A recent systematic review1of delayed-onset post-traumatic stress
disorder (PTSD) concluded that there is ‘no consensus emerging
as to its prevalence’ and that studies demonstrating delayed-onset
PTSD in the absence of prior symptoms are quite rare, although
delayed onset defined as an exacerbation or reactivation of prior
symptoms is relatively common (38.2% of military and 15.3%
of civilian cases of PTSD). Sceptics of delayed-onset PTSD have
criticised the empirical data upon which it is based and have
questioned the existence of the phenomenon.2,3For example,
two large-scale epidemiological studies have reported zero or
extremely low rates of delayed-onset PTSD (0–1% of all cases of
identified PTSD) in civilians4,5whereas a smaller study of former
prisoners of war reported that only 1.4% of all individuals had
PTSD with delayed onset.6Alternatively, two other large-scale
studies have reported higher rates of delayed-onset PTSD in
civilians (0 and 8%) and veterans (16% and 22%), although with
somewhat different rates between studies.7,8A number of other
smaller studies have reported a wide range (as high as 460%)
of delayed-onset PTSD in civilians and veterans.1,9–14Limitations
of the literature include the fact that most studies only look at
respondents’ PTSD rates 1 or 2 years after the index traumatic
event, which sheds little light on onset that may occur 20 or 30
years later. Further empirical studies are needed to advance our
understanding of the concept, prevalence and phenomenological
features of delayed-onset PTSD.
We sought to examine delayed-onset PTSD in a large multisite
study conducted with military veterans in primary care clinics.
Using this sample we had previously examined PTSD prevalence
and correlates, reporting a PTSD point-prevalence (current PTSD)
of 11.5%,15current subthreshold PTSD point-prevalence of
4.6%,16and that veterans in the oldest group (age 565, 6.3%)
had one-third the PTSD prevalence of those in the middle-aged
group (ages 45–64, 18.6%), despite higher rates of combat
exposure.17Post-traumatic stress disorder in this sample was
positively associated with a variety of comorbid psychiatric
disorders, male gender, war zone service, age 565 years, not
working, less formal education and reduced functioning.15
Given that PTSD symptoms may wax and wane over time,13it
was deemed relevant to examine delayed onset of current PTSD
symptoms that are subsyndromal (i.e. ‘subthreshold PTSD’) or
now in remission (e.g. ‘lifetime PTSD only’). Thus, in the present
study we conducted new analyses with this sample in order to
address several important questions.
(a) Among veterans identified with PTSD, what is the prevalence
of ‘delayed onset’?
(b) Among veterans identified with current subthreshold PTSD
and lifetime PTSD only, what is the prevalence of ‘delayed
(c) Among veterans identified with delayed-onset current PTSD,
subthreshold PTSD and lifetime PTSD only, what does the
time course of symptom onset look like (e.g. are there cases
of PTSD onset more than 5, 10, 20 years post-trauma)?
(d) If rates of delayed-onset PTSD symptoms are high enough to
permit additional analyses, are there relevant predictors (e.g.
ethnicity, age, education) or correlates (e.g. other psychiatric
symptoms or disorders, health status, disability, healthcare
service use) that can be identified?
Answers to these questions will carry implications for the
evidence base relevant to managing PTSD disability claims and
clinical service needs.
Study design and procedures
Data were part of a larger cross-sectional study conducted on a
random sample of veterans at four US Veterans Affairs Medical
Centers’ primary care clinics.15Study participants were randomly
selected from a master list of patients during the fiscal year 1999 at
each of the Veterans Affairs primary care sites. Consenting
Delayed-onset post-traumatic stress disorder
among war veterans in primary care clinics
B. Christopher Frueh, Anouk L. Grubaugh, Derik E. Yeager and Kathryn M. Magruder
Only limited empirical data support the existence of delayed-
onset post-traumatic stress disorder (PTSD).
To expand our understanding of delayed-onset PTSD
prevalence and phenomenology.
A cross-sectional, epidemiological design (n=747)
incorporating structured interviews to obtain relevant
information for analyses in a multisite study of military
A small percentage of veterans with identified current PTSD
(8.3%, 7/84), current subthreshold PTSD (6.9%, 2/29), and
lifetime PTSD only (5.4%, 2/37) met criteria for delayed onset
with PTSD symptoms initiating more than 6 months after the
index trauma. Altogether only 0.4% (3/747) of the entire
sample had current PTSD with delayed-onset symptoms
developing more than 1 year after trauma exposure, and no
PTSD symptom onset was reported more than 6 years post-
Retrospective reports of veterans reveal that delayed-onset
PTSD (current, subthreshold or lifetime) is extremely rare 1
year post-trauma, and there was no evidence of PTSD
symptom onset 6 or more years after trauma exposure.
Declaration of interest
The British Journal of Psychiatry (2009)
194, 515–520. doi: 10.1192/bjp.bp.108.054700
assessment and within 2 months were administered a structured
telephone interview by master’s-level clinicians trained and
supervised by a licensed clinical psychologist. Study measures were
read aloud to all participants because many were unable to read
them because of vision problems or insufficient literacy skills.
Additionally, using available medical charts, we conducted a
12-month retrospective review of each participant’s Veterans
Affairs treatment. Initial exclusionary criteria included the
presence of dementia-related symptoms, and being age 80 or
older. After providing a complete description of the study to the
participants, written informed consent was obtained. This study
was conducted with full approval from relevant institutional
Contact information of participants who completed on-site
clinic assessments was sent to the primary site, where clinicians
(master’s level and above) telephoned them to administer
structured interviews. The use of telephone interviews of potential
trauma victims to assess for traumatic event exposure and PTSD
symptoms, using a wide range of instruments, has been relatively
widespread in epidemiological research over the past 15 years,18
with strong psychometric properties and virtually no statistical
differences in rates of either trauma exposure or PTSD diagnoses
when compared with traditional face-to-face interviews, including
samples of elderly adults.19
wereprovided witha semi-structuredclinic
A total of 1198 randomly identified veterans (known to be alive)
were approached for study participation. Of this sample, 885
veterans (74%) provided an informed consent to participate
during the clinic interview. As a result of missing follow-up
telephone interview data, our final sample was reduced to 747
veterans. The average age (s.d.) of the final full sample (n=747)
was 61.23 years (s.d.=11.81), with a range from 25.50 to 81.12
years. Demographic characteristics for the sample are summarised
in Table 1.
Conceptual definition of ‘delayed onset’
There is a notable lack of clarity regarding the conceptual defini-
tion of ‘delayed onset’. Merely because a disorder is recognised
many years after the aetiological event is not evidence that onset
of the disorder was ‘delayed’. It has been noted that PTSD
diagnosed more than 6 months after a traumatic event may
indicate delayed treatment or seeking of disability benefits, delayed
onset of any symptoms of PTSD (identified as ‘definition 1’ by
Andrews et al)1, or delayed onset of the full disorder such that a
change in one or two symptoms alters PTSD diagnostic status
(identified as ‘definition 2’ by Andrews et al). Another issue is
the actual time interval from traumatic exposure to onset, with
‘delayed onset’ counting as any PTSD onset that occurs from
7 months to 50 or more years post-trauma. Thus, there is
definitional and conceptual ambiguity in DSM–IV20that affects
our understanding of delayed-onset PTSD. In fact, Spitzer et al3
have proposed revised PTSD diagnostic criteria for DSM–V,
changing the onset criterion (criterion E) to read as either ‘the
symptoms develop within a week of the event’ or ‘if delayed onset,
the onset of symptoms is associated with an event that is
thematically related to the trauma itself (e.g., onset of symptoms
in a rape survivor when initiating a sexual relationship)’.
The Trauma Assessment for Adults – Self Report Version (TAA)21
assesses the lifetime prevalence of trauma (both military and
non-military) and has been widely used to screen community
and medical populations for trauma history, finding trauma
prevalence rates similar to those of other large-scale studies.22This
survey provided data to categorise individuals as either meeting or
failing to meet DSM–IV PTSD’s trauma exposure criterion A.
The Clinician Administered PTSD Scale (CAPS)23
administered to those participants who endorsed a traumatic
event on the TAA. The CAPS is a structured clinical interview that
measures the intensity and frequency of the 17 DSM–IV PTSD
symptoms. The CAPS has excellent psychometric properties and
utility for making PTSD diagnoses.22For the present study, the
CAPS was used to make classifications of current PTSD and
subthreshold PTSD. Participants were designated as having
‘current PTSD’ if they met criterion A on the TAA, and criteria
B, C and D on the CAPS, with clinically significant distress or
impairment and a duration of all CAPS symptoms greater than
1 month; the presence of symptoms was based on the ‘frequency
Frueh et al
Demographic descriptors for participants in the full sample
Lifetime PTSD only
Gender male, %93.397.6 93.183.8
Age in years, mean (s.d.)61.23 (11.81) 57.35 (10.94) 58.55 (13.05)57.42 (10.56)
Marital status, %
Work status, %
5 than high-school degree
College degree or postgraduate
Military variables, %
PTSD, post-traumatic stress disorder.
a. With the exception of three veterans classified as Hispanic or ‘Other’, all other minority members were African American.
51/intensity 52’ CAPS scoring rule.23,24For current subthreshold
PTSD, the algorithm was based on a prior definition,25which
requires endorsement of the criterion A and criterion B symptom
clusters, meeting diagnostic criteria for either the criterion C or
criterion D symptom cluster, and endorsement of clinically
significant distress and impairment. A mutually exclusive category
for lifetime PTSD only was designated for those who met PTSD
criteria at some prior point in their life, but did not currently meet
criteria for the disorder or for subthreshold PTSD. Interrater
reliability analyses on a random sample of interviews (approx-
imately 8%) showed raters were 100% concordant for PTSD
diagnoses on the CAPS.
Onset of PTSD symptoms was established via item 18 on the
CAPS interview, which inquires when the respondent first started
having endorsed PTSD symptoms, expressed in terms of the
number of months after the index traumatic event that symptoms
started. Thus, this definition is consistent with Andrew et al’s1
‘definition 1’ of delayed onset since it does not ask about full
PTSD criteria, but rather onset of any ‘PTSD symptoms’. As such,
it represents a conservative interpretation of the ‘delayed-onset’
PTSD subtype. Also, as recommended1we express the rate of
delayed-onset PTSD as the proportion of those with PTSD (or
subthreshold PTSD or lifetime PTSD only, as the case may be).
This study was designed so that it would have met Andrews et
al’s criteria for inclusion in their recent systematic review of
prevalence studies on delayed-onset PTSD.
Other measures and interviews included in the parent study of
potential relevance to the current study were the Short-Form
Health Survey (SF–36),27Post-Traumatic Stress Disorder Checklist
– Civilian (PCL–C),28and Mini International Neuropsychiatric
Interview (MINI).29We also conducted an examination of electro-
nic medical records for the 12 months preceding study initiation
for each consenting participant, via research personnel masked to
the diagnostic status of participants, which included medical and
psychiatric diagnoses/conditions and Veterans Affairs healthcare
service use in the year preceding study participation.
Overview of analytic strategies
Analyses were conducted with veterans in this sample to:
(a) identify prevalence of delayed-onset current PTSD;
(b) identify prevalence of delayed-onset ‘subthreshold PTSD’
(based on ‘current’ symptoms) and ‘lifetime PTSD only’
(past history of the disorder, but not currently meeting criteria
for either current PTSD or current subthreshold PTSD);
(c) examine the time course of onset for current PTSD, sub-
threshold PTSD and lifetime PTSD only in identified cases;
(d) if cell sizes permitted, examine relevant predictors (e.g.
ethnicity, age, education) and correlates (e.g. other psychiatric
symptoms or disorders, health status, disability, healthcare
service use) of delayed onset in order to enhance our
understanding of the phenomenon.
A small percentage of veterans with identified current PTSD
(8.3%, 7/84), sub-threshold PTSD (6.9%, 2/29), and lifetime
PTSD only (5.4% 2/37) met criteria for delayed-onset PTSD. Table
2 shows the frequency distribution of temporal onset of PTSD
from the index traumatic event; only 3 of 747 (0.4%) veterans
had current PTSD with delayed onset of symptoms developing
more than 1 year after the trauma, and these were at 4 years
post-trauma for two individuals and at 6 years post-trauma for
the other individual. One of these was a female with childhood
sexual abuse and no combat exposure. The two participants with
delayed-onset sub-threshold PTSD had reported onsets of 9 and
16 months post-trauma. Because the number of delayed-onset
current PTSD, sub-threshold PTSD, and lifetime PTSD only cases
was so low (seven, two and two respectively), secondary analyses
related to predictors and correlates of delayed onset was not
considered feasible. However, several descriptive observations
can be made regarding the seven individuals with delayed-onset
current PTSD: six reported multiple traumatic events; six were
White; six were male; five were receiving Veterans Affairs
service-connected disability payments; five were within the 45–64
age group, only one was 565 years of age; and two were not
related to combat exposure.
Results show that 8.3% of those identified with current PTSD met
criteria for delayed onset using a conservative definition of the
construct. Further, 6.9% of those identified with current sub-
threshold PTSD and 5.4% of those identified with lifetime PTSD
only met criteria for delayed onset. Consistent with the conclu-
sions of a recent review1these findings indicate that delayed-onset
PTSD occurs, but is rare in this large, representative sample of
veterans. One might expect that PTSD, especially delayed-onset
PTSD, would be more prevalent in older veterans if delayed onset
is common given the longer time for onset to occur. In fact, as we
have previously reported, PTSD rates among treatment-seeking
veterans are substantially lower in the 565 age group relative to
the 45–64 age group,17and current results show only one of the
veterans reporting delayed-onset current PTSD as older than 64.
Because PTSD symptoms may wax and wane over time,13we
lifetime PTSD only, from the index traumatic event
Frequency distribution of temporal onset of current post-traumatic stress disorder (PTSD), subthreshold PTSD and
PTSD onset from index traumatic event, months
Lifetime PTSD only
0–177 (91.7) 27 (93.1) 34 (91.9)
2–500 1 (2.7)
6–12 4 (4.8) 1 (3.4)2 (5.4)
13–480 1 (3.4)0
49–72 3 (3.6)00
73 or more000
a. In the complete sample there were 86 veterans with PTSD and 34 with subthreshold PTSD,29but as a result of missing values on the delayed-onset variable, the resulting above
cell sizes are reported.
Frueh et al
examined onset of subthreshold PTSD symptoms to learn whether
there might be a large number of veterans with delayed-onset
PTSD symptoms lurking just beneath the threshold for full PTSD.
This was not found to be the case, suggesting that there are few
veterans with delayed-onset symptoms of subthreshold PTSD who
are likely to develop full delayed-onset PTSD by the waxing of a
few symptoms in the future.
Prevalence, temporal distribution and definitions
The DSM–IV defines ‘delayed-onset’ PTSD as onset occurring at 6
or more months after index trauma exposure, a wide time frame.
Therefore, examination of the frequency distribution of temporal
onset of current PTSD, subthreshold PTSD and lifetime PTSD
only relative to the index traumatic event is instructive. Over
90% of current (77/84) and subthreshold (27/29) cases of PTSD
reported symptom development within the first month after the
index traumatic event, whereas only 0.4% (3/747) of the entire
sample developed current PTSD with symptoms developing more
than 1 year after the trauma (that is, 3.6% (3/84) of those with
current PTSD). Further, there was no PTSD symptom onset for
any group (current PTSD, subthreshold PTSD, lifetime PTSD only)
reported more than 6 years post-trauma. In combination, these
data indicate that PTSD symptom onset 6 or more years after
trauma exposure among veterans either does not occur or is
exceedingly rare. One implication if these findings are replicated
is that the dramatic recent increase in the number of US Vietnam
veterans seeking Veterans Affairs disability payments for PTSD29
cannot be explained as the result of a growing number of new
implications for one aspect of the current discussion29regarding
Veterans Affairs PTSD disability administrative trends and
Although these data on prevalence and temporal distribution
of delayed-onset PTSD are important, they do not clarify the
ambiguity in the DSM–IV definition of ‘delayed-onset’ or speak
to the meaning of different temporal onsets (e.g. onset at
7 months, 4 years and 50 years are currently classified together),
except to indicate that later onset is either rare or non-existent.
Further, as a result of small cell sizes, other phenomenological
features or correlates of delayed-onset PTSD are not satisfactorily
addressed by the current data. Observationally we noted that in a
majority (5five of seven) of individuals with delayed-onset
current PTSD the veterans were: male; White; receiving disability
benefits; within the 45–64 age group; and reporting multiple
traumatic events. Since most people with delayed-onset PTSD in
this sample had had multiple traumatic event exposures, perhaps
PTSD related to an index trauma (nearly always reported as
combat, when combat exposure was present) is activated by
subsequent exposure, or increases vulnerability to subsequent
stressors or traumatic cues. Either would be consistent with
Spitzer et al’s3proposed revisions to DSM–V criteria that delayed
onset be ‘associated with an event that is thematically related to
the trauma’. Unfortunately, the data were not obtained in the
current study that would allow us to examine precipitating factors
for onset, and this issue therefore remains an open question.
The finding that PTSD is more common in younger veterans
suggests a possible cohort effect, which raises the question of
whether there will be higher rates of delayed onset in future
generations of military veterans. A previous finding from this
sample17was that veterans 565 years of age report lower PTSD
and better mental health than those under 65. Other studies have
also found evidence of cohort effects, with lower rates of PTSD
among Second World War veterans30relative to studies of
Vietnam veterans. Several possible explanations may account for
this finding. First, people may become more psychologically
healthy as they age (e.g. a maturational ageing process). Second,
older veterans may be less likely to acknowledge psychiatric
symptoms that exist (e.g. a sociocultural cohort effect related to
‘self-reliance’ or perceptions regarding stigma for mental illness).
Third, veterans with psychiatric problems may be less likely to
survive to advanced age (e.g. a mortality effect). Last, younger
veterans may be more sensitive to and more likely to report
psychiatric symptoms based on changing social expectations
(e.g. evolving interpretations and perceptions of psychiatric
illnesses or a social learning effect).31This fits with general inter-
national trends towards higher levels of psychiatric disability
among younger generations, as well as disorder-specific nuances
such as the finding that ‘flashbacks’, which are a common
symptom among recent combat veterans, are conspicuously
absent among veterans’ symptom reports prior to the Vietnam
War.32There is little basis from the current data to expect
significant rates of future delayed-onset PTSD in those younger
veterans currently without PTSD symptoms in this sample.
However, one might wonder whether delayed-onset PTSD, like
‘flashbacks’, is possibly a culturally bound expression likely to
become more prevalent in the future.
This study has important limitations inherent in the cross-sec-
tional, retrospective nature of its design. Certainly, there is reason
to be concerned about the potential for instability of recall and
various memory biases.1,33–35Thus, recall or report bias cannot
be excluded in the ascertainment of combat experiences, PTSD
symptom severity or the time of onset for PTSD symptoms. Data
show that military veterans’ reports of combat exposure and other
military hazards can change over time36and may even be subject
to exaggeration.37Further, recall for symptom onset that may have
occurred as long as 40 or 50 years ago is likely to involve a certain
degree of imprecision. We acknowledge this as an important
limitation of this study, as it is for most studies reporting on past
trauma exposures or delayed-onset PTSD. However, as Andrews et
al1note, there are also disadvantages to prospective studies, given
that ‘individuals may have had onsets of PTSD after one
assessment that then remitted before the next’. In other words,
many existing longitudinal PTSD studies have significant flaws
with regard to precision of onset estimates. For example, in a
20-year longitudinal study, veterans (n=214) were assessed at four
time points (1 year, 2 years, 3 years and 20 years post-combat)
with a 17-year gap between time point three and time point
four.14Thus, it is not clear when PTSD onsets after time point
three occurred, and the sample was so heavily pathological at
the study outset (61% of the sample had a history of combat stress
reactions, 45% met criteria for PTSD at time point one) that
generalisability is a concern. Thus, there remains a large gap in
the knowledge base regarding delayed-onset PTSD, especially
among veterans and existing studies may even contribute to
potential misconceptions about the prevalence of delayed-onset
The noted limitations of our cross-sectional design are balanced
by important study strengths, including a large, representative
sample of veterans from Veterans Affairs primary care clinics,
inclusion of a long time frame post-trauma (typically 25–40 years
in this sample) for potential PTSD onset to occur, and use of
widely accepted, psychometrically robust structured clinical
interviews for evaluating traumatic event exposure and PTSD
assessment. This study design would have met Andrews et al’s1
suggested criteria for inclusion in their systematic review of
represents a meaningful addition to an important, yet under-
studied and likely misunderstood, conceptual aspect of PTSD.
Even if we stipulate that current estimates of PTSD symptom
onset in our sample are unlikely to be precisely accurate, it seems
plausible that estimates are at least in the ‘ballpark’. Notably, there
is no recency effect for reported PTSD onset, as one might expect
given data that people may forget past episodes of other
psychiatric disorders.34In fact, the converse appears to be true
here, where people with current PTSD recall their symptom onset
as occurring many years before, shortly after the index trauma,
and persisting chronically to the present time. Thus, if we collapse
onsets into three general time periods we are left with the essence
of an important finding: for those with current PTSD, symptom
onset occurs primarily within the first 6 months after the index
traumatic event (91.6%, 77/84), with no onset occurring after 6
years post-trauma. All told, the vast majority (96.4%, 81/84)
of current PTSD onsets occurred within the first year post-trauma,
and a similar pattern holds for subthreshold PTSD and lifetime
PTSD only. Thus, PTSD symptom onset is remarkably consistent
across our three groups (current, subthreshold, lifetime only).
Moreover, the overall pattern of onset and the fact that we did
not find a single incident of ‘late’ delayed onset is consistent with
the findings of the most methodologically rigorous large-scale
prospective studies with civilian samples5,6and with historical
perspectives regarding post-combat psychiatric reactions gained
from experience with veterans of the First World War.38
Future additional longitudinal research is needed to enhance our
understanding of the onset and course of PTSD in veteran and
civiliantrauma survivors, including
phenomenological features associated with delayed onset. Such
longitudinal epidemiological research should take the form of
routine health surveillance among veterans deployed to war zones
and other relevant populations.33Findings will have relevance to
ongoing effortsto refine PTSD
development of services and benefits for veterans.
B. Christopher Frueh, The Menninger Clinic and the Menninger Department of
Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA;
Anouk L. Grubaugh, Derik E. Yeager, Kathryn M. Magruder, Veterans Affairs
Medical Center and Department of Psychiatry and Behavioral Sciences, Medical
University of South Carolina, Charleston, South Carolina, USA
Correspondence: B. Christopher Frueh, Department of Psychology, University
of Hawaii, 200 W. Kawili St., Hilo, HI 96720, USA. Email: firstname.lastname@example.org
First received 8 May 2008, final revision 8 Oct 2008, accepted 3 Dec 2008
This work was partially supported by grants VCR-99-010-2 from Veterans Affairs Health
Services Research and Development (Veterans Affairs HSR&D) to K.M.M., grant CD-
207015 from Veterans Affairs HSR&D to A.L.G., grant MH074468 from the National Institute
of Mental Health (NIMH) to B.C.F and awards from the McNair Foundation and Menninger
Foundation. This work was also supported by the Office of Research and Development,
Medical Research Service, Department of Veterans Affairs. All views and opinions
expressed herein are those of the authors and do not necessarily reflect those of our
respective institutions or the Department of Veterans Affairs.
We thank Carla Sharp, Ph.D. for her helpful comments on an earlier draft of this
manuscript, as well as the thoughtful critiques of three anonymous reviewers.
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Psychiatry without psychiatrists
People with minimal professional training can deliver babies safely and treat life-threatening childhood pneumonia. Are psychiatric treatments
more complex for them to deliver? It appears not. A slew of trials and clinical experience, in some of the poorest communities of the world,
show that various types of non-specialists can deliver a range of psychiatric treatments with good outcomes at a fraction of the cost. The
psychiatrist plans mental health programs, trains and supervises non-specialists, audits the clinical process and provides a referral pathway.
Psychiatry without psychiatrists is the reality for the vast majority of persons living with mental disorders today.
The British Journal of Psychiatry (2009)
194, 520. doi: 10.1192/bjp.194.6.520
10.1192/bjp.bp.108.054700 Access the most recent version at DOI:
2009, 194:515-520. BJP
B. Christopher Frueh, Anouk L. Grubaugh, Derik E. Yeager and Kathryn M. Magruder
veterans in primary care clinics
Delayed-onset post-traumatic stress disorder among war
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