More Than a Diagnostic Checklist: PTSD and the Heterogeneous Nature of Grief

Allison Musante is the associate editor of Clinical Geriatrics and Annals of Long-Term Care. E-mail her with thoughts on this blog entry at

In June, Clinical Geriatrics began a series of clinical review articles examining the incidence, prevention, and treatment of post-traumatic stress disorder (PTSD) in older adults. As I was researching and editing these articles for the journal, I couldn’t help but consider a sentiment best expressed by American author Anne Marrow Lindbergh: “Grief can’t be shared. Everyone carries it alone. His own burden in his own way."

Over hundreds of years—from the Epic of Gilgamesh to combat in Iraq and Afghanistan—the nature of PTSD has eluded us. As Drs. Osei-Boamah, Pilkins, and Gambert noted in part 2 of the series, “the exact cause of PTSD is not well understood, nor are the reasons why some people develop PTSD but not others.” In scientific pursuit of an answer to this question, our understanding of PTSD has certainly progressed from what was once considered a factitious condition stamped onto a cowardly soldier’s ticket home to what is now considered an evidence-based diagnostic entity, representing millions of dollars in healthcare services every year. One of the most salient points that these articles raise is that PTSD can affect anyone and can develop following many different kinds of traumatic events, confronting a historical assumption that PTSD primarily affects men and women who have served on the vanguards of war.

This year, the DSM-5 updated its diagnostic criteria for PTSD to more clearly define a traumatic event that can lead to PTSD. This includes directly experiencing trauma, witnessing trauma, learning of a traumatic event that affected loved ones, and extreme exposure to traumatic events through the media. When you pause to consider this, it seems like practically anyone you know—regardless of location, age, or sex—has experienced a traumatic event that fits into one or more of these categories.

Furthermore, take a moment to revisit some of the “warning signs” of PTSD following a traumatic event, which Drs. Osei-Boamah, Pilkins, and Gambert listed in their review:

-A feeling of intense fear, helplessness, and/or horror

-Persistent anxiety or worrying

-Disruptive sleep

-Increased irritability

How many of us have felt some of these things after losing a loved one? After September 11? After the murders at Sandy Hook Elementary School? I think we can all agree that it would be truly astonishing to find a person who has managed to go through life completely unscathed by trauma or tragedy—whether experienced first-hand or experienced through empathy. But not everyone will develop the PTSD symptoms of intrusive recollection, avoidance, and arousal to such an extreme degree that they impede daily functioning. Many people find ways of moving forward. So, still the question remains: why do some people develop PTSD and not others?

I, for one, am still haunted by flashes of the World Trade Center collapsing into rubble every time I drive into New York City to visit my grandmother in the Village; I will probably always feel a moment of anxiety in a darkened movie theater; and I'll admit that sometimes I hit the “mute” button on my TV while watching local news when I’ve heard enough sad stories for the day. But these feelings do not stop me from getting out of bed every morning, walking out my front door, and going about my day. Yet, the same may not be true for my neighbor.

This series has highlighted an important consideration for healthcare providers: every individual manages trauma in a unique way. Although grief is common to us all, its experience is not homogenous. It seems that PTSD is an extremely personal disorder—more so, perhaps, than any other physical or mental ailment. Why do some people develop PTSD and not others? This may just be the simplest answer.