Psychiatry Research Case Reports 3 (2024) 100207

Contents lists available at ScienceDirect

Psychiatry Research Case Reports
journal homepage: www.elsevier.com/locate/psycr

Challenges in diagnosing Posttraumatic stress disorder in dementia: A
case report
Sjacko Sobczak a, b, c, *, Maaike van Kordenoordt c, d, Renske Uiterwijk a, c, Joan M. Cook e,
Demi C.D. Havermans a, c, f, Larissa Vossen a, Inez Ramakers g, Miranda Olff h, i, Sebastiaan P.
J. van Alphen c, jaDepartment of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
Rotterdam University of Applied Sciences (RUAS), Research Center Innovations in Care. Rotterdam, the Netherlands
Mondriaan mental health center, Heerlen, Maastricht, the NetherlandsdZuyderland Care, Sittard, the NetherlandseDepartment of Psychiatry, Yale School of Medicine, New Haven, CT, USAf
TanteLouise, Bergen op Zoom, the NetherlandsgAlzheimer Center Limburg, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the NetherlandshDepartment of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Neuroscience, & Amsterdam Public Health, Amsterdam, theNetherlandsi
ARQ National Psychotrauma Centre, Diemen, the NetherlandsjVrije Universiteit Brussel (VUB), Department of Psychology, Personality and Psychopathology research group (PEPS), Brussels, Belgiumbc

A R T I C L E I N F O

A B S T R A C T

Keywords:
PTSD
Dementia
Older adults
Personality disorders
Neuropsychiatric symptoms

Background: Assessment of Posttraumatic Stress Disorder (PTSD) symptoms in individuals with dementia isdifficult due to diagnostic challenges like an incomplete self-report, interference of neuropsychiatric symptoms
and overlapping comorbid psychiatric symptoms.
Objective: These diagnostic challenges are articulated here and an in-depth evaluation of assessment of PTSD indementia is given.
Method: A qualitative case design was used including an 88 years old woman, living in a nursing home, withmoderate-severe dementia and suspected PTSD. The TRAuma and DEmentia(TRADE)-interview, a semistructured tool to diagnose PTSD in dementia, was assessed independently by two psychologists, followed bya debriefing in which the outcomes were discussed with the use of informant measures (NeuropsychiatricInventory-Nursing Home (NPI-NH), the Gerontological Personality Disorders Scale (GPS), Levels of Personality
Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0) and Personality Inventory DSM-5-Brief Form (PID5-BF).
Results: TRADE-interview indicated PTSD triggered by a cycling accident with agitation as a neuropsychiatric
symptom. Personality assessment indicated features of a cluster C personality disorder (PD) with core features ofnegative affectivity and detachment. In the debriefing psychologists reported three challenges: attributing
symptoms to the past traumatic event, interference of neuropsychiatric symptoms and overlap in symptoms
between PTSD and PDs.
Conclusions: Distinguishing PTSD symptoms in those with dementia from neuropsychiatric and PD symptoms
requires careful evaluation of all symptoms present. The TRADE-interview can be helpful, but sometimes
additional resourcefulness and good clinical considerations are advised.

Introduction
Traumatic stress, especially when present in early childhood, hasbeen found to increase the likelihood of experiencing psychiatric illness

in both mid-life and late-life, of which of Posttraumatic Stress Disorder(PTSD) is the most prevalent (Iqbal et al., 2022; Riedl et al., 2019). PTSD
is an independent risk factor for cognitive decline and all-cause de­mentia (Gunak et al., 2021) and its comorbidity in dementia is estimated* Corresponding author at: Maastricht University, FPN / NP&PP, P.O Box 616, 6200 MD Maastricht.
E-mail address: sjacko.sobczak@maastrichtuniversity.nl (S. Sobczak).
https://doi.org/10.1016/j.psycr.2024.100207
Received 4 August 2023; Received in revised form 11 January 2024; Accepted 15 January 2024
Available online 15 January 2024
2773-0212/© 2024 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

S. Sobczak et al.

Psychiatry Research Case Reports 3 (2024) 100207

diagnosed with dementia by a clinical geriatrician (DSM-5: Major
Neurocognitive Disorder due to multiple etiologies currently withmoderate severity). She has had chronic pain for 30 years after a serious
traffic accident in which she was involved with her bicycle and got
heavily injured (she was hit by a car), on which she focused more since
her admission to the nursing home. Her medical history reported
COVID-19, hypothyroidism, chronic kidney failure, and a mastectomy ofboth breasts. When her children were teenagers, she was treated by apsychiatrist for five years for depression (severity unknown). Her chil­dren said that this treatment consisted of medication and a short con­versation with the psychiatrist once every two months. She reportedly
found this ’a terrible experience’ and she stopped treatment. Two years
later she was successfully treated for grief at a Mental Health Center for
2 months. Thereafter she felt well for a longer time (length unknown).
According to her children, this has helped her at that time.
Since the woman was admitted, nurses noted that, whenever she
experienced a lot of pain, she expressed feelings of hopelessness andpowerlessness. This happened most frequently when she was alone in
her room without distractions. Every dull moment she started talking
about the pain. According to the nurses and her children, she required a
lot of care and attention and made a strong appeal to them, especially
her son. Her family attributed this ‘dependent’ behavior to her person­
ality. At those moments she perseverated about the cycling accident andher pain. Often in the morning, the pain was perceived with such in­tensity that nurses found it hard to motivate the woman to get out of bed.
She would endorse the pain severity on a scale of 1–10 as a ‘10+’.
However, nurses reported that this intensity was never ‘reflected in her
facial expressions’.
According to her children, the focus on pain complaints had
increased simultaneously with her cognitive decline. The psychologist at
the nursing home suggested that this might be due to an increased focus
on the past and currently fewer distracting activities. Therefore, thepsychologist decided to do a life-review, a treatment technique, in whichmemories are reviewed (Maercker and Bachem, 2013). After thistreatment the woman still often recalled negative memories but could
recall joyful moments in conversations as well.
Since the woman made limited gains in life review treatment, andcontinued to report physical pain and dependent behavior, an in-depth
assessment was taken to assist in diagnosis and treatment planning. As
Fig. 1 shows the procedure. To motivate an in-depth discussion about
the diagnostic challenges two independent psychologists (not previously
involved in treatment and care of the participant) were involved in the
diagnostic procedure; they first independently assessed the findings ofthe participant in order to subsequently arrive at an undivided
consensus PTSD diagnosis, during a debriefing (see Appendix 1). To
reduce information bias, the TRADE-interview was taken simulta­
neously and rated independently.

to be 4.7–7.8 % (Sobczak et al., 2021). Worldwide, the number of people
with dementia is skyrocketing; indeed the number of people with de­mentia will almost double every 20 years to about 115.4 million in 2050
(Prince et al., 2013; Patterson, 2018). Recognizing PTSD symptoms indementia may contribute to prognosis, as it can inform us how careshould be provided (using a trauma informed approach) and can give an
indication for treatment (Couzner et al., 2022). Psychotherapies, forexample Eye Movement Desensitization and Reprocessing (EMDR) and
exposure therapy, can also be efficacious in this group (Driessen et al.,2023; Ruisch et al., 2023).
Diagnosing PTSD in individuals with dementia has several chal­lenges. First, people with dementia often cannot provide a valid life
report, underreport psychological symptoms, and have difficulty selfreporting (Martinez-Clavera et al., 2017). This may complicate attrib­
uting current symptoms to potentially traumatic events (PTEs) (Curcio
et al., 2019), especially in people without a previous documented his­
tory of PTSD or so-called ‘delayed onset’ PTSD (Andrews et al., 2007). In
delayed-onset PTSD, people are initially able to cope successfully, but
symptoms develop over time. Possible triggers may be loss experiences
and cognitive decline.
Second, the presentation of PTSD symptoms in dementia are often
difficult to recognize and are then regarded as neuropsychiatric symp­
toms related to neurodegeneration (Ritchie et al., 2022). For instance,
flashbacks could be interpreted as hallucinations, hyper-vigilance asparanoia, and hyper-reactivity as agitation.
In addition, other disorders are often comorbid with PTSD, such as
depression, substance use and personality disorders (PDs) (Baltjes et al.,2023). There may also be symptom overlap between PTSD and these
disorders, for example problems in affect regulation are present both in
PTSD and borderline PDs (Felding et al., 2021). Thus, comorbid disor­ders should also be considered in diagnosing PTSD in dementia.
Despite, several publications have pointed out diagnostic challenges
in assessment of PTSD in dementia (Martinez-Clavera et al., 2017; vanDongen et al., 2022), there are no previous studies which give an
in-depth evaluation of this assessment. Recently, the TRAuma and DE­
mentia (TRADE)-interview was developed to diagnose PTSD in people
with dementia (Havermans et al., 2023). The current case report reflects
on the diagnostic challenges that may arise, and gives a deeper evalu­
ation of the assessment procedure, using the TRADE-interview.
Methods
A qualitative case design was chosen to generate an in-depth un­derstanding of the complexity of PTSD assessment in people with de­mentia (using the Case Report (CARE) reporting guidelines) (Gagnier
et al., 2013). To achieve this, psychologists who were working at Zuy­
derland Care nursing home and Mondriaan mental health center (theNetherlands) were approached to give a debriefing after psychologicalassessment in a case in which there was possible PTSD. Because no extra
data were taken, and care was as usual, medical ethical evaluation was
not requested. Retrospectively, participant and involved informant gave
both signed consents to use their given information for publication.

Measures
The TRADE-interview is a semi-structured interview designed to di­agnose PTSD, and its severity, in people with dementia. It consists of aself-report, informant and observational questionnaire on PTSD symp­
toms in the past month (Havermans et al., 2023). PTSD is established if
at least one sub-criterion is met in the self-report, informant or obser­
vational part on the DSM-5 main criteria A (a stressor), B (intrusion
symptoms) and E (alterations in arousal and reactivity). The DSM-5
main criteria C and D do not need to be met, based on expert con­census (literature has shown that these are often absent or difficult todistinguish from neuropsychiatric symptoms) (Havermans et al., 2023).
Duration of the symptom must be longer than one month and cannot be
explained otherwise (Criteria F, G & H DSM-5) (APA, 2013).
The Neuropsychiatric Inventory Nursing Home (NPI-NH) version(Cummings, 2009) identifies neuropsychiatric symptoms and psycho­
pathology in people with dementia based on information from nurses.
Research on other translations of the NPI-NH indicates good internal

Case introduction
An 88-year-old Caucasian woman was included after her involved
elderly care physician in the nursing home indicated the need for psy­chological assessment because of her behavior (sadness, resistent tocare, dependent behavior) possibly related to previous traumatic events.
The woman had been living in a Dutch nursing home for the last threemonths due to progression of dementia and interfering somatic
comorbidity.
Her life report showed that she had been widowed in January 1989.
Her husband died suddenly after a four-year illness at relatively young
age. The death of her husband was very difficult for her. She had threechildren on which she had relied heavily after since. In 2019 she was2

S. Sobczak et al.

Psychiatry Research Case Reports 3 (2024) 100207

Fig. 1. Procedure of the study
Gerontological Personality disorders Scale (GPS-iv)
Levels of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0)
Neuropsychiatric Inventory Nursing Home (NPI-NH)
Personality Inventory for Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Brief Form (PID5-BF)
TRAuma and DEmentia-interview (TRADE-interview).

consistency (Selbaek et al., 2008).
The informant version of the Gerontological Personality disorders
Scale- informant version (GPS-iv); (van Alphen, 2006) which maps
habitual behaviors and biographical information was used to establish
the presence or absence of PDs. The GPS-iv is based on the current
DSM-5 diagnostic manual of mental disorders with a categorical classi­
fication approach. It is a reliable and valid screening tool for PDs in(Dutch) geriatric medicine outpatients, with fair to excellent diagnostic
accuracy (Meuwissen-van Pol et al., 2020).
Complementary to the GPS-screening instrument, the Levels of Per­sonality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0) and PID-5 – Brief

Form (PID-5-BF) were assessed due to the dimensional and more intri­cate approach to measure levels of respectively personality functioning
and maladaptive personality traits. The LPFS-BF 2.0 measures person­
ality functioning based on the DSM-5′s Alternative Model for Personality
Disorders (AMPD) (Weekers et al., 2019). An informant version has beendeveloped, with adequate reliability, validity and good internal consis­
tency in older adults in the U.S. (Stone et al., 2020). The PID-5-BF) is an
informant personality trait assessment scale that assesses five person­
ality trait domains: negative affect, detachment, antagonism, disinhi­
bition and psychoticism (Rossi et al., 2014). There is support for thequestionnaire’s reliability and factor structure ( (Anderson et al., 2018).
3

S. Sobczak et al.

Psychiatry Research Case Reports 3 (2024) 100207

The results on NPI-NH are shown in Table 2. Agitation was most
severe; the patient regularly became upset during moments of care andresisted washing and dressing. Depressive symptoms were sad mood andcrying. The participant showed disinhibited behavior by regularly
talking to strangers and inappropriately disclosing personal issues. Ir­
ritability was rated because of dysphoric mood swings.
On the GPS-iv, the participant scored 3 points (unclear) on the HAB
subscale and 6 points (positive) on the BIO subscale, indicating a cluster
C PD (items rated: often concerned about her health, hopes that others
will solve her problems, fears losing those who care for her, and finds it
difficult to stand up for herself).
LPFS-BF 2.0 indicates moderate impairment in personality func­
tioning with a total score on LPFS-BF 2.0 of 22 (mean = 2). Sum scores
were 12 on the self-functioning scale (mean = 2) and 10 on the inter­
personal scale (mean = 2).
On the PID-5-BF (see Table 3), no heightened average domain scores
were found (not higher than 2), although moderate indication for mal­
adaptive personality traits were found on negative affectivity (1.6) anddetachment (1.8). The total score of the PID-5-BF was 31 (maximum
score = 75) and the overall average score was 1.24.
In sum based on the measurements and clinical assessment the psy­chologists established a PD with features of negative affectivity anddetachment (cluster C PD) was present.

Results
Psychological assessments took place in January 2022 and debriefingin February 2022. All three children were equally and well involved, but
her son was best available. As he was living nearby, he was the primary
informal care giver and he knew her story well. Together with her otherchildren it was decided that he would be the best informant. A nurse
filled in the observational scales on the TRADE-interview and rated NPINH.
The results on the TRADE-interview are shown in Table 1. The
traumatic events reported were the cycling accident and sudden death ofher husband. Only the cycling accident fulfills the criterion of DSM-5
traumatic event (criterion A). Recurrent memories, flashbacks andnightmares about the accident were rated in criterion B. Avoidance was
rated because she has never wanted to ride her bike again (criterion C).
She fulfilled criterion D because of reported anger, sadness, and feelingsof despair. Irritable affect and sleep disturbances (accompanied bycomplaining about pain) were present (criterion E). Symptoms lasted
more than one month (criterion F) and created distress (criterion G).
Overall, symptoms got worse with loss of cognitive functioning, de­mentia partially attributed to the current severity (Criterion H). In sum,
the outcome was indicative for PTSD.

Debriefing of the assessment procedure

Table 1
Summary of the TRADE-Interview.
DSM-5 Criteria PTSD

Presence and severity of the criterionNO
YES

Criterion A: The person
was exposed todeath, threatened
death, actual or
threatened serious
injury, or actual or
threatened sexual
violence.
Criterion B: The
presence of one (ormore) intrusive
symptom(s)associated with thetraumatic event(s)that started after thetraumatic event(s)occurred.
Criterion C: Persistentavoidance of stimuli
associated with thetraumatic event(s)that began after thetraumatic event(s)occurred.
Criterion D: Negativechanges incognitions andmood, related to thetraumatic event(s),that started orworsened after thetraumatic event(s)occurred.
Criterion E: Marked
changes in arousal
and reactivity,
related to thetraumatic event(s),that started orworsened after thetraumatic event(s)occurred.

0

1

2

3

4

5

6

7

8

9

10

0

1

2

3

4

5

6

7

8

9

10

0

1

2

3

4

5

6

7

8

9

10

0

1

2

3

4

5

6

7

8

9

10

There was agreement on 31 items (84 %) of the TRADE-interview
and initial disagreement of the two psychologists on six items (16 %):Self-report: Item A2: It was unclear whether the woman witnessed
the passing away of her husband herself and how he passed away. Item
D1: Conflicting answers were given about having negative thoughts
about herself or the world. She said ‘no’, but reported worries such as‘why me?’ and ‘what have I done wrong?’. Item E2 (sleep disturbances)
was attributed to pain by one psychologist, but not by the other one. As
pain could not be objectively verified, consensus was to rate the criterion
as present.
Informant: Item B2: Despite conflicting answers, a ‘no’ was rated as
distressing dreams have been present in the past, however not in the pastmonth. Item D1: ‘No’ was rated as negative thoughts had always beenpresent, also before the PTE.
Observations: Item E1 and E2: Irritability was concluded to be pre­sent however the attribution to the event remained unsure as irritability
was also described as a ‘characteristic’ of her.
The psychologists formulated three main diagnostic challenges: 1)
potential PTSD symptoms were difficult to attribute to a past PTE (cri­terion A) with the incomplete life report, and possible other explana­tions were difficult to exclude, for example with irritability (criterion
E1) and disturbed sleep (criterion E2); 2) interference of neuropsychi­
atric symptoms led to doubts and inconsistencies in the scoring of the
TRADE-interview (e.g. criterion H); 3) overlap in PTSD and PDs
Table 2
Results of the NPI-NH.

0

1

2

3

4

5

6

7

8

9

10

Note. Bold = The criterion is present with this rated severity.
Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5); PosttraumaticStress Disorder (PTSD); TRAuma and DEmentia (TRADE)-interview.

NPI-NH domain

Present

Severity

Delusions
Hallucinations
Agitation/aggression
Depression/dysphoria
AnxietyEuphoria
Apathy/indifference
Disinhibited behavior
Irritability/lability
Aimless repetitive behavior
Nocturnal restlessness/sleep disorder
Appetite/eating behavior change

No
No
Yes
Yes
No
No
No
Yes
Yes
No
No
No

–
–
Moderate
Mild
–
–
–
Mild
Mild
–
–
–

Neuropsychiatric Inventory Nursing Home Version (NPI-NH).
4

S. Sobczak et al.

Psychiatry Research Case Reports 3 (2024) 100207

disturbed sleep was associated with pain in the current case. Painflashbacks (re-experiencing of pain felt during the PTE), are present in
49 % of PTSD patients, the patient’s pain might be regarded as such
(Macdonald et al., 2018). Presence of PTE’s in the past should cue theclinician to consider PTSD.
The third diagnostic challenge in the current case is the interferenceof comorbid PDs in recognizing PTSD symptoms due to symptom over­lap. Indeed, characteristics of PTSD can be indicated by higher scores on
the multidimensional personality trait model (James et al., 2015;
Krueger et al., 2012). The fact that PDs and PTSD often co-occur has
even led to the formulation of complex PTSD (cPTSD) in the 11th Editionof the International Classification of Diseases (ICD-11) (Ford, 2021). For
example, avoidance behavior and affect dysregulation, as demonstrated
in the case, may be present in both cPTSD and PDs. We suggest that inpeople with dementia, specifications about the avoidance behavior may
be difficult to determine and should be carefully considered using all
information available (including a biographic life report if possible) todistinct between these two diagnoses (Havermans et al., 2023). It is
described that when both diagnostic criteria of PTSD and PD are met,
only PTSD should be assigned unless PD diagnosis contributes clinicallyuseful information that is not sufficiently covered by PTSD (Felding
et al., 2021). The added value of using validated tools to diagnose PDs in
older adults with dementia is reflected in the reported conflicting resultson the GPS-iv and LPFS-BF and PID-5-BF. We suggest that using vali­
dated tool would diminish conflicting results.
The strength of this report is the in-depth approach on thecomplexity of assessment of PTSD symptoms and its interference withother symptoms in individuals with dementia in a real-life setting. But toimprove empirical evidence on assessment of PTSD in dementia the
TRADE-interview needs further validation for the appropriate norm
group.
This in-depth evaluation of PTSD assessment using the TRADEinterview in an older woman illustrates that distinguishing PTSD
symptoms in dementia from neuropsychiatric symptoms and PD symp­
toms requires careful evaluation of all symptoms present. It helps tobring awareness of a possible association of present symptoms with aprevious PTE and adding informant information and behavioral obser­
vations. Adding clinical diagnostic instruments can be helpful. But
linking symptoms to a previous PTE may remain difficult. Difficulties inassessment of PTSD may be due to contradictory answers of information
sources, unanswered questions and symptom overlap with other psy­
chiatric disorders which may also be associated with trauma (e.g.
depression). Clinicians should then be resourceful in determination of
PTSD symptoms. Objective measures (e.g. monitoring sleep) can be usedin case of inconsistencies. It is important to note that when doubt of adefinitive diagnosis, recognizing a possible PTSD in people with de­mentia is already clinically relevant.

Table 3Results of the PID-5-BF.
Personality Trait
DomainPID-5 BF
items

Total Raw Domain
Score

Average Domain
Score

Negative Affect8, 9, 10, 11,15
4, 13, 14, 16,18
17, 19, 20,
22, 25
1, 2, 3, 5, 6
7, 12, 21, 23,
24

8

1.6

9

1.8

4

0.8

6
5

1.2
1.0

Detachment
Antagonism
Disinhibition
Psychoticism

Personality Inventory for DSM-5–Brief Form (PID-5-BF).

symptoms (for example unexplained avoidance behavior and irritableaffect) led to uncertainty in rating.
The psychologist also gave some suggestions for improvement. First,
adding clarifying questions beside the TRADE-questions can help the
person with dementia in finding answers. Second, in case of contradic­
tory answers from the three sources, it can be helpful to add objective
measures to facilitate assessment (such as monitoring sleep). Third, assome questions may remain unanswered. It should be better to scorethese items as ‘unknown’. This option is currently not included in the
TRADE-interview.
Discussion
This case report demonstrated the challenges in diagnosis andassessment of PTSD in individuals with dementia. PTSD was establishedby the TRADE-interview in this older woman who was residing in anursing home. Endorsed neuropsychiatric symptoms were agitation,
depression, disinhibited behavior, and irritability and a PD with featuresof negative affectivity and detachment (cluster C PD) was present.
The debriefing of the assessment procedure showed the TRADEinterview to be applicable, but information from the three sources
sometimes contradicted each other, resulting in 16 % disagreement
between the raters. This illustrates limitations of an unreliable selfreport and relying on informant and observer information in di­agnostics, as the first diagnostic challenge. Objective measurements,
such as monitoring sleep by doing nightly checks) could then possibly beworth adding. Clinical practice shows that family members are some­times unaware of the past PTE or its details. People experiencing shametend to hide, deny, and keep the occurrence as well as the details of the
PTE a secret for as long as possible (Shi et al., 2021). In dementia,
re-experiences are often difficult to hide, but may present inconsistently(for example one day one may tell the story in detail and next day she or
he denies). Trauma awareness among those who use the
TRADE-interview is relevant to the given answers. Besides, the clinicalmanifestation of PTSD may differ in dementia; most people do not havesufficient symptoms for a diagnosis (van Dongen et al., 2022) and othersymptoms can be present (e.g., screaming, wandering). Thus, attributing
possible PTSD symptoms to a past event must be carefully considered.
A second diagnostic challenge is differentiating neuropsychiatric
symptoms associated with dementia, or neurodegeneration, withsymptoms of PTSD. Reported symptoms of agitation, depression, disin­hibition, and irritability on the NPI-NH may be regarded as appropriate
for dementia but may also be regarded as unrecognized symptoms of
PTSD. Neuropsychiatric symptoms can be explained by many factors
and using a bio-psychosocial approach in evaluating these symptoms is
recommended. Patient-related factors in this approach include type of
dementia (e.g., aggression in frontotemporal dementia), severity of de­mentia, coping strategies, and physical complaints (Black et al., 2019).
Environmental factors, such as the expertise of nurses, building char­acteristics (noise, light), and social support, may also contribute toneuropsychiatric symptoms (Zuidema et al., 2010). For example,

Funding details
This work was supported by EMDR-Europe under Grant number
2019-04 and Alzheimer Nederland under Grant number WE.09-202102.
CRediT authorship contribution statement
Sjacko Sobczak: Writing – review & editing. Maaike van Korde­
noordt: Writing – original draft, Resources, Investigation. Renske
Uiterwijk: Writing – original draft, Data curation. Joan M. Cook:
Writing – review & editing, Supervision. Demi C.D. Havermans:
Writing – review & editing. Larissa Vossen: Writing – original draft,
Investigation. Inez Ramakers: Supervision. Miranda Olff: Writing –original draft, Supervision, Methodology. Sebastiaan P.J. van Alphen:
Writing – review & editing, Supervision, Methodology.

5

S. Sobczak et al.

Psychiatry Research Case Reports 3 (2024) 100207

Declaration of competing interest

Felding, S.U., Mikkelsen, L.B., Bach, B., 2021. Complex PTSD and personality disorder in
ICD-11: when to assign one or two diagnoses? Australasian Psychiatry,
10398562211014212.
van Dongen, H.E., Havermans, D.C.D., Deckers, K., Olff, M., Verhey, F., Sobczak, S.,
2022. A first insight in the clinical manifestation of Posttraumatic Stress Disorder indementia: a systematic literature review. Psychogeriatrics. 22 (4), 509–520.
Havermans, D.C.D., Olff M, v.A.S., Van der Velden-Daamen, M., Verhey, F., Rutten, B.P.
F., Stuijts, P., Cook, J.M., Sobczak, S., 2023. The need for a diagnostic instrument toassess post-traumatic stress disorder in people with dementia: findings from a delphi
study. J. Geriatr. Psychiatry Neurol. 36 (2), 129–142.
Gagnier, J.J., Kienle, G., Altman, D.G., Moher, D., Sox, H., Riley, D., 2013. The CARE
guidelines: consensus-based clinical case reporting guideline development. J. Med.
Case Rep. 7.
Maercker, A., Bachem, R., 2013. Life-review interventions as psychotherapeutictechniques in psychotraumatology. Eur. J. Psychotraumatol. 4 https://doi.org/
10.3402/ejpt.v4i0.19720.
APA, A.P.A., Diagnostic and statistical manual of mental disorders. 2013. fifth edition.
Cummings, J.L., 2009. Neuropsychiatric Inventory Nursing Home Version. NPI-NH.
Selbaek, G., et al., 2008. The reliability and validity of the Norwegian version of the
Neuropsychiatric Inventory, nursing home version (NPI-NH). Int. Psychogeriatr. 20(2), 375–382.
van Alphen, S.P.J., 2006. Diagnostiek Van Persoonlijkheidsstoornissen Bij Ouderen. Een
bijdrage Aan De Ontwikkeling Van Een Screeningsinstrument. Radboud Universiteit
Nijmegen, Nijmegen.
Meuwissen-van Pol, E.C.H., et al., 2020. Screening for personality disorders in geriatric
medicine outpatients. Eur. Geriatr. Med. 11 (2), 289–295.
Weekers, L.C., Hutsebaut, J., Kamphuis, J.H., 2019. The Level of Personality Functioning
Scale-Brief Form 2.0: update of a brief instrument for assessing level of personality
functioning. Personal. Ment. Health 13 (1), 3–14.
Stone, L.E., Segal, D.L., Noel, O.R., 2020. Psychometric evaluation of the levels of
personality functioning scale-brief form 2.0 among older adults. Personal. Disord.
Rossi, G., et al., Nederlandstalige bewerking van The Personality Inventory for DSM-5®
— Informant Form (PID-5-IRF) — Adult, 2011 op basis van The Personality
Inventory for DSM-5®— Brief Form (PID-5-BF) — Adult, 2011. 2014.
Anderson, J.L., Sellbom, M., Salekin, R.T., 2018. Utility of the personality inventory for
DSM-5–Brief Form (PID-5-BF) in the measurement of maladaptive personality andpsychopathology. Assessment 25 (5), 596–607.
Shi, C., et al., 2021. Shame, guilt, and posttraumatic stress symptoms: a three-level metaanalysis. J. Anxiety. Disord. 82, 102443.
Black, B.S., et al., 2019. Unmet needs in community-living persons with dementia arecommon, often non-medical and related to patient and caregiver characteristics. Int.
Psychogeriatr. 31 (11), 1643–1654.
Zuidema, S.U., et al., 2010. Environmental correlates of neuropsychiatric symptoms innursing home patients with dementia. Int. J. Geriatr. Psychiatry 25 (1), 14–22.
Macdonald, B., et al., 2018. Prevalence of pain flashbacks in posttraumatic stressdisorder arising from exposure to multiple traumas or childhood traumatization.
Can. J. Pain 2 (1), 48–56.
James, L.M., et al., 2015. DSM-5 personality traits discriminate between posttraumaticstress disorder and control groups. Exp. Brain Res. 233 (7), 2021–2028.
Krueger, R.F., Markon KE, D.J., Watson, D., Skodol, A.E., 2012. Initial construction of amaladaptive personality trait model and inventory for DSM-5. Psychol. Med. 42 (9),1879–1890.
Ford, J.D., 2021. C.C., Complex PTSD and borderline personality disorder. Borderline
Personal. Disord. Emot. Dysregul. 8 (1), 16.

The authors declare the following financial interests/personal re­lationships which may be considered as potential competing interests:
Sjacko Sobczak reports was provided by Maastricht University.
Sjacko Sobczak reports a relationship with Maastricht University that
includes: employment. Sjacko Sobczak has patent pending to none.
Supplementary materials
Supplementary material associated with this article can be found, inthe online version, at doi:10.1016/j.psycr.2024.100207.
References
Iqbal, M., et al., 2022. A three-factor model of common early onset psychiatric disorders:temperament, adversity, and dopamine. Neuropsychopharmacology 47 (3),752–758.
Riedl, D., et al., 2019. Domestic violence victims in a hospital setting: prevalence, healthimpact and patients’ preferences–results from a cross-sectional study. Eur. J.
Psychotraumatol. 10 (1), 1654063.
Gunak, M.M., et al., 2021. Post-traumatic stress disorder as a risk factor for dementia:
systematic review and meta-analysis - ERRATUM. Br. J. Psychiatry 218 (3), 174.
Sobczak, S., Olff, M., Rutten, B.P.F., Verhey, F., Deckers, K., 2021. Comorbidity rates of
posttraumatic stress disorder in dementia: a systematic literature review. Eur. J.
Psychotraumatol. 12 (1), 1883923.
Prince, M., Brycea, R., Albanese, A., Wimo, A., Ribeiro, W., Ferri, C.P., 2013. The global
prevalence of dementia: a systematic review and metaanalysis. Alzheimer’s
Dementia 9 (1), 63-75.e2.
Patterson, C., 2018. World Alzheimer Report 2018. Alzheimer’s Disease International,
London.
S N. Couzner, L., Fausto, K., Huo, Y., Vale, L., Elkins, S., Saltis, J., Cations, M., 2022.
Delivering trauma-informed care in a hospital ward for older adults with dementia:
an illustrative case series Front. Rehabil. Sci. 3, 934099.
Driessen, S., et al., 2023. Treating symptoms of posttraumatic stress in people withdementia: expert consensus using the Delphi method. Clin. Gerontol. 1–15.
Ruisch, J.E., et al., 2023. Treatment of post-traumatic stress disorder in people withdementia: a structured literature review. Psychogeriatrics. 23 (3), 523–534.
Martinez-Clavera, C., James, S., Bowditch, E., Kuruvilla, T., 2017. Delayed-onset posttraumatic stress disorder symptoms in dementia. Prog. Neurol. Psychiatry 21, 26–31.
Curcio, N., et al., 2019. Reliability of medical history reporting in older adults with andwithout cognitive impairment. J. Cent. Nerv. Syst. Dis. 11, 1179573519843874.
Andrews, B., et al., 2007. Delayed-onset posttraumatic stress disorder: a systematic
review of the evidence. Am. J. Psychiatry 164 (9), 1319–1326.
Ritchie, K., Cramm, H., Aiken, A., Donnelly, C., Goldie, C., 2022. PTSD symptoms anddementia in older veterans who are living in long-term care. Qual. Health Res. 32(3), 504–519.
Baltjes, F., Cook, J., Van Kordenoordt, M., Sobczak, S., 2023. Psychiatric comorbidities of
PTSD in older adults; a structured literature review. Int. J. Geriatr. Psychiatry.

6