“I felt good for years. I really thought I had put it all behind me. And then, after more than a decade, it all came back – the nightmares, the flashbacks, the anxiety. It was as if the trauma was waiting patiently in hiding to get me again…”
Perhaps you know someone who has told a similar story? Or maybe you yourself are wondering why, after years of relative calm, you are beginning to experience troubling symptoms related to a long-ago trauma. Find out exactly what PTSD is and how is delayed onset PTSD different? Learn about effective treatment options.
Understanding PTSD
When we hear the term PTSD, or post-traumatic stress disorder, our minds often bring up images of soldiers returning from war, struggling with the scars of battle. While this condition is indeed common among veterans, PTSD can affect anyone who has experienced a traumatic event.
Definition of PTSD
Post-traumatic stress disorder (PTSD) is a serious mental disorder that occurs in people who have experienced or witnessed a traumatic event. According to the ICD-11 diagnostic criteria, a diagnosis of PTSD can be made at the earliest one month after the trauma.
In most cases, symptoms appear within 6 months of the trauma, but there is also a form of the disorder that may not manifest until a longer time after the traumatic experience. This is known as delayed-onset PTSD.
Interestingly, recent studies indicate that up to one in four PTSD diagnoses are specifically for cases with delayed onset. This phenomenon deserves special attention, as those affected by the disorder may not link their symptoms to past traumatic experiences for a long time, delaying the proper diagnosis and implementation of appropriate treatment.
What is PTSD with delayed onset?
According to the definition, PTSD with delayed onset is diagnosed when symptoms meeting the diagnostic criteria for post-traumatic stress disorder appear at least 6 months after the traumatic event. In some cases, symptoms may manifest even years after the traumatic experience.
It is worth noting that there is no upper time limit after which PTSD can no longer be diagnosed – the disorder can develop at any point in life, even decades after a traumatic experience.
Diagnostic difficulties
Diagnosing PTSD with delayed onset poses a number of challenges for clinicians:
- Difficulties in linking symptoms to the trauma. When many years have elapsed between the traumatic event and the onset of symptoms, both patient and therapist may fail to see the cause-and-effect relationship. Symptoms may be mistakenly attributed to other mental disorders.
- Symptom overlap. Symptoms of PTSD often overlap with those of other disorders, such as depressive, anxiety or personality disorders. In a patient with delayed PTSD, other disorders may co-occur, complicating the diagnosis.
- Incomplete disclosure of traumatic experiences. Patients may not mention past traumatic experiences, considering them irrelevant to current problems, or because of shame, guilt or fear of stigmatization.
- Cognitive distortions. Over time, memories of traumatic events can become distorted, making it difficult to accurately assess the trauma and its impact on the patient’s current functioning.
- Cultural factors. In some cultures, traumatic experiences are silenced, and psychological symptoms may be expressed mainly through somatic complaints, further complicating the diagnosis of PTSD.
- Impact of subsequent life experiences. The numerous life events that occurred between the original trauma and the onset of symptoms can obscure the clinical picture and make it difficult to isolate the impact of the trauma.
To overcome these difficulties, clinicians should conduct a thorough history that includes the patient’s entire life history, with particular attention to potential traumatic experiences. Standardized diagnostic tools and trauma-focused screening questionnaires can also be helpful.
Symptoms of PTSD with delayed onset
The symptoms of PTSD with delayed onset are essentially the same as those of classic PTSD. It is worth knowing that the two main classifications – DSM-5 and ICD-11 – differ slightly in their description of these symptoms.
According to the DSM-5 (American classification)
DSM-5 distinguishes four groups of symptoms that must persist for at least a month:
- Intrusive (re-experiencing) symptoms
- Recurring, unwanted and intrusive memories of the traumatic event.
- Recurring nightmares of dreams related to the trauma.
- Retrospectives (flashbacks) – feeling as if the traumatic event is happening again.
- Severe psychological or physical discomfort during exposure to stimuli that remind one of the trauma.
- Avoidance symptoms
- Avoidance of thoughts, feelings, or conversations related to the traumatic event.
- Avoidance of people, places, activities, objects or situations that may evoke memories of the trauma.
- Negative changes in thinking and mood
- Difficulty recalling important aspects of the traumatic event.
- Persistent negative beliefs about oneself, other people or the world.
- Distorted thinking about the cause or consequences of the trauma leading to blaming oneself or others.
- Persistent negative emotions (fear, horror, anger, guilt or shame).
- Decreased interest in activities that previously gave pleasure.
- A sense of detachment or alienation from others.
- Persistent inability to feel positive emotions.
- Changes in excitability and reactivity
- Irritability and outbursts of anger.
- Risky or self-destructive behavior.
- Excessive vigilance.
- Increased fright reaction.
- Problems with concentration.
- Sleep disturbances.
According to ICD-11 (World Health Organization classification)
ICD-11 adopts a more concise definition, focusing on three key elements:
- Re-experiencing trauma
- Vivid, intrusive memories of the trauma.
- Flashbacks (feelings of reliving the trauma “here and now”).
- Nightmares related to the traumatic event.
- Avoidance
- Avoiding thoughts and memories associated with the trauma.
- Avoiding people, situations or places that remind you of the trauma.
- Persistent perception of increased threat
- Increased vigilance.
- Excessive fright response.
Why can PTSD develop late?
Why do some people experience PTSD with a delayed onset, while others develop symptoms shortly after the trauma?
- Exacerbation of existing subthreshold symptoms
The most common scenario for the development of PTSD with delayed onset is an exacerbation of pre-existing but milder symptoms that initially did not meet the full diagnostic criteria for PTSD (known as subthreshold PTSD). Research indicates that it is rare for PTSD with delayed onset to develop without pre-existing, even mild, symptoms.
- Exposure to additional life stressors
Additional life stressors can significantly increase the risk of developing full-blown PTSD in people who have previously experienced trauma. Such stressors include:
- Loss of a loved one.
- Loss of a job or financial problems.
- Divorce or relationship breakdown.
- Serious health problems.
- Crisis situations.
These stressors can make a person more prone to ruminations, flashbacks, nightmares or anxiety related to past trauma.
- Experiencing another traumatic event
An additional traumatic experience can seriously affect a person’s ability to cope with previous traumatic experiences. For example, if a person lost a parent in a car accident, experiencing another accident can trigger a traumatic reaction that also activates memories of the earlier trauma. This can lead to a diagnosis of PTSD with delayed onset.
- Coping strategies and their exhaustion
Some people may initially cope with trauma through a variety of adaptive and maladaptive strategies, such as avoidance, denial or dissociation. These coping strategies may be effective for a time, but over the years they may become exhausted or no longer effective, especially in the face of new stressors. When coping strategies fail, previously controlled symptoms can manifest themselves in full form.
- Neurological and physiological changes
Research suggests that trauma can cause long-lasting changes in brain and immune system function that may only reveal themselves over time. Chronic stress associated with trauma can lead to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which in turn may contribute to the development of PTSD symptoms later on.
Groups at increased risk
Although PTSD with delayed onset can occur in anyone who has experienced a traumatic event, certain groups are particularly vulnerable:
- Elderly people – who may have experienced deep trauma in their youth, and who do not develop PTSD symptoms until old age.
- War veterans – who may develop PTSD symptoms many years after their service.
- Victims of childhood abuse – in whom memories of traumatic events may be repressed and then return in adulthood.
- People in recovery from other mental disorders or addictions – who may be more susceptible to developing PTSD.
- Individuals with little social support – lack of support may increase the risk of developing delayed PTSD.
Case study: Anna’s story
Anna, a 38-year-old teacher, functioned for almost 20 years without major mental problems. As a child, she experienced a difficult situation – she witnessed an accident in which her father was seriously injured. Although she had nightmares and sleep difficulties immediately after the event, over time the symptoms subsided. Anna graduated from college, developed a career and started a family.
Everything changed when she witnessed a car accident while on vacation, which reminded her of a traumatic childhood experience. In the following months, she began experiencing worsening symptoms – she had nightmares, difficulty concentrating, reacted with anxiety to sounds reminiscent of the accident, and avoided driving. Initially, she linked these symptoms only to the recent accident, but during therapy it became clear that most of her fears and memories were related to a past traumatic childhood experience.
Anna’s case illustrates the typical mechanism of PTSD with delayed onset – a traumatic childhood experience was “dormant” for many years until a new, similar event triggered full-blown PTSD, reactivating the old, unprocessed trauma.
Treatment of PTSD with delayed onset
The most relevant recommended interventions for PTSD with delayed onset are:
Trauma-focused cognitive-behavioral therapy (TF-CBT)
Therapy typically involves 12-16 weekly sessions lasting 60-90 minutes. During therapy, you learn how to examine your thoughts and feelings related to the traumatic event. The therapist helps you change the negative beliefs and feelings associated with the trauma. The goal is not to forget what happened, but to change your attitude toward those memories.
Prolonged exposure therapy
It involves safely reliving trauma-related memories and confronting situations that have been avoided since the trauma. The therapy is about 8-15 sessions. The mechanism of action of this therapy is based on the habituation (habituation ) of traumatic memories and related emotions, and the processing and reintegration of these memories in a way that reduces their negative impact on daily functioning.
EMDR (Eye Movement Desensitization and Reprocessing) therapy
This is an approach that uses eye movements or other forms of bilateral stimulation when processing traumatic memories. While you focus on the memory, the therapist directs your eye movements, which helps you process difficult experiences. Many patients describe that after EMDR therapy, the memories still exist, but no longer evoke such intense emotions.
Schema therapy
Schema therapy is particularly valuable for complex trauma, especially if the traumatic experience occurred in childhood. Schema therapy helps identify and process difficult experiences that developed as a reaction to unmet emotional needs in childhood. In the context of PTSD with delayed onset, schema therapy can help understand why symptoms took a long time to manifest and how early experiences affected current functioning.
A particularly effective technique in schema therapy is imagery rescripting . This is a powerful therapeutic tool for modifying traumatic memories through imaginal rescripting and transforming them into more adaptive scenarios.
This process affects the formation of new neuronal connections in the following ways:
- Reorganization of emotional memory – During rescripting, emotional memory circuits are activated, mainly in the limbic system (amygdala body), but at the same time areas of the prefrontal cortex responsible for executive functions and emotion regulation are engaged.
- Neuroplasticity – Repeated rescripting experiences lead to the formation of new synaptic connections, which weakens anxiety reactions and strengthens the ability to regulate emotions. The brain’s natural ability to reorganize is used here.
- Integration of experiences – This technique helps to integrate emotions, thoughts and somatic sensations associated with the traumatic experience, which supports the processing of memory from the implicit (unconscious) to explicit (conscious) system.
In the context of emotional pathways, rescripting:
- Creates alternative response pathways – The ability to respond to triggers adaptively, instead of the automatic responses of schemas, is developed.
- Strengthens satisfaction of emotional needs – The patient learns to identify and satisfy his or her own emotional needs, which may have previously been blocked by schemas.
- Develops Healthy Adult Mode – New response patterns based on the perspective of a healthy adult are created, which gradually replaces dysfunctional schema modes.
Neuroimaging studies suggest that successful rescripting is associated with increased activation of the prefrontal cortex while reducing the over-reactivity of the amygdala, reflecting better emotional regulation and greater cognitive flexibility.
Pharmacotherapy
Psychotherapy is usually the first line of treatment for PTSD. However, medications may be prescribed to help patients manage their symptoms. The most commonly used medications are:
- Antidepressants: Can help relieve symptoms of depression and anxiety. Additionally, they can help with sleep problems and poor concentration.
- Anti-anxietymedications: Often prescribed for severe anxiety symptoms associated with PTSD. Some anti-anxiety medications are limited to short periods due to their addictive potential.
- Blockers: Help reduce sleep disturbances and nightmares associated with PTSD.
- Mood stabilizers: Patients with PTSD who do not respond to antidepressants may benefit from mood stabilizers. These medications are often used to treat agitation, anger and irritability associated with PTSD.
PTSD and addictions
Trauma is closely linked to addictions. People who have experienced a traumatic event are more likely to abuse substances in an attempt to numb themselves. The reverse is also true – people who have a problem with alcohol or drugs are more likely to experience traumatic events as a result of their substance use.
It is crucial that people who have experienced trauma find adaptive coping mechanisms that do not involve substance abuse. Such behavior may seem helpful in the short term, but failing to address the root cause of problems can only make things worse in the long term. This pattern of use can lead to physical and psychological dependence on alcohol or drugs, which must be treated by specialists in a rehabilitation center.
Frequently asked questions
Can PTSD occur 10 years after a trauma?
Yes, absolutely. There is no upper time limit after which PTSD can no longer be diagnosed. Some people develop symptoms even decades after a traumatic event.
Are the symptoms of PTSD with delayed onset the same as those of classic PTSD?
In principle, yes. Symptoms are similar, but with delayed onset PTSD, the initial symptoms may be more subtle and gradually increase over time.
Will everyone who has experienced trauma develop PTSD?
No, not every traumatized person will develop PTSD. It is estimated that about 25-30% of people who experience a traumatic event develop PTSD, and of this group, about 25% of cases are PTSD with delayed onset.
Summary
PTSD with delayed onset can develop even many years after a traumatic experience. Trauma has its own pace – in some people, symptoms appear immediately, while in others they can slumber for years, waiting for the right moment to surface. Life stress, subsequent difficult experiences, life changes, and even the natural processes of aging can weaken our defense mechanisms and cause old, unprocessed traumas to make themselves known.
If you recognize in yourself the symptoms described in this article – don’t wait. Don’t think “it was so long ago, so it can’t be a problem”. Time does not heal all wounds – sometimes we need professional help to work through difficult experiences.
Bibliography:
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- World Health Organization. (2019). International Statistical Classification of Diseases and Related Health Problems (11th ed.).
- Andrews, B., Brewin, C. R., Philpott, R., & Stewart, L. (2007). Delayed-onset posttraumatic stress disorder: A systematic review of the evidence. American Journal of Psychiatry, 164(7), 1319-1326.
- Smid, G. E., Mooren, T. T., van der Mast, R. C., Gersons, B. P., & Kleber, R. J. (2009). Delayed posttraumatic stress disorder: Systematic review, meta-analysis, and meta-regression analysis of prospective studies. The Journal of Clinical Psychiatry, 70(11), 1572-1582.
- Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema Therapy: A Practitioner’s Guide. New York: Guilford Press.
- Arntz, A., & Jacob, G. (2013). Schema Therapy in Practice: An Introductory Guide to the Schema Mode Approach. Chichester, UK: Wiley-Blackwell.
- Holmes, E. A., Arntz, A., & Smucker, M. R. (2007). Imagery rescripting in cognitive behavior therapy: Images, treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 297-305.
- https://estss.org/