Annals of Long-Term Care: Clinical Care and Aging. 2016;24(2):12-15.
University of Wyoming Department of Psychology, Laramie, WY
An interview with Joshua D. Clapp, PhD, Assistant Professor, University of Wyoming Department of Psychology, Laramie, WY.
Fear is an important emotion that triggers split-second changes in the body so that it can defend itself against or avoid danger. This “fight or flight” response is a normal reaction meant to protect a person from harm. But in post-traumatic stress disorder (PTSD), this reaction is altered or damaged. People with PTSD may feel stressed or frightened after a traumatic event, even when they are no longer in danger.1
As to the causes of PTSD, currently many scientists are focusing on genes that play a role in creating fear memories. Other scientists are concentrating on studying parts of the brain that deal with fear and stress.1 Understanding how fear memories are created may help to identify or refine interventions for reducing the symptoms of PTSD.
PTSD can occur at any age, including childhood and old age.1 Approximately 70–90% of adults aged 65 years and older have been exposed to at least one potentially traumatic event during their lifetime.2 Based on a community sample of older adults, about 70% of older men reported lifetime exposure to trauma; older women reported a lower rate, around 41%.3
Although the literature on PTSD in older adults is growing, there is still a dearth of studies examining trauma among geriatric populations. It is, therefore, possible that current estimates may under-represent the prevalence of PTSD in older adults.4 Because post-traumatic stress symptoms can emerge or re-emerge late in life, the understanding, assessment, and treatment of post-traumatic stress is a topic of particular significance to professionals working with older adults.2
To gain a better clinical understanding of PTSD in older adults, Annals of Long-Term Care: Clinical Care and Aging® spoke with Joshua D. Clapp, PhD, assistant professor at the University of Wyoming Department of Psychology.
How has our understanding of PTSD evolved over recent decades?
That’s a great question. Unfortunately, as much as we think we know, we also probably don’t know a lot—or as much as we would like to—about some of these issues, especially in older adults. If we take a step back and look at the longer perspective of PTSD, we certainly have evidence that this condition is not something new; it has been occurring throughout history. And we see this in all kinds of historical documents—running all the way up to and through the Vietnam war—but the terms we were seeing were often things like “combat fatigue,” “shell shock,” and the like. PTSD only became formulized as a disease back in 1980, so this is really something we are only just beginning to understand.
It’s interesting to look at the diagnostic criteria at that point in time for what constituted trauma; we had been talking about trauma as something that occurred outside the realm of normal human experience. So, primarily things like combat, torture, war-related atrocities, and things like violent sexual assault, but as we started to study and get larger academic support and surveys of individuals and some of their experiences, one of the things that started to become very clear is that trauma is not rare. Trauma is actually a normative experience. If you go through and look at the types of things that have the potential to cause trauma, we see a number of different things: things like childhood trauma involving physical or sexual abuse, motor vehicle accidents, natural disasters, traumatic injury, adult sexual assault. In truth, these things are actually quite normative. Most people will experience at least one traumatic event in their lifetime, but it’s actually more likely that you’ll experience two or three.
As a consequence of this understanding that trauma is actually quite normative, now the question becomes, what are we looking for? Because 60% of the population that experiences trauma doesn’t have PTSD. Typically, most people are extremely resilient. We have an astounding ability to bounce back from some of these really horrible things, but a small percentage of individuals will get stuck and not experience a normal trajectory of recovery. And that is where we begin to see things like PTSD and other post-trauma reactions.
Do we know anything about why some specific groups are less resilient than others? Does the intensity of the event have anything to do with it?
It’s a combination of a number of things. And really you’ve hit on the question that’s at the center of a lot of PTSD research. Many studies now, as our understanding of this condition continues to develop, are looking at what, if any, are risk factors for developing PTSD or a disorder following a trauma. We’re not sure about all the specific mechanisms, because it doesn’t look like everyone is equally likely to develop PTSD following trauma.
Certainly the severity of trauma is one thing. Not all traumatic experiences are equal. For example, the proportion of people who experience some element of PTSD following a conflict of a sexual nature is much, much higher than that of say a natural disaster. So, depending on what type of trauma we’re talking about, the statistical probability of developing PTSD or other related pathology differs.
But even people who experience an extremely severe traumatic event, such as sexual assault, don’t always have PTSD. So, if you have two people who experience the same objective trauma with the same level of severity, one could have a normal trajectory of recovery while the other person could develop chronic symptoms. A lot of that has to do with interpersonal characteristics, which includes a lot of contributing factors. It’s important to consider a person’s temperament and social support system. Also, prior history of psychological disorders, such as mood problems or depression, have an impact. For example, if you’ve had depression before and experience a traumatic event, we would assume that you are more likely to develop PTSD than someone who has never struggled with mental health issues. Another thing to think about when discussing who is more vulnerable would be preexisting risk factors, such as genetics. People with a family history of anxiety and depression seem to be more vulnerable. All of these things can be risk and protection factors. One of the things we’re trying to really work on is identifying specific mechanisms underlying these processes.
Is age a potential risk factor?
I have actually touched on this before in past research, specifically how age can affect post-traumatic stress in older adults. You know, there is a negative correlation between age and PTSD symptoms, and that’s kind of a controversial issue. Some people have chalked that up to reporting bias and hypothesized that perhaps older adults are just less willing to report or identify these psychological symptoms. However, it’s important to note that this has been a pretty consistent finding that has come up and it just looks like, for whatever reason, older individuals tend to be a little more robust and are perhaps a little more resilient than younger individuals. I think it’s an interesting hypothesis.
Some of our most influential models of PTSD suggest that things like a shift in how one views the world and how you interpret traumatic events are instrumental in who does and doesn’t develop PTSD. I don’t think it’s unreasonable to suspect that maybe some older adults who have more experience and have seen more things are able to make better sense of the events that have happened to them rather than someone who is young and idealistic. For example, if you’re 22 years old and think you’re invincible, and then suddenly you’re in a horrible car accident, that can fundamentally change how you see yourself and the world. That can shake people up. An older individual may already understand that they aren’t invincible and are able to process these types of situations better. So, we definitely see a negative relationship between severity of trauma symptoms and age, but there are a number of different hypotheses on what to make of that.
You mention that older adults might not be reporting PTSD symptoms. What can care providers do to counteract this tendency?
Well, it’s really important to have resources for people to use in order to reach out if they feel the need. There are a number of publications available on how to conduct interviews, evaluate traumatic response, and administer treatments effectively. One of the big things is establishing an environment where people feel comfortable disclosing very difficult memories and their reactions. If a patient comes in and they’ve had something traumatic happen, but they are reluctant to disclose that event to a health provider, their symptoms could easily be attributed to something else. So, it’s possible that the provider could end up missing their PTSD and not providing them with an appropriate treatment.
Can there exist a period of dormancy between the trauma experienced and the evidence of PTSD symptoms?
That’s a great question, and it’s something that has been pretty controversial in post-trauma research. We have this idea of delayed-onset PTSD, and, when we try to take a good look at this from a scientific perspective, it does appear that this can happen, where someone appears to be doing well and then symptoms from something that occurred in the past become more prominent. Now, this isn’t a typical presentation, and it’s not how we normally define things. It looks like very rarely, if ever, would someone have a traumatic event, be completely asymptomatic, be completely fine as if it never happened, until a long passage of time occurs and then all of the sudden explode into symptoms that were never there before. I’m not saying that could never happen; it just looks like it would be very, very rare.
What is more typical—and we’ve seen this when working with older veterans—is that people have something that has happened to them, but they do a pretty good job of avoiding it or pushing it down. So, maybe something happens but you are able to structure your life around managing these symptoms, so that they are not gone but they’re not actively causing you a great deal of stress. Avoidance is one of the big things that goes into this—you don’t want to think about this, so you avoid places that might remind you of it or don’t bring up conversations that would remind you of it. You might notice it in the movies a person chooses to watch, or that person will always be staying really busy as a way to keep memories and symptoms in check. However, what happens sometimes then is that when people retire, and they have more time to kind of sit around, those memories they did a pretty good job of running away from start to creep in. It’s a situation where it probably wasn’t that they didn’t have symptoms or that they weren’t there in the background; it’s just that they never gave them a chance to be expressed. So retirement can be one of the things that kind of brings those memories and symptoms to the forefront.
Psychological stresses can be another. Maybe you’ve done a great job of managing your symptoms, but then you lose your job, end a relationship, experience the death of a friend or family member, or experience some other financial burden or stressor. These can all add on to the stress that is already happening in the background and do a lot to bring symptoms to the forefront. So this idea of delayed onset is very, very interesting, but, more commonly, it looks like things are there in the background, but they’re just not very prominent. It might be helpful to think of it more as an extension of existing symptoms rather than new stuff coming up.
What are the symptoms of PTSD one might expect to see, and how difficult is it to differentiate PTSD from other conditions?
Another one of the controversies in diagnosis is that the symptoms of PTSD can often overlap with those of depression and generalized anxiety. There was recently an update of the core diagnostic symptoms in DSM-V [The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition]. So, our core symptoms are now: (1) intrusive memories (eg, nightmares, memories, flashbacks); (2) avoidance symptoms; (3) changes in cognition or mood (eg, how you think about yourself or other people, blame, loss of interest, interpersonal detachment, affective flattening); and (4) alterations in arousal. Those are “core” symptoms. But, again, these can often look like depression or anxiety. So it’s important for clinicians to be aware of whether a trauma has occurred and may be the cause of some of these symptoms that look like depression.
Is PTSD always related to one singular event?
There’s nothing to say that all symptoms have to be tied to one single event at one point in time. We often see this in combat trauma. If people are on deployments or multiple deployments, there are multiple situations that could be traumatic. Same thing with survivors of chronic abuse. Often, when we’re treating trauma victims, we try to focus on individual events if it makes things more manageable, but one of the things we know about PTSD is that there is a relationship to trauma load. Maybe you have a car accident and you’re a little shaken but ultimately okay. Then you experience a physical assault and then, much later, another car accident. Our data would suggest that, after a while, your ability to bounce back—some of that resilience—starts to become weakened. We’re not sure about the exact mechanism, but those who experience a lot of trauma tend to be more at risk.
What treatments are available to clinicians in long-term care to manage PTSD symptoms?
PTSD is one of those diagnoses where psychosocial treatments and cognitive therapies are the first-line intervention. Often, people will prescribe antidepressant medications or SSRIs, and those have been found to be somewhat effective at managing symptoms of low mood and things along those lines. But, really, this is one of those disorders where psychosocial therapies are really the first line. Best practice, empirically supported interventions are things like prolonged exposure, cognitive processing therapy, and Eye Movement Desensitization and Reprocessing Therapy (EMDR)—though that’s a little controversial. All of these interventions are those we would consider as trauma-focused. And by that, we mean that these techniques and procedures directly target the distressing memory and begin the process of eliminating some of the trauma symptoms. We look at those nightmares and flashbacks and work on targeting some of the emotions and thoughts around those specific events and memories. Those are our best practice interventions.
Is there a concern that this type of exposure therapy could invoke a negative response in patients?
Exposure-based interventions are the only psychosocial interventions recognized by the Institute of Medicine as effective in the treatment of PTSD, but there is concern among some members of the clinical community that exposure-focused treatments will actually make people worse. There is an idea that if I ask somebody about their trauma or revisit that memory, it’s going to be overwhelming for the patient and cause a psychic break or cause them to unravel, which could be counterproductive. In my opinion, there is currently no credible evidence to support this, but people continue to worry about it. If the root of the issue or the source of the patient’s difficulties are these traumatic memories plaguing him, and he does everything in his ability to avoid them, our very best empirical evidence suggests that it is best to attack those memories in some way. We can certainly choose how we want to do that, but leaving them unaddressed certainly is not an advisable course.
Now, with older adults, there is concern that if there are health complications and I ask them to think about these memories, it may cause some kind of complication. Clinicians shouldn’t discount the fact that older adults may present with health-related issues and this shouldn’t be a counter-indication for trauma-focused work; there isn’t the kind of empirical evidence that would lead us to that conclusion. According to the APA’s guidelines for practice with older adults, we don’t want the concern for the well-being of our patients to drift into ageism. This idea that older adults are too fragile or won’t be able to tolerate interventions shouldn’t stop us from ensuring that patients receive our very best treatments. And this is true throughout the limited literature we have on trauma in geriatrics, but it’s one of the things that happens across all demographics. What it comes down to is that we don’t want a fear of treatment to prevent us from actually treating our patients, because, in reality, tiptoeing around the issue can in fact make things worse. Take these things on in a sensitive fashion, of course, but don’t be afraid to take them on.
A good clinician will take their client’s lead, perhaps to determine how intense the exposure is or if treatments should be spaced out. If patients are being treated for trauma symptoms, the underlying cause obviously won’t be a subject they are excited to talk about. With that in mind, if I’m talking to a patient and it isn’t eliciting any sort of reaction or it’s easy to talk about, well then, we might be talking about the wrong thing.
Are there any symptoms of PTSD or considerations for treatment that are specific to older adults?
There is some research that suggests that some presentation might be a little bit different, but for the most part I don’t believe there would be any special considerations beyond what we’ve talked about. We don’t have any strong evidence that says PTSD looks different in older adults than it would in younger adults. There may be variations in terms of treatment such as pacing. The schedules of older adults are often different from those of young and middle-aged people, so providers may want to take that into account. Also, if I’m giving my patients treatment resources, I should be very cognizant of how I’m doing so. If an individual has trouble hearing, audio methods might not be as efficient, or, if I’m giving them something to read, I should make sure that it is clearly legible and that they aren’t going to need a magnifier to read it. But those are really just characteristics you would want to consider in any client.
What challenges remain in regards to treating PTSD?
We still want to understand more about the mechanisms that cause it in certain people. There are studies that suggest people with better support networks or without a family history of depression or anxiety typically aren’t as likely to develop symptoms. So, we have a good idea about some of the things that are related to recovery or that contribute to slow recovery, but some of the specific mechanisms are still a mystery. We’re not able to predict whether a given individual will or will not develop chronic PTSD at this point.
We also need to continue working to develop treatments. We have some very, very good interventions, good trauma-based treatments, but they’re not without their limitations. They don’t work for all patients, and some people who go through and have success in reducing some of their symptoms will continue to have not-negligible symptoms even after our best programs. Some people do completely fine, and others, even when there’s a reduction, continue to struggle. There’s still a lot of work to do.