PhD/PsyD How often do you see delayed expression in PTSD?

[R. Matey]

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I've never seen delayed expression in an PTSD case so I was wondering if I was the only one. If you see it, what does it tend to look like? I'll also take any recommended reading.

 

[Fan_of_Meehl]

I've never seen delayed expression in an PTSD case so I was wondering if I was the only one. If you see it, what does it tend to look like? I'll also take any recommended reading.

Claimed (in VA settings)? All the damned time. No, really. I mean ALL the damned time.

I think most of the research will suggest that--although FULL criteria may not immediately be met for PTSD--it is very typical for 'delayed' onset of meeting full criteria to be preceded by a period of sub-threshold PTS symptoms. Basically, after the traumatic stressor, the patient exhibited some PTS symptoms but did not meet full criteria at that time. However, after a while, the disorder progressed such that their symptoms worsened (and further symptoms were developed) resulting in their eventually (after some 'delay') meeting full criteria for PTSD.

This is all off the top of my head so I'm sure I got something wrong.

 

[thewesternsky]

I've seen it occasionally. I agree with the comment above that the cases I find credible usually involve subthreshold symptoms immediately after the event, which increase to clinical significance when avoidance or other strategies are no longer available or stop working. For example, a man experiences a criterion A stressor in his 40s, has continuous but mild re-experiencing symptoms for years while working 60-hour-weeks, retires and symptoms worsen significantly. Or a woman who is single experiences a sexual assault and has subthreshold symptoms initially; these reach clinical significance only when she enters a romantic relationship a year later.

 

[Sanman]

Claimed (in VA settings)? All the damned time. No, really. I mean ALL the damned time.

I think most of the research will suggest that--although FULL criteria may not immediately be met for PTSD--it is very typical for 'delayed' onset of meeting full criteria to be preceded by a period of sub-threshold PTS symptoms. Basically, after the traumatic stressor, the patient exhibited some PTS symptoms but did not meet full criteria at that time. However, after a while, the disorder progressed such that their symptoms worsened (and further symptoms were developed) resulting in their eventually (after some 'delay') meeting full criteria for PTSD.

This is all off the top of my head so I'm sure I got something wrong.

Agreed with all the time claimed in the VA. That said, I have seen those with delayed onset of clinically significant symptoms following remission from extended alcohol or substance use that was masking the severity.

 

[WisNeuro]

Even in settings with secondary gain, the research suggests it's pretty rare, and more rare in settings where there is no secondary gain. It exists, just not likely at all.

 

[PsyDr]

the neurons that fire together, wire together...later...when it is convenient.

 

[aim-agm]

I think there are at least two broad categories of delayed expression:

1) Subsyndromal symptoms begin soon after the trauma, and self-reinforce in a vicious cycle until they become syndromal. This differs from non-delayed progression primarily just in rate. Oftentimes the symptoms started out relatively mild and it just took longer to get to the usual starting line.

2) Some symptoms are present but are overall stable and don't progress over time, until something happens that exacerbates symptoms and they progress to PTSD (usually rapidly). Usually the event is something we'd expect to exacerbate symptoms in someone who already has PTSD (e.g. encountering the perpetrator of trauma), and oftentimes this sort of presentation isn't actually a delayed expression, they met criteria since the trauma but are presenting for treatment now because of symptom exacerbation.

I have seen both types and agree that it is pretty rare.

 

[cara susanna]

Quite often, actually. People can be quite good at avoidance and that can suppress symptoms.

 

[WisNeuro]

Quite often, actually. People can be quite good at avoidance and that can suppress symptoms.

But these cases would be symptomatic, just perhaps not fully symptomatic? At least in the research, true delayed onset is something like 1% of all cases.

 

[cara susanna]

But these cases would be symptomatic, just perhaps not fully symptomatic? At least in the research, true delayed onset is something like 1% of all cases.

That's true, I guess "expression" is what threw me off.

 

[R. Matey]

Delayed expression is the literal specifier in the DSM. Does psych research make a differential between delayed expression and delayed onset?

 

[cara susanna]

I should have just kept my mouth shut then, lol. I guess you can see how often I give the "with delayed expression" specifier.

I think it's so hard to tell though if it's actual delayed onset or just successful symptom suppression through avoidance.

 

[AcronymAllergy]

Delayed expression is the literal specifier in the DSM. Does psych research make a differential between delayed expression and delayed onset?

It depends on the research; some does, some doesn't. From what I've seen, much of the research that says "delayed onset" is not uncommon is actually talking about "delayed expression" (assuming that by the latter, we mean initially subthreshold symptoms that later meet diagnostic criteria).

 

[ForensicPsychFightClub]

I do a fair amount trauma assessment and I’ve diagnosed it exactly once. As others have seen, it is usually sub threshold symptoms but in this case it involved a psychosocial stressor that exacerbated their trauma symptomatology - namely, they had a sibling that was with them throughout their trauma that they developed a bonded relationship with, and about 9 months after their trauma, this sibling was removed from the home.

That’s n = 1 but I imagine this might be a common case for the specifier: A person who experiences a trauma and has requisite predisposing factors for a traumatic stress disorder, but has just enough protective factors to buffer the negative effects of a full-blown trauma response, and then they later have another nontraumatic stressor.

 

[R. Matey]

I think it's so hard to tell though if it's actual delayed onset or just successful symptom suppression through avoidance.

Not a worry, but that's interesting distinction between onset/expression delay vs. symptom suppression via ineffectual coping.