new strong recommendation for a stepped or collaborative care model. In a stepped-care model people who are more distressed, or considered more at risk of poor psychological adjustment, are monitored, and evidence-based treatment (generally CBT-based) is delivered tailored to the severity and complexity of their symptoms. For adults who have symptoms of PTSD within the first few months of a traumatic event but do not meet the full criteria for diagnosis, TF-CBT or EMDR are recommended in preference to doing nothing, but the evidence for the effectiveness of these treatments is less certain than it is for established PTSD.
For children and adolescents with PTSD symptoms within the first few months, an intervention designed to improve family communication and support, and to teach the child and their caregiver skills to cope with symptoms is recommended in preference to supportive counselling.
As the diagnosis of complex PTSD is new, trials of effective treatment are in their infancy and there is not enough evidence to support specific treatment recommendations. However, the recommendations described above for people with PTSD are relevant to those with more complex presentations. To provide further guidance to practitioners, the PTSD Treatment Guidelines includes a narrative review of complex PTSD, addressing conceptual, diagnostic, assessment, management and treatment issues. In addition, the PTSD Treatment Guidelines include a section on working with particular populations and trauma types. Many of these involve repeated or prolonged trauma. As the trial outcomes come to light over the coming 12–24 months, the complex PTSD guideline recommendations will be updated to reflect these trial results.
Working with particular populations or trauma types
This section of the PTSD Treatment Guidelines provides psychologists with advice on issues to consider in applying the guideline recommendations to particular populations or trauma types.
These sections have been written in collaboration with subject matter experts and provide guidance for psychologists working with the groups such as Aboriginal and Torres Strait Islander Peoples, emergency services personnel, military and ex-military personnel, motor vehicle accident survivors, older people, refugees and asylum seekers, and victims of crime and intimate partner violence.
In addition, Phoenix Australia has developed a range of companion documents, which include information on recovery from trauma for children, adolescents, adults and family members. They may be a useful resource for psychologists’ client base and are available from the Phoenix Australia website (bit.ly/3wTVrfw).
Find out more
The Australian PTSD Guidelines, including the complete listing of the recommendations, the evidence underpinning them and a summary of the interventions themselves, are available on the MagicApp online platform. Additional supporting documents are available on the Phoenix Australia website (see above).
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