Executive summary
- PTSD develops in approximately 20% of people following a traumatic event and is frequently underdiagnosed in primary care. Ask directly about traumatic experiences in patients with persistent anxiety, sleep disturbance, or unexplained somatic symptoms.
- The first-line treatments are psychological, not pharmacological: Trauma-focused CBT (TF-CBT) and Eye Movement Desensitisation and Reprocessing (EMDR) are the NICE-recommended first-line treatments. They should be offered before drug treatment is considered.
- Watchful waiting is recommended within the first month for those with mild/moderate symptoms — active psychological treatment in the first 4 weeks is not beneficial and may be harmful.
- Complex PTSD (following prolonged/repeated trauma, especially in childhood) requires specialist input and differs in its presentation and treatment approach.
Recognition and diagnosis
- Core symptom clusters: Re-experiencing (flashbacks, nightmares, intrusive memories), avoidance (of trauma reminders, emotional numbing), negative cognitions and mood, and hyperarousal (hypervigilance, exaggerated startle, sleep disturbance, irritability).
- Duration: Symptoms must persist for more than 1 month (distinguishing PTSD from acute stress reaction) and cause significant impairment.
- Screening tools: PC-PTSD-5 (5-item primary care screen) or PCL-5 (PTSD Checklist). A positive screen warrants full clinical assessment.
- Differential diagnoses: Depression, generalised anxiety disorder, substance misuse (may co-exist), emotionally unstable personality disorder, and psychosis — clinical history of a traumatic event and the specific re-experiencing symptoms help distinguish PTSD.
- Do not pathologise normal distress — in the first 4 weeks after trauma, distress and re-experiencing are expected and do not constitute PTSD. Active intervention is not indicated in this period unless symptoms are severe.
Management
- Within 1 month of trauma (mild–moderate symptoms): Watchful waiting with a follow-up appointment within 1 month. Provide psychoeducation about normal trauma responses. Do not initiate antidepressants routinely in this period.
- Trauma-focused CBT (TF-CBT): First-line treatment for PTSD. Involves processing the traumatic memory, cognitive restructuring, and graded exposure. Should be delivered by a trained therapist, typically 8–12 sessions. Refer via IAPT/Talking Therapies for mild-moderate severity; specialist PTSD services for complex cases.
- EMDR (Eye Movement Desensitisation and Reprocessing): NICE-recommended first-line equivalent to TF-CBT. Involves bilateral stimulation (eye movements, taps) during guided trauma recall. Available via specialist IAPT therapists or NHS psychology services.
- Drug treatment (second-line/adjunctive): If the patient declines or cannot access psychological therapy, or has comorbid depression/anxiety, venlafaxine or an SSRI (sertraline, paroxetine) may be used — note these are off-label for PTSD in the UK. Use in conjunction with, not instead of, psychological therapy where possible.
- Do not prescribe benzodiazepines for PTSD: They do not treat PTSD and increase risk of dependence and poor outcomes.
Complex PTSD and special populations
- Complex PTSD (ICD-11 diagnosis): Follows repeated, prolonged, or childhood trauma (abuse, domestic violence, torture). Additional features: emotional dysregulation, persistent negative self-perception, and difficulties in relationships. Requires specialist trauma-informed services — not simply a longer course of standard PTSD treatment.
- Children and young people: Offer trauma-focused CBT as first-line. Do not use drug treatment as first-line in under-18s for PTSD.
- Comorbidities: PTSD commonly co-occurs with depression (up to 50%), substance misuse, and chronic pain. Address substance misuse before or alongside PTSD treatment — substances impair trauma processing.
- Refugees and asylum seekers: High prevalence population. Consider interpreters, culturally appropriate services, and the ongoing psychosocial stressors of immigration proceedings which may limit treatment response.
Frequently asked questions
When should I refer to specialist mental health services rather than IAPT?
Refer to secondary care if there is: significant suicide risk, complex PTSD with severe functional impairment, active psychosis, inability to engage with IAPT, or failure to respond to two adequate courses of first-line psychological therapy. IAPT Talking Therapies can manage mild-to-moderate PTSD in those without high complexity.
Can I start an antidepressant while the patient is waiting for EMDR?
Yes, if there is significant comorbid depression, functional impairment, or the wait for psychological therapy is prolonged. Use sertraline or venlafaxine — note these are off-label for PTSD. Frame this as a support alongside therapy, not a replacement for it.
A patient does not want to "relive" the trauma in therapy — what are the options?
This is very common and should be acknowledged. Explain that modern trauma-focused therapies are structured and paced carefully. If they remain unwilling, venlafaxine or an SSRI can be offered as an alternative. Engage the patient in shared decision making and revisit the option of psychological therapy at a later stage.
What is the difference between PTSD and acute stress reaction?
Acute stress reaction occurs within hours to days of a traumatic event, involves similar symptoms (re-experiencing, avoidance, hyperarousal), but resolves within 4 weeks. PTSD is diagnosed when symptoms persist beyond 1 month and cause significant impairment. The two can overlap but require different management approaches.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.