Multilayered Trauma, One PTSD Diagnosis?

Although the DSM-5 provides a foundational diagnostic framework for posttraumatic stress disorder (PTSD), it does not completely operationalize the experiences of individuals exposed to chronic and recurrent trauma. Communities that experience sustained violence and trauma is often an ongoing pathology instead of periodic episodes. Because of this, PTSD may not present in a prototypical manner and may become further exacerbated within different ethnic groups or communities, thus increasing the risk of underdiagnosis or misdiagnosis.

There are several components to consider when evaluating communities plagued with high trauma. Even in individuals without early-life trauma exposure, there remains a potential for intergenerational trauma. From a neurobiology perspective, literature suggests gene regulation can be modified through epigenetic changes between generational offspring, particularly within the hypothalamic-pituitary-adrenal (HPA) axis and within the physiological stress response.² Transmission of neurobiological changes is theorized to affect offspring developmentally; for instance, during pregnancy, a mother’s pathological stress during certain stages of pregnancy may shape a child’s later cognition and behavior.³ From a psychodynamic perspective, adverse childhood experiences can increase the likelihood of psychiatric conditions, including PTSD, in a dose-response relationship, particularly amongst marginalized communities.^4,5 This article explores the gap in assessment, diagnosis, and treatment of PTSD for patients with high incidences of trauma and violence. Notably, this gap is especially prevalent among African American populations and other ethnic groups that face compounded socioeconomic stressors and chronic exposure to community violence, discrimination, and systemic inequities.

Defining Trauma and Violence

Assessing PTSD raises a fundamental challenge in defining what is considered traumatic. Before labeling symptoms, clinicians must consider how trauma is defined and conceptualized. The DSM-5 criteria outline trauma as a form of direct experience of threat or violence, perceived threat, witnessing the threat, or hearing about the threat.¹ In contrast, the Substance Abuse and Mental Health Services Administration expands the concept through its framework of the “Three E’s” of trauma: event, experience, and effect.⁶ This framework emphasizes that trauma should not only acknowledge the event itself, but also by how it is experienced and its impacts on overall well-being.

Understanding trauma requires clarity on how violence is defined. The World Health Organization defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”⁷This definition encompasses the structural and community-level violence, which is relevant for environments where exposure may be repetitive and unavoidable.

In these settings marked by repeated violence (interpersonal, structural, or both), clinicians must consider a critical question: how should clinicians address layered and cumulative trauma? Moreover, what does it mean to treat PTSD when the trauma is not a single event but a continuous condition? These questions underscore why we must reevaluate how PTSD is assessed and treated in high-risk populations. The following case vignette exemplifies the complexity of diagnosing PTSD amid cumulative trauma, with the aim of sparking a more nuanced clinical and diagnostic conversation in distinguishing PTSD pathology from episodic to a survival adaptive response.

Case Vignette: Atypical Presentation of PTSD in a High-Trauma Context

“Ms A” is a 26-year-old African American woman, single and unemployed, who presented via emergency medical services for active suicidal ideation and worsening depression. Past psychiatric history includes self-reported autism spectrum disorder, learning disability, and attention-deficit/hyperactivity disorder (ADHD).

Although Ms A presented with depressive symptoms, her trauma history suggested probable trauma and stressor-related disorder—yet her symptom presentation did not align with the standard diagnostic profile of PTSD.

Chronology of Trauma History

Ms A has an extensive history of trauma integrated throughout developmental stages that began in early childhood:

1. Early childhood (toddler stage): Ms A’s mother died from an opioid overdose. She was subsequently adopted.
2. Adolescence: Ms A experienced poor living conditions and perpetual feelings of being unsafe during this time period. Medical documentation suggested signs of learning difficulties and behavioral outbursts. No formal psychiatric diagnoses were made during this period.
3. Early 20s: Ms A survived a gunshot wound to the collarbone after being caught in crossfire while walking home from work.
4. Mid-20s: A documented history of sexual assault was noted, although Ms A declined to speak about it during the current evaluation.

This trauma history suggests she is at high risk for PTSD. Ms A was unsure whether she had experienced “re-experiencing” symptoms and discussed her traumatic events in an emotionally blunted manner. Her apparent nonchalance raised concern for potentially emotional numbing or culturally learned minimization rather than the absence of a trauma-related disorder.

Psychiatric Symptomatology

During the evaluation, Ms A described persistent symptoms of depression for about 3 weeks, including:

• Anhedonia
• Decreased energy
• Poor appetite
• Poor concentration
• Disrupted sleep (patient reports using cannabis daily to mediate subjective sleep-onset insomnia)
• Episodic feelings of worthlessness
• Suicidality
  

Despite her trauma exposure, the patient denied or expressed uncertainty regarding several hallmark PTSD symptoms such as:

• No apparent reported intrusive thoughts
• No apparent reports of nightmares or flashbacks
• No apparent symptoms of avoidance behaviors

Notably, she did exhibit:

• Impaired concentration
• Lifelong arousal symptoms such as anger outbursts and irritability
• Possible negative shifts in cognition and mood

Given her co-occurring ADHD and cognitive challenges, specific symptoms (particularly impaired concentration) may overlap with her neurodevelopmental conditions. Nonetheless, the severity of her trauma history coupled with her clinical presentation raised concern for subthreshold or atypical PTSD. The absence or uncertainty of other core PTSD symptoms (re-experiencing, avoidance, emotional numbing) warranted further clinical investigation to determine whether the patient meets full diagnostic criteria.

Additional clinical exploration is needed to assess internal and external triggers, physiological reactivity, and coping mechanisms, and potential signs of resilience. Further, behaviors such as threat monitoring could present an adaptive symptom of being in chronically dangerous environments rather than discrete psychopathology, thus complicating diagnostic evaluation. The Table summarizes the clinical signs that may indicate atypical PTSD presentations in individuals exposed to cumulative trauma.

Clinical Interpretation

Ms A met DSM-5 criteria for major depressive disorder, recurrent, severe, based on the constellation of depressive symptoms and active suicidal ideation. She also met criteria for cannabis use disorder. Ms A clinically demonstrated hypervigilance, difficulty concentrating, and negative changes in cognition. However, the negative cognition was not centrally associated with her traumatic events. Although she did not meet full DSM-5 criteria for PTSD at discharge, clinicians maintained high suspicion of trauma-related pathology. Symptoms such as hypervigilance and affective blunting, combined with her complex trauma timeline, supported this clinical impression.

Discussion

This case illustrates the complexity and diagnostic uncertainty often seen in individuals who navigate high-trauma, low-resource environments. This patient’s presentation findings are suggestive of complex PTSD. Complex PTSD is formally recognized within the ICD-11, which involves emotional dysregulation and interpersonal difficulties as well as the core definition of PTSD.⁷ To date, complex PTSD is not included within the DSM-5. The current DSM-5 definition of PTSD may not sufficiently capture nuances such as those posed in this case. The controversy regarding these definitions underscores the need to reframe potential subtypes of PTSD or may indicate future directions in potential specifiers. In populations with neurodevelopmental conditions, emotional processing and expression may also differ from typical clinical expectations, further complicating assessment. Similarly, Sibrava et al found that African American and Latinx individuals often experience trauma as a chronic, ongoing etiology rather than an isolated incident in part due to elevated exposure to discrimination and socioeconomic adversity.⁸ This highlights the need to reconsider how PTSD is conceptualized and diagnosed across diverse populations. A nuanced, trauma-informed, and culturally responsive approach is timely and now essential in evaluating and treating such patient populations.

Concluding Thoughts

Overall, in communities with high exposure to trauma and violence, PTSD frequently does not present in a textbook fashion. This case highlights the call for a more standardized approach on how to assess, approach, and how to diagnose and treat address layers of trauma. Chronic exposure to violence and loss may lead to an atypical symptomatology, potentially masking PTSD beneath depressive or attentional manifestations as demonstrated in this case vignette. Enhanced diagnostic approaches that account for cumulative trauma and incorporate culturally responsive tools may reduce the risk of underdiagnosis or misdiagnosis in vulnerable individuals.

Ms Browne is a medical student at Saint Louis University School of Medicine.

Dr Belean is an associate professor and program director of psychiatry atSSM Health/Saint Louis University School of Medicine.

References

1. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

2. Bowers ME, Yehuda R. Intergenerational transmission of stress in humans. Neuropsychopharmacology. 2016;41(1):232-244.

3. Mennes M, Stiers P, Lagae L, Van den Bergh B. Long-term cognitive sequelae of antenatal maternal anxiety: involvement of the orbitofrontal cortex. Neurosci Biobehav Rev. 2006;30(8):1078-1086.

4. Elkins J, Briggs HE, Miller KM, et al. Racial/ethnic differences in the impact of adverse childhood experiences on posttraumatic stress disorder in a nationally representative sample of adolescents. Child Adolesc Soc Work J. 2019;36(5):449-457.

5. Tabb LP, Rich JA, Waite D, et al. Examining associations between adverse childhood experiences and posttraumatic stress disorder symptoms among young survivors of urban violence. J Urban Health. 2022;99(4):669-679.

6. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. SAMHSA. 2014. Accessed March 2, 2026. https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/samhsa_trauma_concept_paper.pdf

7. International Classification of Diseases, 11th Revision (ICD-11): Complex Post-Traumatic Stress Disorder (6B41). World Health Organization; 2019.

8. Sibrava NJ, Bjornsson AS, Pérez Benítez ACI, et al. Posttraumatic stress disorder in African American and Latinx adults: clinical course and the role of racial and ethnic discrimination. Am Psychol. 2019;74(1):101-116.