Studies estimate that approximately five percent of United States citizens are experiencing Post-Traumatic Stress Disorder (PTSD) at a given time. However, given that seventy percent of people have experienced a traumatic event at some point in their life, and some may even argue one hundred percent of people, it seems that only five percent of Americans developing PTSD is far too small a number to be accurate. In fact, studies are starting to show that PTSD often gets missed in the diagnosis. In a study of adult inpatients in South Africa, 40% of the participants met criteria for PTSD, however only 5.5% of the patients were given a diagnosis of PTSD by the clinic. Another study of adults with a previously diagnosed mental health condition reported that 62% of participants who met criteria for PTSD had never been diagnosed with it before, demonstrating once again that PTSD is being under-diagnosed even by trained professionals. This rate of under-diagnoses jumps up drastically when concerning children. For example, in a study of 426 maltreated 6-18 year old children living in out-of-home care, only 1.7% of the sample was reported to meet criteria for PTSD. This number is likely inaccurate, as other studies have shown that PTSD in children and adolescents was missed by clinicians about ninety percent of the time. How is it that even professionals trained to diagnose mental illnesses fail to identify PTSD at such alarming rates? A possible explanation for this could be that the overlapping symptoms of PTSD with other psychiatric diagnoses leads to the patient receiving an alternative, and more common, diagnosis.
Several symptoms of PTSD can easily be misconstrued as being caused by another disorder. A common example of this occurring is in children who get diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), but who are actually showing symptoms of PTSD. This overlap is especially prominent in the symptom dimension of PTSD involving alterations in arousal and reactivity. This includes difficulty concentrating, which is also represented in the inattention criterion of ADHD. It also includes irritability or aggression and risky or destructive behavior, which can be seen in the impulsivity aspect of ADHD. Additionally, the hyperactivity subtype of ADHD, involving fidgeting, restlessness, and always seeming “on the go,” can look very much like behaviors displayed because of the hyper-vigilance and heightened startle reactions seen in individuals with PTSD. Finally, a child with the predominantly inattentive type of ADHD, or with the sluggish cognitive tempo subtype, will often appear as if they are daydreaming, spacey, and in a daze, while a child who is dissociating because of PTSD would display the same behavior as well. Because of the extensive overlap between the symptoms of these disorders, it is not hard to imagine that one often gets mistaken for the other. However when this happens, it is usually PTSD being mistaken for ADHD because inattentive, hyperactive, and impulsive behaviors make people automatically think it is ADHD (the more common diagnosis) even though these behaviors can also be the result of chaos, neglect or abuse involved in trauma.
Another disorder with overlapping symptomology is generalized anxiety disorder (GAD), or what most people just call anxiety. In this case, the overlap falls across multiple symptom dimensions of PTSD. Under the intrusion symptoms category, the similarities in symptomology are more physical reactions. For example, one of the symptoms for GAD is sleep disturbance, and one of the symptoms for PTSD is nightmares, which would cause sleep disturbance. Another symptom of GAD is muscle tension, which could also happen because of physical reactions after exposure to trauma reminders. Similar to ADHD, GAD also has parallels under the alterations in arousal and reactivity criterion of PTSD. GAD symptoms include irritability and difficulty concentrating, which are also symptoms of PTSD. Restlessness and feeling keyed up or on edge are also symptoms of GAD that would present similarly to the hyper-vigilance and heightened startle reactions seen in individuals with PTSD. An additional congruence between GAD and PTSD is in the excessive anxiety and worry characteristic of GAD. An individual with GAD is likely to have negative cognitions about themself, lower self-esteem, and often be wary of the world around them. These same symptoms can also be seen under criterion of PTSD with negative alterations in cognitions and mood, which includes overly negative thoughts and assumptions about oneself or the world and exaggerated blame of self.
Another disorder that contains these negative alterations in cognitions and mood is Major Depressive Disorder (MDD), or what most people call depression. One of the main points in the diagnosis of MDD is depressed mood most of the day, nearly every day. This mood is also likely to be present in individuals with PTSD, as some of the symptoms include negative affect, feeling isolated, and difficulty experiencing positive affect. Individuals with MDD might also report feelings of worthlessness, much like those with PTSD might have overly negative thoughts about oneself. Along with that, MDD symptoms include excessive or inappropriate guilt, which would be especially prominent in people with PTSD because they may blame themselves for the trauma that occurred. Another major aspect of MDD is anhedonia, or loss of interest in activities the person normally enjoys or doesn’t mind. This symptom may also appear in individuals with PTSD. However, avoidance behaviors associated with the trauma may also look like anhedonia. For example, if someone used to love going to dance class every week and suddenly they no longer go, it might look like they are just experiencing anhedonia associated with depression, but it could actually be that they were assaulted on their way home from dance class and now they avoid it all together to escape reminders of the trauma and protect their own safety. Along with negative alterations in cognitions and mood, other symptom dimensions of PTSD are parallel to those in MDD. Similar to anxiety, nightmares of the trauma would also interrupt sleep and appear like the sleep problems associated with MDD, which include insomnia and fatigue or loss of energy. Finally, MDD symptomology also includes diminished ability to concentrate, as with ADHD, anxiety, and PTSD.
It is possible, and even common, that these disorders could be occurring at the same time though, seeing as approximately eighty percent of individuals with PTSD also have another co-occurring psychiatric disorder. In adults, the prevalence of PTSD is significantly higher among those with ADHD compared with controls. In one study with veterans, 40% of people who were diagnosed with PTSD were also diagnosed with GAD. Finally, MDD is about three to five times more likely in people who have PTSD than in those who don’t. However, even though chances of these disorders occurring together are high, we cannot excuse the fact that PTSD still fails to be diagnosed an alarming percent of the time. Especially because normally when the disorders are co-occurring, the root cause of them lies within the trauma. In these cases, it is extremely important to ensure the trauma gets diagnosed in order to provide the most effective treatment. Because although there is a lot of work that can be done on the comorbid disorders individually or the symptoms of the overlapping disorders that were misdiagnosed, one cannot fully resolve the issue and move forward until the root of the problem is addressed: the trauma. So how can we better ensure that PTSD does not get missed in the diagnosis?
The solution is actually quite simple. An extremely quick and easy way to identify PTSD is to give standardized assessments of traumatic events and PTSD symptoms to everyone. We already give standardized assessments to everyone upon intake to a clinic, so all that would need to be done is to tack the additional PTSD assessment to the end of the pre-existing one. However, clinicians are still hesitant to do even that. Many clinicians are concerned that asking about trauma too soon or that bringing it up will be too upsetting for the clients. This hasn’t shown to be true. One clinician used this practice of universal screening upon intake for nearly 1,000 clients of all ages and found hardly any resistance from his clients. It also seems that we are underestimating the resilience of patients. If clients are coming into the practice for treatment, they want the treatment that is going to work most effectively. Doing so would mean making sure that we give them the proper diagnosis in order to find the best treatment plan, which would be based upon this diagnosis and the abilities of the client. If concerned about it being too much for the client, we have to remember that the client has the ability to not report trauma initially if they are not prepared to handle it at the time, as well know that clinicians are trained to read when they may be pushing the client too hard so they can back down if it really is too much. To assume that addressing trauma would be too much for client before even allowing them the chance to show that it’s not is largely ignorant of the resiliency of humans. We cannot be afraid to talk to about trauma. Without this conversation, thousands of people get missed when diagnosing PTSD or get misdiagnosed with another disorder. Without this conversation, we are sacrificing the opportunity for effective treatment and progress.