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Can You Have Post-Traumatic Stress Disorder Without The Flashbacks, And What Does That Mean?

by — Last updated: 2020-03-08 in Mental Health

Everyone with PTSD is plagued by "reexperiencing" symptoms that force them back into their worst moments — but not everyone has "flashbacks", and flashbacks exist on a spectrum, too.

You all know the drill. 

As the recently returned soldier's young child excitedly — and loudly — darts around the happy and normal-loooking living room that now feels completely alien to the veteran, she sneaks up on her father, who was busy worrying about his upcoming meeting with his dead best friend's widow, or something. In the process, his daughter knocks the glass of water innocently waiting for doom on the kitchen table over, shattering it on a tile floor — BANG. 

In that instant, the veteran is immediately transported — beam-me-up-Scotty-esquely — to the most gruesome, the darkest, moments of his life. Just like that, he's back on the battlefield, accompanied by freefalling limbs and wailing orphans. This scene goes on for minutes, after which the soldier is beamed back to the present and starts yelling at his daughter. 

The flashbacks everyone without PTSD has come to know are portrayed as literal flashbacks in movies and on TV. The flashbacks everyone without PTSD has come to know are, for lack of a better word, photogenic. 

Can you have PTSD without flashbacks? And are the flashbacks we see in popular media the only kind that exists? Let's take a look. 

Does everyone with PTSD experience flashbacks? A look at the diagnostic criteria

Someone who has been exposed to trauma — by directly experiencing it, witnessing it first-hand, or in some cases being exposed to it second-hand, like in the case of first responders or police officers — can be diagnosed with post-traumatic stress disorder if they meet the diagnostic criteria. 

In the United States, these are laid out in the fifth edition of the diagnostic and statistical manual of mental disorders, and the different criteria all come with multiple possible symptoms. All criteria must be met, but that doesn't mean everyone will experience all symptoms within each criterion. The symptoms also have to last at least a month and shouldn't be better explained by another condition. 

Criterion B deals with so-called intrusion symptoms, and people who are diagnosed with PTSD will experience at least one, but can also experience several or all:

  • Intrusive, unwanted, distressing, and persisent memories of the traumatic event(s). 
  • Nightmares related to the trauma. 
  • Dissociative symptoms like flashbacks, in which the person either "feels or acts" as though their trauma was happening all over again. 
  • Experiencing severe emotional distress when something reminds the person of the trauma — something more popularly known as being "triggered". 
  • Experiencing severe psysiological distress in these circumstances — that might include profuse sweating, for instance. 
As you can see, flashbacks are only one of several possible intrusion symptoms people with PTSD can suffer from, and to be diagnosed, a person "only" needs to have one of the symptoms on this list. 

To take a quick look at the remaining criteria, criterion C deals with avoidance symptoms — which can mean avoiding thoughts, feelings, or memories of anything related to the trauma, avoiding people, places, situations, activities, and other external things related to the trauma, or both. 

Criterion D covers alterations in cognition and mood, meanwhile. Someone needs to have two or more of the seven listed symptoms to be diagnosed with PTSD. They are memory gaps related to the trauma, negative beliefs about self and others, self-blame, negative thoughts like fear, terror, or shame, loss of interest in meaningful activities, feelings of detachment from the world, and an inability to experience positive emotions. 

The final set of symptoms, described in criterion E, pertains to hyper-arousal. Again, two or more symptoms are required for a diagnosis of PSTD, and the possibilities are irritable or angry outbursts (physical or verbal), reckless or self-destructive behavior, hypervigilance ("always being on guard"), trouble concentrating, and dysfunctional sleep. 

What could not having flashbacks mean?

Post-traumatic stress disorder doesn't manifest identically in every sufferer, and does have different levels of severity. While avoidance symptoms are always part of the diagnostic criteria, some people with PTSD may have become so "good" at walling off anything that reminds them of the trauma they lived through that they really don't feel much of anything — they have become emotionally numb and dissociative, placing the trauma-related parts of their lives in a "box" that doesn't touch the present in a conscious way. 

One interesting piece of research focusing on flashbacks investigated whether more severe avoidance symptoms could, in fact, suppress the intrusion symptoms associated with PTSD, at least to some extent. Instead of (or in addition to) asking people whether they suffer from flashbacks, they proposed asking whether people would suffer from flashbacks if they reached a point where they could allow themselves to remember traumatic events or reminders thereof. 

This resonated with me, as someone diagnosed with PTSD, because the worst intrusion symptoms didn't start appearing for me until after I had started therapy and worked on healing — through processing and guided exposure to memories in therapy. Sure, I had nightmares and was physically and emotionally triggered by certain stimuli, but the intrusive memories and reexperiencing feelings started only when I was actively working on getting better, which meant trying to deal with the past rather than doing everything I could to deny it into non-existence. 

Could you be having flashbacks without knowing it?

For me, seeing a face that reminded me of the trauma, certain types of touch, or certain situations could certainly trigger brief but powerful "now-like" memories that had me emotionally back in that place. Though they typically left a nasty psychological "hangover", they usually didn't last more than a few seconds. Smell was the most potent cue here, so it was interesting for me to learn that research has indeed looked into olfactory flasbacks in PTSD sufferers. 

Flashbacks don't have to go on for minutes to be flashbacks, and they exist on a spectrum of severity, too — with the hallucination-like experiences it's easy to come across on TV falling on the most intense end. You don't have to be convinced you're physically back there and lose all touch with present reality to have a flashback. The experience can be brief and a kind of "two places at once" situation where part of you knows exactly that the flashback isn't a physical thing but you still feel like you're there. Some people additionally reexperience physical pain. 

I am still not sure whether most of the experiences I had qualify as flashbacks, but now believe there's a good possibility that they do. The smell of disinfectant still does it for me, years after I stopped attending therapy — just for a second, I'm "back there" and taken out of the present, though I know it's just in my mind. It doesn't "play like a movie". It's more like a sudden emotional punch in the face that once again makes me feel powerless and alone. 

If these kinds of thing are happening to you as someone with post-traumatic stress disorder, they would certainly fall under the reexperiencing cluster of PTSD symptoms, and would most likely be considered flashbacks.

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA
  • Photo courtesy of SteadyHealth