PTSD type 1,  OSCILLOPSIA, EMDR and a PTSD type 2

(Something unexpected and new about ‘PTSD’, and, (?) its genetics and epigenetics — a web page for anyone to read)

It explains the result of a 30 year clinical investigation into a chance discovery of a subtle  visual abnormality that can be found in certain people following sudden mental trauma.  Surprisingly, it gives rise to an evidence base that helps disentangle the mixed up Post Traumatic Stress Disorders.  It explains the occasional successful EMDR treatment for only one form of PTSD.

The evidence base challenges the nature of ‘PTSD’ given in DSM 5 .

Synopsis of the web page — the full web page starts after this synopsis

New discoveries feed on many contributors and take time to grow. If this discovery of ‘a tiny bit of new ‘truth’ about human vision’ took thirty years to sort out then it’s unlikely that the telling of it will fit on to the back of an envelope (even though E=mc2  take merely five characters).

In 1946 a London ophthalmologist, Dr Harry Moss Traquair, reported that some of his patients, ex-soldiers fresh from WWII with Traumatic Neurosis (the previous name for ‘PTSD’) were reporting ‘…a stammering of perception in the periphery of their visual fields…’ – i.e. objects that were standing still looked to them to be wobbling about. Traquair was measuring their visual fields at the time, and the ex-soldiers noticed this wobbling vision of theirs only when they held their head and eyes very still, and staring with one eye at a time at a black dot on the vision chart, as they were told to do.  Traquair wrote just those eleven words of the ex-soldier’s observations in his textbook on Visual Fields, and left it at that.

There were many admissions to hospital and many deaths by suicide of ex-soldiers with Traumatic Neurosis after WWII, as there have been and still are after all other wars.

In 1978 the American Psychiatric Association (APA) renamed Traumatic Neurosis to ‘PTSD’.  Details of the ‘new’ PTSD were published their Diagnostic & Statistical Manual of Mental Disorders (the DSM, now in its 5th edition). No mention is made anywhere of any visual symptoms in their ‘PTSD’.

In 1977, a psychiatrist (this author, who had previously been an a/prof neurosurgeon), knowing nothing of Traquair or his finding 30 years earlier, started to investigate a strange visual abnormality that was complained of by several women patients who had been referred to him with Traumatic Neurosis. Everywhere they looked all stationary objects always appeared to them to be waving about, even when they held head their head and eyes quite still.  These women were all  immigrants from southern Europe and the Middle East.  Their Traumatic Neurosis had followed very frightening-to-them accidents at work several years before.  They had all been referred to me by their Compensation lawyers because their visual abnormality had been diagnosed as ‘hysterical’, ‘not real’ by the eye doctors and psychiatrists  their employers’ lawyers had sent them to see. Their own lawyers were sceptical about the diagnosis of ‘hysteria’. This strange visual abnormality didn’t look ‘hysterical’ to them,  nor did it to me, an ex-neurosurgeon psychiatrist. I decided to investigate it.  I got the occasional help of two colleagues, an ophthalmologist and a clinical neuro-psychologist.

After thirty years of investigation, that had included adding a simple visual test to all of the 9000 or so psychiatric consultations conducted with variously referred general psychiatric patients seen by me over the time, this visual abnormality was eventually understood – ‘characterized’.  The visual abnormality was found to be unique to just one form of PTSD, now called PTSD type 1.   It is certainly a very ‘real’ visual abnormality, but for most people with PTSD type 1 it it is very subtle, and only noticed by them when they are tested for it.  It is certainly not ‘hysterical’.   It seems to have been coincidentally noticed by those ex-soldiers when their vision was being tested by Traquair in 1946 for something else.  Those ex-soldiers must have had PTSD type 1.  People with what is now called PTSD type 2 do not have the visual abnormality when tested for it.

Apart from the visual abnormality, usually not noticed until tested for, PTSD type 1 and PTSD type 2 can be clinically indistinguishable one from the other because of the high anxiety and anxiety-related symptoms they both have.  But PTSD type 1 and type 2 are radically different from each other, and when they are there together at the same time, as they can be, there can be endless confusion over treatment and management of those who have been mentally traumatised.

For those immigrant women patients from the Middle East who had prompted this investigation in 1977 their visual abnormality was glaringly obvious.  They too must have had PTSD type 1, though I didn’t know anything about it at the time.

The visual disorder is called Persistent Peripheral Oscillopsia (‘osi-lop-sia’ is a Greek word for ‘wavy vision’).  This had not been recognised previously as a specific clinical entity on its own, as far as is known.  For that reason it was usually called ‘hysterical’ when obviously there for some and there but not noticeable and never tested for in others.   It is a form of oscillopsia quite distinct from all the other well known forms of oscillopsia that can be present in some inner ear and neurological diseases — all other forms of oscillopsia are only present with head and or eye movement.

We had eventually found that all those people with PTSD type 1 and persistent peripheral oscillopsia always had in addition uniquely abnormal, distressing and constantly recurring flashing back and re-experiencing memories of the moment of the sudden event that had triggered their  PTSD type 1 – i.e. if they had peripheral oscillopsia then they also had recurrent abnormal flashbacks of the event.  Abnormal flashbacks are subtly different from the not-abnormal ‘intrusive memories’ of sad mentally and or physically traumatic events of the past

In 1989 an American psychologist, Francine Shapiro, serendipitously discovered a ‘cure  for PTSD’. There had never been such an odd and counter-intuitive cure for anything, let alone for ‘PTSD’.  There had been no cure for Traumatic Neurosis or ‘PTSD’ for two thousand years. Dr Shapiro called her ‘cure’ EMDR, ‘Eye Movement Desensitization and Reprocessing’. EMDR is fully explained in the web page.

Properly performed EMDR  certainly gave us, in 1990, a convincing evidence-base for its effectiveness for some but not for all of our patients with PTSD type 1.  For some, but not for all of those patients who had persistent peripheral oscillopsia and recurrent uniquely abnormal experiential flashing-back memory-recalls the EMDR returned the abnormal vision in the periphery of the visual field back to normal peripheral vision, and, at the same time returned the uniquely and distressing abnormal flashback memories of the moment of the sudden event that had triggered their ‘PTSD’ back to a normal form of memory of the event. EMDR also relieved their persisting anxiety.  But EMDR was always totally ineffective for all patients with PTSD type 2 who did not have persistent peripheral oscillopsia and did not have  abnormal flashbacks of the event. 

Once we had characterised the particular type of mental trauma, the ‘mental shock’ (as defined in detail in the web page) that gives rise to PTSD type 1, and we also had a foolproof visual test for the presence or absence of persistent peripheral oscillopsia, and we could recognise abnormal flashbacks from normal intrusive memories, we had a ‘three-legged evidence base’ for there being two distinct types:  the  PTSD type 1 and the  PTSD type 2.

In 2009 the findings of the 30 year long investigation were published anecdotally by the three of us in the peer reviewed international journal Traumatology 15(3) 22-33 (2009). An anecdotal report of a ‘discovery’ and its apparent implications is a prerequisite for any subsequent ‘scientific examination’ of the implications of the ‘discovery’ – we have had no resources for the latter.

                                                 The present new paradigm PTSD type 1 

  • For some people, but not for all, the experience of a sudden mental shock (as defined) can cause a specific Anxiety Disorder, PTSD type 1.  Some geneticists have  abductively reasoned from the evidence base that in PTSD type 1 there has been an immediate epigenetic DNA methylation, and the switching-off, of certain genes somewhere in the brain.   The epigenetic change has been triggered by the experience of the sudden mental shock. The immediate result of the switched-off genes is (i) recurrent uniquely abnormal experiential flashing back memories of the sensory experiences of the moment of the mental shock, i.e. the uniquely abnormal flashbacks; (ii) the visual abnormality of persistent peripheral oscillopsia; and (iii) persisting abnormal levels of anxiety and anxiety-related symptoms. (Genetics is far more complicated than this but this is more or less the highly simplified gist.)
  • Some geneticists have abductively reasoned from the evidence base that for some people with PTSD type 1 the epigenetic DNA change can be permanently reversed by properly-performed EMDR.  For other people with PTSD type 1 the  epigenetic change of PTSD type 1 cannot be reversed by EMDR.  For them the clinical features (i), (ii) and (iii) in the paragraph above remain indefinitely.  PTSD type 1 does not respond curatively to conventional talking and or physical treatments, helpful as those palliative treatments  may be.

Also from the clinical evidence:-

  • Children over the age of 5 or 6 years, as well as older persons from all walks of life, can be reliably, specifically and sensitively tested for the presence or absence of PTSD type 1 via the visual test; and, from that age they each have a good chance, but no certainty, of responding to EMDR — and the PTSD type 1 is then permanently eliminated.
  • People with the genome for Attention Deficit Hyperactivity Disorder, ADHD i.e. the having genome for a an extra susceptibility to ADHD-type attention and impulsivity impairments in response to experiencing psychological stressors from the environment, appear to be at extra risk to the development of PTSD type 1 in response to the experience of a sudden mental shock.
  • People with the genome for olive skin and dark eyes and develop PTSD type 1 e.g. those of Iberian, Southern European and the Middle East genotypes, appear to be at extra risk to have more severe and obtrusive persistent peripheral oscillopsia, and, a decreased chance of successfully responding to EMDR treatment.

                                                        The present new paradigm PTSD type 2 

For some people, the experience of a mental shock and or experiences of less specific forms of mental trauma perhaps suffered over time, can cause a non-specific, generic Anxiety Disorder, PTSD type 2.  In PTSD type 2 there are no uniquely abnormal symptoms.  PTSD type 2 has no chance of responding curatively to EMDR.  PTSD type 2 can usually be eliminated slowly over time and by conventional talking and or physical treatments – Cognitive Behaviour Therapy with or without medication.

                                                                 PTSD type 1 and PTSD type 2

  • Either can be of any degree of symptom severity from the outset — very severely disabling for some, far less disabling but still noticeable for others, somewhere in between for most.
  • Either or both together can co-occur with other mental disorders, with mental illnesses and with physical disorders, post traumatic or other.

                                                        With or without PTSD types 1 & 2,

Any mentally and or physically traumatic experiences can give rise to virtually endless mental distress. Even getting rid of PTSD types 1 and 2 is not always a panacea for future contentment. There can be inconsolable grief; anger and resentment; lost and irreplaceable relationships; unemployability; endless depressed and anxious moods; persisting physical disability and disfigurement; reliance on drugs; self harm and suicidal ideation……Worst of all is for those with severe PTSD type 1 that cannot be eliminated by EMDR, often compounded by other severe mental distressors and physical disability.

The miserable lives of those with any form of post mental and or physical trauma demand open and honest approaches and knowledge of how, if possible, they can be recognised and helped.  If this 30 year investigation has gone some small way to help then it has not been in vain.

                                                                END OF SYNOPSIS

Dr Robert Tym (psychiatrist retired; formerly an a/prof neurosurgeon)

ptsd.net@hotmail.com

………………………………………

More details of the 30 year investigation, of the history of ‘PTSD’, of illustrative case histories and of the entanglements of PTSD types 1 & 2 with mental distress, mental disorders and mental illnesses, are all to be found in the book ‘The Ladies with Stammering Vision’, recently published by Austin Macauley in London.

THE WEB PAGE < PTSD.NET >

A quick and simple Q & A to get started  — more details follow.

  Q.  What’s all this about ? Whatever is oscillopsia  ?  How’s it pronounced ?  Why should we know about it?

A. It’s pronounced ‘osi-lop-sia’,  a Greek word for ‘wavy vision’.  It’s a subtle visual abnormality in which stationary objects in the periphery of vision appear to be waving about all the time when keeping one’s head and eyes quite still and staring straight ahead.  It’s called Persistent Peripheral Oscillopsia’. If it is there but not noticed then it is there whenever it is tested for. It’s quite unlike other forms of ‘oscillopsia’ that can occur in neurological diseases such as multiple sclerosis and in inner ear diseases  in which the oscillopsia is only present with head and or eye movements.

Q. Whatever has this persistent peripheral oscillopsia got to do with ‘PTSD’ ?

A. It’s unique in that it’s only to be found in one form of ‘PTSD’, PTSD type 1, and not in the other form of ‘PTSD’, PTSD type 2, and it is not found in any other disorder. Most people with PTSD type 1 don’t notice any peripheral oscillopsia until it’s tested for, and most but not all of those who do happen to notice it can ignore it.  If it wasn’t so subtle it would not have taken us 30 or so years and seeing and testing 9000 or so patients to sort it all out. There is now a very simple but very accurate Visual Test to detect the presence or absence of persistent peripheral oscillopsia.  Also unique to PTSD type 1, and vastly more noticeable and obtrusive than the persistent peripheral oscillopsia,  is the constant recurrence of abnormal flashbacks, they are uniquely abnormal recurrent ‘re-experiencing’ memory-recall flashbacks of what was being experienced at the moment of the event which caused the  PTSD type 1.  This is an abnormal form of recurrent intrusive memory.  PTSD type 2 has neither of these unique features, but can have the rather similar but normal recurrent intrusive memories — as can PTSD type 1 in addition to its abnormal flashbacks.  PTSD type 2 can be virtually indistinguishable from PTSD type 1 most of the time unless one specifically looks for the  persistent peripheral oscillopsia and the abnormal flashbacks.

Q. So why are oscillopsia and abnormal flashbacks there with PTSD type 1?

A. God hasn’t told anyone exactly why, it’s just God’s ‘nomological law’ ‘… persistent peripheral oscillopsia and abnormal flashbacks are always there together in PTSD type 1 — this is neither logically necessary nor theoretically explicable but is just so…’. ( It is true that in any branch of medicine nothing is always and nothing is never’ but if one of these two abnormal features is there then the other is ‘always’ there, and when successful EMDR gets rid of PTSD type 1, then neither is there, as sure as anything ever is ‘always’ in medicine.). There is a geneticist’s abductive reason based on the clinical evidence base  as to why the two are always there together — it’s due to an ‘epigenetic change’ in the DNA of some part of the brain that was triggered by the experience of the sudden mental shock that caused the PTSD type 1. It is described in Section 2 of the webpage.

Q. OK then: So what difference does it make if persistent peripheral oscillopsia is always there but it’s hardly ever noticed?

A. Before treating ‘PTSD’ one must know which ‘PTSD’ is which.  PTSD type 1 does not go away on its own, nor does it respond to talking therapies or to medication, but for those of western European heritage PTSD type 1 can be cured completely in 9 cases out of 10 or so cases by EMDR, but not for 10 out of ten cases.   We’ll get to EMDR in a moment, just below.  EMDR is also fully explained in the web page.   PTSD type 2 can go away on its own, slowly, but by no ways always, and may be helped along with talking therapies and medication or both, but PTSD type 2 does not respond to EMDR at all.  Getting PTSD types 1 & 2 mixed up means getting the treatments mixed up, which rapidly becomes  fruitless and frustrating. Many people who don’t distinguish the two end up saying “…EMDR doesn’t work for ‘PTSD’…it’s a waste of time…”

Q. So now: just what on earth is EMDR ?

A. EMDR was serendipitously discovered by the brilliant psychologist Francine Shapiro in 1989. EMDR stands for Eye Movement Desensitization and Reprocessing.  It sounds a lot more complicated than it is. It’s a peculiar, very simple treatment. It can be successful in eliminating PTSD type 1 for 9 or so out of 10 in people of western European heritage with PTSD type 1. As we shall see below, anyone can learn how to correctly recognise PTSD type 1 with the visual test and then learn how to correctly perform EMDR. There’s another of God’s nomological laws for EMDR ‘…the success of EMDR in eliminating PTSD type 1 in many people who have it, but not all who have it, is neither logically necessary nor theoretically explicable but it is just so…’,.  God hasn’t provided any explanation as to why EMDR works. Some geneticists abductively reason from the evidence that EMDR some how allows ‘epigenetic reversal’ in the brain while EMDR is in progress. There is no explanation as to why it only works for 9 out of 10, and less often in those of heritage of some other regions of the world, but we suspect that geneticists will be able to explain it one day.  Nine out of 10 of those with PTSD type 1 getting better is a lot better than zero out of 10 getting better as it was for the two thousand and more years before 1989 and Dr Shapiro. We speculate that those with PTSD type 1 not getting better with EMDR will have to wait until geneticists find some way other than EMDR to reverse the epigenetic change of PTSD type 1.

Q. So how to tell the difference between PTSD type 1 and PTSD type 2 ?

A. The simple visual test specifically, reliably and sensitively detects the presence or absence of peripheral oscillopsia., and hence the presence or absence of PTSD type 1, regardless of the presence of PTSD type 2 or other conditions other than blindness or uncooperativeness.  It enables a trial of EMDR treatment to get started asap if PTSD type 1 is there. How the test is done is all explained in the web page below.  If the test for peripheral oscillopsia is negative then PTSD type 1 is not there, and so treatment for PTSD type 2, if there, can get started asap.  Only if and when PTSD type 1 has been fully eliminated by EMDR is the visual test result for persistent peripheral oscillopsia ‘negative’. Getting things mixed up can lead to treatment chaos. If PTSD type 1 is not eliminated then as things are at present it’ll be there life long — and that can be very tough for the quality of life of children and anyone else with PTSD type 1, and may well cost them their lives in the long run.

Q. So what other differences are there between PTSD type 1 and PTSD type 2 ?

A. PTSD type 1 can only follow a sudden mental shock, and it comes on instantly.  A mental shock is defined as ‘experiencing intense fear or horror triggered by experiencing a sudden, unexpected and out-of-control event’. PTSD type 2 can also follow a mental shock and or any sort of not-so-sudden mental trauma, and can come on straight away, or it can come on after a day or two or can come on much later. PTSD types 1 and 2 can be there together in the same person at the same person from the same traumatic event, or,  from separate events at separate times, and together giving rise to a ‘complex PTSD’.   Both PTSD type 1 and 2 can be of any severity. The spectrum of severity for both types is from ‘horrendous’ to ‘just noticeable and tolerable’ and of any intensity in between.  Both PTSD type 1 & 2 can be diagnosed, and for most they can be successfully treated, at any age over 5 or 6 years.

Q. That’s not how ‘PTSD’ described in the books, why ?

A. True, and that’s why the American Psychiatric Association’s description of ‘Post Traumatic Stress Disorder’ in the Diagnostic and Statistical Manual of Mental Disorders, the DSM 5, cannot be left as it is.  The DSM 5 ‘PTSD’ doesn’t distinguish between the two type of ‘PTSD’, and DSM 5 has a mixture of other disorders that can directly follow mental trauma that are said by that book not to be ‘PTSD’ —  and this causes great confusion.   We have to try to get the APA to change it. We have to get ordinary people, as well as ‘experts’, willing and able to do the simple visual test and to distinguish PTSD type 1 and type 2 for themselves, and then willing and able to trial properly performed EMDR themselves for those with PTSD type 1.

Q.  How is it going to be changed ? How come no one knows about all this oscillopsia test stuff ?

A. ‘All this’ comes from the 30 year long investigation into persisting subtle visual abnormalities in people who had been mentally traumatised. And ‘all this’ has been published by us in the peer-reviewed international scientific literature { Traumatology 15(3) 22-33 (2009)  }.  But the ‘PTSD authorities’ around the Western World — the APA, the psychiatrists and psychologists of academia and of the armed services and emergency services — don’t countenance such a counter-intuitive idea of a unique visual abnormality following purely mental trauma that distinguishes between two types of ‘PTSD’. This prevents them from finding EMDR to be reliable. They shun EMDR, and that leaves many with PTSD type 1 untreated, and sadly, many with PTSD type 1 left untreated commit suicide. Those not wanting to believe in persistent peripheral oscillopsia must avoid looking for it, just as Galileo’s good friend, the philosopher Cremonini, avoided looking through Galileo’s telescope because he didn’t want to believe in the moons going around Jupiter.

So we have taken assurance from Thomas Huxley, the 19th Century biologist, known as ‘Charles Darwin’s bulldog’, and said to be ‘the cleverest man in all England’ at the time. He stated: ‘…the ultimate court of appeal is to observation and experiment, not to authority….’ So for us, here is that necessary combination — (i) Our ‘observation’ that only some patients with ‘PTSD’ report that they always observe persisting peripheral oscillopsia on testing; (ii) Our ‘observation’ that those same patients always report observing recurrent abnormal flashbacks; and (iii) Our ‘experiment’ of treating all patients with ‘PTSD’ with EMDR and ‘observing’ that some of patients with (i) and (ii) above report observing the permanent elimination of their persistent peripheral oscillopsia and their abnormal flashbacks at the same time (this is now called PTSD type 1); and, our ‘observation‘ that  those patients  without (i) and (ii) above don’t report observing any change with EMDR (this is now called called PTSD type 2). This combination provides the ‘legs’ (i), (ii) and (iii) for the ‘three-legged evidence base’ for two types of ‘PTSD’, PTSD types 1 & 2, and an appropriate place for EMDR treatment of PTSD type 1 providing the permanent elimination of  PTSD type 1, but successful in doing so for only some of the patients with PTSD type 1.

CONTENTS — THE WEB PAGE DETAILS

  • Preface
  • Section 1  Some of the problems with DSM 5 and ‘PTSD’.
  • Section  2  What is the new ‘PTSD’ — the formal paradigms of PTSD types 1 and 2.
  • Section 3  Persistent peripheral oscillopsia (unique to PTSD type 1) and  The Visual Test for its presence.
  • Section 4  The re-experiencing abnormal flashback memories (unique to PTSD type 1).
  • Section 5   The spectrum of the severities of PTSD type 1 and PTSD type 2.
  • Section 6  EMDR treatment for PTSD type 1 and the treatment for PTSD type 2.
  • Section 7  Can PTSD type 1 be heritable?

Preface

The full story of the ups and downs during the 30 years of the investigation, together with many descriptive case histories, and details of the many mental health issues entangled with PTSD types 1 and 2, is all in a book entitled ‘The Ladies with Stammering Vision’ published by Austin Macauley, London.  The words ‘stammering vision’ are in deference to Dr Traquair,  who first recorded it — mentioned in the Synopsis above. The book’s title refers to the women first seen by us in 1977 who had ‘Traumatic Neurosis’ and the unknown of at the time visual abnormality.

Understandably, people can let any term mean whatever they want it to mean.  The term ‘PTSD’ is used world over — in armies, in emergency services, in law courts, in media, in workplaces, in pubs, even in parliaments.  Each psychiatrist and psychologist more or less has his or her own idea of what it means to them. Alas, ‘PTSD’ is used as though people are all talking about the same thing.  Which they mostly are, but each meaning little more precise than ‘…very unpleasant mental distress-related and anxiety-related symptoms, together with very unpleasant memories, all triggered by one or more experiences of mental trauma…’.  With no agreed precise description of ‘PTSD’ there has been no agreed precise treatment of ‘PTSD’. And most must agree that the long description of ‘PTSD’ given in the APA’s DSM 5 is far from precise and gives rise to an awful lot of unresolvable clinical (and legal) problems.


Section 1

Problems with the DSM 5 description of  ‘PTSD’

The American Psychiatric Association, the APA, publish details of their ‘PTSD’ in their Diagnostic and Statistical Manual of Mental Disorders. It is now in its 5th edition, DSM 5, 2013.  But ‘PTSD’, replacing the vague term Traumatic Neurosis, does not describe a specifically defined psychiatric or psychological entity.

The APA had added a few extra ‘distress and anxiety disorders’ that can follow ‘traumatic-stress’ that are ‘not PTSD’ (even though they obviously are ‘post traumatic stress’ disorders).  They include ‘Acute Stress Disorder’, ‘Adjustment Disorders’, and some others. But from the descriptions given by the APA for these extra disorders it is still not always possible to distinguish them from the DSM version of  ‘PTSD’ itself.  Distinguishing one from another can certainly be impossible in the earliest stages following the mentally traumatic event that triggered them — or at any other time when the anxiety and distress levels are or remain very high.

What is more, the APA authors stipulated in their DSM 5 that there can be no ’PTSD’ unless the mentally traumatic event triggering it had been …an exposure to actual threatened death, serious injury or sexual violence …. in various specified ways……  In other words, in DSM 5 terms: it is the nature of the mentally traumatic event that is important in the diagnosis of ‘PTSD’, not how the person was actually affected by the mentally traumatic event, regardless of its nature.   This is rather like saying: it’s a broken leg if it happened in a violent road accident;  but it’s not a broken leg for an old lady with osteoporosis if it happened while she was just turning over in bed.  True, all broken legs have x-rays to show there is a break ….. Well, there is now a simple, reliable and sensitive visual test to show that PTSD type 1 is or is not there. People of any age above 5 or 6 years have widely different susceptibilities and vulnerabilities to the development of PTSD type 1 and or PTSD type 2 in response to experiencing a mentally traumatic event of any severity.

In 2013 Dr Allen Frances, M.D. an APA member who had worked for many years on the ‘DSM’ task force, wrote his own book in 2013 entitled  ‘Saving Normal’, published by Wm Morrow.  The book is a critique of the DSM. He has a Chapter entitled ‘Fads of the Present’. This chapter contains his section on ‘PTSD’, a section headed ‘Hard to get it right’. He comments  ‘The diagnosis of PTSD is imprecise because it’s based exclusively on the person’s self report — there is no laboratory test or objective measure’.

There is still ‘no laboratory test or objective measure’ for PTSD type 1. Nor is there one for practically any other psychiatric disorder except for, perhaps, porphyria.  But there is now a simple, specific, reliable and sensitive Visual Test for PTSD type 1.  There is no visual test for any other psychiatric disorder, including PTSD type 2.  The Test Visual Test is there for anyone taking trouble enough to use it. It detects the presence or absence of a precise and specific PTSD type 1, and regardless of the nature of the traumatic event that triggered it and regardless of the severity of the PTSD type 1, and regardless of the presence of any other mental or physical disorder other than blindness and uncooperativeness.

There is also an imprecise, amorphous, and non specific  PTSD type 2 to replace the mixture of those other equally amorphous ‘trauma and stressor related disorders’ listed in DSM that can follow mental trauma, those disorders that in DSM are supposedly ‘not PTSD’.

The women who were referred to me in 1977 with Traumatic Neurosis, who also had the odd visual abnormality, had certainly been very frightened by their accidents at work. But they had not been in very serious accidents otherwise.   And when there is a compensation issue over any form of ‘PTSD’ then it surely has to be settled on the subjective severity of the mental effect the traumatic event had on the person, regardless of the objective severity of the causal traumatic event.   It can no longer be the case that ‘…you can’t have ‘PTSD’ because the stressful traumatic event you experienced wasn’t bad enough…’.


Section 2

The formal paradigm of PTSD types 1 and 2

(cf. The ultimate court of appeal is to observation and experiment — not authority)

The paradigms given here of PTSD types 1 & 2 conform with the parsimony demanded by the 14th Century philosopher, William of Ockham — Ockham’s Razor (‘Entities should not be multiplied unnecessarily). The paradigm for PTSD type 1 alone also conforms with demands for falsifiability of the 20th Century philosophers of science, Popper and Kuhn, and conforms with a necessary ‘three legged stool’ evidence base — i.e. the constant presence from the outset of its two unique clinical features that for some can be eliminated simultaneously with EMDR.  

In retrospect, and with 20/20 hindsight, all that was needed by the APA in their dividing up of the old paradigm ‘Traumatic Neurosis’ in 1978 was a more parsimonious division.  A division of ‘Trauma- and Stressor-related Disorders’ conflated into a joint PTSD of two types 1 and 2. The two types are at times clinically indistinguishable from each other except for the two unique clinical features of PTSD type 1.

PTSD type 1

  • PTSD type 1 is a Unitized disorder (cf. Koch’s 19th Century postulates for a specific ‘disease’ entity. i.e. the disorder is either all there or it is not there at all).
  • PTSD type 1 is a disorder of persisting anxiety and distress. The intensity of the non-specific amorphous anxiety and distress symptoms ranges from the most horrific to the much less so.
  • PTSD type 1 has one ‘necessary’ condition: it was caused by, and only by, and at the time of, an event giving rise to an experience of mental shock (i.e. a momentary experience of instant fear or horror triggered by experiencing a sudden, unexpected and subjectively out-of-control mentally traumatic event).
  • PTSD type 1 has no necessary condition of the objective dimension of the event (how big or small or how bad) that triggered the mental shock.
  • PTSD type 1 has two ‘necessary-and-sufficient’ conditions: Two unique clinical abnormalities present from the outset: (a) A unique abnormality of vision — a subtle and mostly unnoticed persistent peripheral oscillopsia — this is unique to PTSD type 1 (described in detail in Section 3); (b) A unique abnormality of memory, an all-too-noticeable recurrent abnormally experiential flashing back memory of the sensory experiences at the moment of the mental shock. This form is also unique to PTSD type 1. (It is described  in detail in Section 4).
  • PTSD type 1  has no necessary condition of the subjective severity or obtrusiveness of either of the two unique abnormal clinical symptoms (see Section 5).
  • PTSD type 1 has no necessary condition for the subjective severity or obtrusiveness of associated non-unique mental distress, anxiety- or depressed mood-related symptoms (Section 5).

[  Herewith the speculative jump — some geneticists’ abductive reasoning from clinical observation to a theory of PTSD type 1: The ‘simplest and most likely explanation’:

The experience ofsudden and momentary surge of high anxiety of a mental shock had instantly caused an epigenetic methylation of DNA somewhere in the brain, This methylation switches off genes, in turn causing an instant cascade of malfunction in three functionally-unrelated sites of the brain — one site controls ‘processing of the specific memory of the experiences of that moment of mental shock’, one site controls ‘an appropriate resting anxiety level’, and one site controls ‘visual image stability’.  This multiple malfunctioning remains indefinitely unless and until there is a spontaneous reversal of epigenetic change during EMDR treatment.

If and when there is elimination of PTSD type 1 by EMDR it is sometimes quickly effective in ten seconds of treatment, sometimes very slowly and only after several months of repeated sessions, usually over some time in between those two extremes. For some people with PTSD type 1 EMDR is totally ineffective in eliminating their PTSD type 1. The geneticists’ abductive reasoning from the evidence is that during the EMDR treatment sessions there is, rapidly for some, more long drawn out for others, an epigenetic reversal and a switching back on of the genes controlling the three sites of malfunction.]

Every aspect of PTSD type 1 has a spectrum, going from extreme to extreme of clinical severity,

One cannot define a disorder by its response to treatment, but — the specific clinical features of PTSD type 1 do not fade in severity over time spontaneously, nor is PTSD type 1 eliminated in response to medication or talking therapies, helpful as those treatments may be otherwise. It has a probability, but no certainty, of permanent elimination by EMDR (or its equivalents) (Section 6) during which the two unique abnormal clinical symptoms are simultaneously degraded and then permanently eliminated step by step and in step.  The simultaneous elimination of these two unique clinical symptoms by EMDR (or its equivalents), confirmed by visual testing, supplies the falsifiability of the evidence base for the PTSD type 1, and, the treatment effectiveness of the EMDR for that particular person. There may be two or more abnormal flashbacks from two or more mental shocks coming at different times, each requiring separate elimination by EMDR — the persistent peripheral oscillopsia remains until there is no fragment of any aspect of any abnormal flashback that is evocable. ]

PTSD type 2

  • PTSD type 2 is a Dimensional (non-unitised) Disorder.
  • PTSD type 2 has amorphous symptoms of anxiety and distress. The intensity of the symptoms of anxiety and distress ranges from the most horrific to the much less so. These non specific amorphous symptoms of anxiety and distress can be indistinguishable from those same symptoms of PTSD type 1.
  • PTSD type 2 has a necessary condition of having been caused by experiencing one or more events giving rise to mental trauma or traumas (fear and or distress), with or without mental shock. Its onset may be sudden, slow or delayed.
  • PTSD type 2 has no unique abnormal features of vision and no abnormal forms of memory — perhaps many horrible and intrusive memories in normal form, but not in the form of the abnormal flashbacks unique to PTSD type 1 .
  • PTSD type 2 can slowly fade away spontaneously over time; it can respond to talking and medication treatments, but EMDR treatment has no effect. .

[A ‘speculative jump’ going abductively from observation to theory: In PTSD type 2 it is as though there has been a subconscious ‘once bitten, twice shy’ learned mental disorder of anxiety and or depressed mood triggered immediately, or with a delayed onset, by the experience of mental trauma(s). It takes time and re-learning to diminish in intensity. It may not fully recover over time if other sources of mental trauma continue to be present, e.g. from persisting lameness, relationship or other deprivation, persisting grief, persisting drug and or alcohol abuse, or from the development of other mental illness or disorder. ]

Complex PTSD

  • PTSD types 1 & 2 can arise alone or rise together in the same person following the same traumatic event or from different events at different times.
  • PTSD types 1 & 2 can persist together, and can be present together with other mental illnesses, including psychotic mental illnesses, and together with physical injuries and disorders.
  • The simple visual test detects the presence or absence of PTSD type 1 among other mental and physical disorders which may be present, including PTSD type 2.  If and when PTSD type 1 is eliminated by EMDR then the other comorbid disorders, including PTSD type 2, remain to be treated.
  • Attempts at any treatment for Complex PTSD, not knowing which mental disorder is which, or that both are there together, can lead to frustration and discouragement, fostering scepticism about the effectiveness of any treatments for ‘PTSD’.

Conclusion

Mental shock (as defined —  a momentary experience of instant fear or horror triggered by experiencing a sudden, unexpected and out-of-control mentally traumatic event) may cause nothing at all, may increase resilience, but may cause PTSD type 1 (of any degree of severity), may cause PTSD type 2 (of any degree of severity) and may cause both PTSD 1 & 2 together (of any degree of severity).  Mental trauma without mental shock may cause nothing at all, may increase resilience, and may cause PTSD type 2 (of any degree of severity), but cannot cause PTSD type 1.


Section 3

The  Visual Test to detect the presence or absence of Persistent Peripheral Oscillopsia, unique to PTSD type 1 —  and hence The  Visual Test is a test to detect the presence or absence of PTSD type 1.

(It takes a lot longer to read how to do this simple visual test than the 30 seconds it takes to do it).   

Persistent peripheral oscillopsia is ‘persistent’ in that it is always to be found at any time if there is even a fragment of an abnormal flashback of PTSD type 1 that is spontaneously evocable or can be evoked voluntarily.  Its presence is regardless of how long since any abnormal flashback or fragment of an abnormal flashback was last evoked.  The abnormal flashback does not have to be evoked at the time of The Visual Test

For the sake of this description of The Visual Test let us suppose that the subject being examined here is a ‘he’, the examiner here is a ‘she’. If possible a friend or relative of the subject will be present also, looking on to reassure him.

  • The test can be performed by anyone on anyone who is fully co-operative, including children of five or six years or older. For those not understanding English there will need to be an interpreter.
  • The test cannot be performed if the subject is acutely anxious — there are many transient and chaotic visual abnormalities during a panic attack or in near-panic that can confuse the test result.  One must wait until any signs of acute  panic are well passed.
  • Throughout the test he remains seated.  He must hold his head and eyes perfectly still throughout the ten seconds of the test.
  • One of his eyes must remain covered (let us say his left).
  • He is asked to focus with his right eye on her, the examiner’s, left eye.  She stands a metre or so in front.  She has her right eye covered.
  • Her left arm is then held out, and held rigid and horizontal. The fingertips of her left hand must just reach the outer periphery of his right visual field. He can just see the examiner’s finger tips but no further out. This is an essential detail.
  • She fixates her left eye on his right eye, ensuring  that during the ten seconds of the test he does not shift his focus the tiniest bit unobserved by her — the visual axis (patient’s eye fixation  to examiner’s eye fixation)  is thereby held rigid.
  • During the ten seconds of the test he is asked not to shift his fixation of his right eye from her left eye, or blink. He is asked to pay attention to what, if anything, appears to happen to her left arm and hand whilst his right eye remains focussed on her left eye.
  • After 10 seconds she lowers her left arm and asks him to demonstrate with his right arm, how her left arm appeared to him during the 10 seconds of keeping his right eye fixed on her left eye.
  • The test is positive for ‘persistent peripheral oscillopsia’ when he reports:  (a) that at some time within ten seconds of commencing his steady fixation, some part of her outstretched left arm, or hand or just her fingers appeared to move up and down, or round and round — to oscillate — at about two to five cycles per second; (b) that the oscillation continued uninterruptedly to the end of the ten seconds, or for as long as his right eye remained fixated on her left eye and her left arm remained extended and stationary.

Details of persistent peripheral oscillopsia vary from subject to subject:

  • For any one person the oscillations may appear to be there, at each test, from the outset or only appear after a few seconds — a constant delay in onset which may be from 1 to 6 or 7 seconds of steady fixation.
  • For any one person the oscillations, at each test, have a constant frequency — of about one to three or more waves or cycles per second.
  • For any one person the oscillations, at each test, have a constant amplitude — of a few degrees or possibly be up to 45 or more degrees.
  • For any one person the oscillation, at each test, has a constant extent over the visual field — the extent of apparent movements may have been just in the periphery of the visual field, just the examiner’s fingers appearing to oscillate, or more extensive with the examiner’s hand and fingers appearing to oscillate, or more extensive throughout the visual field with the examiner’s fingers, hand and forearm appearing to oscillate — or possibly throughout the whole of the visual field with examiner’s whole arm appearing to oscillate.
  • There may be an apparent very brief ‘jerk’ or two, up or down, of the examiner’s arm during the ten seconds. These are normal illusions.  They do not persist and are not abnormal oscillations.
  • During successful EMDR — i.e. as EMDR continues and there is a steady step by step degradation of the details of the abnormal flashback — there is a simultaneous steady step by step and in step degradation of all features of the oscillopsia seen on serial testing.
  • Some degree of persistent peripheral oscillopsia is ‘persistent’ in that it is always to be found at any time if there is even a fragment of an abnormal flashback of PTSD type 1 that is revocable spontaneously or can be evoked voluntarily, and regardless of how long since any abnormal flashback or fragment of one was last evoked.
  • If there is a suspicion that the subject is dissembling over a negative or a positive test result then the examiner can redo the test and oscillate the left arm, simulating a positive test result, or, have multiple re-tests over time.
  • The test gives a positive result before EMDR treatment for PTSD type 1 and gives a negative visual test result immediately after properly-performed EMDR has successfully permanently eliminated the PTSD type 1 — no oscillopsia and no abnormal flashback. This negative visual test result contributes to the evidence base for the effectiveness of EMDR in successfully eliminating PTSD type 1 for that person, regardless of any other mental disorder still persisting e.g. PTSD type 2, a psychotic or other mental illness — (PTSD type 1 is not all that uncommon in those with a psychotic illness and EMDR is no more or less effective in the presence of a psychotic illness.)

Some patients with PTSD type 1 have oscillopsia of all stationary objects throughout their whole visual field persistently, with no delay in onset and present all day everyday, with their head and eyes held perfectly still and with head and eyes moving about (this had been the case with those first patients of Middle East and southern Europe ethnic origin who had been referred to me in 1977 — and several other patients of southern European ethnic origin since) (Section 7).


Section 4

A recurrent  abnormal experiential  flashback of PTSD type 1.

People who have PTSD type 1 always have this unique clinical feature. It is a recurring  abnormal re-experiencing iconic flashback memory recall of the sensory and physical experiences during the moment of mental shock — the momentary experience of instant fear or horror triggered by experiencing a sudden, unexpected and out-of-control mentally traumatic event— the experience of the mentally traumatic event that had triggered the PTSD type 1.

  • It is an abnormal form of iconic memory-recall, a ‘re-experiencing’ or ‘re-living’ of the physical and sensory sensations that had been experienced during the moment of the mental shock at the time of the event that triggered the PTSD type 1… ‘as though it is all happening again’.
  • The features, briefly or not so briefly, that are re-experienced are (i) The sensations of the emotion felt during that moment e.g. the fear, anxiety, panic; (ii) Of what was seen during that moment e.g. a coloured, often a detailed still picture or a constantly re-running video clip of what was seen e.g. A threatening gun pointed at one. A grinning aggressive face of an angry superior at work while being reprimanded.  A bloodied corpse at an accident, or at a bomb site, or at a murder site, or in a burnt out building. The room one was looking at from where one was listening to a frightening phone call, or from where one was having a panic attack.  A vehicle seen immediately prior to an unavoidable collision. A smashed windscreen seen immediately after an accident. A face in a coffin. A colleague who was standing next to one now bleeding to death after being shot……There is myriad unique possibilities of what is ‘seen’ in people’s real life abnormal flashbacks.  (iii) Of what was heard during that moment e.g. the words spoken, the screams, the screech of brakes, the crumbling metal, the gunfire…. (iv) Of what felt physically during that moment e.g. the pain, the penetration, the choking, the falling…. (v) Of what was smelled during that moment e.g. the petrol, the putrefaction, the faeces, the smoke…..
  • The abnormal flashback is NOT a dream.  It is experienced only whilst wide awake.  When coming in the middle of the night it was perhaps triggered by a nightmare of similar frightening events.
  • The abnormal flashback can occur spontaneously, can be triggered and can be voluntarily re-evoked.
  • There may be several different abnormal flashbacks from several different moments of mental shock from one traumatic event or from many different traumatic events which may have been separated in time from minutes to days to decades.
  • Abnormal flashbacks may recur from many times a day to once or twice a year.
  • Abnormal flashbacks last from a few seconds to several minutes.
  • Attempts are usually made to get rid of an abnormal flashback by distraction, by a violent action e.g. hitting a wall with a fist; smashing a glass; self harming with a cigarette burn to the arm;  by a swift acting drug or a swig of alcohol;  by immediately leaving the room…
  • Abnormal flashbacks recur each time with the same intensity of distress. The distress may be extremely severe, may be relatively unobtrusive or anywhere in between.
  • Abnormal flashbacks must be distinguished from recurrent normal intrusive distressing memories of traumatic events, from distressing dreams and nightmares of traumatic events — any or all of which may be intermingled with abnormal flashbacks of PTSD type 1
  • When an abnormal flashback has responded to EMDR or other treatment, then the details of its content can still be recalled but the recall is in normal non-experiential form, still distressing as it may well be.

Section 5

Severity of PTSD type 1 and or PTSD type 2

There is a spectrum of subjective severity for both PTSD type 1 and PTSD type 2. Either can be hideously severe with terrible anxiety, frustration and depressed moods that destroy relationships and shorten lives.   Either type can be not very severe, just noticeable. Most are somewhere in between in terms of severity.  Only in PTSD type 1 is there always present persistent peripheral oscillopsia, very subtle and not noticed until tested for, or, very obvious and there all the time, or, anywhere in between.  In PTSD type 1 only there are always abnormal flashbacks, lots and lots of different ones or just one or just a few.  They are severely distressing or they are hardly noticeable or they are anywhere in between in number.  Only in PTSD type 1 is there a high chance but no certainty of it being permanently eliminated by EMDR.   PTSD type 1 is there with its two unique features or it is  not there at all.

There is a spectrum of the objective severity of the events that triggered the PTSD type 1 and or type 2 — how big and terrible and frightening the event was or how small but frightening the event was.  The subjective severity of experience that can trigger mental shock and PTSD type 1 and or PTSD type 2, and the subjective severity of mental trauma that can trigger PTSD type 2 differs very widely from person to person.

Some firefighters, soldiers, paramedics and other emergency workers of either sex, amongst many others of either sex, can get horrendously severe PTSD type 1 and or PTSD type 2 from horrendously traumatic experiences that are endlessly distressing, relationship-destroying and life shortening.  And some of them can get only mildly distressing PTSD type 1 and or PTSD type 2 from a frightening personal confrontation or a frightening reprimand at work or at school.

Some 5 and 6 year old boys and girls can get horrendously severe PTSD type 1 and or PTSD type 2  from experiencing horrendously collateral trauma in war or child abuse at home that are endlessly distressing, relationship-destroying and life shortening. And some of them can get mild PTSD type 1 and or PTSD type 2 from being frightened by a teacher shouting at them in the classroom or being bullied by a classmate in the playground.


Section 6

EMDR Treatment of PTSD type 1,  and the treatment of PTSD type 2.

The aim of EMDR is to deconstruct the abnormal iconic form of the abnormal flashback memories, leaving only a normal form of non-experiential memories of the moments of mental shocks, and, to eliminate persistent peripheral oscillopsia. Properly-performed EMDR is effective in eliminating correctly-diagnosed PTSD type 1 for about 9 out of 10 cases of those of northern European genotype, perhaps fewer in other genotypes.  EMDR is a lot simpler than the wording of its long title would suggest.  Virtually anyone anywhere can properly diagnose PTSD type 1 with The Visual Test and then virtually anyone anywhere can properly perform EMDR for anyone over 5 or 6 years who has PTSD type 1.   Either or both can be done just behind the battlefield or in the living room at home. EMDR is as equally effective for children aged 5 to 6 years with PTSD type 1 as it is for adults.   There appear to be genetic factors in certain races militating towards a greater severity of their persistent peripheral oscillopsia and towards greater difficulties over their response, if any response at all, of their PTSD type 1 to EMDR.

Adjunctive talking therapies, with or without the help of anti-anxiety medication, e.g. a tricyclic or SSRI antidepressant, must be part of the overall management of PTSD of either type.

……………………………………………………

Let us say that that the subject being treated with EMDR here is a ‘he’, the therapist here is a ‘she’. If possible a friend or relative of the subject will be present and looking on, to reassure him.  For those not understanding English there will need to be an interpreter.

  • He sits comfortably in a chair. She, the therapist, sits or stands in front, a metre or so away.
  • At the commencement, he is asked to re-evoke one (perhaps of several) abnormal flashback, and then ‘hold’ the re-experience of the instant fear or horror and the re-experience of the visual and other sensations of the moment of mental shock that had been triggered by the experience of a sudden, unexpected and out-of-control event.
  • This may raise his anxiety to an almost unbearable level, and he will need reassurances that his anxiety will only be at its most severe with the first session or two of EMDR, and he must do whatever he can to tolerate the discomfort at the beginning of the EMDR.
  • Whilst the abnormal flashback is being ‘held’, he has a run of repeatedly moving his eyes from side to side by following the moving hand of the therapist, as she repeatedly sweeps her hand from left-to-right-to-left at one to three sweeps per second in front of him.
  • He is told to stop the run of eye movements as soon as his abnormal flashback goes — the therapist’s hand-sweeps then stop too.  This may have taken a run of just several of her hand-sweeps before the abnormal flashback goes, or a run of ten or twenty or thirty or more of her hand-sweeps.
  • The procedure is repeated — each repeated run of eye movements with his abnormal flashback re-evoked each time and each run continued until his abnormal flashback goes each time.
  • If EMDR is being effective, then following each run, or every few runs of side to side eye movements, he senses that the repeatedly re-evoked abnormal flashback is, step by step, degrading in its intensity of sensation — his anxiety is less, the visual detail and colouring of the ‘picture’ of his flashback is less, the hearing detail is less, his pain is less …..
  • The runs of eye movements must continue until no fragment of his abnormal flashback can be re-evoked. It may take as few as two or three runs of eye movements at his first session, or it might take several once or twice per week sessions of repeated runs of eye movements over weeks or even several months before no fragment of his abnormal flashback can be re-evoked and is permanently eliminated.
  • If he has other abnormal flashbacks — he may have several others — then each must be eliminated similarly, serially one after the other, if the PTSD type 1 is to be permanently eliminated.
  • She can only be sure that EMDR has been effective in permanently eliminating his PTSD type 1 when his visual test gives a negative test result — free from any degree at all of his previously-present persistent peripheral oscillopsia, and, he cannot re-evoke any  fragment of any of his previously-present abnormal flashbacks.

The presence of (1) his persistent peripheral oscillopsia and (2) his abnormal flashbacks together before his EMDR, and (3) his certainty of the simultaneous total absence of both after his EMDR, is the independent ‘three legged stool’ evidence base for the effectiveness of EMDR in having eliminated his PTSD type 1 — regardless of PTSD type 2 or any other post-mental-trauma issue or mental illnesses he may have and which may well still persist after the successful EMDR elimination of his PTSD type 1.

There are other ‘EMDR-equivalent’ treatments said to be effective for ‘PTSD’.  One such treatment is with alternate left side, right side tapping instead of alternate left to right eye movements. One treatment is with evoking the visual image and other details of the abnormal flashback and then ‘mentally rewinding’ the details of the event which triggered the PTSD type 1. This last-mentioned treatment  is called ‘Rewinding’, but, is this truly effective for PTSD type 1 (probably not, but probably effective for PTSD type 2) — the success of any ‘EMDR-equivalent’ treatment for PTSD type 1 must be confirmed by The Visual Test positive result before treatment and The Visual Test negative result after treatment.

The treatment for non-specific PTSD type 2 symptoms is numerous sessions of talking therapy with or without the help of anti-anxiety medication, e.g. a tricyclic or SSRI antidepressant. EMDR is ineffective for PTSD type 2.

There is an ‘EMDR Institute’ and an ‘EMDR International Association’, with memberships limited to certain selected psychologists worldwide.  Neither establishment shows willingness to acknowledge the evidence base given here for the two abnormal pathophysiological findings that characterise PTSD type 1, nor the evidence base for the specific effectiveness of EMDR in the elimination of PTSD type 1 in certain people. It is purported by these two establishments that there is a wide range of ill-defined mental states and mental phenomena that ‘respond’ to EMDR — but they provide no evidence base for their purported ‘responses’ that is comparable to the evidence base given here for the response of PTSD type 1 to EMDR.  However, since EMDR certainly does do something highly effective for some people with PTSD type 1, then EMDR may or may not be doing something that is effective for some people within that wide range of ill-defined mental states and mental phenomena they speak of.


Section 7

Is PTSD type 1 heritable ?

There cannot be data as to the prevalence of PTSD type 1 in the general population, yet.  There is the rough USA estimate that the prevalence of ‘PTSD’ is 1 in 14.    There is the rough USA estimate that the prevalence of those with ‘ADHD impairments of any severity’ is 1 in 10.

Obviously if there are no experiences of mental shock then there can be no PTSD type 1, regardless of what genotype one has — no one is born with PTSD type 1. However, it appears that one can inherit an enhanced predisposition to the development of PTSD type 1 in response to experiencing a mental shock.

It has been our clinical experience that amongst any one hundred of the one in fourteen or so of the general population of any age with ‘PTSD’ of any severity, and attending for treatment for PTSD type 1 of any severity, about 40 of that hundred with PTSD type 1 were found to have in addition, ‘confirmed’ ADHD impairments of any severity — but only when ADHD impairments of any severity were routinely looked for in all, and confirmed. Those 40 confirmed with ADHD impairments were confirmed as well as ADHD impairments can ever be confirmed. The remaining 60 with PTSD type 1 were confirmed not to have ADHD impairments as well as not having ADHD impairments can ever be confirmed.

It has been our clinical experience that amongst any one hundred of the one in ten of the population of any age with with ‘confirmed’ ADHD impairments, and attending for treatment of those impairments, about 30 of that hundred were found to have, in addition, ‘confirmed’ PTSD type 1, of any severity — but only when PTSD type 1 of any severity was tested for in all.  The 70 others were tested and found not to have PTSD type 1.  Those 100 confirmed with ADHD impairments of any severity were confirmed as well as ADHD impairments can ever be confirmed.

If having ADHD were independent of having PTSD type 1, then finding the two together would have a probability of 1/140 or so.  But finding PTSD type 1 with ADHD in those attending for treatment of ADHD impairments appears to have a probability of 3/10 or so, and finding ADHD with PTSD type 1 in those attending for treatment of PTSD type 1 appears to have  a probability of 4.2/10 or so.

The onset of PTSD type 1 and or type 2 may trigger ADHD impairments in someone with the genome for the susceptibility to ADHD impairments when no impairments had been evident before that onset of PTSD type 1 and or type 2.  The co-occurrence of ADHD impairments and PTSD type 1 and or type 2 is a form of ‘Complex PTSD’.  The persistence of ADHD impairments following elimination of PTSD type 1 and or treatment of PTSD type 2 complicates post treatment recovery.

PTSD types 1 and or PTSD type  2 can occur from experiences of mentally traumatic events before or after the onset of genetically determined schizophreniform illnesses, bipolar disorder illnesses or other major psychiatric illnesses, and then remain.  The Visual Test will detect the PTSD type 1 in these patients with mental illnesses. EMDR will have some probability of eliminating PTSD type 1 in these patients with mental illnesses.  Any Attention Deficit Hyperactivity Disorder impairments for coping with life’s exigencies can be present before and after the onset of major mental illnesses similarly — but difficult to detect anew in those with mental illnesses.

In conclusion: It seems virtually certain that some gene combinations can predispose to the development of ADHD impairments of any severity in response to difficult life exigencies; and, it seems probable that those same gene combinations can predispose to the development of PTSD type 1 of any severity in response to experiences of mental shock.

For some therapists, alas, it appears that it is easiest of all not to bother looking for either PTSD type 1 of any severity or ADHD impairments of any severity, let alone both. It appears that all too often therapists will diagnose only ‘Depression and Anxiety’ on the basis of the commonest symptoms of each, and treat with medication and or talking therapies.

THE END

Dr Robert Tym (psychiatrist retired; formerly an a/prof neurosurgeon)

ptsd.net@hotmail.com