Four Ways Sufferers Contribute to Missed PTSD Diagnoses

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The problem: Diagnoses of PTSD are frequently missed.

Post-traumatic stress disorder (PTSD) may be the most difficult psychiatric disorder to diagnose accurately. In one study with adult inpatients on a psychiatry unit in South Africa, researchers discovered that treating clinicians missed the diagnosis of PTSD 85 percent of the time (Van Zyl et al., 2008). The same story goes for children and adolescents; treating clinicians at two mental health programs missed the diagnosis of PTSD 91 percent of the time (Miele and O’Brien, 2010).

However, clinicians in the hospital ward or in the office are not the only individuals who miss the diagnosis. There are no known studies of how often trauma sufferers miss the diagnosis in themselves (or parents miss the diagnosis in their children), but I think it is likely just as commonly missed at home.

How it happens: Four things trauma sufferers do to hide problems

In several previous blogs, I explained things clinicians do that lead to missed diagnoses. These included not using standardized assessment tools, misdiagnosing PTSD as a different disorder, and missing the internalized symptoms of PTSD while focusing on the externalized symptoms of comorbid disorders. The purpose of this post is to explain things that trauma sufferers do that lead to missed diagnoses. In my experience, there are at least four main reasons.

1. Functioning with workarounds: In the scientific literature, patients’ lack of readiness to engage in psychotherapy for PTSD has often been referred to in terms of lacking sufficient emotional stability (Cook et al., 2017). That pattern may be more apparent in patients who come to offices, but a very different problem, which I think is more common, is that victims of trauma have, in fact, developed emotional coping skills sufficient to allow them to continue to function fairly normally.

Almost all of them figure out how to avoid triggers in their environments. Many of them work harder to get their work done or keep their grades up. Some individuals may turn to marijuana, alcohol, or cigarettes to calm their nerves. Many individuals can keep this up for decades. As long as they can function, they lack the motivation to seek help. As each year passes, they lose a little bit of motivation to address the PTSD in psychotherapy.

2. Fear of retaliation: In many cases of sexual assault, there have been two threats. The first threat was the actual assault on the victim. The second assault was a threat by the perpetrator that if the victim tells anyone, the perpetrator will come back and kill their family. These threats prevent many victims, particularly children and adolescents, from disclosing their assaults.

3. Admissions of problems feel like being declared unfit: Disclosure of trauma can be perceived as a sign of weakness to oneself and to others. An obvious example would be military men and women who hide symptoms following combat trauma because they do not want to appear unfit to their fellow soldiers. I think this phenomenon likely applies to everyone outside the military, too, because we all have our tribe mates who depend on us.

4. Many believe they deserve to suffer: Some rape victims blame themselves, thinking, maybe I should not have worn that dress. Some victims of domestic violence feel like they deserved it, thinking, I knew what he was like when I got involved with him. Some victims of accidents and war who lost friends feel like they deserve to feel guilty because they survived when their friends did not.

Many victims of all sorts of traumas feel a sort of acceptance of their guilt and suffering, thinking maybe this is what fate has in store for them, and they must bear it. Because of feelings of guilt or fate, many sufferers are not motivated to acknowledge and deal with their PTSD.

What it means

For those who do seek help, make sure you have a thorough discussion about trauma experiences and PTSD symptoms with your provider. If your provider does not give you a standardized questionnaire of trauma exposure and PTSD symptoms, there are many free ones on the internet you can do yourself.

Post-Traumatic Stress Disorder Essential Reads

Trapped in War Zones

The Trauma Paradox

If you start psychotherapy focused on PTSD and find yourself losing motivation for it, ask yourself if you may have one of the reasons above. Are you getting by in your work because of workarounds? Do you feel like you are unfit and possibly letting people down around you? Do you feel survivor guilt and/or believe you deserve to suffer? These issues may be causing you to miss out on treatment that can help you.

For those who do not ask for help, you should know that good help is available. Every therapist may not be right for treating PTSD, so you may need to shop around. You can screen clinicians over the phone and be sure to ask if they use evidence-based treatments for PTSD, such as cognitive-behavioral therapy. In 2017, the Veterans Administration launched a useful online PTSD Treatment Decision Aid that walks you through your treatment options. It is free and does not collect your personal information.

All of us, clinicians and sufferers alike, are trying to understand the confusing things that happen following trauma. None of us has been given a user manual for the brain. The diagnosis of PTSD is perhaps one of the more tricky things to figure out.