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Late-Onset Posttraumatic
Stress Disorder
Abstract
Posttraumatic stress disorder (PTSD) is derrecognized and undertreated disorder
a complex psychological response to a that can result in psychosocial disability,
perceived life-threatening trauma that in- substance use, and other negative health
© 2008/Comstock, JupiterImages Corporation

cludes re-experiencing the trauma, avoid-
ance, intrusive thoughts, hyperarousal, and
dissociation. Exposure to trauma in early
adulthood increases the potential for fur-
ther psychological threats throughout life.
In older adult populations, PTSD is an un-
outcomes. This article examines the range
of symptoms related to PTSD in older adults
and expands on health care provider sensi-
tivity to the interrelationship of mental and
physical health when addressing the needs
of older adults with this disorder.

Marsha Snyder, PhD, PMHCNS, BC

Journal of Psychosocial Nursing • Vol. 46, No. 11, 2008 39

 W
ithin the last cen-
tury, the average life
span has increased
by 37%, with many people liv-
ing well into their 80s and 90s. It
is estimated that by 2030, more
than 15 million older adults will
experience a mental illness. The
aging of the Baby Boomer cohort
and greater longevity is responsi-
ble for this statistic (U.S. Depart-
ment of Health and Human Ser-
vices [USDHHS], Office of the
Surgeon General, 1999). The es-
timated prevalence rate for anxi-
ety disorders in adults age 55 and
older is approximately 11%. This
percentage is greater than that of
any other disorder associated with
older adults (USDHHS, Office of
the Surgeon General, 1999). In
particular, posttraumatic stress
disorder (PTSD) in older adults
is an underrecognized and under-
treated disorder that can result in
psychosocial disability, substance
use, and other negative health
outcomes. For this reason, the
purpose of this article is to exam-
ine this disorder as it relates to
older adults and increase health
care provider sensitivity to the
interrelationship of mental and
physical health when addressing
the needs of older adults with
this disorder.
Differential Diagnosis
of PTSD
As Americans live longer,
the psychological stressors some
individuals sustained at earlier
life stages can become deterrents
to successful aging (USDHHS,
Office of the Surgeon General,
1999). This is especially true
for individuals who are exposed
to trauma related to combat,
ravages of war, sexual abuse, or
events a person conceptualizes as
catastrophic, and when available
coping mechanisms fail (Murray,
40
2005). In the case of older adults,
research surrounding trauma and
responses to trauma has been pri-
marily inclusive of male veteran
populations. However, several
studies do address trauma-related
issues for civilian older adult fe-
male populations. An area of re-
cent interest is the reoccurrence
of trauma-related stress symp-
toms in later life.
Acute Stress Disorder
The majority of individuals
exposed to an acute stress epi-
sode will recover in the months
following the traumatic event
and will not require formal inter-
vention. These individuals fall
within the diagnostic categories
outlined in the Diagnostic and
Statistical Manual of Mental Dis-
orders, fourth edition, text revi-
sion (American Psychiatric As-
sociation, 2000) for acute stress
disorder (ASD) (Bryant, 2003).
Symptoms related to ASD occur
within a month of a traumatic
event. Symptoms are categorized
into six areas:
l Cluster A—fearful re-
sponse after a traumatic event.
l Cluster B—three dissocia-
tive symptoms.
l Cluster C—re-experienc-
ing symptoms.
l Cluster D—marked avoid-
ance.
l Cluster E—marked anxiety.
l Cluster F—evidence of sig-
nificant distress or impairment in
everyday task completion.
PTSD
Disturbance in all six areas
identified for ASD must last a
minimum of 2 days and a maxi-
mum of 4 weeks before the diag-
nosis of PTSD can be assigned.
Three Cluster B symptoms of dis-
sociation need to be present for a
diagnosis of ASD:
l Subjective sense of numb-
ing or detachment.
l Reduced awareness of sur-
roundings.
l Derealization, depersonal-
ization, or dissociative amnesia.
These symptoms block processing
of traumatic memories and adap-
tation. Interestingly, individuals
who develop PTSD do not always
report Cluster B symptoms (Bry-
ant, 2003). It is proposed that
both individuals who experience
all symptoms and those who ex-
perience all but Cluster B symp-
toms can be at risk for developing
PTSD (Bryant, 2003). Symptoms
can abate and resurface over
months or years and can reoccur
in full force if the person is retrau-
matized. While survivor symp-
toms can persist as an individual
ages into older adulthood, how
these symptoms are expressed is
very individual and may depend
on genetic and epigenetic fac-
tors, premorbid personality traits,
early life experiences, and social
support (Weintraub & Ruskin,
1999). Consistent findings report
that delayed onset of PTSD is rare
when no prior exposure to trauma
has occurred (Andrews, Brewin,
Philpott, & Stewart, 2007).
Predictive Factors
for PTSD
Age can offer a protective
shield against the effects of a trau-
matic event through the passage
of time and successful life expe-
riences. Factors that seem to be
associated with resilience against
the development of PTSD in-
clude marriage, social support,
increased socioeconomic sta-
tus, and religion (Weintraub &
Ruskin, 1999). Across studies, no
agreement has been reached on
the symptom combination that is
predictive of PTSD, and for this
reason, increased attention has
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been directed toward biological
indicators (Bryant, 2003).
Biological Indicators
The connection between the
basal ganglia, limbic system, and
prefrontal cortex brain structures
are well supported in the litera-
ture. This connection seems to
include processing of both so-
cial and emotional information
(Flannelly, Koenig, Galek, & El-
lison, 2007). The basal ganglia,
although primitive, provides an
autonomic system for threat as-
sessment. The basal ganglia and
the limbic system operate in pre-
consciousness for both language
and emotional arousal. For this
reason, in the case of PTSD, as-
sessment of threat is excessive and
sometimes in error, as the person
perceives a threat when there is
none. All three brain components
(basal ganglia, limbic system, and
prefrontal cortex) rely on sensory
input from the prefrontal cortex
and amygdala for their assessment
information regarding a threat,
as well as past experience and
memories. Judgments regarding
threat potential seem to be routed
primarily through emotional pro-
cessing rather than through cog-
nitive reasoning and, as a result,
are unconscious, rapid, and auto-
matic, with the response outcome
not necessarily within a person’s
conscious awareness (Flannelly et
al., 2007).
Another area of biological
investigation is research that ad-
dresses the relationship between
increased glucocorticoid levels
and PTSD symptoms. On the ba-
sis of peripheral and neuroendo-
crine studies of individuals with
PTSD symptoms, Grossman et
al. (2006) reported greater sensi-
tivity in the central brain to glu-
cocorticoids. This phenomenon
was expressed through height-
Journal of Psychosocial Nursing • Vol. 46, No. 11, 2008
ened declarative memory sug-
gestive of hippocampal involve-
ment; impairment in working
memory suggestive of prefrontal,
cingulated, temporal, and pari-
etal cortexes; and neurotransmit-
ter systems associated with dopa-
mine and serotonin (Grossman
et al., 2006).
Increases in these measures
seem to reflect a preexisting vul-
nerability trait that heightens
the risk for developing PTSD fol-
lowing a traumatic event. Func-
tional brain images for patients
who have had PTSD reflect sig-
nificant activation in the ventral
frontoparietal network and left
hippocampal area, which are
Opportunity exists for primary care and
psychiatric nurses to come together and shape a
system of care that is responsive to patient needs.
connected with visual attention
and memory (Bryant, 2003). As
a result, even slight traumatic
stimuli can initiate flashbacks
in the presence of poor concen-
tration and attention. It seems
this traumatic stimulus becomes
associated with arousal and sub-
sequent development of fear
conditioning that can trigger fur-
ther conditioning. Mechanisms
for this sensitization are unclear,
but it does seem evident that re-
petitive activation of traumatic
memories increases sensitivity
within the limbic system (Bry-
ant, 2003).
Psychological Indicators
Development and continued
experience of acute and chronic
symptoms of PTSD are mediated
by cognitive responses to the
traumatic event. These cogni-
tive responses are demonstrated
through persistent negative ap-
praisal of the traumatic event
and subsequent events through
disturbance in memory that is
characterized by “poor elabo-
ration and contextualization,
strong associative memory, and
strong perceptual priming” (Bry-
ant, 2003, p. 792).
As the traumatic event is pro-
cessed, understanding and mean-
ing are attributed to the event
within the contexts of social and
cultural environments. Studies
indicate the level of psychologi-
cal impact of the trauma experi-
ence on the individual depends
heavily on pretrauma function-
ing. Preexisting depression and
anxiety and multiple trauma
exposures seem to increase an
individual’s vulnerability to the
stressors related to trauma, with
the highest rates of PTSD as-
sociated with violent or sexual
trauma (Nakell, 2007).
POPULATIONs at risk
Veteran Survivors
Veterans who meet criteria
for PTSD also report symptoms
of major depression, generalized
anxiety disorder, panic disorder,
and alcohol abuse. Older vet-
erans seen in primary care who
reported depression and symp-
toms of PTSD also reported more
suicidal ideation, smoking, and
negative perceptions of their
health than did those who did
not report these symptoms. These
symptoms contributed to difficul-
41
 ty concentrating, worry, feelings
of worthlessness, and depressed
mood (Rauch, Morales, Zubritsky,
Knott, & Oslin, 2006). Although
intrusive thoughts, hyperarousal,
avoidance, and dissociation are
associated with PTSD, veterans
reported that over time they ex-
perienced a decline in intrusive
thoughts and survivor guilt. How-
ever, these survivors reported that
avoidance symptoms and estrange-
ment from others were symptoms
that lingered into advanced age
(Nakell, 2007). The relationship
between PTSD and alcohol abuse
is reflected inconsistently in data
(Rauch et al., 2006).
War veterans seem to be at
increased risk for reactivation of
PTSD symptoms in later life. In
an extensive review of case stud-
ies and group studies literature,
Andrews et al. (2007) suggested
the delay in onset of PTSD symp-
toms is likely due to reactivation
of prior symptoms rather than
delay in onset of the disorder.
In midlife, these veterans did
not report symptoms related to
any stress disorder, but later in
advancing years, they began to
reminisce about combat-related
thoughts and feelings (Andrews
et al., 2007). Persistence of
PTSD symptoms has been linked
to premorbid personality traits or
experiences, as shown in older
male combat veterans who were
exposed to highly stressful events
either in their childhood or in
combat as young adults (Wein-
traub & Ruskin, 1999).
The chronic nature of PTSD
increases victims’ vulnerability to
threats throughout life, especially
from midlife through old age. The
experience of loss generally as-
sociated with the aging process,
retirement, physical changes, and
recognition of one’s own mor-
tality stimulate memory in later
42
years. As levels of activity shift
from productivity to introspec-
tion—in combination with losses
in daily structure and routine, self-
esteem, status, and social interac-
tion—usual coping mechanisms
are threatened and challenged
(Weintraub & Ruskin, 1999).
Older Female Survivors
Older women are at higher risk
for PTSD than are older men due
to higher rates of sexual and do-
mestic physical abuse experienced
by women. Although they are at
higher risk, older women are un-
derdiagnosed for PTSD and are
given diagnoses related to depres-
sion, anxiety, or poor health. As a
result, women may seek help more
frequently, but they do not always
receive appropriate intervention
or treatment (Franco, 2007). Old-
er women who sustained repeated
physical assault at an early age
report more negative emotional
responses to the event than do
those who reported being sexually
assaulted (Acierno et al., 2007).
Women who sustained a sexual
assault up to 50 years prior to cur-
rent symptom expression report
autonomic arousal and avoidance
symptoms associated with PTSD
(Acierno et al., 2007). The impact
of early and repeated trauma on
current symptoms is critical when
treating older women and must
be considered an integral part of a
health assessment (Franco, 2007).
Implications for
Practice
Many older adults will at-
tempt to live with multiple
symptoms of PTSD before seek-
ing professional help. The reason
for treatment avoidance may be
related to shame and embarrass-
ment regarding symptoms, as
well as events surrounding the
trauma, the need to be tough and
not a coward, or fear of having
a serious physical or mental dis-
order (Murray, 2005). Initially,
avoidance behaviors serve to in-
sulate the individual from trigger
situations, but when the ability
to meet everyday needs is inter-
rupted because of the inability
to focus on anything other than
the triggers, older adults may be
motivated to seek help (Murray,
2005). When older adults even-
tually do seek help, it is because
they feel unsafe or have physical
symptoms. Seeking psychiatric
help for their difficulties is gener-
ally not a serious consideration.
Primary Care and Older
Adults
Due to feelings of stigma asso-
ciated with seeking mental health
treatment, older adults will most
likely seek help within primary
care. Primary care settings offer
the option of community-based
services that are convenient and
affordable. Within primary care,
mental disorders in older adults
can be both identified and treated
(USDHHS, Office of the Surgeon
General, 1999). Co-occurrence of
psychiatric problems with medi-
cal disorders can significantly af-
fect the trajectory of a medical
disorder (Nakell, 2007). Sleep
disturbance, a symptom associated
with both aging and PTSD, can be
further compromised by posttrau-
matic nightmares and flashbacks,
which can lead to increased psy-
chiatric complaints. Nakell (2007)
reported that individuals with de-
pression who also screened positive
for PTSD reported more severe
depression and poorer prognosis,
lower levels of social support, and
more frequent medical visits, and
were more likely to report suicide
ideation than those with a single
diagnosis of major depressive dis-
order. Complaints related to de-
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terioration in physical health are
evident in older women who expe-
rienced early and repeated trauma,
especially interpersonal, during
their lifetime (Franco, 2007). of posttraumatic stress disorder (PTSD) symptoms.
Recognition and optimal treat-
ment of PTSD in primary care,
however, presents a challenge
because symptoms are vague and
complex and reflect intense dis-
tress (Nakell, 2007). In a 5-year
follow-up study of mental disorder
recognition in primary care, Jack-
son, Passamonti, and Kroenke
(2007) reported that 29% of the
sample was identified at baseline
as having a mental disorder, 26%
of which had more than one dis-
order. Across the 5 years, the per-
centage diagnosed with a disorder
increased to 33%. Symptoms that
persisted over time were more
likely to be diagnosed.
Comprehensive assessments
that include life histories are im-
perative for PTSD and other co-
morbid mental disorders. Several
brief PTSD assessment scales are
available and can be used within
primary care settings. Breslau’s
7-item screening tool for PTSD
is designed especially for use in
primary care (Breslau, Peterson,
Kessler, & Schultz, 1999). The
scale demonstrates good reliabili-
ty compared with the widely used
17-item Clinician-Administered
PTSD Scale (CAPS) (Blake et
al., 1995). Breslau’s tool offers a
time-efficient and reliable meth-
od for assessment in primary care
(Kimerling et al., 2006).
Integrated Health Care
Integration of physical and be-
havioral health services can offer
optimal treatment outcomes for
older adults with PTSD. A 2006
report from the Institute of Med-
icine (IOM) states that:
improving the quality of men-
tal health and substance abuse
Journal of Psychosocial Nursing • Vol. 46, No. 11, 2008
KE Y P OINTS
1. Older adults exposed to trauma earlier in their lives can experience reactivation
2. Primary care is a point of entry into the health care system for older adults and
offers opportunity for early recognition of PTSD.
3. Integration of physical and behavioral health services allows optimal treatment
for older adults who experience PTSD reactivation.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.
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health care—and general health primary care and psychiatric nurs-
care—depends upon the effective es to come together and shape a
collaboration of all mental, sub- system of care that is responsive
stance-use, general health care, to patient needs. Because of their
and other human service provid- holistic approach to patient care,
ers in coordinating the care of nurses are uniquely prepared to
their patients. (p. 210) integrate both physical and men-
While collaboration among tal health care and can assume
mental health and general health leadership within a collaborative
care practitioners is essential, ex- interdisciplinary team.
isting separation of mental and Collaboration between prima-
substance use health care from ry care and mental health provid-
general health care makes it dif- ers can expand available clinical
ficult (IOM, 2006). Although resources. Traditional treatment
much work is needed to actual- approaches for PTSD are either
ize delivery of integrated health pharmacology or psychotherapy.
care, several models already ex- Selective serotonin reuptake in-
ist. Four service delivery models hibitors have been shown to be
for integrated care have been at- the most effective pharmacologi-
tempted (Alfano, 2005): cal approach to address PTSD
l Embedding primary care symptoms (Stein, Ipser, & Seed-
providers within mental health at, 2005). Primary care providers
programs. are trained in the medical model
l Unified programs that offer of care that relies heavily on
both mental health and primary medications, treatments, and ad-
care under a single administration. vice. Although medication offers
l Initiatives to improve col- great opportunity for the treat-
laboration between independent, ment of mental disorders, there is
office-based primary care and strong evidence that an effective
mental health providers. therapeutic alliance and formal
l Co-location of behavioral psychotherapy are also important
health providers in primary care components of treatment.
offices. Initiation of a therapeutic al-
Integrated approaches are in liance with older adults can be
their infancy, but with these ini- forged by primary care or mental
tial steps, opportunity exists for health providers. However, aug-
43
 mentation of pharmacotherapy
with psychotherapy falls within
the expertise of mental health
providers. The literature dis-
cusses multiple psychotherapy
approaches for PTSD: trauma-
focused cognitive-behavioral
therapy, stress management, eye
movement desensitization and
reprocessing, hypnosis, group
cognitive-behavioral therapy,
and family therapy (Murray,
2005). Choice of therapeutic in-
terventions for older adults with
PTSD is largely dependent on
individual clinician and patient
preferences, as limited research
evidence supports use of these
approaches with older adults.
Along with continued work
toward collaborative models of
care for older adults, further re-
search is needed that addresses as-
sessment of and intervention for
anxiety disorders in this popula-
tion, particularly in older women.
The long-term impact of the bi-
ology of PTSD on physical and
mental health is another area that
requires further investigation.
Summary
Reemergence of PTSD in
later years can challenge older
adults’ coping resources and af-
fect their physical and mental
health. Primary care serves as a
point of entry into the health
care system for older adults and
can provide initial screening
and treatment of noncomplex
mental health needs in this pop-
ulation. Older adults with physi-
cal and mental health disorders
may also experience complex
symptoms related to late-onset
PTSD. These individuals can
benefit from integrated primary
and mental health services. In-
tegrated care can provide the
existing mental health system
with a way to meet the needs of
44
these older adults and improve
not only their health but also
their quality of life.
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Dr. Snyder is Clinical Assistant Pro-
fessor, University of Illinois at Chicago,
Department of Health Systems Science,
Chicago, Illinois.
The author discloses that she has
no significant financial interests in any
product or class of products discussed
directly or indirectly in this activity,
including research support.
Address correspondence to Marsha
Snyder, PhD, PMHCNS, BC, Clinical
Assistant Professor, University of Illinois
at Chicago, Department of Health
Systems Science, 845 South Damen
Avenue, Chicago, IL 60612-7350; e-mail:
snyderm@uic.edu.
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