Criterion D1 reflects the inability to remember (an) important aspects of the traumatic event(s) as a result of dissociative amnesia. That is, this item captures an inability to remember aspects of the traumatic event that WERE encoded. Therefore, if there are factors present that would interfere with encoding, such as head injury, unconsciousness, or substance use, we do NOT code any associated difficulty remembering the event here. Like B3, this is a low base rate item. Most people have the opposite experience of intrusive memories; they wish they could forget.

If the person reports that they cannot remember but also doesn’t want to remember, it is important to ask if he/she has ever tried to remember. Then, the following heuristic may be useful for coding: 1) clearly present = the person cannot remember the event but has never tried to do so OR the person has tried to remember the event but one or more important part is hazy; 2) pronounced = the person has tried to remember the event but can recall little of it;
3) extreme = the person has tried to remember the event but the important parts are completely gone (e.g., a rape survivor has no memory of penetration despite efforts to remember).

For D1, we code amount instead of frequency. When administering this item, it can be useful to label the aspects that are difficult to recall initially, to ensure that the intensity of the amnesia is directly linked to the amount of aspects forgotten. According to the CAPS-5 key, amount can be operationalized as follows: 1) clearly present = one important aspect cannot be recalled; and 2) pronounced = several important aspects cannot be recalled. This suggests that 3) extreme = most/all important aspects cannot be recalled. Note that there is no minimal frequency for D1.

If the person can remember the trauma itself but struggles to remember peripheral information about the day of the trauma (e.g., the time of day, the first name of one of the men who died), be wary of coding this as a symptom. Whereas people generally believe that they should remember EVERY detail of a trauma, this is usually not realistic. Dissociative amnesia more logically applies to the parts of the event that would be too painful to remember.  You can redirect discretely if they report an inability to remember something that is not an important detail to avoid coding it for this item.

If the trauma involves multiple events, such as child sexual abuse, it may be helpful to pick a typical example of the abuse (one instance) and query about associated amnesia with that event. 

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Criterion D2 captures persistent and exaggerated negative beliefs or expectations about oneself, others, the world, such as, “I am bad,” “No one can be trusted,” “The world is completely dangerous,” or “My whole nervous system is permanently ruined”.

To administer this item, first ask the initial prompt question “In the past month, have you had strong negative beliefs about yourself, other people, or the world?” Only ask “can you give me some examples?” if their only response is “yes.” If they respond “yes” and begin to give you examples, you do not need to ask, “can you give me some examples?” Instead, you can skip immediately to the italicized examples. This will help reduce the amount of time the person spends providing information about strong beliefs that may not be relevant for this item (e.g., beliefs about the how the president is running the country).

Make sure to pause after reading each italicized example and allow the person to consider and respond before moving on to the next example. If the respondent endorses more than one of the italicized examples (e.g., “I am bad” and “the world is completely dangerous”), it can be helpful to choose the strongest belief to focus on for the remaining probes. This is because, unlike other multi-part questions, for this item an extreme intensity can be given even if only one of the beliefs is endorsed. 

To determine the intensity rating, think about whether you would subject the belief to cognitive restructuring in a therapy session. In general, only give an extreme intensity if the respondent can see no other ways of thinking about the belief(s).

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Criterion D3 captures persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. The focus of this item is on assessing for appropriate versus inappropriate blame, rather than discriminating self- from other- blame. Therefore, if the person endorses both self and other blame, you should rephrase the next follow up question to read “How much do you blame yourself and others?” This will help you capture the inappropriate blame as a whole. In this context, blame equals intent for the actual harm to occur. Therefore, if the person indicates that the government is to blame and cannot see any other way of thinking about the incident, this is likely inappropriate blame (e.g., the government likely did not intend for this respondent’s friend to die in any given battle).

The item should be given a zero if the only source of blame is the perpetrator, as in a sexual assault. This is because this blame is not distorted – the perpetrator did intend for the harm to occur.

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Criterion D4 captures a persistent negative emotional state, which can include fear, horror, anger, guilt, and/or shame. When administering this item, first read the prompt question (“In the past month, have you had strong negative feelings, such as fear, horror, anger, guilt, or shame?” and note which of these the respondent endorses (if any). If the person mentions fewer than the five you asked about (e.g., the person says “I feel anger and guilt”), go back and ask about the ones they didn’t mention (e.g., “what about fear? Horror? Shame?”). This is important because as a multi-part question, you would generally not give an extreme intensity unless most or all of the emotions are endorsed; however, respondents may only initially endorse a selection due to primacy, recency, and/or salience biases.

The emotions in D4 do not need to be cued by a trauma reminder, but they may be. To assess intensity, you can ask follow-up questions about how the emotions impact them behaviorally, such as how the emotions are interfering in their lives.

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Criterion D5 captures markedly diminished interest or participation in activities (i.e., anhedonia). This item can be challenging to separate from some of the other PTSD symptoms (e.g., avoidance and difficulty concentrating). 

To distinguish D5 from avoidance, determine whether the lack of participation is driven by a lack of interest in activities or due to safety concerns. For example, if a respondent indicates that he no longer attends baseball games, you can ask “If you knew that the stadium was completely safe, and you could choose who was at the stadium with you, do you think you’d enjoy it?” If the respondent indicated that under this circumstance, he would enjoy it, the diminished involvement would be better coded as avoidance.

To distinguish D5 from difficulty concentrating, determine whether the respondent is still interested or motivated to participate in the activity but cannot attend to it versus lacking the initial motivation. If the former, it is better coded under difficulty concentrating; if the latter, it is better conceptualized as anhedonia.

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Criterion D6 captures feelings of detachment or estrangement from others. For this item, pets generally do not count, but a relationship with a therapist does. Of note, if the only relationship the person reports having is with their therapist, you would likely give an extreme (4) on item 24, impairment in social functioning. According to the CAPS-5 key for this item, you will generally give a clearly present for intensity if the respondent reports a notable distance from others but still feels some interpersonal connection with several people, and will give a pronounced intensity if the respondent only feels close to one or two people.

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Criterion D7 captures a persistent inability to experience positive emotions such as happiness, satisfaction, or loving feelings. Be mindful to code only for difficulty experiencing positive feelings and not difficulty expressing these feelings to others. For example, a respondent may indicate that it is hard for him to tell his wife he loves her, even though he feels love; this would not count for this symptom.

Heuristics that may be helpful for coding this item’s intensity include: 1) clearly present = although the positive emotional experience is reduced, the respondent can still feel some positive emotions to their full extent; 2) pronounced = all positive emotions are dampened; and 3) extreme = most or all positive emotions are absent (i.e., the respondent is numb to positive emotions). Again, we strongly caution against reifying these suggestions for coding. Clinicians should always use their best judgment when coding an individual’s response to questions.

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