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Trauma may not be readily observable in older adults. Patients may not acknowledge or may minimize the importance of their experiences, and health care providers may not recognize or provide timely and appropriate mental health treatment (

). Data from a study examining the influence of chronic 

 (PTSD) on biological aging processes in older adult men and women with PTSD in New York City found that 43% were currently receiving some kind of medication or psychotherapy.

 Of those, less than 25% were receiving an adequate dose and duration of a first-line pharmacotherapy option, and not one individual was currently participating in an evidence-based psychotherapy for PTSD, which is disappointing given the larger treatment effect sizes observed with such psychotherapy compared with pharmacotherapy.

 (For more information on the prevalence of PTSD and similar issues, please see the previous review article, “

These low rates are consistent with national findings from the US Department of Veterans Affairs Health Care System. Although most older veterans with newly diagnosed PTSD received at least 1 follow-up mental health visit, increased age was associated with decreased odds of receiving combined psychotherapy and 

, decreased number of psychotherapy visits, and increased waiting times.

There are many reasons for mental health providers to be enthusiastic about promoting healing from trauma and PTSD in their older adult patients and a number of options exist (

). Even though most randomized controlled trials of psychotherapy do not include sufficient numbers of older adults to make definitive age comparisons, existing data suggest that psychotherapy is feasible and efficacious for older individuals.

 However, it may require adjustments for this age group, including increasing the number of sessions, or modifications such as adding additional content or components.

For example, although there are case studies

 that show acceptability and preliminary efficacy for an evidence-based psychotherapy for PTSD—prolonged exposure (PE)

—results of the first randomized controlled trial of PE that specifically focused on older adults indicated that effects may not be as strong as those reported in studies for younger adults.

 who received PE and those who received the comparison condition (relaxation therapy) experienced significant declines in PTSD symptoms after intervention, many symptom gains were lost by the time of the 6-month follow-up. In addition, depression symptoms did not significantly change over time, nor were they moderated by treatment condition. It is possible that while exposure can reduce PTSD symptoms in older adults during active engagement, it does not work as well during the maintenance phase. This may be due to several factors, including the difficulty in recalling older memories and potentially weakened trauma processing. Some older adults may need additional frequency and intensity of PE sessions to gain full therapeutic effect. In addition, 

 delivered via internet or mobile devices may be used to increase the reach of PE and other evidence-based psychotherapies, as well as to help older adults engage more actively in treatment or enhance care after formal intervention has ended.

These findings are consistent with those from a study of another evidence-based psychotherapy, cognitive processing therapy (CPT).

 A multivariate model predicting post-CPT symptom severity indicated lower PTSD symptoms for veterans of wars in Iraq and Afghanistan than for Vietnam veterans.

 Thus, treatment for older veterans with moderate-to-severe PTSD may also need to address such issues as aging and retirement and incorporate motivational techniques. A current psychotherapy trial in Israel testing the use of life review

 compared with a supportive control condition for PTSD, depression, and/or prolonged grief in 

 Life review takes a narrative approach and includes the developmental life-span orientation as well as exposure therapy.

The gold-standard pharmaceutical treatments for PTSD

 in the general adult population are selective serotonin reuptake inhibitors (SSRIs), particularly sertraline, paroxetine, and fluoxetine, and a selective serotonin and norepinephrine reuptake inhibitor (SNRI), venlafaxine; all of these are commonly used for depression.

However, few pharmacotherapy studies focus on or include patients who are 65 years and older. Simply generalizing findings from randomized controlled trials of younger adults with PTSD to the clinical treatment of older adults may be problematic. It is possible that age-related changes in the brain (eg, declining locus coeruleus functioning with consequent alterations in noradrenergic tone

) may specifically affect treatment responses to SSRIs and SNRIs in older adults. Moreover, intervention studies exclusively enrolling younger adults typically do not contain outcome measures relevant to older adults, such as assessments of cognitive and physical functioning. It may be the case that, similar to the aforementioned psychotherapy trials for PTSD, pharmacotherapy in older adults will require aging-informed adjustment in order to achieve optimal responses. For example, good clinical medication management for PTSD in older adults must also consider potential frailty, complex comorbidities, multimorbidity, and polypharmacy.

Differences in clinical phenomenology, brain mechanisms, and treatment responsivity based on age have been well documented in the case of major depressive disorder in older adults, which is quite relevant to individuals with PTSD given its frequent cooccurrence.

 The average response to antidepressant medication tends to be higher in younger than older adults.

 Reasons for attenuated responses and more chronic clinical courses include age-related biological processes, such as cerebrovascular infarcts; development of frailty; inflammation and neurochemical changes like diminished dopamine signaling; and oxidative stress and mitochondrial aging.

 One forward-thinking strategy is to identify and deploy precision treatments rather than apply an empirical treatment (eg, antidepressant medication) that may not address the specific disease process occurring in a given patient.

 In addition, optimal management of late-life depression should begin earlier in adulthood, incorporating preventive strategies as well as a focus on such lifestyle strategies as 

Thus, while pharmacotherapy research into PTSD in older adults is lagging far behind the psychotherapy literature, lessons learned from treatment of depression in older adults may be informative. In addition, innovative pharmacotherapy augmentation or second-tier interventions for increasing the mental health treatment response in older patients with PTSD include the use of d-cycloserine and 3,4-methylenedioxymethamphetamine

 as well as an α-2 adrenergic receptor antagonist, yohimbine.

One important caveat to the issues presented earlier in this article is that most of the empirical literature focuses on older adults with trauma occurring earlier in life (eg, combat, sexual assault). Attention must also be paid to older adults who are currently experiencing trauma. At least 11% of community-residing older adults in the United States have experienced some form of mistreatment—emotional, physical, sexual, financial, and neglectful events—in the past year.

 Older adults who are experiencing current polyvictimization are also in need of identification, assessment, and intervention. Methods to promote help-seeking and healing in survivors of elder abuse are available and should be integrated across a range of health care and law enforcement systems.

Trauma-related psychiatric disorders such as PTSD and grief often go undetected and untreated in older adults. There are evidence-based psychotherapies and pharmacotherapies that could provide great benefit in symptom reduction and increased life functioning, although augmentation or modification may be necessary for older adults. In order to assist older survivors in receiving timely and appropriate mental health treatment, targeted outreach, psychoeducation, and assessment in health care settings is warranted.

is a professor of psychiatry, Yale School of Medicine, New Haven, CT.

is the John and Myrna Daniels Professor of Psychiatry in Honor of Dr Herbert Pardes, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, and co-director, Research Area on Brain Aging and Mental Health, New York State Psychiatric Institute, New York, NY.

is the executive director, Trauma and Resilience Center, vice chair for Veterans Affairs, and professor in the Louis Faillace Department of Psychiatry at McGovern Medical School, University of Texas Health Science Center at Houston.

The authors report no conflicts of interest concerning the subject matter of this article

1. Rutherford BR, Zilcha-Mano S, Chrisanthopolous M, et al. 

Symptom profiles and treatment status of older adults with chronic post-traumatic stress disorder.

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Summary of the clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults.

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Mental health treatment for older veterans newly diagnosed with PTSD: a national investigation.

Post-traumatic stress disorder in older adults: a systematic review of the psychotherapy treatment literature.

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A review of PTSD augmentation strategies for older adults and case of rTMS-augmented prolonged exposure. 

Older adults with PTSD: brief state of research and evidence-based psychotherapy case illustration. 

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Effectiveness of prolonged exposure for PTSD in older veterans.

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Prolonged Exposure Therapy For PTSD: Emotional Processing of Traumatic Experiences

10. Thorp SR, Glassman LH, Wells SY, et al. 

A randomized controlled trial of prolonged exposure therapy versus relaxation training for older veterans with military-related PTSD.

11. Price M, Yuen EK, Goetter EM, et al. 

mHealth: a mechanism to deliver more accessible, more effective mental health care.

Cognitive Processing Therapy for PTSD: A Comprehensive Manual

13. Chard KM, Schumm JA, Owens GP, Cottingham SM. 

A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy.

15. Forstmeier S, van der Hal E, Auerbach M, et al. 

Life review therapy for Holocaust survivors (LRT-HS): study protocol for a randomised controlled trial.

16. Shibata E, Sasaki M, Tohyama K, et al. 

Age-related changes in locus ceruleus on neuromelanin magnetic resonance imaging at 3 Tesla.

Functional neuroimaging in PTSD: from discovery of underlying mechanisms to addressing diagnostic heterogeneity.

18. Mulsant BH, Blumberger DM, Ismail Z, et al. 

A systematic approach to pharmacotherapy for geriatric major depression.

19. Rutherford BR, Taylor WD, Brown PJ, et al. 

Biological aging and the future of geriatric psychiatry.

20. Tuerk PW, Wangelin BC, Powers MB, et al. 

Augmenting treatment efficiency in exposure therapy for PTSD: a randomized double-blind placebo-controlled trial of yohimbine HCl.

21. Williams JL, Racette EH, Hernandez-Tejada MA, Acierno R. 

Prevalence of elder polyvictimization in the United States: data from the National Elder Mistreatment Study.

22. Burnes D, Acierno R, Hernandez-Tejada M. 

Help-seeking among victims of elder abuse: findings from the National Elder Mistreatment Study.

Trauma-related psychiatric disorders such as PTSD and grief often go undetected and untreated in older adults. Here's how to help. 

PTSD in Late Life: An Update on Clinical Issues 

My wife and I do not watch much TV, but we almost always watch CBS Sunday Morning. I am not sure that the show this past Sunday, which had 2 segments on posttraumatic stress disorder (PTSD) and veterans, was a follow-up to the just passed Veterans Day, but it sure seemed that way.

This show’s cover story was on “New hope in treating PTSD with psychedelic drugs.”

 It focused on a veteran of 2 tours in Iraq, who had been struggling with severe PTSD for about a dozen years. Treatment as usual was not helping, as is often the case with PTSD, especially when there is moral injury involved. In his case, he felt strong guilt about being unable to rescue, but only being able to watch, another fellow soldier burn to death from an explosive device.

He then heard of a US Food and Drug Administration therapeutic breakthrough trial on psychedelics for treating PTSD and was able to enroll. The treatment was MDMA, aka ecstasy, with the crucial complement of psychotherapy. After 3 sessions, his symptoms dissipated and have continued to do so.

Later in the show, there was a report about a woman who had found 2 Army uniforms in a dumpster. Finding that unusual, she wanted to find the owner, but only had the last name of McKenzie on a jacket. Eventually, she found out they were from a veteran who had served twice in Afghanistan, developed PTSD, and then died from suicide in 2018. She decided to make the 1000 mile drive to his wife and teenage son to deliver them in person. The son was overwhelmed and felt that she returned more than the uniforms. She returned hope for the future. If only the father could have tried a psychedelic.

Hopefully, the outstanding results and protocols will continue to pan out in this new paradigm.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. CBS Sunday Morning. New hope in treating PTSD with psychedelic drugs. YouTube. November 14, 2021. Accessed November 16, 2021. 

https://www.youtube.com/watch?v=rMBRgBFp7TI

Psychedelics: returning hope to veterans with PTSD. 

Psychedelics Providing Hope for Veterans and Others

When the United States withdrew from Afghanistan earlier this year, clinicians noted a sharp increase in calls to veteran crisis center hotlines.

 One survey found that 90% of veterans with a history of mental illness were experiencing new or worsening symptoms since the country fell.

For veterans with posttraumatic stress disorder (PTSD), news about 

Afghanistan brought back powerful memories of traumas

 many of them were trying to forget. Nightmares invaded their sleep, intrusive thoughts distracted them from work and family, and flashbacks were so powerful there was no place to hide.

PTSD has a complicated history and neurobiology, and an array of potential comorbidities. In order to diagnose and treat it, clinicians should understand all these factors, and tailor their treatment plans accordingly.

The Prevalence of PTSD and Comorbid Disorders

Civil War General William Tecumseh Sherman put it bluntly when he said, “War is hell.” For veterans with PTSD, that hell can seem inescapable. Between the Iraq and Afghanistan wars, an estimated 500,000 US troops, about 20%, have been diagnosed with PTSD.

However, less than half of veterans in need of mental health services receive treatment. Of those who do get help, less than one-third receive evidence-based care.

 And of the 5 million service members being cared for by the US Department of Veterans Affairs (VA), only 8% have been diagnosed with PTSD. Left untreated, PTSD can lead to hospitalization, unemployment, and poverty.

There are myriad reasons for this lack of appropriate care. Veterans face unique barriers in getting treatment for 

. From the minute they enter the military, service members are trained to be tough. This, after all, is what gives them the mettle needed to survive. However, this attitude can also feed stigma, as any mental health condition might be considered a sign of weakness.

When the bullets stop flying and service members return home, the horrors they hoped to forget often follow. These unprocessed traumas bang on the door of their subconscious, demanding attention. However, talking about traumas can be an extremely uncomfortable experience, one that threatens to trigger retraumatization.

There are also societal barriers to access. Veterans who seek services from the VA must have received either an honorable or general discharge and, even then, there are usually long waits to receive services. Those living in rural areas are even less likely to get access.

Instead, many veterans turn to drugs and alcohol to dull the pain. In the 1980s, a study of Vietnam veterans with PTSD found that 74% had a comorbid substance use disorder (SUD).

 A more recent study found 76% met the criteria for both alcohol and SUDs.

Adding to the complexity, mood and anxiety 

 are high with PTSD and can complicate diagnosis and assessment. Veterans with PTSD are 3 to 5 times more likely to have major depressive disorder. Many also have anxiety disorders.

 wondering if they are irreparably broken. Between the wars in Afghanistan and Iraq, more than 30,000 veterans have died by suicide.

 It is a statistic that belies a troubling need for care.

PTSD has gone by many names over the years. During 

. During World War I, soldiers called it 

. After the Vietnam War, when almost 25% of soldiers required some kind of psychiatric care, it was known as 

The work of Charles Myers, MD, during World War I is widely credited with how PTSD is treated today. A medically trained psychologist, Myers was brought on by the British military to study and treat soldiers who were unable to function without any discernible cause.

At the time, many viewed shell shock as cowardice. Myers, on the other hand, argued that it was a psychiatric condition that caused affected soldiers to dissociate from a traumatic experience and repress its memory. The treatment, he concluded, involved connecting the traumatic memory back into one’s awareness through a series of psychotherapy sessions. These were ideally held within a military setting but away from gunfire.

 became an official diagnosis in the third edition of the DSM. Initially considered an anxiety disorder, PTSD is part of a separate group of trauma- and stressor-related disorders in DSM 5. DSM 5’s PTSD diagnosis also includes witnessing an event as a qualifying trauma.

PTSD is expressed by 4 main clusters of symptoms: reexperiencing the trauma in the form of intrusive memories, flashbacks, or nightmares; avoidance of anything that reminds an individual of the event; arousal and hyperreactivity, such as being easily startled or feeling tense; and effects on cognition and mood that include negative thoughts, feelings of guilt or blame, or a loss of interest. To receive a diagnosis of PTSD, these symptoms have to last more than a month and be functionally impairing.

Although anyone experiencing a trauma may have these reactions, symptoms usually fade over time and do not lead to PTSD. For others, however, the symptoms are severe, persist, and cause significant dysfunction.

The disorder can be diagnosed by using the Clinician-Administered PTSD Scale for DSM 5, a 30-item structured interview.

 It is considered the gold standard for measuring PTSD in clinical trials, but it is difficult to use in a clinic setting. The PTSD Checklist for DSM 5 is a 5- to 7-minute questionnaire that may be more practical to use in the clinic. It is regularly used to establish national PTSD outcome data.

Since the 9/11 terrorist attacks in 2001, 775,000 troops have 

 on a mission to retaliate and stabilize the region. More than 2400 died, about 20,000 were wounded, and countless others have been haunted by what they have seen and experienced.

When the Taliban regained control of Afghanistan in August, texts to the Veterans Crisis Line jumped 98% compared to a year prior. Chats and phone calls rose 40% and 7%, respectively.

 While this is troubling, the VA also noted it was an encouraging sign that more veterans were seeking help for their mental health issues. One survey revealed that one-third of veterans seeking counseling were doing so for the first time.

About 70% of veterans have struggled with mental health issues since serving in the Afghanistan war.

 Since August, 90% of Afghanistan service members have experienced new or worsening mental health issues. About 75% are experiencing new or worsening symptoms of depression, 58% have started or increased drug or alcohol use, and 64% have new or worsening thoughts of suicide.

 tend to experience more severe symptoms and lower remission rates compared to noncombat-related PTSD.

 Indeed, the kind of warfare experienced in Afghanistan is likely to put anyone on edge. This includes guerrilla attacks, roadside and suicide explosives, and a wary uncertainty about safe zones and battlegrounds. When an attack can come from anywhere at any time, the amygdala will be more active, and PTSD may be more likely.

Although improvements in body armor and combat medicine protect service members who would have died from their wounds in earlier wars, it leaves them with psychological scars as well as possible PTSD, brain injury, and a host of other lifelong debilities.

Troops today are serving at younger, more impressionable ages.

 In the Vietnam War, troops mostly served a single tour. Now, more than half return to action, with some serving more than 5 tours.

 Studies have shown that morale decreased and psychiatric problems as well as the use of psychotropic medication increased during the second or third deployment. Similarly, communication with family was difficult, and separation or divorce rates increased.

Younger age, female gender, minority background, as well as lower socioeconomic status, military rank, and education all indicate a higher risk of PTSD.

 In addition to trauma from battle, sexual trauma is common in the military, with about 1 in 3 women and 1 in 50 men reporting military sexual trauma (MST).

 With fewer women in the military, 1 in 3 veterans who report MST are men.

In addition to PTSD, many Afghanistan combat veterans also suffer from moral injuries, which occur when a trauma cuts so deep it violates an individual’s moral beliefs.

 Moral injury also describes an individual’s internal conflict over things they have done to others, actions they have failed to do, and events they have witnessed others doing or failing to do. Examples of moral injury include killing others (innocent or not), dismembering bodies, torturing others, or abandoning comrades during battle.

Moral injury is highly common among service members, with at least 1 symptom appearing in 90% of veterans and 80% of active duty military.

 It is a separate and distinct syndrome from PTSD that can co-occur and be influenced by the same event. Although it shares similar symptoms with PTSD, it would be a mistake to treat it the same. In fact, the existence of unresolved moral injury can hinder the treatment of PTSD, as well as 

Shame is the underlying theme of moral injury. It is shaped by the event that caused it, and it continues to develop for years after a service member has returned home.

 Disgust also plays a major role. Studies indicate that elevated levels of disgust, whether moral or bodily, can increase intrusive thoughts and tend to be higher in those with PTSD.

Moral injury also involves feelings of guilt, betrayal, loss of meaning and trust, difficulty forgiving, self-condemnation, and inner conflict over moral implications. Moral injury can shake a patient’s spirituality and call into question their relationship with a higher power.

 It is also correlated with social anxiety isolation, depression, and 

As the understanding of PTSD has advanced, it has become clear that it is a neurobiological disorder driven by environmental trauma. It is likely a product of both nature and nurture and may be caused by a combination of biological vulnerability and 

PTSD involves the amygdala, prefrontal cortex, and hippocampus. The amygdala regulates intense emotions, particularly fear. It governs fear conditioning and contributes to symptoms of altered arousal and reactivity. The prefrontal cortex regulates conditioned fear, normally turning down the alarm signal from the amygdala. PTSD can occur when decreased activity in the prefrontal cortex prevents it from appropriately regulating heightened activity in the amygdala.

The hippocampus can help buffer the effects of increased amygdala activity. There is evidence to suggest that the hippocampus tends to be smaller in those with PTSD, but it is not entirely clear whether that is the cause of PTSD or the result of it. Studies of identical twins have indicated that a smaller hippocampus at baseline may make people more vulnerable to developing PTSD.

Since the fall of Afghanistan, 31% of veterans have sought professional mental health services for the first time.

 It is a sign of hope that barriers to treatment are softening. 

, in particular, has become a useful way to reach patients who are either hesitant to engage in treatment or live in remote places.

A 2014 survey of 7600 veterans revealed that those who believed they needed treatment, kept a positive attitude, and had strong social networks were more likely to be successfully treated for PTSD.

 However, treating PTSD can be a challenge, and current treatment options are not always effective.

Close to 60% of those with PTSD do not achieve remission, and although treatment-resistant PTSD is hard to define, up to one-third of patients do not find relief with current therapies.

 Chronic PTSD can lead to decreased life satisfaction as well as increase suicide risk and depression rates.

Trauma-informed care seeks to tailor treatment around the unique vulnerabilities of each patient. The goal is to help a patient process their PTSD experiences without retraumatizing them in the process. To do this, clinicians need to fully understand every aspect of a patient’s traumatic event, including earlier ones. Additionally, they put a high emphasis on safety, encourage patients to rebuild control, and teach them to build upon their individual strengths.

Homeless veterans with PTSD, in particular, can benefit from trauma-informed care. While veterans comprise 7% of the total US population, they represent 12% of homeless adults.

Providing a trauma-informed approach necessitates adapting treatment to the needs of these patients. It helps earn their trust and protects them from retraumatization. PTSD is like a giant wound that many veterans will carry throughout their lives. Healing must start from the inside out. As clinicians, our job is to help them integrate the experience of trauma without being overwhelmed by it.

 used as first-line treatments of PTSD. With cognitive processing therapy, therapists teach patients coping skills and help them identify negative thoughts associated with a traumatic event and replace those thoughts with coping skills. With prolonged exposure (PE), patients revisit the trauma repeatedly in a safe, clinical setting to change how they react to the memories of the event. PE has an efficacy rate of about 60% of veterans with PTSD.

. In treating PTSD, the use of medications, specifically selective serotonin reuptake inhibitors (SSRIs), is to make therapy more effective by reducing the intensity of the overwhelming anxiety caused by PTSD. This anxiety can limit how effectively patients are able to discuss and process their trauma in therapy, which can hinder the healing process. SSRIs have a 60% rate of response in patients with PTSD, but only 20% to 30% achieve complete remission.

, such as ketamine and psilocybin mushrooms, is also currently being researched in their potential to treat PTSD, but these studies are still in the early stages of understanding how they might be useful.

Eye-movement desensitization reprocessing (EMDR).

 After ensuring a patient is prepared to process their trauma, this treatment works to replace negative images and beliefs with more positive ones. During treatment, a patient pays attention to a back-and-forth sound or movement while recalling a traumatic event. The sound or movement gives them a focus that allows them to explore and process their trauma.

 is showing potential as a possible future treatment. It works by delivering highly focused magnetic fields to modulate neural circuits in the brain. It is currently used for patients with treatment-resistant depression. Studies indicate TMS could be used to treat the poor extinction of traumatic memory by targeting the prefrontal cortex.

. Yoga and breathing-based meditation are thought to help calm the hyperactive sympathetic nervous system brought on by PTSD. In one study, veterans who practiced Sudarshan Kriya yoga showed reductions in PTSD scores, anxiety symptoms, and respiration rate.

 In another study, half of the group of veterans who practiced transcendental meditation for 3 months did not meet the criteria for PTSD at study completion, compared to a control group at 10%.

 has also been shown to indirectly reduce self-stigma felt by many veterans as well as other symptoms of PTSD.

. For veterans suffering from moral injury, programs such as 

 can help trauma survivors address a variety of spiritual concerns.

In these programs, which are administered by trained chaplains, veterans explore issues of forgiveness, their relationship with a higher power, and why that higher power allows evil to occur in the world.

 is still under investigation, it seems to have a positive effect on those with PTSD. One study found that cannabis lowered threat-related activity in the amygdala.

 A second study observed that cannabis seemed to diminish the intensity of memories associated with trauma.

 The use of cannabis to treat PTSD has not been approved by the US Food and Drug Administration and remains illegal in many states.

The US withdrawal from Afghanistan stirs memories of trauma among veterans.

PTSD’s Long Reach

Many confident psychiatrists have quipped, “I can recognize posttraumatic stress disorder (PTSD) as it walks down the hall.” It may be an exaggeration, but it does belie a surprising truth about the disorder. Even without knowing that someone has been traumatized, PTSD is recognizable.

PTSD is a constellation of maladaptive changes that can occur after an extreme stressor, though it does not happen to everyone who is traumatized.

 When it occurs, it involves disturbing experiences, such as flashbacks to the trauma and potentially long-term alterations to patterns of thinking, behavior, and biology. 

While these changes have long been described, our current conceptualization of PTSD was identified as 

 in 1915 by World War I soldiers. It described the experience of fatigue, tremor, confusion, nightmares, and impaired sight and hearing among soldiers recovering from battle.

 The definition of shell shock has changed over the years to include different categories of traumas, such as sexual trauma and indirect trauma. And while PTSD used to be considered an anxiety disorder, it is now just one among a separate group of 

Making the initial diagnosis of PTSD can be challenging, as PTSD symptomology runs the gamut of phenomenology described in the DSM-5. PTSD can both resemble and commonly co-occur with a broad range of other psychiatric conditions.

 Dissociative experiences such as flashbacks can strongly resemble hallucinations. Perfectionism may present as 

 (OCD). Dramatic mood swings may be difficult to differentiate from bipolar disorder. Concurrent substance abuse issues are also quite common, not to mention the changes in cognition and sense of self that mimic several different personality disorders. The list of doppelganger or complicating diagnoses that may accompany PTSD includes nearly every other diagnosis listed in DSM-5.

So then, what does PTSD look like when it walks down the hall? How can clinicians recognize PTSD even if the patient is in 

? And how can a clinician conduct the interview on this sensitive topic without retraumatizing the patient in the process?

Not every patient with PTSD will experience every symptom of the disorder. In fact, it is not atypical for patients to display the opposite of some symptoms. What is typical of PTSD is that there is no middle ground. There is an all-or-nothing quality to these changes. As a model of nonrecovery after trauma, each may be conceptualized as either an over- or under-compensation.

DSM-5 lists 5 criteria for diagnosing PTSD,

 but the order in which they are presented is almost precisely backward from how they will present during a session. Unless you happen to work in a PTSD clinic, where every patient is presumed to have experienced a trauma, you will not necessarily know this from the start. So, let us review the criteria in reverse order.

Criterion E: Alterations in Arousal and Reactivity

In particularly severe cases of heightened arousal or hypervigilance, the patient may refuse to walk down the hall ahead of you. They simply cannot abide anyone walking behind them. You may gesture for them to go ahead of you, and they will instead gesture for you to go ahead of them. It creates an unmistakably awkward moment. Others may handle the hallways just fine but then refuse to go into the office before you.

, this behavior is more subtle. If you are not present when the patient logs on, they may panic and call the office, convinced they did something wrong or that they will be billed a no-show fee. Of course, all patients may do this after a long wait, but patients with PTSD tend to do this after a surprisingly short amount of time, even if they have been asked to wait.

Patient with PTSD  may point out flaws that exist in your paperwork, scheduling, or front-office operations. While most patients try to make a good impression, a patient with PTSD may put you on the defensive. Or, they might not show up at all.

This heightened arousal and reactivity has a neurobiological basis. The hypothalamic-pituitary-adrenal system (HPA axis) and the sympathetic nervous system have long been known to regulate the stress response. Both are activated acutely during or after the trauma, but their sensitivity or reactivity to stress also increases over the long term, even after the stressful event has ended.

The details of these long-term changes to the HPA axis and the sympathetic nervous system have yet to be fully mapped. However, both systems in PTSD patients appear to lack or have lost calming influences. For instance, the stress hormone cortisol, though elevated during acute stress, has also been shown to help patients process their traumatic memories afterward.

 Yet it is chronically low in patients with PTSD. Whether this is a cause or the result of PTSD is still unclear. While the sympathetic nervous system is typically implicated in the short-term fear response, it appears to lose inhibitory input over the long term, making the fight-or-flight mode easier to access.

Signs of heightened arousal may pervade the clinical picture in patients with PTSD even beyond the formal criteria. Patients with PTSD almost invariably have trouble sleeping. Studies of comorbidities often find high associations with both sedative and 

Criterion D: Negative Alterations in Cognitions and Mood

There are 2 themes at work with this criterion: extremes in thinking, and numbing or avoidance. Though the biology of these changes is still not well understood, numbing symptoms can be thought of as being on a continuum with dissociation, a more severe form of detachment from reality.

 In these criteria, numbing is distinct from avoidance, which is discussed further in Criterion C. Patients may also have trouble with 

Here’s how to catch a PTSD chameleon using DSM-5 criteria.

PTSD

PTSD in Late Life: An Update on Clinical Issues

Psychedelics Providing Hope for Veterans and Others

PTSD’s Long Reach

When PTSD Walks Down the Hall

A Generation in Crisis?

Treatment of Military Populations

Afghanistan Veterans Struggling With Mental Health

The Long Shadow of the Towers

Comparing COVID Doctors and 9/11 First Responders

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