Promoting recovery after trauma Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder © Phoenix Australia - Centre for Posttraumatic Mental Health, 2013 ISBN Print: 978-0-9752246-0-1 ISBN Online: 978-0-9752246-1-8 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from Phoenix Australia - Centre for Posttraumatic Mental Health. Requests and inquiries concerning reproduction and rights should be addressed to Phoenix Australia - Centre for Posttraumatic Mental Health ([email protected]). Copies of the full guidelines, and brief guides for practitioners and the public are available online: www.phoenixaustralia.org www.clinicalguidelines.gov.au The suggested citation for this document is: Phoenix Australia - Centre for Posttraumatic Mental Health. Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. Phoenix Australia, Melbourne, Victoria. Legal disclaimer This document is a general guide to appropriate practice, to be followed only subject to the practitioner’s judgement in each individual case. The guidelines are designed to provide information to assist decision making and are based on the best information available at the date of publication. In recognition of the pace of advances in the field, it is recommended that the guidelines be reviewed and updated in five years’ time. Publication Approval These guidelines were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on 4 July 2013, under Section 14A of the National Health and Medical Research Council Act 1992. In approving these guidelines the NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of 5 years. NHMRC is satisfied that they are based on the systematic identification and synthesis of the best available scientific evidence and make clear recommendations for health professionals practising in an Australian health care setting. The NHMRC expects that all guidelines will be reviewed no less than once every five years. This publication reflects the views of the authors and not necessarily the views of the Australian Government. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder Endorsed by The Australian Psychological Society The Royal Australian College of General Practitioners The Royal Australian and New Zealand College of Psychiatrists Acknowledgments Funding bodies We gratefully acknowledge the financial contribution of the Department of Veterans’ Affairs, the Department of Defence and beyondblue in the development of these Guidelines. Steering group Professor Beverley Raphael, Psychiatrist Professor David Forbes, Clinical Psychologist (Population Mental Health and Disasters, (Director, Phoenix Australia - Centre for Disaster Response and Resilience Research Group, Posttraumatic Mental Health, University of Melbourne) University of Western Sydney) Working party Professor Beverley Raphael, Psychiatrist Professor Justin Kenardy, Clinical Psychologist Chair (Acting Director, Centre of National Research (Population Mental Health and Disasters, on Disability and Rehabilitation Medicine, Disaster Response and Resilience Research Group, University of Queensland) University of Western Sydney) Associate Professor Brett McDermott, Psychiatrist Professor Richard Bryant, Clinical Psychologist (Executive Director, Mater Child and Youth Mental (School of Psychology, University of New South Wales) Health Service) Professor Mark Creamer, Clinical Psychologist Professor Alexander McFarlane, Psychiatrist (Department of Psychiatry, University of Melbourne) (Director, Centre for Traumatic Stress Studies, University of Adelaide) Associate Professor Grant Devilly, Clinical Psychologist Dr Lynda Matthews, Rehabilitation Psychologist (School of Applied Psychology, Griffith University) (Senior Lecturer, Faculty of Health Sciences, University of Sydney) Professor David Forbes, Clinical Psychologist (Director, Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne) Multidisciplinary panel Professor Beverley Raphael, Psychiatrist Professor Brian Draper, Old Age Psychiatrist Chair (Conjoint Professor, School Of Psychiatry, University (Population Mental Health and Disasters, Disaster of NSW and Acting Director, Academic Department Response and Resilience Research Group, for Old Age Psychiatry, Prince of Wales Hospital) University of Western Sydney) Dr Rob Gordon, Clinical Psychologist (Clinical and Consulting Psychologist) Trauma specialists Dr Chris Lee, Clinical Psychologist Associate Professor David Crompton, Psychiatrist (Senior Lecturer, School of Psychology and (Executive Director, Addiction and Mental Health, Exercise Science, Murdoch University) Metro South Hospital and Health Service, and Disaster Advisor, Centre for Disaster, Trauma, Ms Cait McMahon, Psychologist Resilience and Recovery) (Managing Director, Dart Centre for Journalism and Trauma – Asia Pacific) ii Professor Helen Milroy, Psychiatrist Australian Child and Adolescent Trauma, (Director, Centre for Aboriginal Medical and Loss and Grief Network Dental Health, University of Western Australia) Ms Michelle Roberts (Psychologist) Associate Professor Shirley Morrissey, Australian College of Mental Health Nurses Clinical and Health Psychologist Professor Brenda Happell (Fellow) (School of Applied Psychology, Griffith University) Australian Guidance and Counselling Association Professor Louise Newman, Psychiatrist Ms Roslyn Isles (President) (Director, Centre for Developmental Psychiatry and Psychology, Monash University) Australian Guidance and Counselling Association Ms Lesley Fraser (Secretary) Associate Professor Reginald D. V. Nixon, Clinical Psychologist Australian Psychological Society (Director, Clinical Psychology Program, Mr David Stokes (Executive Manager, Professional Flinders University) Practice) Dr Rebecca Reay, Senior Research Coordinator Australian College of Rural and Remote Medicine (Academic Unit of Psychological Medicine, Dr Gerald Goodhand Australian National University) Occupational Therapy Australia Professor Kevin Ronan, Clinical Psychologist Ms Ann Drew (Foundation Professor in Psychology and Chair, Clinical Psychology, CQUniversity) Royal Australian College of General Practitioners Dr Caroline Johnson (Fellow) Professor Derrick Silove, Psychiatrist (Director, Psychiatry Research and Teaching Unit, University of New South Wales) Consumer representatives nominated by the Mental Health Council of Australia Dr Kevin Vaughan, Psychiatrist (Clinical Senior Lecturer, Sydney Medical School, Ms Cassandra Bertram University of Sydney) Ms Karene Eggleton Mr Richard Weston, Chief Executive Officer Ms Larisa Trotter (Healing Foundation) Industry representatives Ms Carolyn Worth, Manager (South Eastern Centre Against Sexual Assault) Australian Red Cross Mr Andrew Coghlan (National Manager, Ms Ruth Wraith, OAM Emergency Services) (Child Psychotherapist) beyondblue Ms Suzanne Pope (Director, Research and Planning) Professional colleges/associations Australian Defence Force Centre for Mental Health Australian and New Zealand College Dr Duncan Wallace (Psychiatrist) of Psychiatrists Professor Malcolm Hopwood (President Elect) Australian Association of Social Workers Ms Elizabeth Sommerville (Mental Health Professional Officer) iii Special population and trauma types area experts Aboriginal and Torres Strait Islander peoples Military and veterans Professor Helen Milroy, Psychiatrist Professor Mark Creamer, Clinical Psychologist (Director, Centre for Aboriginal Medical and Dental (Department of Psychiatry, University of Melbourne) Health, University of Western Australia) Professor Alexander McFarlane, Psychiatrist Mr Tom Brideson, State-wide Coordinator (Director, Centre for Traumatic Stress Studies, (NSW Aboriginal Mental Health Workforce Program) University of Adelaide) Dr Ann Harrison, Psychiatrist Dr Duncan Wallace, Psychiatrist (Winnunga Aboriginal Community Controlled Health (Australian Defence Force Centre for Mental Health) Organisation) Professor Ernest Hunter, Psychiatrist Emergency services (Adjunct Professor, James Cook University) Mr Andrew Coghlan, National Manager Ms Joyleen Koolmatrie, Psychologist (Emergency Services, Australian Red Cross) (Aboriginal Psychological Counselling and Consultancy) Professor Alexander McFarlane, Psychiatrist Professor Beverley Raphael, Psychiatrist (Director, Centre for Traumatic Stress Studies, (Population Mental Health and Disasters, Disaster University of Adelaide) Response and Resilience Research Group, University of Western Sydney) Disasters Mr Richard Weston, Chief Executive Officer (Healing Foundation) Mr Andrew Coghlan, National Manager (Emergency Services, Red Cross) Refugees and asylum seekers Sexual assault Professor Derrick Silove, Psychiatrist (Director, Psychiatry Research & Teaching Unit, Ms Carolyn Worth, Manager University of New South Wales) (South Eastern Centre Against Sexual Assault) Mr Mariano Coello, Research Coordinator (Service for the Treatment and Rehabilitation of Torture Victims of crime and Trauma Survivors) Associate Professor Grant Devilly, Clinical Psychologist Dr Ida Kaplan, Clinical Psychologist (School of Applied Psychology, Griffith University) (Direct Services Manager, Victorian Foundation for Survivors of Torture) Motor vehicle accidents Associate Professor Harry Minas, Psychiatrist (Director, Victorian Transcultural Psychiatry Unit) Professor Richard Bryant, Clinical Psychologist (School of Psychology, University of New South Wales) Older people Dr Richard Bonwick, Psychiatrist Terrorism (Deputy Editor, International Psychogeriatric Professor Mark Creamer, Clinical Psychologist Association) (Department of Psychiatry, University of Melbourne) Professor Brian Draper, Old Age Psychiatrist (Conjoint Professor, School Of Psychiatry, University of NSW and Acting Director, Academic Department for Old Age Psychiatry, Prince of Wales Hospital) iv Phoenix Australia project team Project Leader Dr Andrea Phelps Project Managers Dr Lisa Dell Dr Bronwyn Wolfgang Writers Dr Vanessa Cobham Ms Susan Fletcher Ms Alexandra Howard Special Populations Contributors Professor David Forbes Dr Andrea Phelps Ms Anne Laure Couineau Ms Dzenana Kartal Associate Professor Meaghan O’Donnell Consultant methodologist Dr Adele Weston (Executive Vice President, Optum AsiaPacific) Systematic review team Adelaide Health Technology Assessment Tracy Merlin Joanne Milverton Managing Director Research Officer Skye Newton Judy Morona Senior Research Officer Research Officer Jacqueline Parsons Stynke Docter Senior Research Officer Research Officer Ben Ellery Zhaohui Liufu Research Officer Senior Research Officer v Contents Acknowledgements ii List of abbreviations xiv Plain language statement 1 Executive summary 2 Complete list of Guideline recommendations 6 1 Introduction 16 Comparison with the 2007 Guidelines 16 Guideline aims 16 Scope of the Guidelines 17 Development of the Guidelines 18 Additional notes 19 Implementation of the Guidelines 20 Disclaimer 20 References 20 2 Trauma and trauma reactions 22 Trauma, traumatic event and potentially traumatic event 22 Potentially traumatic events 22 Common responses to potentially traumatic events 22 Traumatic stress syndromes 23 Acute stress disorder 23 Posttraumatic stress disorder 25 Re-experiencing symptoms 25 Avoidance and numbing symptoms 25 Arousal symptoms 25 Features commonly associated with PTSD 27 Prevalence and incidence of PTSD 27 Comorbid conditions 28 The course of PTSD 28 Resilience in the face of potentially traumatic events 28 vii Posttraumatic mental health disorders: Key differences between ASD and PTSD 29 Screening, assessment and diagnosis 29 Comprehensive assessment of PTSD 30 Diagnosis 32 Differential diagnosis 32 ‘Recovered memories’ 33 Symptom exaggeration and malingering 33 Assessment instruments 33 Structured clinical interviews 34 Self-report measures 34 Intervention planning 37 Factors influencing treatment outcome 37 Chronicity and delay in treatment 37 Comorbidity 37 Compensation 39 Therapeutic alliance and treatment expectations 39 Motivation for change 39 Demographics 39 Treatment setting 40 Potential mechanisms of change 40 Treatment goals 41 Cultural and linguistic diversity (CALD) 42 The impact of PTSD on family 42 General professional issues 43 Self-care 44 References 45 3 General considerations when working with children and adolescents 52 Trauma and trauma reactions 53 Trauma, traumatic event and potentially traumatic event 53 Clinical presentations in children and adolescents following potentially traumatic events 53 Traumatic stress syndromes 54 Acute stress disorder 54 Posttraumatic stress disorder 54 Moving to DSM-5 55 Prevalence 55 Comorbid conditions 55 The course and prognosis of PTSD in children and adolescents 56 Risk factors 56 Relational PTSD patterns: The importance of parents 57 Assessment 57 Who to talk to? The low rate of agreement between parents and children 58 When to assess for trauma exposure and symptoms 58 How to assess for trauma exposure and symptoms 58 viii