Psychological First Aid
Events that involve actual or threatened In the immediate aftermath of trauma,
This brochure is based on:
death or serious injury (real or perceived) practitioners should monitor the person’s
The Australian Guidelines
for Treatment of Adults
to self or others (e.g., accidents, assault,
mental state and provide tailored
with Acute Stress Disorder
natural disasters and wars) and evoke
support. This includes attending to the
and Posttraumatic Stress
feelings of fear, helplessness or horror.
person’s practical needs and encouraging
Disorder. For a complete
Certain events (e.g., interpersonal
the use of existing coping strategies
copy of the Guidelines
please refer to:
violence, direct life threat and prolonged and social supports.
duration) are more likely to result in a
ASD and PTSD are treatable disorders
This brochure is intended to assist
practitioners in providing best
ASD and PTSD
often missed in clinical practice.
practice clinical care for persons
ASD and PTSD are disorders charact-
Screening is an important means of
with ASD and PTSD. It is to be
followed subject to the medical
erised by symptoms that include
rectifying this and facilitating appropriate
practitioner’s judgment in each
individual case. The Guidelines
distressing re-experiencing and active
care (see Quick Guide).
include advice on issues pertaining
avoidance of the traumatic memories,
to special populations and trauma
emotional numbing and hyperarousal.
Please see the following
(See Additional Information for
Trauma-focussed psychological therapy
publications for more information
is the most effective treatment for
about the Guidelines:
people who develop ASD and PTSD.
Treating adults with acute stress
disorder (ASD) and posttraumatic
stress disorder (PTSD) in primary
care: A clinical update. The
Most people recover after a traumatic
Medical Journal of Australia,
event without serious problems. Some
Where medication is required for
(2007) 187 (2), 120-123.
develop more severe and persistent
the treatment of PTSD in adults,
The Australian guidelines for
the treatment of adults with
symptoms like PTSD. Those who develop selective serotonin reuptake inhibitor
acute stress disorder (ASD) and
antidepressants should be considered
posttraumatic stress disorder
chronic PTSD (i.e., lasting longer than
(PTSD). The Australia and New
three months) are unlikely to improve
as the first choice.
Zealand Journal of Psychiatry,
(2007) 41, 637-648.
without effective treatment.
other Disorders Following Trauma
The Australian Centre for
Posttraumatic Mental Health
Other common mental health disorders
(ACPMH) would like to thank
the Australian Government
Around 15–25% of people who experience that people can develop following
Department of Veterans’ Affairs
exposure to a traumatic event include
for funding the development of
a potentially traumatic event (PTE) may
develop PTSD making it one of the most
depression, substance abuse and other
These Guidelines are endorsed
common anxiety disorders.
by the Royal Australian College of
General Practitioners, the Royal
Australian and New Zealand
College of Psychiatrists and the
Australian Psychological Society.
For more information:
T H E R O YA L
A U S T R A L I A N A N D N E W Z E A L A N D
C O L L E G E O F P S Y C H I A T R I S T S
(Within two weeks of trauma exposure)
PSyCholoGICAl FIRST AID
Monitor the person’s mental state and screen for ASD and PTSD (see Quick Guide).
Support the person’s use of adaptive coping strategies (e.g., enlisting the support of family and friends),
as well as his or her own coping strategies if they seem helpful.
Encourage the person to re-engage in normal routines.
• Attend to any injuries or physical health concerns.
• Ensure basic needs are met (e.g., housing, safety).
Most people recover from initial psychological distress. However, if distress/symptoms persist for more
than two weeks, consider diagnosis of ASD/PTSD.
Symptoms may include:
• Distressing or unwanted memories of the trauma
• Avoidance of reminders and memories
Risk factors for developing ASD/PTSD include:
• Exposure to severe trauma
• Lack of social supports and other stressful life events
• A past history of trauma and/or previous psychiatric disorder
TAlKInG AbouT ThE TRAuMA EXPERIEnCE
Support those who want or need to talk about the experience.
Do not push those who prefer not to talk about the experience.
GPs have an important role in referral and care coordination.
Referrals to psychiatry, psychology and allied health professionals can be made under Medicare arrangements which may
include completion of a mental health care plan.
When referring for psychological interventions, consider referring to practitioners trained in trauma-focussed interventions
Referral for mental health care under third party funding arrangements should be considered where appropriate.
ASD/PTSD Suspected or diagnosed
(ASD can be diagnosed between two days to four weeks following trauma. PTSD can be diagnosed from four weeks onward.)
SuPPoRT AnD SCREEn
Encourage, and if necessary facilitate, engagement with social supports.
Stabilise and introduce simple stress or anxiety management strategies
(e.g., controlled breathing, exercise or other coping strategies).
Screen for ASD and PTSD (see Quick Guide).
REFER OR PROVIDE:
Conduct a thorough assessment of ASD/PTSD, including comorbid diagnoses such as depression, substance
use disorders, safety issues, physical health, social and vocational functioning, and social supports.
The Posttraumatic Checklist (PCL) can be used to assess all PTSD diagnostic criteria.
First line treatment is trauma-focussed psychological therapy. This includes addressing the traumatic memory
and the use of in vivo exposure (for details see Additional Information). Training in the use of trauma-focussed
treatment is recommended.
If one form of trauma-focussed therapy fails to produce a sufficient response, consider another and/or the
use of pharmacotherapy.
Trauma-focussed therapy should be embedded in a treatment plan that includes stabilisation, psycho-education,
symptom management and attention to key relationships and roles.
Where no trauma-focussed psychological therapies are effective, available, or acceptable to the person, consider
referral for nontrauma-focussed interventions (e.g., anxiety management) and/or pharmacotherapy.
1 SSRI antidepressants (evidence does not distinguish a preferred SSRI)
2 Other newer antidepressants or tricyclic antidepressants
3 MAOI antidepressants (preferably by a psychiatrist)
Where symptoms have not responded to antidepressant treatment, control ed studies have demonstrated potential
benefits of adjunctive atypical anti-psychotics (preferably by a psychiatrist).
Increase dose if non-responsive, being mindful of side effects. If effective, provide 12-month initial course.
Stopping antidepressants should be via gradual weaning. Only use as first line if trauma-focussed psychological
therapy is not available. Pharmacotherapy should always be supported by optimal psychotherapy.
PTSD with comorbidity
PRIoRITIES FoR TREATMEnT oF CoMoRbID DISoRDERS
PTSD and Depression
Treat PTSD first when depression is mild to moderate as depression will often improve as PTSD symptoms reduce.
If depression symptoms are severe, however, they should be treated first to minimise suicide risk and improve the
ability of the person to tolerate therapy.
PTSD and Substance use Disorders:
Treat both simultaneously because the two are likely to interact to maintain each other.
When treating simultaneously, the substance use should be control ed before the trauma-focussed component of PTSD
When people present with substance dependence, intoxication or acute withdrawal, the substance disorder should
be treated first.
MAnAGInG CoMPlICATIonS AnD PERSISTInG PRoblEMS
People with PTSD may have fluctuating or continued severe distress and significant potential for self-harm
(see Severe Distress). These people should be referred for urgent psychiatric care and stabilisation.
Primary treatment interventions still apply but may involve multiple practitioners (e.g., GP, psychologist,
psychiatrist and social/vocational rehabilitation consultants). A high level of communication and coordination
of interventions is essential.
If a person’s PTSD symptoms appear to be resistant to change, the following aspects of treatment should
be revised where necessary:
• Consider whether the skill-set and experience of the treating practitioner are adequate for the treatment
of the persisting problems.
• Consider referral for a second opinion.
• Consider whether the duration, intensity and setting of treatment are appropriate.
If a person presents with severe distress at any stage, particularly if they express thoughts about self-harm
or suicide, appropriate steps to ensure safety include psychiatric care or hospitalisation.
Other indicators of severe distress include severe insomnia, agitation, dissociation and social withdrawal.
Acute treatment may involve pharmacotherapy using sedating, calming or antidepressant medication.
Long term use of benzodiazepines is not recommended. They do not treat the underlying condition and
involve risk of dependency.
WhAT IS TRAuMA-FoCuSSED PSyCholoGICAl ThERAPy?
First line treatment should be trauma-focussed therapy (trauma-focussed cognitive behaviour therapy (CBT)
or eye movement desensitisation and reprocessing (EMDR) in addition to in vivo exposure).
KEy ElEMEnTS oF TRAuMA-FoCuSSED
Within the overall course of treatmment, 8–12
Addressing the traumatic memory in a controlled
sessions of trauma-focussed treatment are generally
and safe environment (imaginal exposure)
needed but more may be required for more severe
or complex cases.
Confronting avoided situations, people or places in
a graded and systematic manner (in vivo exposure)
Ninety minutes should be allowed for sessions that
involve imaginal exposure.
Identifying, challenging and modifying biased or
distorted thoughts and interpretations about the
The development of a robust therapeutic alliance
event and its meaning (cognitive therapy)
may require extra time for people who have
experienced prolonged and/or repeated traumatic
As the available evidence does not support the
importance of the eye movements per se in EMDR,
treatment gains are more likely to be due to the
Further sessions may be required where:
engagement with the traumatic memory, cognitive
• there are several problems that arise from multiple
processing and rehearsal of coping and mastery
• PTSD co-occurs with traumatic bereavement; or
• PTSD is chronic and associated with significant
disability and comorbidity.
To reduce the likelihood of an enduring disability, people with ASD and PTSD should be actively encouraged to
return to their normal social and occupational roles as quickly as they feel able and in an appropriately managed
way. This may mean that they will continue to experience symptoms, albeit at reduced levels, as they return to
previous roles. There should be a focus on psychosocial rehabilitation from the beginning of treatment.
SPECIFIC PoPulATIonS AnD TRAuMA TyPES
For more information on specific populations (Aboriginals and Torres Strait Islanders, refugees and asylum
seekers, military and emergency service personnel, motor vehicle accident and other injury survivors, victims
of crime, sexual assault, natural disasters, survivors of terrorism) download the PDF on these populations
under publications and resources at www.acpmh.unimelb.edu.au/for_professionals.html
DSM-IV CRITERIA FoR PTSD
A1. The person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury to self or others.
A2. The person’s response involved intense fear, helplessness or horror.
b. Re-experiencing (1 required)
C. Avoidance / Numbing (3 required)
D. Hypervigilance (2 required)
1. Recurrent and intrusive distresssing
1. Efforts to avoid thoughts, feelings or
1. Difficulty falling or staying asleep
recollections of the event, including images,
conversations associated with the event
thoughts or perceptions
2. Irritability or outbursts of anger
2. Efforts to avoid activities, places or people
2. Recurrent distressing dreams of the event
that arouse recollections of the event
3. Difficulty concentrating
3. Acting or feeling as if the event were
3. Inability to recall an important aspect of the
5. Exaggerated startle response
4. Intense psychological distress at exposure
4. Markedly diminished interest or participation
to internal or external cues that symbolise or
in significant activities
resemble an aspect of the event
5. Feeling of detachment or estrangement from
5. Psychological reactivity on exposure to
internal or external cues that symbolise or
resemble an aspect of the event
6. Restricted range of affect (e.g., unable to
have loving feelings)
7. Sense of foreshortened future (e.g., does
not expect to have a normal lifespan)
E. Duration of the symptoms (criteria B, C and D) is more than 1 month.
F. The symptoms cause clinically significant stress or impairment in social, occupational, or other important areas of functioning.
for ASD and PTSD
If the person reports having experienced a potentially traumatic event:
Is it a recent trauma (within the first 2 weeks)?
If yes, provide Psychological First Aid:
• Monitor mental state and stabilise if required
• Encourage re-engagement in routines and use of social supports
• Ensure basic needs are met (e.g., housing, safety)
• Review in a week or two
If symptoms do not settle following the first 2 weeks, or if the trauma is not recent:
• Assess for ASD or PTSD (ASD can be diagnosed between 2 days and 4 weeks;
PTSD from 4 weeks onwards) – see brief screen below
• Consider comorbidity e.g., depression, substance abuse
(see PTSD with Comorbidity for treatment sequencing)
• Ensure stabilisation and safety
• Refer for (or provide if appropriate) trauma-focussed therapy (see Additional Information)
• Consider pharmacotherapy
• Encourage resumption or maintenance of family and work roles as far as functioning allows
Screen for PTSD
(Prins, et al., 2004, Primary Care Psychiatry)
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the
past month, you:
1. Have had nightmares about it or thought about it when you did not want to?
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings?
If two or more are answered with “yes”, a diagnosis of PTSD is probable.
A copy of the screen for PTSD is available at www.acpmh.unimelb.edu.au/trauma/ptsd.html#screening
For a more complete scale including all 17 PTSD symptoms see the PTSD Checklist (PCL).
This scale is useful for diagnostic purposes and monitoring change over time.
Quick Guide for ASD and PTSD
how do I make a referral?
Referrals to psychiatry, psychology, and allied health care can be made under Medicare arrangements.
This should include completion of a mental health plan.
Referral for mental health care under third party funding arrangements should be considered where
Practitioners trained in trauma-focussed interventions (e.g., CBT) are preferred.
• Psychologists: A list of psychologists can be found at:
• Psychiatrists: A list of psychiatrists can be found at:
• Social workers and other allied health professionals with mental health training
Mental health plan
• Consider recommendations regarding trauma-focussed CBT for required treatments.
See Additional Information when completing mental health plans.
• In addition to the K10, consider including the PTSD Checklist (PCL).
It can also be used for re-assessment to monitor progress at treatment review.
• Focus on psychosocial rehabilitation: emphasise functional outcomes (e.g., social and vocational
goals) from the outset.
Screening for traumatic events
GPs should also ask about past traumatic events where a person has repeated non-specific health
A good opening question is: Have you ever experienced a particularly frightening or upsetting event?
It is often useful to ask about specific events that the person may have experienced, such as the following:
• Serious accident (like a car accident or industrial accident)
• Natural disaster (like a fire or flood)
• Physical attack or assault
• Sexual assault
• Seeing somebody being badly hurt or killed
• Domestic violence or abuse
• Physical or emotional abuse as a child
• Being threatened with a weapon or held captive
• War (as a civilian or in the military)
• Torture or an act of terrorism
• Any other extremely stressful or upsetting event
T H E R O YA L
A U S T R A L I A N A N D N E W Z E A L A N D
C O L L E G E O F P S Y C H I A T R I S T S