A Quarter of Cases of Posttraumatic Stress Disorder Is With Delayed Onset

This month’s guest post is by Geert Smid. Geert is a psychiatrist with Foundation Centrum ’45, the Dutch national institute for specialized diagnosis and mental health treatment after persecution, war and violence. He is also a researcher at Arq Psychotrauma Expert Group. Geert completed his PhD on Delayed Posttraumatic Stress Disorder in 2011 with a number of beautiful publications. He’ll make your brain work a little on this very topic:

According to the current edition of the Diagnostic and Statistical Manual of Mental Disorders, delayed posttraumatic stress disorder (PTSD) must be diagnosed in individuals fulfilling criteria for PTSD if the onset of symptoms is at least 6 months after the trauma. The prevalence of delayed PTSD has for a long time remained unclear, and only few studies have examined factors that may explain its occurrence. The findings summarized below are based on prospective investigations in disaster survivors and unaccompanied refugee minors, as well as a comprehensive meta-analysis of prospective studies.

1. About a quarter of PTSD cases is with delayed onset. The results of our meta-analysis showed that delayed PTSD occurs in about one quarter of all PTSD cases. The risk of delayed PTSD did not decrease between 9 and 25 months after the traumatic event, and when traumatized populations were followed up for longer periods of time, more delayed PTSD cases were found. These findings suggest ongoing potential risk for some individuals.

2. During the interval between the trauma and delayed PTSD onset, some symptoms are likely to occur. Delayed PTSD occurred most often in individuals already reporting “subthreshold” symptoms after the traumatic event. These symptoms that precede the full PTSD syndrome are called “prodromal.” Prodromal symptoms may include intrusive memories and avoidance of reminders as well as feelings of depression and anxiety.

3. Delayed PTSD is associated with mental health service utilization. We found a high likelihood of mental health service utilization in participants endorsing delayed PTSD 4 years after a disaster. Two thirds of disaster survivors endorsing delayed PTSD used or continued using mental health services. This finding strongly suggests that symptom progression in delayed PTSD is clinically relevant.

4. Delayed PTSD can be explained from pre-existing, trauma-related, and posttraumatic factors. Survivors reporting total home destruction after a disaster, i.e. very severe disaster exposure, were at elevated risk of developing delayed PTSD. We also found that cognitive ability as indicated by higher education was associated with delayed PTSD after a disaster, presumably by promoting initial adaptation to the traumatic event and thus mitigating initial distress. Lack of perceived social support as well as new stressful life events several years after a disaster increased the risk of delayed disaster-related PTSD.

In unaccompanied refugee minors, increasing age emerged as a risk marker for delayed PTSD. This highlights the importance of the stressful transitions for these youths at the age of 18 years. For example, their legal status will be reviewed, and they will be uncertain regarding their future right to remain in theNetherlands. Thus, factors associated with delayed PTSD may be pre-existing, trauma-related, or related to the posttraumatic phase.

These factors may explain the occurrence of delayed PTSD in one of three ways. First, factors may increase the risk for PTSD in general. Second, factors may promote initial adaptation to the traumatic event and thus explain why symptoms are not full-blown from the start. Third, factors may precipitate PTSD onset despite initial adaptation and thus explain why symptoms increase in number or severity later on.

5. Severe traumatic event exposure may lead to stress sensitization. We found prospective evidence of stress sensitization, that is, enhanced reactivity of individuals to new stressors following extreme disaster exposure (such as total home destruction) during the first years after a disaster. Stress sensitization may explain progression of distress over time and has important practical implications. Averting foreseeable stressors and resource losses in the aftermath of severe trauma, diminishing the impact of chronic stressors as well as reducing stress sensitization may be a target for preventing and treating progression of posttraumatic distress.

Towards a better definition of delayed PTSD.

According to the latest proposal for DSM-5, PTSD “With Delayed Expression” is defined as follows: “if the diagnostic threshold is not exceeded until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).”  Compared with previous DSM editions, this definition is a clear step forward, because it explicitly allows for prodromal symptoms preceding the onset of full delayed PTSD. Thus the revised definition more realistically describes the possible delayed impact of traumatic events that may show a crescendo pattern over time. This is important, because effects of trauma or stressor exposure are likely not restricted to PTSD alone, but to be relevant to a wide range of psychopathology. For example, delayed trajectories of depression have also been found following a disaster, and stress sensitization has been implied in the development of psychosis.

Do you think stress sensitization could be involved in the development of depression?

And could the concept of stress sensitization be helpful in developing innovative treatment strategies for trauma- and stressor-related disorders?

Reference of the meta-analysis:
Smid GE, Mooren TT, van der Mast RC, Gersons BP, & Kleber RJ (2009). Delayed posttraumatic stress disorder: systematic review, meta-analysis, and meta-regression analysis of prospective studies. The Journal of Clinical Psychiatry, 70 (11), 1572-82 PMID: 19607763

8 thoughts on “A Quarter of Cases of Posttraumatic Stress Disorder Is With Delayed Onset

  1. Hi Geert,….

    As a civilian (non-clinitian / researcher),…these clinical findings mirror my practical experiences over a 40 year period from age until present. Basically I was raised in a very violent home environment and had “mild” undiagnosed symptoms of anxiety from ages 8 through 21. At age 21 while in the military,…another [traumatizing] event occured and my psychological floods-gates burst open horribly….!!! During the past 40 years I have unravelled much of the puzzle in a reverse order via various means. It seems as though science is catching up with what I have horribly experienced with [minimal] help from the medical community due to lack of clinical knowledge and understanding to say the least.
    I currently have a Blog (HowardLovelyJr.wordpress.com) where I’m attempting to chronical my experience in hopes of helping myself and others (young or old) who may be having a similar experience. I am also currently writing a memoir about my 40 year journey and have a professionally complete [Book-Proposal].

    Thank you for your work and profound insight that [will] go a long way toward helping many individuals imminately because of the [accurate] theories you have outlined with your research.

    Howard Lovely, Jr.

    • Hi Howard, I very much appreciate your comment. I feel you are very courageous to write about your experiences. I am sure this is helpful to others. Thank you very much! All the best.
      Geert Smid

  2. I have dealt with chronic PTSD for 30 years clinically with hundreds of clients from all sources including war veterans, disaster survivors, rape victims, abuse victims etc. Delayed onset does occur around 25% of the time as you have found.

    PTSD is best thought of as spectrum of anxiety levels rather than a single complaint. It triggers under a wide variety of circumstances but almost invariable requires a continued high level of pre-existing anxiety (at least 5 years) to trigger. Until the trigger occurs some elements of the clinical diagnosis are often found. I find the delayed onset is as a result of the cumulative effect of stress both pre and post- trauma trigger. When the cumulate effect reaches a certain level (which varies from victim to victim) the full clinical presentation of PTSD occurs.

    There is always a biochemical component to the elevated anxiety levels which modifies the action of neurotransmission in a way that induces chronic depression and modifies coping skills related to anger and despair.

    Once the biochemical effects are taken care of, most effectively by nutritional intervention, the emotional aspects are easy to deal with. I typically take out the flashbacks and associated anxiety within two hours. And they don’t return.

    However an important ingredient in full recovery is to rebuild life skills. Long term victims tend to identify themselves by their PTSD. It invades every aspect of life. When you remove the PTSD it is important to create a new self perception and future or you run the risk of abreactions and a sense of loss.

  3. Hello
    As a clinician who has worked with trauma for many years I definitely have witnessed delayed onset symptoms and protracted suffering when there are continuous stressors or repeated trauma and a lack of safety or resolution to the traumatic event(s)/triggers. For the sake of making sure that we are discussing the same phenomena, Geert and Eva could you please be explicit as to your definition of “Stress sensitization” from a neuropsychiatric and experiential perspective? Thank you.

    • Hi Julia, Thank you for your comment and your question. From a neuropsychiatric perspective, stress sensitization may involve a repertory of cognitive processes as well as neurobiological systems. Neurobiological systems that may be implicated in sensitized responses in PTSD include the hypothalamus-pituitary-adrenal system, involved in coordinating the body’s response to stress, the noradrenergic system, involved in enhanced encoding of the emotional memories in individuals who develop PTSD, and other systems. From an experiential perspective, stress sensitization may be understood within Hobfoll’s Conservation of Resources theory. This theory states that people strive to retain, protect, and build resources and that what constitutes a stressor to them is the potential or actual loss of these resources. According to this theory, resource loss is disproportionally more salient than resource gain. Therefore, those who already lack resources (e.g., due to a prior traumatic event) are more vulnerable to resource loss (due to new stressors).

  4. In 1983 I was raped while serving in the military and never reported it. As it was then and is now difficult for society to believe and treat rape victims with respect: I somehow placed the traumatic incident out of mind until recently when it resurfaced. My whole life as a young adult to the present had been determined due to the trauma and I now realize I suffered from PTSD. How I responded to authority, my inability to physically have children (due to STD) my lack of discipline in dealing with financial matters, insubordination, even my reason for marriage were; in retrospect were all determined by that incident. I coped with life as best as I knew how. Now, 30 years later I can see how I established defense mechanisms and coping skills which became a part of my personality- allowing me to live with the trauma always lurking in a subconscious manner. When I married (4 years after the incident) I didn’t think to inform my fiancee of what had occurred because it was hidden from my memory. Knowing that there is now identified a delayed PTSD observed by and documented, I hope to find a resolution for my situation.
    When the traumatic event occurred the military had no method of connecting the experience of rape with PTSD. Therefore soldiers like me serving in the military were left to fend for themselves as best as they could. Now that I am filing for VA compensation for PTSD due to MST (military sexual trauma) I am informed that without medical proof of some sort I have no leg to stand on. I hope your work will help future victims of trauma whether it’s in war or peace. The delay of 30 years fails to deny the experience; but forces the flood gates to be opened and treatment with sympathy and compassion become the common trend. In cases where the incident is reported, the victim is still not guaranteed a safe state of being. I found that if there are no witnesses, i.e. gang raped or video cam recordings, the victim is left without any support. Thank you.

  5. My question is…
    If someone is molested at pre~puberty age, over a period of three years, could there be a delayed onset psychological impact occur as late as 25 years later, if during those 25 years there was a
    developmental trauma in place.

  6. Also. I can say that the pre~puberty molestation caused a premature closure of identity formation, which led to a developmental trauma lifestyle.
    A death occurred which was the stressor…

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