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‘PTSD’, Oscillopsia and EMDR.

A definitive clinical evidence-based paradigm for the two different anxiety disorders of ‘PTSD’.

            (Simple & readily verifiable clinical observations and their implications.)

PTSD type 1.  A categorical anxiety disorder, characterized by two invariant unique clinical features: (a) One or more epigenomic-engendered ‘abnormally processed circumscribed memories’ each of an event that gave rise to momentary sudden anxiety-‘mental shock’; each event being recurrently recalled abnormally in an experiential ‘abnormal flashback’. (b) Each ‘abnormally processed circumscribed memory’ has a unique subtle anxiety-related visual disorder of ‘persistent peripheral oscillopsia’.  I.e. PTSD type 1 is characterised by two subjective clinical criteria and no objective criteria. PTSD type 1 can be helped but not eliminated by time, talking and or medication. For some but not all with PTSD type 1, each abnormal circumscribed memory can respond, one at a time, to EMDR treatment that allows epigenomic reversal and normal processing of each, eventually resulting in the permanent elimination of all abnormal flashbacks and oscillopsia and hence of PTSD type 1. 

(EMDR is fully explained later)

PTSD type 2. A dimensional generic anxiety disorder, unrelated to genomics and with no unique clinical symptoms of memory or vision. It can be triggered by a variety of mentally traumatic experiences over time. It can have only normal-in-form distressing memory recall of the experiences.   It can usually be, but not always is eliminated by time and by talking and or medication treatments. There is no response to EMDR.

(i.e. There are two very clinically similar-appearing but distinctly very different anxiety disorders that can follow mental trauma.  For both types – from person to person there is a wide spectrum of objective severity of causal event and of clinical severity of the disorder.  The two types have always been getting mixed up with each other, especially when both are present at the same time, from the same or different traumas, as they often are.  The urgent problem for further ‘PTSD’ research is to find an alternative mode of epigenomic reversal for those with severe PTSD type 1 not responding to properly performed EMDR treatment.) See also <ptsd.net/cases >

Introduction.  

Understandably, people can let any term mean whatever they want it to mean.  The term ‘PTSD’ (post traumatic stress disorder) is used the world over in armies, emergency services, law courts, pubs… and used as though people are all talking about the same thing.  Which they mostly are, but each meaning little more precise than ‘…long-persisting and very distressing  anxiety-related symptoms, with very unpleasant memories and with social upheaval, and all triggered by one or more experiences of mental trauma…’. Each psychiatrist and psychologist has his or her own idea of what exactly ‘PTSD’ means to them.  Most must agree that the long descriptions of ‘PTSD’ given in the APA’s DSM 5* and the European’s ICD 10** are far from clinically precise – descriptions that have given rise to endless unresolvable clinical and legal problems for many, from battle-hardened marine veterans to five and six year old girls and boys.  Mentally traumatic events and ‘PTSD’ don’t discriminate anywhere for anyone.

* Diagnostic & Statistical Manual 5th Ed.of the American Psychiatric Association (APA) ** European Psychiatrist's International Classification of Diseases 10th Ed.

This web page presents a robust clinical evidence-based categorization for this highly emotive hitherto mixed up field of ‘PTSD’. The clinical evidence, there for all to see who look, is based on novel clinical observationsand the implications of those observations – a clinical evidence based paradigm at odds with the necessary-at-the-time clinically ad hoc paradigm ‘PTSD’ given in the DSM 5 and ICD 10.

The evidence-base had originated from a chance clinical ‘observation’ * of an inexplicable and subtle abnormality of ‘wavy vision’, briefly mentioned in few words in a text book by a London ophthalmologist, Traquair, in 1946. It had been reported to him while he was examining the vision of some war veterans from WWII who were suffering from Traumatic Neurosis (a.k.a., ‘shell shock’ and many other names over the past 2000 or so years). The clinical observation was not investigated and seemingly all but forgotten.  In 1977  (the year before the name ‘PTSD’ appeared) we (a psychiatrist, with the occasional help of an ophthalmologist and a clinical neuro-psychologist) chanced upon a similar clinical ‘observation’ * of an inexplicable and subtle abnormality of ‘wavy vision’ reported  by some women suffering from Traumatic Neurosis following accidents at work.   Knowing nothing of Traquair’s report 31 years earlier, it was decided to investigated it. Mostly a lone wolf investigation, a quest fellow psychiatrists deemed chimerical, it took 30 or so years to sort out.

The novel clinical findings were eventually published anecdotally in the peer reviewed international journal Traumatology 15(3) 22-33 (2009).   The novel clinical evidence base and its implications are now ready to be questioned, tested and disputed by anyone, and can be readily understood by anyone – meaning anyone who has an open mind for things that are new and possibly counterintuitive.

* Observation: Clinical evidence, the basis of clinical science, depends in large part on clinical 'observations'. Let us be clear on this: The clinical 'observation' made by ophthalmologist Traquair in 1946 was of hearing a series of separate individual ex-soldiers, each with Traumatic Neurosis,  separately reporting to him their personal 'observations' of a particular form of abnormal 'wavy vision'. They only observed this 'wavy vision' during Traquair's routine testing and mapping of their visual fields.  Our clinical 'observations' in 1977 were hearing a series of female patients with Traumatic Neurosis reporting to us their personal'observations' of a particular form of abnormal 'wavy vision' persisting all day. We then deliberately tested for its presence or absence in other patients. When found to be present we asked about the presence of any invariant clinical correlates that were personally 'observed' by those patients. 
We have no evidence to suggest that the reports of observations by the #1 'observers' (the soldiers and our patients) were being influenced in any way by the #2 'observers' (Dr Traquair and us) who were observing them - 'just listen to your patient, he is telling you the diagnosis' was the advice of 'the father of modern medicine' William Osler; and never forgetting the adage 'nothing is always, nothing is never' in any branch of clinical science.

Introduction (cont’d)

Precis of the web page contents. (1800 words)

The initial clinical observation turned out to be of a unique form of ‘oscillopsia’ (‘osi – lop -sia’ a Greek word for wavy vision).  It can be found to be consistent in form and indefinitely persisting in some peoplenot all  people, following an experience of a traumatic event that gave rise to a sudden and unexpected anxiety-ridden ‘mental shock‘ (as defined: a sudden surge of intense anxiety – fear or disgust – coming in response to a sudden and unexpected perception of some out-of-control threat or other distress).   Most clinicians who are told of this visual abnormality by their patients have considered it to be of no clinical significance, to be a ‘hysterical’ symptom, somehow attributable to ‘anxiety’ and best ignored: certainly there is never any injury to the visual system or any neurological or inner ear disorder present to account for it, and is unrelated to microsaccades.  Certainly there are many brief, sporadic and erratic visual symptoms, not only ‘wavy vision’, reported by many people at moments of transient high anxiety, such as during a panic- or near panic-attack, but they soon pass and vision returns to normal. Many clinically inexplicable transient symptoms of all sorts have frequently been called ‘hysterical’.  But, the particular ‘wavy vision’ symptom being referred to here is not brief, sporadic or erratic: it is indefinitely consistent in form and indefinitely persistent, often very subtle, easy to miss or likely to be ignored, but always there when looked for in those patients.  The London ophthalmologist, Traquair, did not refer to it as a ‘hysterical’ symptom in those soldier veterans from WWII.

* We have no neuro-biological explanation for the associations between anxiety and abnormalities of visual perceptual stability - the wavy vision.

What follows in the web page are the clinical findings (the outcome of the observations), and the implications of those findings, that have emerged from the 30 year clinical investigation and subsequently: an investigation into the nature and clinical significance of this particular and consistent subtle ‘wavy vision’, called ‘persistent peripheral oscillopsia’ (‘osi-lop-sia’, Greek for ‘wavy vision’) and, how it is always to be found in association with a particular and consistent abnormal form of a memory retention and recurrent memory recall (an abnormal flashback) of what had been experienced at a moment of sudden and unexpected anxiety-ridden ‘mental shock’.

This recurrent abnormal flashback is defined as: An abnormal form of recurring distressing experiential (re-experiencing) memory recall of the emotional (anxiety) and ‘all’ the other sensory experiences that were recorded present during the circumscribed moment of anxiety-ridden ‘mental shock’.   The recalled information content does not decay over time, nor does a degree of the intensity of re-experienced anxiety decay over time.  Normal forms of memory recall of a traumatic  experience are not abnormally experiential.  Normal forms of memory recall of a traumatic experience can decay in information content and in emotional intensity over time. Normal forms of memory of a traumatic experience are not associated with persistent oscillopsia.

Persistent peripheral oscillopsia is defined as: The onset (instant or delayed for up to ten seconds*) of an illusory perception of a persistent and consistent rhythmical oscillation of stationary objects seen in a greater- or lesser-wide rim of the periphery of the visual field when, with one eye covered, the other eye is steadily fixated on a stationary object for up to 10 seconds. The illusory perception of oscillations persists for as long as steady fixation is maintained. (This is described in detail in Section 3 of the web page below). It is a quite different form of oscillopsia from those forms of oscillopsia associated with neurological disorders such as multiple sclerosis, and vestibular disorders, which are present only with head and or eye movements.  We find no persistent peripheral oscillopsia in Panic Disorder unless recurrent abnormal flashbacks (i.e. PTSD type 1) is there also.  It is not possible to perform the simple but reliable and sensitive clinical visual test for persistent peripheral oscillopsia (which we are coming to) during a panic attack or near-panic attack.

* We have no explanation for the delay in onset. It differs from 0 to 10 seconds from person to person and remains constant in form indefinitely for each person when tested via the visual test. We have no explanations for the differing-from-person-to-person extant of the visual field in which oscillation of stationary objects is seen - from the whole visual field to a thin outer rim - nor for the differing amplitudes and rates of oscillation,  For each person these features remain constant year after year.

There was no understanding of any of this at the outset of our investigation.  The investigation had to involve the brief asking about  (eventually developing the visual test for) the vision of each of 9000 or so psychiatric patients, of all ages over 5 years and from all walks of life, who were randomly referred to the psychiatric practice over a 30 year period.  Abnormal clinical findings that are rare and subtle require a large sample, a lot of people, to search through.

The findings of the investigation have now been commented on by senior academic geneticists (personal communications). The geneticists abductively reason from their own experience of the clinical evidence base (i.e. infer a construct of a known entity for an unknown entity) that: ‘at the moment of the sudden high anxiety of the ‘mental shock’ there had been a sudden epigenomic change * that ‘somehow or other’ instantly affects the normal laying down of the memory of what is being experienced at that circumscribed moment of anxiety-ridden ‘mental shock’.   This results in an abnormal form of circumscribed memory formation and retention of ‘all’ recorded information of what had been experienced during that circumscribed moment, and subsequently, a recurring abnormal form of re-experiencing (experiential) memory recall of ‘all’ information of what had been experienced during that circumscribed moment , including the re-experiencing of intensity of the anxiety, of the information detail of what had been seen, the detail of pain that had been felt, the detail of sound that had been heard…..(i.e. the abnormal flashback of PTSD type 1) .  It can reasonably be assumed that each abnormal form of  permanent circumscribed information retention includes the abnormal permanent retention of some degree of the anxiety.  It can be reasonably assumed also that each abnormal permanent retention of anxiety is responsible (somehow or other) for that circumscribed memory’s ‘own persistent peripheral oscillopsia’ – the unique abnormal persistence of a specific form of anxiety-related ‘wavy vision’.

* The sudden attachment of methyl groups or other compounds to the DNA molecules of certain genes, modifying their activity.

So: PTSD type 1 is a unique categorical anxiety disorder that can only arise from and at the time of an experience of a sudden, unexpected anxiety-ridden ‘mental shock’, and at any age above 5 years.  It has the two invariant unique clinical abnormalities above. Neither of the two unique invariant clinical abnormalities is found in any other mental or physical disorder – they are unique to the anxiety disorder PTSD type 1.  PTSD type 1 does not resolve spontaneously over time, and does not respond to conventional therapies – talking and medication (helpful as they may be palliatively). For some it can be permanently eliminated by EMDR treatment.

And: PTSD type 2 is a non-specific, dimensional generic anxiety disorder that can follow at the time of, or follow later, one or more experiences of sudden, unexpected anxiety-ridden ‘mental shock’ or can follow experiences of less-specific frightening or shocking mental trauma over time. PTSD type 2 has no uniquely abnormal clinical features.   Normal-in-form distressing intrusive recurrent memories can be present.  PTSD type 2 can resolve spontaneously over time, and can respond to conventional therapies.  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.

PTSD type 1 and type 2 can be present at the same time in the same person, having arisen from the same experience, or, having arisen from different experiences at different times.

Each person with PTSD types 1 or PTSD type 2, or both PTSD type 1 and type 2 together, has different levels of anxiety and anxiety-related symptoms.  Each person has different levels of severity of the symptoms.  The levels of severity range from being highly distressing to being much less so.  The anxiety-related symptoms common to both PTSD types 1 & 2 can include sudden startles, hyper-vigilance, headaches, insomnia, nightmares, avoidance, emotional withdrawal, depressed mood, recurrent distressing intrusive memories (clearly clinically distinct from the recurrent abnormal flashbacks that are confined to and specific to PTSD type 1), irritability, loss of concentration……… .

The same anxiety and anxiety-related symptoms in both PTSD types 1 & 2 can make the two different disorders clinically indistinguishable – but indistinguishable ONLY IF the two unique clinical features of PTSD type 1 are not first looked for and recognised.

The simple visual test for the presence or absence of persistent peripheral oscillopsia (easily performed by anyone on anyone of any age above 5 years; it is fully described in the web page) in effect specifically, reliably and sensitively detects the presence or absence of PTSD type 1, despite the presence of other mental and physical disorders (other than un-cooperativeness and blindness) including PTSD type 2 and psychotic disorders and traumatic brain injuries (TBI’s).

Properly performed EMDR treatment (fully described in the web page.) can permanently eliminate PTSD type 1 in some people, not all people with PTSD type 1 .  Senior geneticists abductively reason from their experience of the clinical evidence base (give their best possible explanation) that: properly performed EMDR, when successful in permanently eliminating PTSD type 1, ‘some how or other’ effects, one at a time, an epigenomic reversal * of each abnormally processed memory, allowing normal processing and editing of the recorded information of each memory to a permanent normal form of anxiety-free memory retention, and the disappearance of the anxiety-related oscillopsia . There is then a normally processed and information edited non-experiencing circumscribed memory recall of the circumscribed moment, and, when all such abnormal flashbacks have been fully processed there is then stable peripheral vision – this last being confirmable via the simple visual test’  i.e. no PTSD type 1 – all consistent with the clinical findings.

de-methylation of the DNA

It is reported by others, but without the evidence based visual test being applied that is applied in this study, that other forms of alternating bilateral sensory stimulation, e.g. alternating left-right tapping not involving eye movements, effects ‘a cure’ for some with PTSD type 1. This has not been confirmed by us. There is no clinical evidence base for properly performed EMDR treatment having any long term beneficial effect on PTSD type 2.

Genome factors in PTSD type 1

There is clear clinical evidence (see web page Section 7) that those with a genome for a predisposition to the development ADHD type impairments in response to environmental stressors (i.e. ‘those with ADHD’) are at a considerably higher risk, at any age above 5 years, of developing PTSD type 1 in response to an experience of an anxiety-ridden ‘mental shock’ than are those without that genome.  A genome for ADHD can be passed on to the next generation, perhaps making it look as though PTSD type 1 can be passed on to the next generation, and cluster in extended families, when there is no clinical or other evidence that it can be.

There is no clinical evidence that an experience of an anxiety-ridden 'mental shock' at some age earlier than 5 years can give rise to a permanent epigenetic change to some other aspect of brain function in some genome-susceptible children (e.g. to an autism spectrum disorder).

It has been our clinical experience that those with PTSD type 1 and have genes for light iris and light skin (e.g. northern European ethnicity phenotype) appear to have a 9 out of 10 or so chance of properly diagnosed PTSD type 1 being successfully eliminated by properly performed EMDR .  Those with PTSD type 1 and have genes for dark iris and olive skin (e.g. Iberian, Mediterranean ethnicity phenotypes) who develop PTSD type 1 appear prone to develop more obtrusive persistent peripheral oscillopsia and a much lower chance of successful elimination of their PTSD type 1 with EMDR. than those of northern European ethnicity phenotype.

The urgent problem for further ‘PTSD’ research

There is an urgent need to find an alternative mode of elimination of PTSD type 1 for those with PTSD type 1 not responding to properly performed EMDR treatment.  Persisting anxiety is inimical to the immune and cardiovascular systems. It has been our clinical experience that many of those with PTSD type 1 not responding to properly performed EMDR face miserable and shortened anxiety ridden lives, too often shortened further by suicide.

Although the discovery of EMDR by Shapiro in 1989 was serendipitous, Shapiro none the less deserves our thanks for reporting it and publicising it, albeit she appears unreceptive to ideas of a paradigm PTSD types 1 & 2 given here.

* All this above is a necessarily simplified construct - genetics and neurobiology being infinitely complex, ultimately dependent, no doubt, on three dimensional plus time quantum field effects at the subatomic level: millions - a surging wave - of methyl groups being attached to millions - a field or volume - of DNA molecules, triggered by a sudden surge of whatever constitutes 'anxiety' in terms of molecules and neuron electrical activity that can follow a sudden perception of danger - and whatever that is in terms of molecules and neuron electrical activity . There are 100 billion or so neurons in the brain and biology doesn't work one molecule or one neuron at a time.                                                                 (Not forgetting that there may be some entirely different, non-genomic 'explanation' for PTSD type 1 and its abnormal flashbacks, and if anyone knows of an alternative possible explanation please contact this author!)  

                                                               ………………………………………

The web page < ptsd.net/cases > gives some illustrative case histories typifying clinical presentations of PTSD type 1 and its treatment. More details of the 30 year investigation, of the history of ‘PTSD’, of more 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’.

                                                            THE WEB PAGE < PTSD.NET >

“…truth is the daughter of time, not authority…” said Francis Bacon in 1660 or so. If the finding of ‘a tiny bit of new truth about human vision’ in 1946 triggers a fresh paradigm PTSD types 1 & 2  seventy years later then it is unlikely that the new paradigm will be accepted ‘overnight’ by the authors and practitioners of any paradigm it tries to replace. But a replicable clinical evidence base is the ultimate criterion by which any new idea can stand or fall.

Contents

  • Section 1  Some problems with DSM 5 / ICD 10 and ‘PTSD’.
  • Section  2  The formal paradigm 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 experiential abnormal flashback  (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?

Section 1

Some problems with DSM 5 / ICD 10 and ‘PTSD’

As things were in 1978, just after the Vietnam War, the APA changed the name from Traumatic Neurosis to ‘PTSD’.  They then endeavoured to describe the new ‘PTSD’ in their DSM, and for it to be an improvement on ‘Traumatic Neurosis’ described in Germany in 1892 for the ‘mental disorders following trauma’. The APA’s clinical descriptions of ‘PTSD’ given in DSM and ICD had inevitably to be ad hoc since there was nothing clinically specific known at the time to distinguish any specific post mental trauma disorder from any other.  In the light of the many sufferers amongst the participants in the Vietnam War there was an urgent need at the time, and since, for a way of determining who did and who did not qualify for compensation for a post-traumatic stress disorder.   The APA’s chosen option for whether or not a disorder is to be called ‘PTSD’ and compensable was to be based on the objective features and nature and timing of the causal event (exactly how big or how bad, and what the traumatic event was and when it was) that had been experienced and had triggered the ‘PTSD’.  It was not to be based on any specific subjective clinical findings in the person (exactly how the person was suffering) because there was none uniquely specifiable. In effect they stipulated in DSM that there can be no ’PTSD’ unless the mentally traumatic event triggering it had been significantly objective e.g. ‘…an exposure to actual threatened death, serious injury or sexual violence …. in various specified ways…’ *.

* This is rather like saying  '... it can be a broken leg in a healthy young man if it happened in a violent road accident; but it can't be a broken leg in an old lady with osteoporosis if it happened as she was turning over in bed....'.

There is still a whole host of different names listed in DSM 5 and ICD 10 for a wide spectrum of clinical disorders of different severities, all triggered by one form or another of ‘traumatic stress’ but not to be called ‘PTSD’.  The new clinical evidence-based paradigm provides a clinically rigorous clarification of a PTSD type 1  dependent entirely on subjective clinical criteria and not at all on objective criteria – but with individual vulnerability playing an unspecifiable part.

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Section 2

The formal paradigm of PTSD types 1 and 2  : ‘The ultimate court of appeal is to observation and experiment, not authority’ to quote Thomas Huxley .  

The paradigm  PTSD types 1 & 2 is clinical evidence based and conforms with Ockham’s Razor: i.e. ‘entities should not be multiplied unnecessarily’. It also conforms with the demands for falsifiability by Popper and Kuhn by giving a necessary ‘three legged stool’ clinical evidence base:   i.e. the invariant presence from the outset of two unique abnormal clinical features following a definable anxiety-ridden ‘mental shock’ that for some can be permanently eliminated simultaneously with properly performed EMDR.  

  • PTSD type 1 is a categorical Anxiety Disorder (cf. Koch’s postulates for a specific ‘disease’ entity, i.e. the invariant  features of the disorder are either all there or not there at all).
  • 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 sudden surge of intense anxiety (fear or disgust) coming in response to a sudden and unexpected perception of some out of control threat or other distress) 
  • PTSD type 1 has no necessary condition of the objective dimension of the event that triggered the mental shock (how big or small or how bad or what type of event).
  • PTSD type 1 has two ‘necessary-and-sufficient’ conditions: Two invariant unique clinical abnormalities present from the outset: (a) a unique abnormality of vision – persistent peripheral oscillopsia, a form that is unique to PTSD type 1 (described in detail in Section 3); (b) a unique abnormality of memory recall – abnormal experiential flashbacks. This form of memory recall that is unique to PTSD type 1. (It is described  in detail in Section 4).
  • PTSD type 1 has persisting anxiety and distress. The spectrum of intensity of its non-specific amorphous anxiety and distress symptoms ranges from being the most horrific in some to being much less so in others.
  • PTSD type 1  has no necessary condition of the subjective severity or obtrusiveness of either of the two unique abnormal clinical symptoms of vision and of memory recall  or of the non-specific amorphous anxiety and distress symptoms (see Section 5).

PTSD type 2

  • PTSD type 2 is a dimensional non-specific, generic Anxiety Disorder.
  • PTSD type 2 is a disorder of persisting anxiety and distress. The spectrum of intensity of its non-specific amorphous anxiety and distress symptoms ranges from the most horrific in some to the much less so in others.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 over time 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 recall– perhaps many intrusive memories in normal form, but not in the abnormal form of the abnormal flashbacks unique to PTSD type 1 .

Complex PTSD

Mental shocks (as defined: a sudden surge of intense anxiety (fear or disgust) coming in response to a sudden and unexpected perception of some out of control threat or other distress) may cause nothing at all, may increase resilience, and 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 types 1 & 2 together at the same or different times (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.

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

PTSD type 1 does not resolve on its own over time, and does not respond to conventional therapies – talking and medication (helpful as they may be in easing the distress).  Some people with PTSD type 1 have persisting high anxiety that ultimately affects the immune and cardiovascular systems with life shortening, all to often shortened further by suicide. If and when PTSD type 1 is eliminated by EMDR then the other comorbid disorders, including PTSD type 2, may remain to be treated.


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. However, there are myriad ways to detect one's own persistent peripheral oscillopsia, and myriad ways to invent more sophisticated 'technological' ways to test others, making sure that there are safe guards against voluntary or involuntary false positive or false negative test results. 
  

Persistent peripheral oscillopsia is defined: The onset of an illusory perception of a persisting  rhythmical instability of stationary objects seen in a greater or lesser segment of the periphery of the visual field when, with one eye covered, the other eye is steadily fixated on a stationary object for up to 10 seconds, and the illusory perception persists for as long as steady fixation is maintained. 

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 age of the subject being examined can be as young as 5 or 6 years in our clinical experience.

  • 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 or near-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 on his part.  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 their 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 the psychiatric practice 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  – clinical details.

People who have PTSD type 1 always have this unique clinical feature. It is a recurring abnormal sensory and physical re-experiencing iconic flashback memory recall of the sensory and physical experiences during the circumscribed moment of mental shock  (i.e. a sudden surge of intense anxiety (fear or disgust) coming in response to a sudden and unexpected perception of some out of control threat or other distress ).  The recalled intensity of the experienced anxiety and the detail of the experienced physical and sensorial contents of the experiences of the mentally traumatic event that had triggered the PTSD type 1 do not decay over time.

  • It is an abnormal form of memory-recall, a recurrent ‘re-experiencing’ or ‘re-living’ of the physical and sensory sensations that had been experienced during the circumscribed moment of the mental shock that triggered the PTSD type 1… An experiential recurrence ‘as though it is all happening again’.
  • The features that are re-experienced, briefly or not so briefly, are (i) Sensations of the emotion felt during that moment e.g. the fear, anxiety, panic, disgust; (ii) A picture of aspects of what was seen during that moment e.g. a coloured, often a detailed still picture or a constantly re-running brief 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 background region of 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 shattered windscreen seen immediately after an vehicle accident; a face in a coffin; a colleague who was standing next to one who is now bleeding to death after being shot; the walls of the room in which one was being raped……There is myriad unique possibilities of what is ‘seen’ in people’s real-life abnormal flashbacks.  (iii) Re-hearing what was heard during that moment e.g. the words spoken, the screams, the screech of brakes, the crumbling metal, the gunfire, the breathing of a rapist…. (iv) Re-feeling what had been felt physically during that moment e.g. the pain, the penetration, the choking, the falling…. (v) Re-smelling 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 its onset 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 can 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 can recur from many times a day to once or twice a year.
  • Abnormal flashbacks can 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  and distinguished 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, anxiety-related symptoms, 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.   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 can trigger 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.

There is a spectrum of vulnerability to the development of PTSD type 1. 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 that are endlessly distressing, relationship-destroying and life shortening following horrendously traumatic experiences .  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 that are endlessly distressing, relationship-destroying and life shortening following experiencing horrendously collateral trauma in war or child abuse at home . 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, or watching a frightening scene on TV


Section 6

EMDR Treatment of PTSD type 1,  and the treatment of PTSD type 2. See also <ptsd.net/cases >

The aim of EMDR is to eliminate PTSD type 1. 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.  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 by a paramedic or colleague or in the living room at home by a parent or friend. 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, e.g. Cognitive Behaviour Therapy, 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  types 1 & 2.

…………………………………………………..

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. The age of the subject being treated can be as young as 5 or 6 years in our clinical experience.

  • 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 surge of intense anxiety (fear or disgust) coming in response to a sudden and unexpected perception of some out of control threat or other distress.
  • 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.
  • While 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 same 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, are these other methods truly effective for PTSD type 1 ?   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. There is no evidence-base to suggest that EMDR is specifically effective for PTSD type 2, palliative as the attention given over it may be.

There is an ‘EMDR Institute’ and an ‘EMDR International Association’, with memberships seemingly 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 specifically or nonspecifically 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 at some time in life.

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 specifically 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 successful EMDR 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 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 currently 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.

There must be some slight contribution to this higher risk for getting PTSD type 1 coming from extra trauma-prone high risk and impulsive behaviours of some with ADHD impairments.

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 non-specific antidepressant medication and or talking therapies.

THE END

Dr Robert Tym (psychiatrist, retired from active clinical practice; formerly an a/prof neurosurgeon)

ptsd.net@hotmail.com