# data[].attributes.body
You can email plh-tr.mtcpsychology@nhs.net for Major Trauma referrals

# data[].attributes.body
We meet with the psychiatric liaison team every 2 weeks to discuss shared cases.

# data[].attributes.body
We communicate with the ICU team when shared patients are stepped down from the ICU and moved to the wards. This is to find out if patients are having ongoing support from the rehabilitation team/psychology team and any concerns around delirium or hallucinations.

ICU also join our meetings with psychiatric liaison if there is a need to discuss shared patients.

# data[].attributes.body
Scan to access relevant mental health and practical signposting for Major Trauma patients

# data[].attributes.body
Role: A Specialist Clinical Health Psychologist
Availability: Works in Major Trauma from Monday - Thursday. Heidi is based in her outpatients clinic in Tavistock on a Monday. On Tuesdays and Thursdays Heidi is based in Major Trauma from 8:00am-1pm, in the afternoons she works in her other health clinics.
Work: Heidi created and runs the Major Trauma Psychology Service. She provides the outpatient telephone clinics for patients, runs the outpatient therapy clinic, provides inpatient screenings in more complex cases and inpatient follow ups where necessary. She also provides supervision for the assistant psychologist and any trainee psychologists in post.
Contact: heidi.muir@nhs.net

# data[].attributes.body
We provide automatic inpatient screening for all major trauma patients who meet our referral criteria, except for those injured by fall who will need to be referred for a screening. We aim to screen patients within 5 days of admission.

Screening involves completing two questionnaires with patients. First the Clinical Outcomes in Routine Evaluation (CORE-10) which is a general measure of psychological distress. Secondly, the Post Traumatic Adjustment Scale (PAS) which is a predictive screening instrument for posttraumatic stress disorder and depression. These are not diagnostic measures.

After inpatient screening patients who have elevated scores may have further inpatient work, be referred for an outpatient telephone clinic with the Specialist Clinical Psychologist or be signposted to more relevant services.

# data[].attributes.body
During inpatient screenings we can offer some basic psychoeducation on why patients experience memory loss and flashbacks after a Major Trauma injury. Psychoeducation can normalise patients experiences and reduce distress around concerns about why they are experiencing symptoms.

# data[].attributes.body
• Must be a Major Trauma Patient
• Distress must be in relation to their Major Trauma not pre-existing mental health difficulties. For example distress in relation to flashbacks, memory loss and adjustment to injuries.
• We will automatically screen major trauma patients with the following injury mechanisms: vehicle incident, crush, blow, blast, shooting, stabbing and drowning.
• Major trauma patients who were injured through a fall must be referred for a screening.

# data[].attributes.body
Patients who scored above clinical threshold during inpatient screening may be offered a telephone follow up approximately 1 month after screening, in line with the NICE guidelines for PTSD. Patients will have another screening over the phone, using the CORE 10 and PCL (a 20 item checklist of PTSD symptoms based on the diagnostic criteria). The Specialist Clinical Health Psychologist will explore the difficulties the patient is experiencing and will make recommendations i.e. signposting, referrals to other services and self help resources. Some patients may be accepted for therapy in our Outpatient Therapy Clinic in Tavistock, however there are limited slots available.

# data[].attributes.body
• We don't work with patients unless they are considered Major Trauma Patients. Major Trauma is a medical term, therefore we won't see anyone who has been through a traumatic event unless their injuries are classed as Major Trauma.
• We do not work with patients who carry risk for example suicide attempts, psychiatric liaison work with these patients and ask for our input where needed.
• We do not work with patients while they are on the ICU, once they have been stepped down from the ICU and are discharged from ICU rehab/psychology we will screen patients
• We do not work with patients who are not orientated, have severe cognitive difficulties. However if their cognition improves we can see them.

# data[].attributes.body
Role: Assistant Psychologist
Availability: Works in Major Trauma on Tuesdays and Thursdays.
Work: Provides automatic inpatient screenings for major trauma patients. Screenings can include some basic psychoeducation on why flashbacks happen and normalising memory loss in Trauma. From the initial screening Liz can refer patients to Heidi's outpatient telephone clinics and provide signposting for patients in their rehabilitation prescription (our notes that patients receive upon discharge).
Contact: e.hart7@nhs.net

As a band 4 assistant psychologist Liz is not HCPC registered and therefore cannot work with risk, disclosures of suicidal ideation are managed by a discussion with Heidi or a referral to psychiatric liaison.

# data[].attributes.body
The Specialist Clinical Health Psychologist offers a face to face outpatient therapy clinic in Tavistock on a Monday. This is only for complex cases as we don't have many outpatient therapy clinic slots available. Patients who need psychological support but don't qualify for the clinic may be referred to appropriate services.

# data[].attributes.body
We don't currently have a trainee. In the past trainees have supported with inpatient screening and run outpatient clinics for therapeutic support with less complex clients.

# data[].attributes.body
• Inpatient screen: Major Trauma patients with the following injury mechanisms: vehicle incident, crush, blow, blast, shooting, stabbing and drowning will be automatically screened by the Assistant Psychologist. If screening scores are elevated patients can be offered inpatient support through psychoeducation or more complex work where required. Patients with elevated scores may be referred for an outpatient telephone clinic.

• Rehab Co-ordinators: The major trauma rehab team identify patients they have concerns about in relation to psychological distress, this is likely to be from the falls category as we do not automatically screen patients injured through falls. They can be referred via email or verbal discussion. Patients who are referred will usually have an inpatient screening to assess their needs and what support is appropriate.

• Telephone Clinic: Major Trauma patients often have telephone clinics with the rehab co-ordinators post discharge, during these they will be asked about their psychological distress, any concerns and if they would like a referral to psychology.

• Self Referral: Patients can contact the service for up to six months post discharge and book a telephone clinic with the Specialist Clinical Health Psychologist.

# data[].attributes.body
We don't offer inpatient therapy on the wards, as flashbacks, nightmares and memory loss are normal reactions to trauma in the first month. However, if these symptoms continue after a month a trauma focused intervention may be appropriate, in line with the NICE guidelines. Therapy can be offered at our outpatient clinic or through IAPT services.

Our inpatient service is only open when Dr Heidi Muir is available. If Heidi is on annual leave we only offer psychological screenings and psychoeducation.

# data[].attributes.attachment_link.readable_text
1.1 Recognition of post-traumatic stress disorder

1.1.1 Be aware that people with post-traumatic stress disorder (PTSD), including complex PTSD, may present with a range of symptoms associated with functional impairment, including:

re-experiencing

hyperarousal (including hypervigilance, anger and irritability)

negative alterations in mood and thinking

emotional numbing

dissociation

emotional dysregulation

interpersonal difficulties or problems in relationships

negative self-perception (including feeling diminished, defeated or worthless). [2005, amended 2018]

1.1.2 Be aware of traumatic events associated with the development of PTSD. These could be experiencing or witnessing single, repeated or multiple events and could include, for example:

serious accidents

physical and sexual assault

abuse, including childhood or domestic abuse

work-related exposure to trauma, including remote exposure

trauma related to serious health problems or childbirth experiences (for example, intensive care admission or neonatal death)

war and conflict

torture. [2005, amended 2018]

1.1.3 When assessing for PTSD, ask people specific questions about re‑experiencing, avoidance, hyperarousal, dissociation, negative alterations in mood and thinking, and associated functional impairment. [2005, amended 2018]

1.1.4 When assessing for PTSD, ask people with symptoms in recommendation 1.1.1 if they have experienced 1 or more traumatic events (which may have occurred many months or years before). Give specific examples of traumatic events as listed in recommendation 1.1.2. [2005, amended 2018]

1.1.5 For people with unexplained physical symptoms who repeatedly attend health services, think about asking whether they have experienced 1 or more traumatic events and provide specific examples of traumatic events (see recommendation 1.1.2). [2005, amended 2018]

Specific recognition issues for children

1.1.6 Do not rely solely on the parent or carer for information when it is developmentally appropriate to directly and separately question a child or young person about the presence of PTSD symptoms. [2005, amended 2018]

1.1.7 When a child who has been involved in a traumatic event is treated in an emergency department, emergency staff should explain to their parents or carers about the normal responses to trauma and the possibility of PTSD developing. Briefly describe the possible symptoms (for example, nightmares, repetitive trauma-related play, intrusive thoughts, avoiding things related to the event, increased behavioural difficulties, problems concentrating, hypervigilance, and difficulties sleeping), and suggest they contact their GP if the symptoms persist beyond 1 month. [2005, amended 2018]

Screening of people involved in a major disaster, refugees and asylum seekers

1.1.8 For people at high risk of developing PTSD after a major disaster, those responsible for coordinating the disaster plan should think about the routine use of a validated, brief screening instrument for PTSD at 1 month after the disaster. [2005, amended 2018]

1.1.9 For refugees and asylum seekers at high risk of PTSD, think about the routine use of a validated, brief screening instrument for PTSD as part of any comprehensive physical and mental health screen. [2005, amended 2018]

1.2 Assessment and coordination of care

1.2.1 For people with clinically important symptoms of PTSD presenting in primary care, GPs should take responsibility for assessment and initial coordination of care. This includes determining the need for emergency physical or mental health assessment. [2005, amended 2018]

1.2.2 Assessment of people with PTSD should be comprehensive, including an assessment of physical, psychological and social needs and a risk assessment. [2005, amended 2018]

1.2.3 Where management is shared between primary and secondary care, healthcare professionals should agree who is responsible for monitoring people with PTSD. Put this agreement in writing (if appropriate, using the Care Programme Approach) and involve the person and, if appropriate, their family or carers. [2005, amended 2018]

Supporting transitions between services

1.2.4 To support transitions when people with PTSD are moving between services:

give the person information about the service they are moving to, including the setting and who will provide their care

ensure there is effective sharing of information between all services involved

involve the person and, if appropriate, their family or carers in meetings to plan the transition

address any worries the person has, for example about changes to their routine or anxiety about meeting new people. [2018]

1.2.5 Provide additional support:

1.2.6 During transitions between services for people with PTSD who need ongoing care, the referring team should not discharge the person before a care plan has been agreed in the new service. [2018]

1.3 Access to care

1.3.1 Promote access to services for people with PTSD by:

reassuring them that PTSD is a treatable condition

providing care that places a positive emphasis on the range of interventions offered and their likely benefits

ensuring that methods of access to services take into account the needs of specific populations of people with PTSD, including migrants and asylum seekers, people who are homeless or not registered with a GP, looked-after children and young people, and preschool-aged children

minimising the need to move between different services or providers

providing multiple points of access to the service, including self-referral

establishing clear links to other care pathways, including for physical healthcare needs

offering flexible modes of delivery, such as text messages, email, telephone or video consultation, or care in non-clinical settings such as schools or offices

offering a choice of therapist that takes into account the person's trauma experience - for example they might prefer a specific gender of therapist

using proactive person-centred strategies to promote uptake and sustained engagement

assessing the need for further treatment or support for people who have not benefited fully from treatment or have relapsed. [2018]

1.3.2 Do not delay or withhold treatment for PTSD solely because of court proceedings or applications for compensation. Discuss with the person the implications of the timing of any treatment to help them make an informed decision about if and when to proceed, in line with Crown Prosecution Service guidance ( Therapy: provision of therapy for child witnesses prior to a criminal trial or Therapy: provision of therapy for vulnerable or intimidated adult witnesses). [2018]

To find out why the committee made the 2018 recommendations on access to care and how they might affect practice, see rationale and impact.

1.4 Principles of care

Supporting people with PTSD

1.4.1 Provide information in both verbal and written format and in line with recommendations in the NICE guidelines on service user experience in adult mental health and patient experience in adult NHS services. [2018]

1.4.2 Give information and support to people with PTSD (and their family members or carers as appropriate) covering:

common reactions to traumatic events, including the symptoms of PTSD and its course

assessment, treatment and support options

where their care will take place. [2018]

Peer support

1.4.3 Tell people about and help them access peer support groups if they want to and could benefit. Peer support groups should:

be facilitated by people with mental health training and supervision

be delivered in a way that reduces the risk of exacerbating symptoms

provide information and help to access services. [2018]

Maintaining safe environments

1.4.4 Be aware of the risk of continued exposure to trauma-inducing environments. Avoid exposing people to triggers that could worsen their symptoms or stop them from engaging with treatment, for example, assessing or treating people in noisy or restricted environments, placing them in a noisy inpatient ward, or restraining them. [2018]

Involving and supporting families and carers

1.4.5 Consider providing information and support to family members and carers of people with PTSD. This could cover:

the treatment and management of trauma-related psychological and behavioural problems, including the person's possible risk to themselves and others

discussing with family members and carers how they are being affected by the person's PTSD

how they can support the person to access treatment, including what to do if they do not engage with, or drop out of treatment. [2018]

1.4.6 Involve family members and carers, if appropriate, in treatment for people with PTSD as a way to:

1.4.7 Consider providing practical and emotional support and advice to family members and carers, for example directing them to health or social services or peer support groups. [2018]

1.4.8 Think about the impact of the traumatic event on other family members because more than one family member might have PTSD. Consider further assessment, support and intervention for any family member suspected to have PTSD. [2018]

1.4.9 For members of the same family who have PTSD after experiencing the same traumatic event, think about what aspects of treatment might be usefully provided together (such as psychoeducation), alongside individual treatments. [2018]

1.5 Language and culture

1.5.1 Pay particular attention to identifying people with PTSD in working or living environments where there may be cultural challenges to recognising the psychological consequences of trauma (see recommendations on avoiding stigma and promoting social inclusion in the NICE guideline on service user experience in adult mental health). [2005, amended 2018]

1.5.2 Ensure that screening, assessment and interventions for PTSD are culturally and linguistically appropriate. [2005, amended 2018]

1.5.3 If language or culture differences present challenges to the use of psychological interventions in PTSD, think about using interpreters or offering a choice of therapists. See recommendations on communication in the NICE guideline on patient experience in adult NHS services. [2005, amended 2018]

1.6 Management of PTSD in children, young people and adults

Planning treatment and supporting engagement

1.6.1 When discussing treatment options with people with PTSD (and their family members or carers as appropriate):

give them information about any proposed interventions, including:

their aim, content, duration and mode of delivery

the likelihood of improvement and recovery

what to expect during the intervention, including that symptoms can seem to get worse temporarily

that recovery is more likely if they stay engaged with treatment

take into account the person's preferences, any previous treatment, associated functional impairment and coexisting conditions

take into account any social or personal factors that may have a role in the development or maintenance of the disorder, such as childhood maltreatment and multiple traumatic experiences. [2018]

1.6.2 Be aware that people with PTSD may be apprehensive, anxious, or ashamed. They may avoid treatment, believe that PTSD is untreatable, or have difficulty developing trust. Engagement strategies could include following up when people miss appointments and allowing flexibility in service attendance policies. [2018]

1.6.3 For people with PTSD whose assessment identifies a significant risk of harm to themselves or others, establish a risk management and safety plan (involving family members and carers if appropriate) as part of initial treatment planning. [2018]

Active monitoring

1.6.4 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. [2018]

Psychologically-focused debriefing

1.6.5 Do not offer psychologically-focused debriefing for the prevention or treatment of PTSD. [2018]

Psychological interventions for the prevention and treatment of PTSD in children and young people

Prevention for children and young people

1.6.6 Consider active monitoring or individual trauma-focused cognitive behavioural therapy (CBT) within 1 month of a traumatic event for children and young people aged under 18 years with a diagnosis of acute stress disorder or clinically important symptoms of PTSD. [2018]

1.6.7 Consider a group trauma-focused CBT intervention for children and young people aged 7 to 17 years if there has been an event within the last month leading to large‑scale shared trauma. [2018]

1.6.8 Group trauma-focused CBT interventions for children and young people who have been exposed to large-scale shared trauma within the last month should:

Treatment for children and young people

1.6.9 Consider an individual trauma-focused CBT intervention for children aged 5 to 6 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 1 month after a traumatic event. [2018]

1.6.10 Consider an individual trauma-focused CBT intervention for children and young people aged 7 to 17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3 months after a traumatic event. [2018]

1.6.11 Offer an individual trauma-focused CBT intervention to children and young people aged 7 to 17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event. [2018]

1.6.12 Individual trauma-focused CBT interventions for children and young people should:

1.6.13 Consider eye movement desensitisation and reprocessing (EMDR) for children and young people aged 7 to 17 years with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event only if they do not respond to or engage with trauma-focused CBT. [2018]

Drug treatments for children and young people

1.6.14 Do not offer drug treatments for the prevention or treatment of PTSD in children and young people aged under 18 years. [2018]

Psychological interventions for the prevention and treatment of PTSD in adults

Prevention for adults

1.6.15 Offer an individual trauma-focused CBT intervention to adults who have acute stress disorder or clinically important symptoms of PTSD and have been exposed to 1 or more traumatic events within the last month. These interventions include:

Treatment for adults

1.6.16 Offer an individual trauma-focused CBT intervention to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 1 month after a traumatic event. These interventions include:

1.6.17 Trauma-focused CBT interventions for adults should:

1.6.18 Consider EMDR 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 the person has a preference for EMDR. [2018]

1.6.19 Offer EMDR to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a non-combat-related trauma. [2018]

1.6.20 EMDR for adults should:

1.6.21 Consider supported trauma-focused computerised CBT for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event if they prefer it to face-to-face trauma-focused CBT or EMDR as long as:

1.6.22 Supported trauma-focused computerised CBT interventions for adults should:

1.6.23 Consider CBT interventions targeted at specific symptoms such as sleep disturbance or anger, for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event only if the person:

Drug treatments for adults

1.6.24 Do not offer drug treatments, including benzodiazepines, to prevent PTSD in adults. [2018]

1.6.25 Consider venlafaxine[] or a selective serotonin reuptake inhibitor (SSRI), such as sertraline[] for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Review this treatment regularly. [2018]

1.6.26 Consider antipsychotics such as risperidone[], in addition to psychological therapies to manage symptoms for adults with a diagnosis of PTSD if:

they have disabling symptoms and behaviours, for example severe hyperarousal or psychotic symptoms and

their symptoms have not responded to other drug or psychological treatments.

Antipsychotic treatment should be started and reviewed regularly by a specialist (see how to use antipsychotic medication in NICE's guideline on psychosis and schizophrenia in adults). [2018]

1.7 Care for people with PTSD and complex needs

1.7.1 For people presenting with PTSD and depression:

usually treat the PTSD first because the depression will often improve with successful PTSD treatment

treat the depression first if it is severe enough to make psychological treatment of the PTSD difficult, or there is a risk of the person harming themselves or others. [2018]

1.7.2 Do not exclude people with PTSD from treatment based solely on comorbid drug or alcohol misuse. [2018]

1.7.3 For people with additional needs, including those with complex PTSD:

build in extra time to develop trust with the person, by increasing the duration or the number of therapy sessions according to the person's needs

take into account the safety and stability of the person's personal circumstances (for example their housing situation) and how this might affect engagement with and success of treatment

help the person manage any issues that might be a barrier to engaging with trauma-focused therapies, such as substance misuse, dissociation, emotional dysregulation, interpersonal difficulties or negative self-perception

work with the person to plan any ongoing support they will need after the end of treatment, for example to manage any residual PTSD symptoms or comorbidities. [2018]

To find out why the committee made the 2018 recommendations on care for people with PTSD and complex needs and how they might affect practice, see rationale and impact.

Terms used in this guideline

Complex PTSD

Complex PTSD develops in a subset of people with PTSD. It is a diagnosis in the ICD‑11, which defines it as arising after exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (for example, torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). The disorder is characterised by the core symptoms of PTSD; that is, all diagnostic requirements for PTSD are met. In addition, complex PTSD is characterised by:

severe and pervasive problems in affect regulation

persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the traumatic event

persistent difficulties in sustaining relationships and in feeling close to others.

DSM‑5 does not include a diagnosis of complex PTSD. It covers the complexity of presentation through a wider range of core PTSD symptoms (such as 'negative mood and cognitions') and the potential specifier of a 'dissociative subtype'.

# data[].attributes.attachment_link.description
1.1.1 Be aware that people with post-traumatic stress disorder (PTSD), including complex PTSD, may present with a range of symptoms associated with functional impairment, including: re-experiencing hyperarousal (including hypervigilance, anger and irritability) negative alterations in mood and thinking emotional numbing dissociation emotional dysregulation interpersonal difficulties or problems in relationships negative self-perception (including feeling diminished, defeated or worthless).