Nightmares and flashbacks are often two of the easiest to spot symptoms of PTSD. However, in DSM-5, to meet criterion B (the re-experiencing cluster), someone only needs one of the possible symptoms, which are nightmares, flashbacks, intrusive memories, emotional and physiological reactivity to reminders of the trauma. Therefore, the diagnosis can be met in the absence of flashbacks or nightmares, if someone is having one or more of the other re-experiencing symptoms.
As nightmares in particular are very common symptoms (about 75% of people with PTSD have them), if they are absent, then make sure you assess their symptoms carefully, using an assessment tool such as the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). In particular, check that memories are genuinely intrusive, rather than driven by rumination, and that symptoms in all of the other clusters are present. Upsetting memories are common in lots of different disorders, such as depression, and might be important to the formulation, but your treatment plan will likely be different if the memories are dwelled on rather than re-experienced.
Practice points:
· Nightmares and flashbacks are common symptoms of PTSD
· However, the diagnosis can be made in the absence of nightmares or flashbacks if another re-experiencing symptom is present (intrusive memories, emotional or physical reactivity to trauma)
· Assess carefully that symptoms are genuinely re-experiencing rather than rumination-driven.