This is an important distinction to make when assessing someone for PTSD. It can be a common mistake to make to assume that someone who has had a trauma, and is thinking a lot about it, probably has PTSD; the memories need to be ‘re-experienced’ for them to count as a symptom. Re-experienced memories are different from ruminating about the trauma in their ‘here and now’ quality and their intrusiveness, but this may not be a distinction that clients will automatically make, and statements such as ‘I can’t stop thinking about it’ could imply either. This is additionally complicated by the fact that many clients have both re-experiencing symptoms and ruminate, and both commonly trigger each other.
In the CAPS-5 assessment tool, there are some useful prompt questions to help us, for example ‘How do you start thinking about the trauma?’. This often helps us to see whether the memory has been triggered by a reminder or appeared to come out of the blue (more likely an intrusive memory), or was a more conscious, deliberate effort to understand the trauma (more likely rumination). Other useful questions might be: ‘When you have the memory, is it like a picture in your mind?’, ‘Can you see, feel, smell, taste or hear what happened when you remember it?’ and ‘Does it feel like a memory from the past or as if it is happening again?’ (qualities of re-experienced memories).
It can be helpful to explain the difference between a trauma memory and a normal memory to our clients. This would include emphasising the sensory qualities of trauma memories, their intrusiveness, and how they feel current rather than memories from the past. Clients with PTSD will usually recognise this description, as their trauma memories will feel qualitatively different from their other autobiographical memories. Then, taking a specific memory that our client has told us about, you can ask your client whether it is re-experienced in this way. Rumination, on the other hand, is not re-experiencing the trauma but thinking in a circular, repetitive way about the trauma and dwelling on particular related topics e.g. why it happened or who was to blame.
Of course if someone is ruminating a lot about a traumatic event but doesn’t have PTSD, they may still benefit from treatment. It may be that they would meet criteria for another disorder, such as depression or adjustment disorder, so these would need careful assessment. Our treatment plan will most likely differ in the absence of re-experiencing symptoms, for example with less emphasis on memory processing.
Practice points:
It is important to distinguish re-experiencing symptoms from rumination when assessing for PTSD
Asking about what triggers the process and the qualities of the memories helps us assess the difference
We can also explain the difference to our clients to help them distinguish
Rumination in the absence of re-experiencing does not mean the client does not potentially still need treatment, but would not indicate PTSD