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Post-traumatic Stress Disorder (PTSD)

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Summary: All you need to know about assessing, treating and referring adult patients with PTSD.
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Who’s it for: Mental Health Nurse, GP

What is Post-traumatic Stress Disorder (PTSD)?

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Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by having experienced or witnessed a traumatic event, series of traumatic events or set of shocking circumstances (see box for examples ➡️)

Someone with PTSD often relives the traumatic event through nightmares and flashbacks, and symptoms are severe and persistent enough to significantly impact day-to-day life.

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What are the symptoms?
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Who gets it?
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What are the risk factors?
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Co-existing Conditions
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Complex post-traumatic stress disorder

Complex post-traumatic stress disorder develops in a subset of people with PTSD. This occurs usually after exposure to an extremely threatening or horrific event (or series of events), that is (are) prolonged or repetitive, and from which escape is difficult/impossible.

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As well as the core symptoms of PTSD, Complex PTSD patients also experience:
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What is a ‘traumatic event’?
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A traumatic event is a shocking, scary, or dangerous experience that can affect someone emotionally and physically. Some examples are:

Diagnosing PTSD

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For all adults with clinically important PTSD symptoms → refer to a specialist mental health service (e.g., PCMHT).
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Other key diagnostic points to keep in mind:

Penrose Health Action Plan

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Treatment Goals
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Our aim is to work in partnership with our patients to achieve lifelong mental health and wellbeing for them. The goals of treatment and how we accomplish them are:

Adults with PTSD treated in secondary care may be transferred back to primary care for ongoing management via a shared-care arrangement.

We aim to keep the number of Mental Health Nurse visits to a maximum of 6 per patient in any given episode. See Schedule of Reviews below for more specific/detailed guidance.

⚠️ Safety netting

Assess for safeguarding concerns for children or vulnerable adults.

If at any time a patient presents:

  • with a significant change in risk status; or
  • if there is a commencement/change in medication

The visit count resets back to the beginning (i.e. First review)

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Other services

Secondary and External services may be better placed to help/support patients than we are.

  • Secondary services offer psychological treatments (e.g., interpersonal/psychodynamic therapies, CBT)
  • External services in the community offer many options for social and psychological help through relationships with the wider service network (e.g. Social Prescriber, Befriender, Care Coordinator, Therapist, Lifestyle Coach, etc.)

We do not provide any form of psychotherapy within our surgeries.

Patient Journey - Determining Schedule of Reviews

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Perform risk assessment at every appointment. If patient is high risk or in crisis → refer to crisis service, secondary MH service, and/or discuss with another professional (e.g. GP, PCMHT team) as appropriate.

Click toggle for a schematic of the action plan/treatment policy for all Penrose Health Surgeries, or follow the guidance below.

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Schematic
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First review:

If patient already on long-term medication, or does not want to start medication → review in 1 month

If starting/changing medication, then:

  • Aged 18-25 → review <2 weeks.
  • Aged over 25 → review in 2 weeks.

Signpost/refer to services as appropriate (see Referring Onward below).

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Managing referrals
  • If a patient is actively managed by another mental health provider → liaise with services as required and conclude routine MHN appointments.
  • If rejected by secondary services and patient is at high risk → review again in <1-2 weeks.
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Second review:

If patient is already on long-term medication, or does not want to start medication, and:

  • is stable/improving → conclude routine MHN appointments.
  • has issues ongoing:
    • Reconsider medication if appropriate or consider up-titration → review in 1 month

If this is second review after initiation of medication and patient:

  • is stable/improving → review in 4-6 weeks.
  • has issues ongoing:
    • Reconsider medication if appropriate or consider up-titration → review in 2-4 weeks.

If any patient is not improving, consider concurrent low mood/depression → repeat PHQ-9 and GAD-7

If patient is starting/changing medication → go back to First review.

Signpost/refer to services as appropriate (see Referring Onward below).

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Third review:

If patient is already on long-term medication, if this is third review after initiation, or patient does not want to start medication, and:

  • is stabilised/improving → conclude routine MHN appointments.
  • has issues ongoing:
    • Consider discussing patient with another professional, either within Penrose or external service.
    • Reconsider medication if appropriate or consider up-titration.

If patient is starting/changing medication → go back to First review.

Signpost/refer to services as appropriate (see Referring Onward below).

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Further care:

If patient remains on medication for a long-term, routine review should occur every 6 months.

If patient needs ongoing MHN input after senior discussion → Reviews may be offered every 2 months, for a maximum of 3 further sessions.

If patient has had the maximum 6 appointments with MHN, but still has low-level needs requiring further check-ins, consider booking in with Mental Health Care Coordinator (MHCC) for follow-up.

Referring/Signposting Onward

Below are some services to which you can signpost/refer patients. More services can be found on the Penrose Portal in 🧠Mental Health Services Database.