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• PTSD with delayed expression occurs when the full criteria for PTSD are not met for at least 6 months after the traumatic event(s); in some cases the individual will not meet full criteria for PTSD until years after the traumatic event(s).
• Military samples tend to have higher rates of delayed onset PTSD than other trauma-exposed groups.
• Delayed onset usually involves subsyndromal PTSD symptoms that later escalate to the full diagnosis of PTSD. The majority of individuals who later go on to be diagnosed with PTSD report some PTSD symptom development prior to the diagnosis. It is exceedingly rare that a Veteran will have no PTSD symptoms for years after trauma exposure and then later meet criteria for PTSD based on the initial traumatic event(s).
• Subsyndromal PTSD cases are significantly more likely to go on to develop delayed onset PTSD if they have met two or more PTSD criteria initially.

Example of Delayed Onset Presentation

Jon is a 47-year-old Operation Iraqi Freedom (OIF) Marine Corps Veteran who was deployed on four occasions. He was injured during two of the deployments but subsequently recovered, and during each of the deployments he was exposed to numerous environmental toxins, which have contributed to his recently diagnosed chronic obstructive pulmonary disease (COPD). He noted that after his third deployment, in which the hand-to-hand combat was substantial, he experienced several PTSD symptoms including nightmares and flashbacks. Upon retirement from the Marine Corps, he sought and gained employment as a Department of Defense (DOD) contractor, but in the last year has had to quit due to his COPD. He is seeking assessment and treatment because in the last 3 months his PTSD symptoms related to his combat experiences have become more distressing and have expanded to include avoidance, numbing, and irritability, which interfere with his relationships and functioning.

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An individual has PTSD with dissociative symptoms when, in addition to meeting PTSD criteria, he or she experiences persistent or recurrent symptoms of depersonalization (persistent and recurrent experiences of feeling detached from one's mind or body) or derealization (persistent or recurrent experience of unreality of surroundings).
In samples of Veterans with PTSD, dissociative symptoms (as defined by depersonalization, derealization, and reduction in awareness) have been found in approximately 15% of the men and 30% of the women.
Individuals with the dissociative subtype of PTSD tend to have a higher level of exposure to childhood and adult sexual assault compared to individuals who meet criteria for PTSD without the dissociative subtype.
Women with the dissociative subtype of PTSD tend to have higher rates of comorbid borderline and avoidant personality disorder diagnoses.
Individuals with the dissociative subtype of PTSD tend to generally be more symptomatic than those without the subtype. Specifically, they demonstrate higher rates of psychiatric comorbidity, functional impairment, and suicidality.

Example of Dissociative Subtype Presentation

Mary is a 38-year-old Air Force Veteran who was medically discharged from the military six months ago for PTSD related to a sexual assault that occurred while on active duty. During her intake interview, she reported that she had been sexual abused by an uncle from the ages of 3-7. When interviewing her, you notice she occasionally stares off out the window and seems to not hear your questions. She notes that she most often copes with her PTSD symptoms by avoiding thinking about what happened to her. She notes that she often feels that she is "in a dream," and often feels like her dreams are more real than her waking life. She reports that these feelings began in childhood, but since the sexual assault that occurred while on active duty, they have become more intense. She has a history of suicidal ideation in her later teens, which dissipated when she entered the Air Force.

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