An Exploratory Clinical Evidence-based Clarification of the Problematic ‘PTSD’

A clinical evidence based paradigm for the two different Anxiety Disorders of ‘PTSD’ – the two that can appear clinically very similar but are neuro-biologically very distinct: a categorical PTSD type 1 and a dimensional PTSD type 2 – purporting to replace PTSD as per DSM 5  & ICD 11

What is purported to be new & useful about the content of this webpage:  It provides a readily available clinical evidence-based means of certain diagnosis of the presence or absence of a categorical PTSD type 1 as distinct from a clinically very similar dimensional PTSD type  2 i.e. via a simple visual test that is sensitive, reliable & specific for the presence or absence of PTSD  type 1. Thus, a means of giving clinical certainty for (i) finding the correct indication for a treatment trial of a particular patient with PTSD type 1 or with PTSD type 2, and, for (ii) assessing the effectiveness of treatment (e.g. EMDR) aimed at eliminating PTSD type 1 in any particular patient.

SYNOPSIS (*Glossary of terms below).

The argument (consequentia): Applying Occam’s razor (eliminating the irrelevant) to the clinical implications of finding  two hitherto-indistinctly characterised unique abnormal clinical features to be invariant (always there together) – one of visual perception  and one of memory form i.e. finding a constant relationship between two complex and unique abnormal clinical phenomena. This unique clinical relationship is found to be present only in some people, found not to be present in all people, who present with a ‘Post-Traumatic’ Anxiety Disorder that had been triggered by one or more mentally traumatic (anxiety provoking) experiences.

The exploratory clinical findings arose in an investigation that had started in 1977 and continued over a 30 year period of general clinical psychiatric practice.  Its long-term nature was of ‘gathering observations, gathering thoughts’. It included the exploratory asking about, later developing and utilising a simple visual test for examining  a specific aspect of vision. This was applied to each of 9000 or so consecutive psychiatric patients. The patients were of all ages over 5 years old and from all walks of life and of mixed ethnicity, who were randomly referred to the non-specialised general psychiatric practice over a 30 year period. Hitherto uncharacterised abnormal clinical phenomena that are rare, subtle and variable in extent require a large patient sample to search through in order to characterise them.

The long-term purpose  was to investigate the characteristics of a subtle hitherto-undefined visual perceptual abnormality  – later characterised as ‘persistent peripheral oscillopsia’ (PPO)* and its correlates, if any. This visual perceptual abnormality was being persistently reported by some people but not by all people who were presenting with a persisting Anxiety Disorder, ranging in severity from mild to severe, that had been triggered by one or more mentally traumatic experiences from a wide range of events of differing objective severity.  And later finding an invariant correlate: persistent peripheral oscillopsia was only being reported by those people who were also reporting a specifically characterised abnormal form of memory recall: ‘persistently recurrent abnormal experiential flashback memories of the traumatic experience ‘*, and vice versa.

Finding this constant relationship between two unique and complex clinical phenomena suggested a novel and clinically evidentially-definitive  paradigm of two superficially clinically very similar, but neurobiologically very different Anxiety Disorders, either of which can be triggered by one or more similar mentally traumatic experiences of events of any type or severity. The Clinical findings purport a PTSD type 1 and a PTSD type 2 .   The distinguishing diagnostic feature of PTSD type 1 & type 2 rely on the invariant presence (PTSD type 1) or the invariant absence (PTSD type 2) of the two neurobiologically abnormal clinical features. Both Anxiety Disorders are in response to similar subjectively mentally traumatic experiences of events, and regardless of the objective natures of those mentally traumatic experiences.

This novel clinical evidence based paradigm of anxiety disorders PTSD types 1 and 2 is necessarily at odds with the clinically ad hoc paradigm  ‘Trauma- & Stressor-Related Disorders’ 309.81 (PTSD), 308.2 (ASD) 309’89 & 309.9, as given in DSM 5.

The postulated implications of the clinical findings are that complex human genomics and complex neuro-biology of human memory and visual systems are involved in the genesis of PTSD type 1 but not in PTSD type 2.   Of necessity what follows must be a proposed simplified ‘stop gap’ ontology of anxiety disorders PTSD types 1 and 2.

Pragmatically, our clinical experience suggests that the simplified  differentiation of anxiety disorders PTSD type 1 and PTSD type 2 significantly aids the clinical management of those presenting under the rubric Trauma- & Stressor-Related Disorders of DSM 5.     See also www.ptsd.net/cases

Section One

General descriptions (* See glossary of terms immediately below)

PTSD type 1

A categorical *Anxiety Disorder, characterized by two unique and invariant abnormal clinical features.

(i)  A persisting (? epigenomic-engendered *) unprocessed ‘proto-memory’ * of the sensory experiences during a circumscribed (momentary) period of acute anxiety – a ‘mental shock ‘* – triggered while experiencing a mentally traumatic event.   The unprocessed ‘proto-memory’, including the anxiety, is stored and recurrently recalled only as a distressing ‘abnormal experiential (re-experiencing) flashback memory’*.

(ii) A persisting  anxiety-related subtle visual abnormality of ‘persistent peripheral oscillopsia’* (persistent wavy vision) inextricably linked to the presence of a persisting ‘proto-memory’.

(iii) Persisting non-specific anxiety symptoms and distressing memories in normal form are present also. PTSD type 1 is seen to occur at any age over 5 years old regardless of gender.

Clinically PTSD type 1 may be helped (but not eliminated) by time, talking and or medication. For some but not for all people with PTSD type 1, each ‘proto-memory’ can respond, one at a time, to EMDR* treatment ( ? by epigenomic reversal*), allowing each proto-memory to be normally processed to normal memory form and normal form of memory recall.  When all ‘proto-memories’ have been fully processed, i.e. no abnormal experiential flashbacks remain (can be re-evoked), then persistent peripheral oscillopsia is no longer present on testing. This implies permanent elimination of the PTSD type 1. The contents of the abnormal flashback can thereafter be remembered and recalled in normal non-experiential form.  At present, for those with PTSD type 1 not responding to EMDR, their PTSD type 1 persists indefinitely.

PTSD type 2

A dimensional* generic* anxiety disorder, causally unrelated to genomics.

It has non-specific anxiety symptoms similar to those of PTSD type 1 but has no unique abnormal clinical symptoms of memory or of vision. It can be triggered by a variety of anxiety-ridden mentally traumatic experiences over time, including ‘mental shock’. It can have only normally-processed distressing memories and distressing normal memory recalls of the distressing experiences.   Normal forms of memory recall can be intrusive and distressing but are not experiential and can, but not always do decay in information content and emotional intensity over time.

PTSD type 2 can usually be, but not always is eliminated by time and by talking therapies and or medication treatments. There is no specific response to EMDR.  It is seen to occur at any age above five years old and regardless of gender.

Dimensional Disorder
Having a wide range of severity and type of non-specific anxiety-related symptoms.
Generic Anxiety Disorder
It has no unique clinical symptoms, Its non-specific anxiety-related symptoms are common to other differently-named Anxiety Disorders triggered (caused) by different circumstances and experiences.

Complex PTSD (a generic disorder)

(a) PTSD types 1 & 2 can be co-morbid, both arising in the same person  from the same event, or arising from different events at different times. The high anxiety of types 1 & 2 occurring together is cumulative.

And (b) PTSD types 1 and or 2 can be co-morbid with other disorders, mental ( including psychotic) disorders, and or physical (including traumatic brain injuries  – TBI) disorders.

When PTSD type 1 is co-morbid with other disorders, its elimination with successful EMDR) can leave other disorders, including PTSD type 2.  Similarly the elimination of PTSD type 2 can leave other disorders remaining.

Glossary of terms in brief

Categorical Disorder
An explicit, unambiguous and specific disorder – either all there or not there at all.
Epigenomic- engendered
Geneticists abductively reason from their own personal experiences of the clinical evidence (by inferring a construct of a known entity for an unknown entity) that sudden high anxiety, a ‘mental shock’*, can trigger (not always does) a sudden insertion of methyl groups into the DNA molecules of some gene mechanism for normal memory processing. As a result of this abnormal DNA the normal memory processing of what was perceived at that circumscribed moment of mental shock cannot proceed to the normal form of memory formation.
Mental Shock
A sudden surge of intense anxiety from fear or disgust coming in immediate response to a sudden and unexpected perception of some out of control threat or other distress.
Proto-memory (or some such name)
Seemingly the brain’s initial imprint of all registered information of the experiences during a circumscribed moment of perception. Under normal circumstances this first imprint is instantly processed to normal form of memory – to permanent non-experiential information storage of the experience, and prone to decay in detail over time. The disruption of normal memory processing by the postulated epigenomic consequences of a momentary mental shock leaves the ‘proto-memory’ persisting i.e. leaving ‘the first edition’ of all that the brain had registered during the circumscribed moment of mental shock – the raw anxiety, the raw sensations and the raw detailed information – unprocessed and ‘frozen’ intact and not decaying in detail over time. There is no explanation as to why this epigenomic disruption happens some times in some people in response to a ‘mental shock’ and not at other times, and appears not to happen at all in other people. There is some evidence that genomic factors can play a part in a person’s susceptibility. (See Section 6) In PTSD type 1 there may be more than one ‘proto-memory’, each having arisen at different times during one or more different circumscribed mentally-traumatic events that gave rise to mental shocks, giving rise to one or more different abnormal experiential flashbacks.
Abnormal experiential flashback
The recurrent recall of the circumscribed contents of the ‘proto-memory’. This can include a flashing-back physical re-experiencing of the intact raw anxiety, the intact raw physical (rapid heart, perspiration) & sensory sensations, including the intact raw eidetic visual, sound, pain.. and other detailed information. The intensity of the anxiety, of the raw sensations and the eidetic visual and of other sensory detail in the proto-memory recall does not decay over time. There may be more than one ‘proto-memory’ from more than one momentary experience giving rise to Mental Shock.
Oscillopsia (osi-lop-sia)
A Greek word for ‘wavy vision’ – an abnormality of visual perception. Oscillopsia has many different forms and many different causes. There is no neuro-biological explanation for the occasional co-occurrence of anxiety with abnormalities of visual perception, e.g. the chaotic wavy vision occasionally experienced by some people during moments of high anxiety such as a panic attack.
Persistent peripheral oscillopsia’ (PPO)
A unique form of anxiety-related oscillopsia. It is invariably found to persist for as long as a ‘proto-memory’ persists – i.e. as long as PTSD type 1 persists. For many with PTSD type 1 its presence is unnoticeable until tested for via a simple visual test (see next paragraph). It must be assumed that the persistent retention of anxiety in the ‘proto-memory’ is responsible for the persistent presence of anxiety related peripheral oscillopsia. PPO is persistently found to be present on clinical visual testing whether or not the proto-memory is being recalled as an experiential flashback at the time of testing or has or has not been recalled recently.  The simple, sensitive, reliable and specific visual test for the presence or absence of PPO, and hence for the presence or absence of PTSD type 1, is given in detail in Section .The test can be performed by anyone on anyone over 5 yrs anywhere & requires no apparatus. The reasons why PPO is rarely noticed in everyday life and has to be tested for:(a) The onset of apparent oscillations throughout the whole or just the periphery of the visual field is ‘seen’ either immediately or only after a delay of from 1 to 6 to 7 seconds of steady fixation on a stationary object; (b) in everyday life people rarely maintain fixation on any stationary object for more than a few seconds; (c) in everyday life whenever there is apparent movement in the periphery of the visual field there is most likely to be a instinctive immediate glance towards that movement, and with PPO there is nothing seen to be moving in central gaze, so any apparent movement in the periphery is ignored.
EMDR
‘Eye Movement Desensitization and Reprocessing’, is a passive non-invasive treatment. (It is described in detail in Section 5 ) There is no explanation of how or why EMDR can, but not always does affect epigenomic reversal (via (?) enzymatic de-methylation), allowing the currently-being-treated proto-memory of the event to be processed to a normal memory of the circumscribed event. EMDR can be effective in 10 seconds in one session or take as long as three months or more in many sessions or not be effective at all.
Epigenomic Reversal
Epigenomic Reversal (via enzymatic demethylation) can occur in some people of any age above 5 years with PTSD type 1, but does not occur in all people with PTSD type 1, in response to EMDR – epigenetic reversal allows normal memory processing of the ‘proto-memory’ to proceed. EMDR is described in detail in Section 7.

Section Two

Formal Clinical Definitions of PTSD types 1 & 2

PTSD type 1

  • 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) having dimensional severity of subjective symptoms.
  • 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 immediate 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 (as defined); (b) one or more unique abnormal-in-form recurrent experiential flashback memories (‘proto-memories’ as defined), each ‘proto-memory’ being of a circumscribed event that triggered an immediate mental shock (as defined).  
  • PTSD type 1 has persisting anxiety. The spectrum of intensity of its non-specific amorphous anxiety and distress symptoms ranges between being the most horrific to being much less so.
  • PTSD type 1  has no necessary condition of the  dimension of subjective severity or obtrusiveness of either of the two unique abnormal clinical symptoms – of peripheral vision  and of the circumscribed ‘proto-memory’ recall.
  • PTSD type 1 is unlikely to be diagnoseable below the age of 5 years.

PTSD type 2

  • PTSD type 2 is a dimensional non-specific, generic Anxiety Disorder, having no unique clinical features.
  • PTSD type 2 has a necessary condition of having been caused by experiencing one or more mentally traumatic events, with or without mental shock. Its onset may be sudden, slow or delayed.
  • PTSD type 2 is a disorder of persisting anxiety and anxiety-related symptoms. The spectrum of intensity of its symptoms ranges between the most horrific to the much less so. These nonspecific amorphous symptoms of anxiety and distress can be indistinguishable from those same symptoms of PTSD type 1.
  • PTSD type 2 has no unique abnormal features of vision and no abnormal forms of memory recall but may have distressing intrusive memories in normal form.                                                                                                

The anxiety-related symptoms common to both PTSD types 1 & 2 can include sudden startles, hyper-vigilance, headaches, inattentiveness, insomnia, nightmares, avoidance, emotional withdrawal, depressed mood, recurrent distressing intrusive memories in normal form.

Section Three

3.1 Persisting Peripheral Oscillopsia

The oscillopsia is an illusory perception of persistent and consistently illusory rhythmical oscillation of stationary objects that are seen in the periphery of the visual field.  It is present only with head and eyes held still. It is a persisting manifestation of the persisting presence of a proto-memory of the circumscribed moment of a mental shock in the pasrt    This form of oscillopsia is a distinctly different form from those transient chaotic forms of high anxiety-related oscillatory visual instability associated with transient high anxiety and panic attacks, and distinctly different from those forms of oscillopsia associated with neurological disorders such as multiple sclerosis and vestibular disorders of vertigo or nystagmus associated with head or eye movement.  There is no persistent peripheral oscillopsia  in Panic Disorder unless experiential flashbacks (i.e. PTSD type 1) is there also.

 

LEGEND. The blue area is the full visual field of the right eye – the left eye closed.  It is against a blank background. The image of the solid stationary black rod, held a metre or so away, extends from the centre of visual fixation (the red dot) to the outer limit of the right visual field.   The right eye is held fixated centrally on the red dot. The onset of the apparent oscillation may be delayed for from 1 to 6 or 7 seconds: once present it persists for as long as steady fixation is held centrally. Glancing away or blinking immediately stops the apparent oscillations until steady fixation is resumed and again held until re-onset.

From person to person with PPO the length of the outer portion of the staff appearing to oscillate would range from between just the extreme outer tip, to, its whole length; the range of amplitude would vary from 5 degrees to 45 or more; the oscillation frequency would vary from  1 cycle per second to 10 or more . For any one person these three parameters remain constant over decades if a proto-memory remains i.e. if PTSD type 1 remains. More detail is given in Section Five below.

Three reasons why PPO is rarely noticed in everyday life and its persistent presence usually needs to be tested for:

(a) The onset of apparent oscillation of part of the image is ‘seen’ either immediately on fixation or, more usually, only ‘seen’ after a DELAY of from 1 to 6 or 7 seconds of steady fixation.

(b) In day-to-day life people rarely maintain steady fixation on any stationary object for more than a few seconds.

(c) In day-to-day life, whenever there is apparent movement in the periphery of the visual field one instinctively immediately glances towards that movement, and with PPO there is nothing seen to be moving, so any apparent movement is ignored.

3.2  The recursive clinically-controlled Visual Test for the presence or absence of persistent peripheral  oscillopsia, hence for the presence or absence of PTSD type 1

The examiner as seen by the subject during the clinical visual test for the presence or absence of PTSD type 1.

LEGEND.  The subject holds the LEFT eye closed. The open RIGHT eye fixates the LEFT eye of the examiner. The LEFT eye of the examiner fixates the RIGHT eye of the subject. This ensures that the subject’s steady fixation is seen to be strictly maintained throughout the test – a fixed visual axis between the subject’s right pupil and the examiner’s right pupil. The examiner, standing a short distance in front of the subject, has the LEFT arm held rigid, adjusting the distance away such that the fingertips as seen by the subject reach the outer limit of the subject’s RIGHT visual field.  After ten seconds of steady fixation the examiner lowers the left arm and the subject is asked to demonstrate with their own RIGHT arm and hand how the examiner’s LEFT arm appeared to be during the ten seconds. It is a simple, clinically controlled visual test that is reliable, sensitive and specific for the presence or absence of persistent peripheral oscillopsia. The test requires no apparatus and takes overall 30 seconds to perform. It can be performed anywhere by anyone on anyone over 5 years of age, i.e. anyone who is not blind or uncooperative.  It cannot be performed reliably during a transient panic attack or the transient high anxiety of a near-panic attack, because of the difficulties in paying attention and the possible interference of vision by, for example,  the occasional non-specific chaotic swaying about of visual perception experienced during a panic attack or near-panic attack. MORE NECESSARY DETAIL IS GIVEN IN SECTION FIVE BELOW

3.3  EMDR – Eye Movement Desensitization and Reprocessing

Its performance in brief: One or more sessions in which an abnormal experiential flashback of PTSD type 1 ( i.e. a proto-memory) is voluntarily repeatedly recalled and, each time it is  held present the patient is subjected to voluntarily-performed repeated runs of rapid alternating left-to-right-to-left…. eye movements. These are continued until the abnormal experiential flashback  goes. It is then re-evoked and once again subjected to voluntarily-performed repeated runs of rapid alternating left-to-right-to-left… eye movements until the abnormal experiential flashback goes again.   This continues. EMDR has successfully eliminated PTSD type 1 only when no fragment of any abnormal experiential flashback can be voluntarily recalled i.e. all one or more proto-memories have been processed to a normal memories of the circumscribed event(s) and can only be recalled normally – i.e. non-experientially.   Only when all proto-memories have been processed to normal memories does the PPO Visual Test give a negative test result for the presence of persistent peripheral oscillopsia. More Detail is given in Section Seven below.

Section Four

Explanatory noes on the provenance of the novel paradigm PTSD types 1 & 2

As things were in 1978, just after the Vietnam War, the APA changed the name from Traumatic Neurosis (TN) to PTSD, replacing TN that had been described by Oppenheim in Germany in 1889 for the ‘mental disorders following mental trauma’. The APA’s clinical criteria of ‘PTSD’ given in DSM (and ICD) had inevitably to be ad hoc since there was nothing clinically specific known at the time sufficient to clearly distinguish any one specific post mental trauma mental disorder from any other.  In the light of the many sufferers among the participants in the Vietnam War and others, there was an urgent need at the time, and since, for a way of determining who might and who might not justly qualify for compensation for a persisting anxiety disorder that was post-traumatic. The APA’s chosen option for whether or not a disorder is to be called PTSD was to be based on the objective features, nature and timing of the causal event experienced and had triggered the PTSD. It was not to be based on specific subjective clinical findings in the person.

In 1977, the year before the name ‘PTSD’ appeared, this author (then a newly trained Clinical Psychiatrist, previously an A/Prof Neurosurgeon with previous experience in neuro-ophthalmology) chanced upon patients reporting an inexplicable and long persisting subtle abnormality of ‘wavy vision’. This phenomenon was reported to be observed by several women of Middle East ethnicity suffering from Traumatic Neurosis following relatively trivial accidents at work. They were claiming Worker’s Compensation.  The then ad hoc explanation was that the visual phenomenon was ‘hysterical’ and or ‘of no clinical significance’, ‘not real’. Incuriosity reigned. Certainly there was never any history of injury to the visual system or any neurological or inner ear disorder present to account for it, and it was unrelated to microsaccades.   Nonetheless it was decided to investigate it.  Helped occasionally by an Ophthalmologist and a Clinical Neuropsychologist, but mostly a lone wolf investigation, and a quest fellow psychiatrists deemed chimerical, the investigation took 30 or so years to complete.

In 1990, it was found that this same visual phenomenon associated with Traumatic Neurosis had been briefly mentioned in few words in a 1946 text book ‘Visual Fields’, written by a London Ophthalmologist, Dr Harry Moss Traquair. The ‘persisting wavy vision in the perimeter of the visual field’ was reported to Traquair by some WWII war veterans suffering from Traumatic Neurosis when he was examining their visual fields. The clinical ‘observation‘ made by  Traquair 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 i.e. with one eye covered, the other kept open and held fixated on the central dot of the visual field chart.

In 1989 Dr Francine Shapiro published her serendipitous EMDR findings re- ‘A treatment for PTSD’. It was initially based on her own personal observation.  A first trial of EMDR on our patients in 1990 had a dramatic permanent treatment effect on some with PTSD type 1. During EMDR there was reported by patients with PTSD type 1, but not all patients with PTSD type 1, a step-by-step and in-step simultaneous permanent elimination of persistent peripheral oscillopsia together with the abnormal experiential flashback memory, and a there-and-then significant and permanent diminution in the levels of anxiety and anxiety related symptoms. These were clinical features that in some of the treated patients had been followed for 10 years and hitherto found unresponsive to all other treatments and to time.  For some patients with PTSD type 1 there was no response at all to EMDR, Nor did EMDR have any demonstrable treatment effect on patients who had only PTSD type 2 or had only any other mental disorder.

It is reported by many others , but without the confirmatory evidence based on the PPO visual test being applied i.e. before and after treatment, 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 as per DSM 5/ ICD 11’. This has not been confirmed by us.

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 iteratively for its presence or absence in all other patients. regardless of the reason for their referral.  When found to be present in any degree 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 WWII 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’ said William Osler. ‘The ultimate court of appeal is to observation and experiment, not authority’ said Thomas Huxley. “…truth is the daughter of time, not authority…” said Francis Bacon. If the finding of ‘a tiny bit of new truth about human vision’ in 1946 by Traquair triggered a fresh paradigm PTSD types 1 & 2 seventy years later, then the replicable evidence base for the fresh paradigm is the ultimate criterion by which the new idea can stand or fall. Not forgetting the adage ‘nothing is always, nothing is never’ in any branch of clinical science.

There is strong clinical evidence to suggest that the incidence of PTSD type 1 is related to some significant degree is related to genome. It appears that one can inherit an enhanced predisposition to the development of PTSD type 1 in response to experiencing a mental shock at or after the age of 5 years. We have no information as to whether experiencing a mental shock before the age of 5 years can have any comparable effect on the neurobiology of the brain.

At the present time there can be no data for the prevalence of PTSD type 1 in the general population. There is the rough USA estimate that the prevalence of ‘PTSD’ as per DSM is 1 in 14.    There is the rough USA estimate that the prevalence of those with ‘Attention Deficit Hyperactivity Disorder (ADHD) impairments of any severity’ is 1 in 10.

It has been our clinical experience that amongst any one hundred of the supposedly one in 14 or so of the general population of any age over 5 years 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 was routinely looked for in all, and confirmed (as well as ADHD 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 the  one hundred of the supposedly one in 10 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 confirmed by a positive PPO Visual Test result, and by providing a history of recurrent abnormal experiential flashbacks in all cases.  The 70 others were tested and found not to have PTSD type 1 by those clinical criteria. 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.  The co-occurrence of ADHD impairments and PTSD type 1 is a form of ‘Complex PTSD’. The persistence of ADHD impairments following successful EMDR elimination of PTSD type 1 can complicate post treatment recovery.

Although impossible to quantify, it has been our clinical experience that those with PTSD type 1 having a genome 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 having a genome for dark iris and olive skin (e.g. Iberian, Mediterranean ethnicity phenotypes) who develop PTSD type 1 appear prone to develop more obtrusive PPO and a much lower chance of successful elimination of their PTSD type 1 with EMDR.

It has been our clinical experience that many but not all 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, and this despite the best available-for-them support. There is an urgent need for a dedicated scientific effort 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.

There is no clinical evidence that an experience of an anxiety-ridden ‘mental shock’ at some age earlier than 5 years in some genome-susceptible children, gives rise to a permanent epigenomic change to some other aspect of brain function, though this may be the case. The web page < ptsd.net/cases > gives some illustrative case histories typifying clinical presentations of PTSD type 1 & 2 and its treatment.

Further 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’.

Section Five

The Performance of the Visual Test

Therapists may well shy away from performing the test, since it involves explaining to the client why the test is necessary when the client may have made no complaint of ‘PTSD’ or of vision.  PPO is unique to PTSD type 1. PTSD type 1 can be of any degree of severity or obtrusiveness, and can co-occur with any mental or physical disorder. Clients can be unaware of having PTSD type 1, and likely to leave their therapist unaware similarly without the therapist’s confirmation of the presence or absence of PTSD type 1.

It takes a lot longer to read how to do this simple PPO visual test than the 30 seconds it takes to do it. However, there are myriad ways to detect one’s own PPO, and myriad ways to invent more sophisticated ‘technological’ ways to test others, but always 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 (instant or delayed for up to ten seconds) of an illusory perception of 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.

Persistent peripheral oscillopsia (PPO) is ‘persistent’ in that it is always to be found at any time if there is even a fragment of a ‘proto-memory’ of PTSD type 1 that is spontaneously evocable or can be evoked voluntarily as an abnormal experiential flashback.  The presence of PPO is regardless of how long since any abnormal experiential flashback or fragment of an abnormal experiential flashback was last evoked. The abnormal experiential flashback does not have to be evoked at the time of the PPO Visual Test.    As long as persistent peripheral oscillopsia can be detected then one or more ‘proto-memories’ and their abnormal experiential flashbacks persist and hence PTSD type 1 persists.

For the sake of this description of The PPO Visual Test let us suppose that the subject examined is male, the examiner female. 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. If the subject has only one normally functioning eye the test is still valid, utilising the one good eye.

  • 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 the language an interpreter will be needed. If glasses are usually worn then they should be for the test.
  • 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 the subject 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 the left).
  • He is asked to focus with his right eye on the examiner’s left eye.  The examiner stands a metre or so in front. She has her right eye covered.
  • The examiner’s left arm is then held out, and held rigid and horizontal. The fingertips of her left hand must just reach the outer periphery of the subject’s right visual field – so that he can just see the examiner’s finger tips but no further out: this is an essential detail.
  • The examiner fixates her left eye on the subject’s 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 (subject’s eye fixation to examiner’s eye fixation) is thereby held rigid and controlled.
  • During the ten seconds of the test the subject is asked not to shift fixation of his right eye from the examiner’s 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 fixated on the examiner’s left eye.
  • After 10 seconds the examiner lowers her left arm and asks the subject to demonstrate with his right arm, how her left arm appeared to him during the 10 seconds of keeping his right eye fixated on her left eye.
  • The PPO visual test is positive when the subject 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 be detached or swing, and starts moving up and down, or round and round, i.e. 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 PPO vary from subject to subject:

  • For any one subject the oscillations may appear to be there, at each test, from the outset; or they appear only after a few seconds, i.e. there is a constant delay in onset which may be from 1 to 6 or 7 seconds of steady fixation at each testing.
  • For any one subject the oscillations, at each test, have a constant frequency – of about one to three or more waves or cycles per second.
  • For any one subject 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 subject the oscillations, at each test, have a constant extent over the visual field – the extent of apparent movements may be just in the periphery of the visual field, i.e. 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 and her arm appearing to oscillate.
  • The subject may report seeing only one or two very brief single ‘jerks’, up or down, of the examiner’s arm during the ten seconds of steady fixation on the examiner’s eye, when in fact there were no such jerks. These are normal illusions of no clinical significance on the part of any normal person under such circumstances.  They do not persist and are not part of PPO.
  • During successful EMDR, i.e. as EMDR continues and there is a steady step by step degradation of the details of the abnormal experiential flashback, there is a simultaneous steady step by step and in step degradation of all features of the oscillopsia seen on serial testing in between runs of EMDR treatment.
  • Some degree of PPO is ‘persistent’ in that it is always to be found at any time if there is even a fragment of a proto-memory and its abnormal experiential flashback of PTSD type 1 that is re-evocable spontaneously or can be re-evoked voluntarily, and regardless of how long since any abnormal experiential 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 successful treatment for PTSD type 1 and gives a negative PPO visual test result immediately after properly-performed EMDR has successfully permanently eliminated the PTSD type 1 — no oscillopsia and no abnormal experiential flashback. This negative PPO 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 uncommon in those with a psychotic illness, and EMDR is no more or less effective in the presence of a psychotic illnesses.

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 European ethnic origin who had been referred to the psychiatric practice in 1977 — and several other patients of southern European ethnic origin since) (See Section 7).

Section Six

Abnormal experiential flashbacks of PTSD type 1, i.e. recalls of one or more ‘proto-memories’ of the experiences during one or more moments of mental shock.

  • The sensory experiences that have been ‘remembered’ but not fully processed and left as a ‘proto-memory’, are sensorily re-experienced on recall.  The sensory re-experiences are (i) Sensations of the physical emotion felt during that moment re-experienced as e.g. the fear, the anxiety, the panic, the disgust… . and, any one or more of the following (ii) A eidetic 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 or blowing curtain 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 approaching 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 writhing about and bleeding to death after being shot; the coloured walls of the room in which one was being raped……There is myriad unique possibilities of what is ‘seen’ as still pictures or video-clips in people’s real-life abnormal experiential 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 experiential flashback is experienced only whilst wide awake.  When coming in the middle of the night its onset can have been triggered by a nightmare of similar frightening events.
  • The abnormal experiential flashback can occur spontaneously, can be triggered and can be voluntarily re-evoked.
  • There can be several different abnormal experiential flashbacks of several different ‘proto-memories of different moments of mental shock from the experience of one traumatic event or from many different traumatic events which may have been separated in time by seconds, minutes, days or decades.
  • Abnormal experiential flashbacks can recur from many times a day to once or twice a year.
  • Abnormal experiential flashbacks can last from a few seconds to several minutes.
  • Attempts are usually made to get rid of an abnormal experiential flashback by mental distraction, or by a violent action e.g. mouthing an expletive, 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 experiential flashbacks recur each time with the same un-decayed intensity of distress and sensory detail. The distress ranges from extremely severe to relatively unobtrusive.
  • Abnormal experiential 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 experiential flashbacks of PTSD type 1
  • When an abnormal experiential 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 Seven

EMDR (Eye Movement Desensitization and Reprocessing) Treatment of PTSD type 1,  and the treatment of PTSD type 2.

(See also ptsd.net/cases)

Virtually anyone anywhere can properly diagnose PTSD type 1 with the PPO 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 can be as equally effective for children aged 5 to 6 years with PTSD type 1 as for adults. There appear to be genetic factors in people with PTSD type 1 that militate towards a greater severity of their persistent peripheral oscillopsia (PPO) and towards greater difficulties over their response, if any response at all, to properly performed EMDR treatment

Preferably adjunctive talking therapies are part of the overall management of PTSD  types 1 & 2, e.g. non-specific psychotherapy support, formal Exposure Therapy, formal Cognitive Behaviour Therapy – and with or without the help of anti-anxiety medication, e.g. a tricyclic or SSRI antidepressant.

Let us say that that the subject with PTSD type 1 being treated with EMDR here is male, the therapist female. If possible a friend or relative of the subject will be present and looking on, to reassure the subject.   For those not understanding the language an interpreter will be necessary. The age of the subject being treated can be as young as 5 or 6 years. EMDR is equally effective for those of poor vision or who are blind in one eye.

  • The subject sits comfortably in a chair.  The therapist sits or stands in front, a metre or so away.
  • At the commencement, the subject is asked to re-evoke one (perhaps of several) abnormal experiential flashback, and then ‘hold’ the flashback – the recalled ‘proto-memory’.
  • This may raise the subject’s anxiety to a near-unbearable level, and he will need reassurances that his anxiety will  be at its most severe only with the first trial or two of EMDR, and he must do whatever he can to tolerate the discomfort at the beginning of the EMDR.
  • As soon as the abnormal experiential flashback image is ‘held’, he has a run of repeatedly moving his eyes from side to side by following the moving hand of the therapist, as the therapist repeatedly sweeps her hand from far left-to-far right-to-far left… at one to three sweeps per second in front of him.
  • He is told to stop the run of his eye movements as soon as his abnormal experiential flashback image goes – and the therapist’s hand-sweeps then stop also.  This disappearance of the image may have taken a run of just several of the therapist’s hand-sweeps, 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 has the subject’s same abnormal experiential flashback image re-evoked each time, and each run is continued until his abnormal experiential flashback image goes each time.
  • If EMDR is being effective, then following every few runs of side to side eye movements, the subject says that he senses the repeatedly re-evoked abnormal experiential flashback image (or other sensation(s) if there is no visual image in the flashback) is, step by step, degrading in its intensity of sensation i.e. his anxiety is less, the visual detail and colouring of the ‘picture’ of his experiential flashback is less, the hearing detail is less, his pain is less ….. .  If and only if there is no other abnormal experiential flashback of another proto-memory, then on re-doing the PPO Visual Test the persistent peripheral oscillopsia will be lessening in range over the visual field, lessening in amplitude of oscillation and or lessening in frequency of oscillation.
  • The runs of eye movements must continue until no fragment of the subject’s abnormal experiential flashback image can be re-evoked. It may take as few as two or three runs of eye movements at the subject’s 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 of repeated sessions before no fragment of his abnormal experiential flashback image can be re-evoked and is permanently eliminated.
  • If he has other abnormal experiential flashback images – 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.
  • The therapist can only be sure that EMDR has been effective in permanently eliminating the subject’s PTSD type 1 when his PPO Visual Test gives a negative PPO Visual Test result — free from any degree at all of his previously-present PPO, and, he cannot re-evoke any  fragment of any of his previously-present abnormal experiential flashback image or sensation.

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.

The treatment for non-specific PTSD type 2 is numerous sessions of talking therapy. e.g CBT, with or without the help of a non-addictive anti-anxiety medication, e.g. a tricyclic or SSRI antidepressant. There is no evidence to suggest that EMDR is specifically effective for PTSD type 2, palliative as the attention given over it may be.

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 non-specifically effective for some people with a wide range of ill-defined mental states and mental phenomena – but so far there is no clinical evidence base comparable to the PPO Visual Test having given a permanent positive result before treatment and a permanent negative result after treatment.

Section Eight

Heritable vulnerability to developing PTSD type 1.

At the present time there can be no data for the prevalence of PTSD type 1 in the general population. There is the rough USA estimate that the prevalence of ‘PTSD’ as per DSM 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 can be born with PTSD type 1. It appears that one can inherit an enhanced predisposition to the development of PTSD type 1 in response to experiencing a mental shock at aged five  years or older. (We have no information as to whether experiencing a mental shock before the age of 5 years can have any comparable effect on the neurobiology of the brain. )

It has been our clinical experience that amongst any one hundred of the one in 14 or so of the general population of any age over 5 years 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 was routinely looked for in all, and confirmed (as well as ADHD 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 10 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 confirmed by a positive PPO Visual Test result, and by providing a history of recurrent abnormal experiential flashbacks in all cases. The 70 others were tested and found not to have PTSD type 1 by those clinical criteria. 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 major psychiatric illnesses, and then remain. The PPO Visual Test will detect the presence or absence of PTSD type 1 in patients with mental illnesses. EMDR will have some probability of eliminating PTSD type 1 in 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 highly probable 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.

Postscript

It would appear that some therapists do not test for PTSD type 1 of any severity or for ADHD impairments of any severity, and diagnose ‘Depression and Anxiety’ on the basis of the commonest symptoms of each, and treat with non-specific antidepressant/anti-anxiety  medication and or talking therapies.

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

 

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