Ptsd

Posttraumatic Stress Disorder in Older Adults: A Conceptual Review Patricia M. Averill Ph.D.a and J. Gayle Beck Ph.D., b a Department of Psychiatry, University of Texas Medical School, Houston, TX, USA b Department of Psychology, State University of New York at Buffalo, Buffalo, NY, USA Available online 28 April 2000. Abstract —Issues that are salient in understanding posttraumatic stress disorder (PTSD) in older adults are examined in this review. Although this issue has received scattered attention in the literature since introduction of the diagnosis of PTSD to the Diagnostic and Statistical Manual (DSM) in 1980, it is clear that numerous conceptual and defining questions exist in our understanding of the aftermath of trauma exposure in older adults. In approaching this issue, studies pertaining to diagnostic status as well as broader dimensions of psychosocial functioning are examined. Concerns that are unique to older adults are highlighted throughout, with particular attention to areas where additional research is warranted. Author Keywords: PTSD; Aging; Trauma Article Outline • Posttraumatic stress disorder: diagnostic criteria and cardinal features • What are the unique symptoms of posttraumatic stress disorder in older adults' • Comment • Prevalence of posttraumatic stress disorder in older adults • Comment • Can posttraumatic stress disorder begin many years after trauma exposure in older adults' • Comment • What comorbid features are associated with posttraumatic stress disorder in older adults' • Comment • What are the radiating effects of exposure to trauma on the elderly' • General Psychological Effects • Physical Effects • Coping Strategies • Coping With Nontraumatic Age-Related Stressors • Comment • Summary • Acknowledgements • References Although posttraumatic stress disorder (PTSD) was not formally included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1980 (American Psychiatric Association, 1980), it has long been recognized that a traumatic event can leave a distinct collection of psychological symptoms in its aftermath. Earlier writing on this topic referred to these symptoms as manifestations of shell shock, combat fatigue, transient situational disturbance, survivor's syndrome, war neurosis, and related conditions. Although seemingly different on the surface, each of these accounts described similar symptomatology. Clearly, trauma exposure manifests itself in a very distinct fashion. Although substantial research has documented the impact of PTSD in combat-exposed Vietnam veterans (Kulka et al., 1990), women who have been sexually assaulted (Koss & Harvey, 1991), and more recently, individuals who have been involved in motor vehicle accidents (Blanchard & Hickling, 1997), there is scarce information about PTSD in older adults. Perhaps this state reflects the absence of PTSD in older adults, suggesting that as one ages, the psychological impact of trauma is lessened. This review indicates that PTSD does occur in older adults with similar symptoms as noted in younger adults. Interestingly, some salient differences in PTSD have been documented in older adults, such as differences in the natural course of the disorder, suggesting that the expression of PTSD may be influenced by factors such as natural changes brought about by aging, the societal zeitgeist at the time of trauma, and the presence (or absence) of diagnostic comorbidity. This review highlights issues that are central to understanding PTSD in the elderly. After a review of the current diagnostic criteria for PTSD, examination of the unique symptoms of PTSD in older adults, including whether delayed PTSD can onset in later life, and a consideration of the radiating impact of trauma on the elderly will be discussed. The goals for this review were threefold: (1) to summarize and integrate the extant literature on PTSD in older adults, (2) to spotlight special concerns that are involved in understanding PTSD in older adults, and (3) to set the stage for future research in this relatively neglected area. Because the literature on assessment strategies and treatment interventions for older adults with PTSD is so sparse, this review focuses exclusively on the diagnosis and conceptualization of this disorder among the elderly. Posttraumatic stress disorder: diagnostic criteria and cardinal features Posttraumatic stress disorder is initiated by exposure to extraordinarily stressful life events, such as military combat, violent personal assault, being taken hostage, natural or manmade disasters, and severe car accidents. The specific symptoms of PTSD are described in Table 1 and fall into three categories: (a) reexperiencing symptoms, (b) avoidance and numbing symptoms, and (c) increased physiologic arousal. Although there have been changes in the specific symptoms demarcated as comprising PTSD since its introduction to the DSM in 1980, the cardinal characteristics have remained fairly consistent across time. A new addition to the criteria, provided in DSM-IV (American Psychiatric Association, 1994), is the stipulation that the individual's reaction to trauma exposure was one of “intense fear, helplessness, or horror” (p. 428). Although it is tempting to state that trauma exposure causes PTSD, it is important to recognize that there is not a one-to-one relationship between exposure to a traumatic stressor and the development of PTSD. Indeed, it is accurate to state that, in PTSD, we can only identify the proximal event that activates the disorder (Barlow, 1988). As discussed below, this issue is particularly salient in considering delayed-onset PTSD in older adults. Additionally, DSM-IV contains several specifiers to the diagnosis of PTSD, such as the acute versus chronic specifier (to indicate whether the duration of symptoms is less than or more than 3 months) and the delayed onset specifier (to indicate if the onset of symptoms occurred at least 6 months after the trauma). Because the diagnosis of PTSD requires symptoms of at least 1 month duration, the addition of acute stress disorder within DSM-IV permits closer study of the immediate negative effects of trauma. The diagnostic criteria for acute stress disorder emphasize dissociative symptoms and emotional reactions. Because of the relative novelty of the acute stress disorder diagnosis, this review focuses on PTSD, as well as issues pertaining to adjustment after trauma exposure. Table 1. Diagnostic Criteria for Posttraumatic Stress Disorder, as Contained Within the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Full-size table (<1K) View Within Article What are the unique symptoms of posttraumatic stress disorder in older adults' Because criteria for the diagnosis of PTSD largely have been defined based on symptoms reported by younger adults, it is important to examine the unique features of this disorder that are reported by older adults. The studies on this topic are reviewed in two groups: reports of PTSD symptoms in older individuals who were traumatized in young adulthood and those studies examining the sequelae of trauma occurring in later life. Most older adults who were traumatized earlier in their life report an episodic course, with symptom exacerbations and remissions over time (e.g., Hyer, Summers, Braswell, & Boyd, 1995). McLeod (1994) described an evolution of PTSD among World War II (WW II) veterans, in which they initially coped relatively well, followed by an exacerbation of symptoms lasting approximately 5 years. Many of these men then reported a period of “masked” symptoms during middle age, when they were involved with careers and rearing families. As these men aged, PTSD symptom exacerbation was common, suggesting that time of study is likely to impact the presentation of symptoms. Additionally, symptoms such as sleep disturbance and memory impairment are seen more commonly in older adults in general and may not be associated with trauma exposure per se (Zeiss & Dickman, 1989). Thus a number of issues complicate consideration of the symptoms that define PTSD in older adults. With these caveats in mind, it seems that older adults who were exposed to trauma earlier in their lives report a variety of ongoing PTSD-related symptoms. For example, Yehuda, Kahana, Schmeidler, Southwick, Wilson, and Giller (1995) compared Holocaust survivors who met criteria for PTSD with survivors who were not diagnosed with PTSD and control participants who were matched on ethnic and cultural background. Those with PTSD reported more intrusive thoughts, avoidance, hyperarousal, and dissociation when compared with the other two groups. Among WW II veterans, McFarlane (1990) found that intrusive symptoms reduced over time, whereas avoidance symptoms and estrangement from others increased as these men aged. Kaup, Ruskin, and Nyman (1994) noted that the most commonly reported symptoms among WW II veterans attending a mental hygiene clinic included insomnia (80%), nightmares (75%), irritability (65%), social isolation (50%), and flashbacks (45%). Likewise, in a study of older veterans who survived Pearl Harbor, Wilson, Harel, and Kahana (1989) noted that 45 years later, 65% still experienced intrusive memories, 42% reported survivor guilt, and approximately 33% reported avoidance and hyperarousal symptoms, as well as emotional numbing. Most of these veterans indicated that their symptoms had reduced over time, with the greatest decline occurring in intrusive thoughts and survivor guilt. Thus in these particular groups of veterans, it appears that many experienced similar types of symptoms as those reported in younger, combat-exposed veterans. To examine the impact of specific war experiences, Fontana and Rosenheck (1994) compared WW II, Korean, and Vietnam veterans on PTSD and general psychiatric symptoms. Each of these groups survived markedly different war experiences, which conceivably could influence the occurrence and continuation of PTSD. These authors noted that all three veteran groups reported significant symptomatology in these domains. However, WW II veterans had lower scores compared with Korean veterans, who in turn had lower scores than Vietnam veterans. Although these results suggest that PTSD symptoms in general may decline in older life, the authors highlight that these differences may be the result of other factors, such as cultural perceptions of the desirability of the specific war and specific coping strategies. Additionally, other authors have suggested that the declining symptom patterns noted in older adults may be the result of differential attrition of veterans with PTSD, owing to natural death, suicide, institutionalization, or physical illness (Hyer et al., 1995). To focus specifically on the unique features of PTSD in older life, Hyer et al. (1995) compared veterans from WW II, Korea, and Vietnam, all of whom were diagnosed with PTSD. Younger veterans scored higher on all PTSD symptoms (e.g., sleep disturbance, anger, concentration difficulties, hypervigilance, excessive startle response, and hyperarousal). Among the older veterans, the most salient PTSD symptoms were distress when exposed to trauma-related events and diminished interest in usual activities. This finding is supported in other studies (e.g., McFarlane, 1990), suggesting that older adults with PTSD may be prone to symptom exacerbation when faced with trauma-related triggers. Studies examining PTSD symptoms in individuals traumatized later in life show that older adults may experience somewhat different symptoms than those reported by younger adults after trauma exposure. In a study examining PTSD symptomatology among survivors of a train accident, Hagstrom (1995) noted that adults over age 65 reported more preoccupation with the accident, avoidance, sleep disturbance, intrusive thoughts about the accident, and crying spells compared with younger adults (ages 45–64). Individuals ages 18 to 24 showed similar symptom profiles as the older adults on these dimensions (with the exception of sleep disturbances and crying spells), suggesting that we should not expect a linear relationship between age and trauma-related symptomatology. Likewise, Goenjian et al. (1994) found that older adults who were impacted by an earthquake in Armenia reported more hyperarousal symptoms, but fewer intrusive thoughts, compared with younger earthquake survivors. Clearly, studies that focus on specific symptom profiles of PTSD in older versus younger adults can assist in helping us to identify the unique features of this disorder as they present in the elderly. Comment Although it is clear that similar features are reported by older adults who carry the PTSD diagnosis, there are suggestions that symptom profiles may be different in some respects as well. However, the literature has not yet evolved to the point where consistent findings indicate which symptoms are particularly salient in the elderly. Most likely, this issue can best be examined through comparison of recently traumatized individuals across the lifespan, given the innumerable research issues that arise in the study of individuals with chronic PTSD. In the extant literature, however, there are some interesting hints concerning the unique features of PTSD in the elderly. For example, distress when exposed to trauma-related cues appears to be potentially salient. It is possible that this symptom motivates other features of PTSD in older adults, such as avoidance and emotional numbing. This constellation of symptoms may lead to misdiagnosis in the elderly, particularly if exposure to trauma was not evaluated before assessment of current symptomatology. For example, an aging veteran may report feelings of depression, agitation, sleeplessness, emotional flatness, and guilt, symptoms that could lead to a diagnosis of major depression or dysthymia. These specific symptoms conceivably could be reflective of PTSD. However, this diagnosis would not be considered unless careful interviewing were conducted. This issue also pertains to delayed-onset PTSD, as will be discussed in a later section. Clearly, greater information concerning the unique features of both acute and chronic PTSD in older adults could assist in accurate identification of the disorder, particularly among primary care physicians. Prevalence of posttraumatic stress disorder in older adults Given the mixed collection of findings concerning PTSD symptom profiles in older adults, it is not surprising that prevalence estimates likewise vary. Prevalence data are based primarily on three groups of survivors: war veterans, Holocaust survivors, and victims of recent disasters. Although there is the suggestion that prevalence rates of PTSD—like all anxiety disorders—decline with advancing age (Regier et al., 1988), it is important to examine these data more closely, particularly in light of special concerns raised by the study of PTSD in the elderly. For example, PTSD prevalence rates among veterans are based primarily on individuals seeking treatment (Clipp & Elder, 1996), who may not be representative of all WW II and Korean veterans, particularly given the “John Wayne” mentality of this age cohort wherein men were not expected to express their feelings (Lipton & Schaffer, 1986). Additionally, the study of PTSD is a relatively recent phenomenon, thus no prevalence studies were conducted at the time of these wars. Because many veterans of WW II are now deceased, it is not possible to determine the representativeness of published prevalence rates (Molinari & Williams, 1995). Changes in the diagnostic criteria over time further compound these problems. Additionally, examination of older veterans who currently report PTSD symptomatology results in a heterogeneous sample, although some of these individuals have a history of chronic PTSD, others indicate that symptomatology resurfaced after a period of symptom-free functioning, and yet others report the onset of combat-related PTSD in later life. Additionally, older adults with PTSD may be more likely to be misdiagnosed as having a medical problem, because older adults tend to focus on physical symptoms and are more likely to be perceived as having a medical condition than their younger counterparts (Lyons & McClendon, 1990). As such, reported PTSD prevalence rates among older adults may underestimate the occurrence of the disorder. A final problem with studies of prevalence rates among older war veterans is that they focus primarily on men and therefore provide little information about PTSD in older women. Despite these limitations, prevalence rates of PTSD among older adults who were exposed to severe trauma provide useful information about the effects of trauma in later life. Among WW II and Korean veterans, a range of prevalence rates of PTSD has been reported, with higher rates generally being associated with more extreme trauma exposure or injury. As noted in Table 2, prevalence rates range from 3% to 56%. The variability in these rates is explained, in part, by differences in study samples and diagnostic methods. In general, those studies that relied on structured clinical interviews report higher prevalence rates relative to studies that used questionnaire assessment of prevalence. Despite the considerable range, these rates suggest that large numbers of veterans of WW II and the Korean war continue to experience PTSD, even 40 to 50 years after they experienced combat trauma. As seen in Table 3, prevalence rates of PTSD reported for prisoners of war (POWs) are even higher, as would be expected given the relationship between the severity of trauma exposure and PTSD. Studies using structured clinical interviews indicate that upwards of 67% of former POWs report a lifetime prevalence of PTSD, regardless of where they were held in captivity. Table 2. Sample of Posttraumatic Stress Disorder Prevalence Rates Among World War II (WW II) and Korean Combat Veterans Full-size table (<1K) View Within Article Table 3. Sample of Posttraumatic Stress Disorder Prevalence Rates Among World War II (WW II) and Korean Prisoners of War Full-size table (33K) View Within Article Consideration of the prevalence of PTSD among Holocaust survivors is characterized by the same types of problems discussed with respect to the study of veterans. In addition, it is even more difficult to gather information about Holocaust survivors because there are no centralized facilities available for their medical and mental health treatment, as are provided to veterans. Because many Holocaust survivors relocated after the war, it is not surprising that there are no lifetime prevalence studies of PTSD among this group. However, there is some documentation that PTSD is fairly common among this population. For example, Yehuda et al. (1995) noted that 57% of 72 Holocaust survivors met current criteria for PTSD. What is particularly salient in this report is that these individuals were not seeking treatment, suggesting that PTSD may be very common among this traumatized group. Most studies reporting PTSD prevalence rates for individuals who experienced trauma in later life have examined the survivors of natural disasters. For example, Green, Gleser, Lindy, Grace, and Leonard (1996) compared older and younger survivors of the Buffalo Creek Dam collapse. The authors found that, during the 18 to 26 months after the flood, 24% of individuals age 52 to 61 and 28% of those age 62 to 73 met criteria for a diagnosis of PTSD. These figures are comparable with those reported for younger adults in this study. Livingston, Livingston, Brooks, and McKinlay (1992) compared 31 elderly individuals with 24 younger survivors 1 year after the Lockerbie, Scotland air disaster and noted that the elderly had a similar rate of PTSD as younger participants, with 84% and 100% of the older and younger adults meeting diagnostic criteria for PTSD, respectively. These authors observed 19 of the older participants over a 3-year interval, noting that although there was a significant reduction in anxiety symptoms, 16% continued to meet criteria for PTSD (Livingston, Livingston, & Fell, 1994). Shore, Vollmer, and Tatum (1989) examined age and gender differences in PTSD among two rural communities in the United States that had experienced considerable exposure to flooding. Among men aged 60 to 79 (n = 110), 1.1% had lifetime PTSD, although 0% of the women in this age bracket received this diagnosis. Among the male sample, only those in the 45 to 59 age bracket had lower rates (0.7%), although both men (5.2%) and women (7.9%) in the 35 to 44 age bracket had the highest rate of PTSD. In general, these studies suggest that older adults fare at least as well, if not better, than younger adults when faced with trauma. Comment Most prevalence data are derived from veteran samples, a fact that is understandable in light of their availability for study via Veterans Administration facilities. These figures indicate that PTSD is indeed prevalent in older veterans and bears a clear relationship to the severity of trauma exposure. Less is known about the prevalence of PTSD in survivors of other types of trauma. For example, we have no data about the prevalence of PTSD in older adults who have been victimized by others (via crime or other forms of elder abuse) or been involved in motor vehicle accidents. However, the literature suggests that such individuals may meet criteria for PTSD. Older victims of rape (Falk, Van Hasselt, & Hersen, 1997) and various types of maltreatment (Goldstein, 1996) are particularly likely to experience PTSD as a result of their victimization. However, these individuals may underreport their traumatic experiences (e.g., Tyra, 1993) and as such, may be a difficult group to study. Given increasing national concern with issues involving the elderly, it is possible that the near future will include greater study of these populations. Can posttraumatic stress disorder begin many years after trauma exposure in older adults' Delayed-onset PTSD is an infrequently diagnosed variant of the disorder, despite its recognition in each version of the DSM. This syndrome has been most commonly examined among Vietnam war veterans (Watson, Kucala, Manifold, Vassar, & Juba, 1988), although recently, increased attention has been devoted to this topic in the elderly (Sleek, 1998). Herrmann and Eryavec (1994) described two older men who met the criteria for delayed-onset PTSD. In one, the onset of PTSD symptoms was associated with increased pain and disability as a result of rheumatoid arthritis, whereas the second individual could not identify a specific precipitant. Both individuals were exposed to heavy combat, including witnessing numerous casualties. Although one cannot generalize from case studies, this report documents that PTSD can begin many years after trauma exposure. Several theories have been suggested to account for delayed-onset PTSD in later life. These include consideration of the fact that older adults may experience a reduction in physical and mental resilience over time, which reduces their capacity to “ward off” trauma-related memories and feelings (Aarts & Op den Velde, 1996). Additionally, the occurrence of normal stressors such as retirement and bereavement may precipitate delayed-onset PTSD in older adults, because these individuals may not have the psychological resources to cope with life changes. Several studies support this notion. For example, Kuilman, and Suttorp (1989) noted most of 100 WW II survivors had either delayed-onset PTSD or a worsening of PTSD symptomatology, beginning in mid- to later life. These authors noted that 43% of those who experienced delayed-onset PTSD symptoms reported significant life changes during the previous year. Loss of employment and loss of (or separation from) family members were the most frequently reported life events. The findings of Zeiss, Dickman, and Nichols (1985) echo this point: 36% of POWs from both WW II and the Korean war reported delayed-onset PTSD symptoms in later life, having functioned relatively well after repatriation. Apart from the direct effects of life stress, other authors have noted that indirect effects of aging may be relevant as well. Hertz (1990) commented that older adults have more time to reflect on events that occurred earlier in life (including traumatic events) after the demands of their jobs and families are lessened. Indeed, retirement is the most commonly identified event that has been associated with late-onset PTSD (Kahana and Kuilman & Suttorp 1989). However, it may not be retirement per se that is uniquely associated with the beginning of PTSD symptoms. Aarts, Op den Velde, Falger, Hovens, De Groen, and Van Duijn (1996) found that many WW II veterans who were involved in the Dutch Resistance functioned well for many years. However, all but 6 of these men (n = 147) took early retirement (mean age, 61.5), primarily because of conflicts with colleagues. This report suggested that these men may have begun to have difficulty functioning in middle age, which instigated early retirement. It is impossible to ascertain if these job difficulties were the result of the emergence of PTSD symptomatology from this report. Events that resemble the initial trauma also may be likely to trigger delayed-onset PTSD. For example, two reports suggest that the Gulf War triggered delayed-onset PTSD among WW II veterans (Robinson, Netanel, & Rapaport, 1992). It is possible that these older veterans were particularly affected by the Gulf War because they perceived their own traumatization as being in vain (Aarts & Op den Velde, 1996). Case studies may help us understand how such a process occurs. For instance, Christenson, Walker, Ross, and Maltbie (1981) described a veteran who manifested PTSD symptoms at age 55 after observing a 9-year-old boy die in an emergency room. Years before, while involved in combat in WW II, this veteran had to shoot a 10-year-old boy who was believed to have been wired as a human bomb. Apparently, the similarity in the boys' ages triggered distressing memories of the previous trauma, which had not been bothersome earlier. Another possible factor in the development of delayed-onset PTSD is the nature of developmental tasks that are specific to later life. Erikson (1965) described late life as the time when one reflects on earlier events to find the meaning of one's life. According to Erikson's developmental model, this reflection can lead to either ego integrity or despair, depending on the meaning that is given to previous life events. It may be quite difficult to place a positive meaning on events such as observing a friend killed in combat or watching one's family members being taken to the gas chamber. Additionally, it is possible that, in reflecting on life experiences, those who were traumatized earlier in life are forced to review painful memories that they avoided previously. A final consideration is the possibility that cases of delayed-onset PTSD are more accurately reflective of delayed help-seeking. Specifically, some individuals may struggle with PTSD symptomatology for years without seeking help. When older adulthood begins, the individual may seek help, finally recognizing the severity of their symptoms or perhaps motivated by the requests of family members. Comment Although there has not been extensive study of delayed-onset PTSD in older adults, available reports indicate that this phenomenon does occur. Unfortunately, we do not have information on the prevalence or associated features of those individuals who apparently functioned well for many years before the beginning of PTSD symptomatology. Although numerous ideas abound concerning why PTSD could begin many years after exposure to traumatic events, systematic examination of these theories has yet to be undertaken. It does appear that life changes that are normally associated with aging play a role in this process, although their exact role is unknown. Certainly, this issue is central in our understanding of PTSD in the elderly, particularly given the possibility of designing prevention programs for individuals at risk for the development of PTSD in their later years (e.g., veterans). Additionally, the phenomenon of delayed-onset PTSD in the elderly offers a good opportunity to learn more about lifespan development processes and psychopathology. What comorbid features are associated with posttraumatic stress disorder in older adults' Apart from having a diagnosis of PTSD, older traumatized individuals are likely to experience additional psychiatric diagnoses, including major depression, other anxiety disorders, somatic conditions, cognitive disturbances, and alcoholism. This issue has received particular attention among veterans. In these individuals, notable rates of lifetime major depression (37%) and alcohol abuse (53%) have been reported (Herrmann & Eryavec, 1994). In a study of 140 community-dwelling WW II and Korean veterans, Summers, Hyer, Boyd, and Boudewyns (1996) reported higher comorbidity of depression, anxiety, and substance abuse in those diagnosed with PTSD, relative to veterans who met partial criteria for PTSD and those who were symptom-free. Several other studies have reported high levels of alcohol abuse among WW II and Korean veterans (e.g., Branchey; Buck and Sierles). Often, the use of alcohol is rationalized as a means of self-medication to reduce symptoms such as recurrent nightmares, insomnia, and anxiety. Davidson, Kudler, Saunders, and Smith (1990) reported a progression of comorbid diagnoses after trauma exposure in which individuals were diagnosed initially with PTSD, followed quickly in time by a secondary diagnosis of alcohol abuse. Later in life, additional Axis I disorders were noted, including generalized anxiety disorder, panic disorder, and major depression. In this same vein, Herrmann and Eryavec (1994) found that veterans who were diagnosed with PTSD were more likely to meet criteria for a diagnosis of generalized anxiety disorder (50%) when compared with veterans without PTSD (26%). It is noteworthy that comorbid disorders are not unique to traumatized combat veterans. Livingston et al. (1992) noted that older adult observers of the Lockerbie air disaster had high rates of major depression in the initial period after the trauma, as well as 3 years later (Livingston et al., 1994). Aside from this report, however, little work has been conducted to examine the patterns of comorbid disorders that accompany PTSD in older adults. Clearly, we have much to learn in this domain. Comment Comorbid disorders are common in older veterans with PTSD, as has been observed in younger veterans. Unfortunately, there are scant data concerning this issue in other populations, as was noted in the section on the prevalence of PTSD in older adults. It is possible that comorbid disorders are more easily overlooked in the older adult with PTSD, implicating that misdiagnosis may occur. Likewise, older adults may receive symptomatic treatment (e.g., hypnotics for sleep disturbance) in lieu of interventions that target the broader symptom pattern of PTSD and its comorbid disorders. A larger database is needed to explore these issues, particularly in nonveteran samples of older adults who have experienced traumatic stressors. What are the radiating effects of exposure to trauma on the elderly' In addition to a recent focus on the prevalence and symptom patterns of PTSD in older adults, a larger body of literature exists that examines related features of trauma exposure among older persons. These writings approach this issue from a nonpsychiatric perspective, emphasizing clinical features, physical consequences, and social-psychological aspects of trauma exposure. This diverse collection of writings is reviewed in this section, with particular emphasis on what these sources tell us about adaptation to stress in the elderly. Initial attempts to examine the acute response to extreme stressors in older adults were characterized by a focus on general distress. Typically, the age ranges in these studies were quite broad, with inclusion of individuals as young as 36 in the “older adult” category (e.g., Price, 1978). Mixed conclusions emerge from these studies. Some of these reports indicated that, relative to younger individuals, older adults reported greater distress both immediately after a trauma (e.g., Hansson, Noulles, & Bellovich, 1982) and up to 3 years later (e.g., Kilijanek & Drabek, 1979). Other investigations reported the opposite effect, specifically that older individuals were less distressed by exposure to extreme stressors and showed greater resilience than younger adults (e.g., Bell; Gleser and Taylor). Given this diversity of findings, it is difficult to draw conclusions from this literature. This issue is particularly relevant to understanding the concept of risk and vulnerability in the development of PTSD. As discussed cogently by Fields (1996), advancing age potentially represents a differential vulnerability factor that moderates the impact of exposure to a stressor. Presumably, if older persons are more susceptible to the effects of a stressor, greater negative effects on their psychosocial functioning could be expected, regardless of the type of trauma to which they are exposed. Ample reasons exist to suspect greater vulnerability to extreme stress among older adults, including diminished personal coping skills, physical and cognitive deterioration, lessened social support, and reduced financial resources to replace material loss. Alternatively, the older person may be better able to accommodate the impact of a stressor, based on a lifetime of learning to adjust to negative events (e.g., Bell, 1978). In this regard, it is useful to examine the impact of exposure to extreme stress at multiple levels, including psychological phenomenon, physical consequences, and available coping strategies. General Psychological Effects Studies examining the psychological impact of exposure to extreme stress suggest that pretrauma psychological functioning is the overall best predictor of emotional outcomes after a trauma. For example, Yehuda et al. (1995) examined the impact of recent stress on older Holocaust survivors with and without PTSD and comparison participants. Results indicated that recent stressful events were associated with a greater severity of trauma-related symptoms, particularly avoidance symptoms, but only in those individuals with a PTSD diagnosis. Similarly, in a study of 200 older (aged 55+) survivors of two consecutive floods (Phifer, 1990), pretrauma levels of anxiety, depression, and general distress accounted for 30% to 40% of the variance in postflood symptom levels. Demographic factors, including age, accounted only for 3% of the variance in symptoms. In fact, individuals aged 55 to 64 showed the highest levels of psychological distress relative to participants aged 65 and older in this study. Although both psychological and physical consequences were related to the severity of the flood (Phifer & Norris, 1989), preflood psychological functioning was the best predictor of outcome. Thus the psychological effects of trauma exposure in older adults depend heavily on the individual's premorbid functioning, particularly with regard to anxiety, depression, and extant PTSD. Some authors have speculated that experience with a previous trauma contributes to positive adaptation with a subsequent extreme stressor (e.g., Norris and Phifer). For example, Norris and Murrell (1988) examined a sample of elderly flood victims and noted evidence for both direct tolerance (exposure to a specific stressor inoculates the individual to the subsequent effects of the same type of stressor) and cross tolerance (exposure to a specific stressor inoculates the individual to the subsequent effects of a different stressor). However, characteristics of the stressor and individual differences in coping skills appeared significant in this report. In this same vein, Solomon and Prager (1992) noted that the psychological effects of exposure to the Persian Gulf War were considerably greater on older Israeli citizens who were Holocaust survivors relative to citizens who did not have this background. In particular, Holocaust survivors reported greater perceptions of danger, more psychological distress, and higher levels of both state and trait anxiety. Again, trauma characteristics and individual differences appeared significant in this study. As discussed by Lyons (1991), perceptions of control, interpretations of the meaning of the initial trauma, and social support after trauma exposure most likely influence coping with subsequent stressors. Physical Effects Physical consequences of trauma exposure are an additional dimension that deserves discussion when considering the impact of stressors on the elderly. It is well-established that specific laboratory stress tasks create excessive physiological reactivity that eventually may contribute to the development of physical disorders such as cardiovascular disease, diabetes, headaches, and chronic pain (e.g., McNeilly & Anderson, 1996). However, little work has examined these interrelationships directly in the elderly, an omission that limits our understanding of the long-term, radiating impact of stress exposure. Research with WW II veterans has noted increased cardiovascular risk compared with recent surgical and heart patients (Falger, Op den Velde, Hovens, Schouten, DeGroen, & Van Duijn, 1992). It is difficult to determine whether this finding reflects poorer health habits (e.g., lack of exercise, poor diet, smoking) or is indicative of the long-term effects of combat exposure. The complexity of this issue is compounded by the possibility that older adults are more likely to manifest trauma-related symptoms somatically (e.g., Lipton and Nichols). For example, a comparison of Holocaust survivors with control participants who were matched on ethnic and cultural backgrounds indicated that the survivors reported more physical symptoms, but only for illnesses that could be psychogenic in origin (e.g., ulcers; Kahana, 1992). No differences were noted between survivors and comparison participants on diseases such as cancer, Parkinson's disease, and arthritis. Clearly, this complex issue deserves greater attention, with sensitivity to lifestyle factors, cultural effects, and gender differences. Coping Strategies Consideration of the effects of exposure to extreme stressors would not be complete without a discussion of coping strategies (Lazarus & Folkman, 1984). In this domain, there are very few empirical studies that focus on coping strategies used by older adults after a traumatic event. In some respects, this may be reflective of a professional tendency to look for negative effects (symptoms) after trauma exposure, with a concomitant neglect of positive adaptation. Clearly, both aspects are relevant in our understanding of trauma recovery in the elderly. The changing cultural environment has contributed to this process as well. As noted by Summerfield (1996), “a victim processes traumatic experiences as a function of what it means, meanings that are drawn from the society and culture of the times” (p. 375). Thus many veterans of WW II returned home with the goal of putting the war behind them and rebuilding their work and family lives. There was a feeling that the war atrocities to which these men had been exposed would not be forgotten, nor should they be, given the nature and meaning of these experiences (Summerfield, 1996). This perspective argues for more careful examination of positive coping strategies after trauma exposure, particularly in light of generational differences in the perception of what constitutes a trauma. This view is supported by Kahana's (1992) study of elderly Holocaust survivors. As noted in this study, despite reporting greater psychological distress on the Symptom Checklist-90 (SCL-90), the survivor group had superior job histories, higher incomes, greater residential stability, and lower divorce rates relative to a comparison sample matched for ethnic and cultural background. Additionally, this sample was split with regard to their perception of whether the Holocaust had a positive effect on them (34%) or a negative effect (46%). Factors that were significantly associated with positive affect among the survivors included discussing Holocaust experiences with family and friends, having an altruistic orientation toward the world, maintaining an internal locus of control, and having a spouse who was a survivor also. Similar findings have been reported in an uncontrolled study of elderly survivors of Pearl Harbor (Wilson, et al., 1989) and discussed in clinical writings (e.g., Molinari & Williams, 1995). In many respects, these reports highlight the important role of social support, perceptions of control, and related dimensions of positive coping with extreme stressors. Perhaps the more useful findings regarding coping with trauma exposure come from three life course studies that provide information about premorbid functioning and the development of PTSD in veterans (Clipp & Elder, 1996). These studies include the Oakland Growth Study (birth years 1920–1921), the Berkeley Guidance Study (birth years 1928–1929), and the Lewis Terman Study (birth years 1904–1920). As discussed by Clipp and Elder, although the severity of combat experience was associated with symptomatology both immediately after the war and during later years, other factors also appeared important. For example, individuals who reported more stress symptoms after combat service had higher levels of perceived self-inadequacy, were more introspective, and reported lower levels of ego resilience during adolescence. Additionally, 75% of individuals who reported emotional problems after combat had experienced nightmares in childhood. Timing of combat exposure also was an important factor. Younger soldiers were more likely to experience stress reactions after combat exposure, suggesting that emotional maturity may increase resilience in coping with trauma (Hastings, 1991). These longitudinal studies suggest that premorbid coping styles may be relevant in considering how individuals process traumatic experiences, both at the time of occurrence as well as during later life. Coping With Nontraumatic Age-Related Stressors A related body of literature has examined coping with age-related stressors, such as the death of a spouse, physical disability, and relocation to a structured care environment, such as a nursing home. Although these life events are clearly stressful, they do not approximate traumatic stressors. It is unclear whether one can generalize from these studies to draw conclusions about coping after an extreme stressor. However, these studies offer a preliminary glimpse at how older adults adapt to changing life circumstances and, as such, are reviewed briefly. One of the more thorough studies in this domain is the Life Events and Aging Project (e.g., Guarnaccia & Zautra, 1996). This study examined two common uncontrollable life stressors associated with aging, the death of a spouse and the onset of a disability resulting from illness or injury. After these stressors, participants were assessed monthly for 10 months and subsequently 6 months later, with particular focus on stressful life events and psychological functioning. The results clearly highlight the fact that the type of stressful life event deserves consideration, particularly given the nature of stressful events that are most typical for older adults. Bereaved individuals, although reporting depression immediately after the death of their spouse (as expected), experienced less overall psychological distress throughout the assessment interval. In fact, most of the bereaved individuals showed significantly greater emotional recovery in the 16 months after the death of their spouse relative to the disabled sample. One of the factors that mediated successful adaptation for both the bereaved and disabled participants was engaging in active efforts to cope with their life changes. Additionally, the bereaved sample showed improved coping with subsequent loss events (e.g., the death of a close friend), a finding that echoes the evidence for direct tolerance (inoculation) reported by Norris and Murrell (1988). Related literature has focused on relocation of the elderly into a structured care environment. Although the complete scope of this literature is outside the focus of this article (see Fields, 1992), it is clear that better psychological functioning has been reported among nursing home residents after the initiation of interventions designed to increase their sense of control (e.g., Langer & Rodin, 1976). This type of study clearly suggests that the specific nature of the stressful event is salient in determining psychological adjustment in the elderly, as well as the individual's approach to coping. It is possible that increased attention to psychological factors, such as perception of control, may help us to learn more about the development of PTSD in older adults, particularly in light of what these studies suggest about coping with age-related stressors. Comment If one takes a broader perspective in examining older adults' adaptation to traumatic life events, several issues surface. In contrast with earlier literature, more recent studies have shown refinements in methodology, such as clarification of age categories that define “older adults” and consideration of trauma characteristics. In addition, the focus has shifted from attempting to compare younger versus older adults to determine whose adaptation to trauma is superior. This shift in emphasis reflects an understanding that trauma exposure does not necessarily impact adults in a linear fashion with regard to age. Specifically, one cannot expect a one-to-one relationship between age and functioning after trauma exposure. Clearly, this shift in focus has benefited our understanding of how older adults cope with enormously stressful events by highlighting the complexity of this issue. Despite this positive shift in focus, a number of questions remain. It is clear that premorbid functioning plays a major role in determining whether an older individual is at risk for experiencing PTSD after trauma exposure. However, what is unclear is how related factors influence this process. For example, in some studies trauma exposure appears to inoculate the individual to the negative effects of subsequent trauma exposure. In other reports, the additive negative effects of multiple trauma exposures are apparent. Is the nature of the trauma salient in this regard (e.g., the trauma of a natural disaster, such as a flood, versus war atrocities)' Unfortunately, direct comparison of these studies is confounded by differences in time course. Survivors of the Holocaust and WW II have by definition “lived with” the aftermath of trauma exposure for a considerably longer time than individuals who have been studied after natural disasters. One also has to ask if additional dimensions are involved. For example, the available literature highlights the role of both negative (avoidance and emotional numbing) and positive (use of social support, perceptions of control) coping strategies in mediating this process. These processes emerge in studies that focus on exposure to traumatic events, as well as age-related stressors, suggesting some degree of conceptual convergence on the importance of coping processes in older adults. Clearly, study of risk factors for the development of PTSD in the elderly could benefit from greater integration with the broader literature on stress and coping in later life (e.g., Stephens, Crowther, Hobfall, & Tennenbaum, 1990). Additionally, we know very little about the physical effects of trauma exposure on the elderly. Given that adverse physical effects of laboratory stress have been well documented, it would be timely to extend these paradigms to older adults. This basic laboratory work could help us to differentiate the effects of stress per se from the natural physical changes associated with aging. Given the fact that considerable heterogeneity exists among older adults with respect to physical status, this research area appears ripe for exploration. Summary In reviewing the literature on PTSD in older adults, one is struck by the many questions that remain unanswered. It is clear that PTSD does occur in the elderly and can be diagnosed using the DSM criteria, which were derived from studies involving younger samples. Specific symptom profiles may differ in the older adult, particularly in those individuals with chronic PTSD. These potential differences could lead to misdiagnosis of PTSD in the elderly, an outcome that would impact derivation of accurate prevalence rates and documentation of comorbid disorders that accompany PTSD in elders. Although the study of PTSD in older adults is a complicated undertaking, identification of those symptoms that are unique to older adults would greatly advance our research and clinical efforts in this arena. The phenomenon of delayed-onset PTSD is another interesting facet of this literature. This issue is characterized by numerous theories, each of which potentially can enrich our understanding of aging and psychopathology. The role of life stressors, particularly those associated with normal aging (such as bereavement and retirement) appears salient in this regard. Given intergenerational differences in the acceptability of reporting emotional difficulties, as well as use of coping strategies, this topic can enhance our knowledge about risk factors for the development of PTSD. In particular, the concept of vulnerability to traumatic stressors appears to be a useful organizing scheme for understanding both acute and delayed-onset PTSD in older adults. In reviewing the available literature on general psychological effects of trauma exposure, suggestions concerning those factors that predispose an individual to PTSD emerge. In particular, multiple dimensions of psychosocial functioning surface in the literature as interesting and useful factors that will assist in understanding risk and vulnerability, including pretrauma symptomatology, the availability of adequate social support networks, use of positive and negative coping strategies, and perceptions of the meaning of the traumatic event. Importantly, these are dimensions that have been identified as relevant in the development of PTSD in younger adults as well. One should not necessarily assume, however, that these processes influence older adults in the same way as younger adults. Certainly, aging brings about unique changes that deserve consideration in the study of PTSD in older adults. Hopefully, future studies will help us to develop coherent conceptual models of PTSD that account for these unique facets of the disorder as expressed in the elderly. 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