CRACKING THE CODE OF “PTSD”
Fresh clinical evidence telling us about the biological nature of “PTSD”.
Understanding, managing and treating “PTSD” rationally.
Dr Bob Tym, Clinical Psychiatrist, formerly an A/Professor of Neurosurgery — now retired from active clinical practice.
The blog is written for the everyday person. What is written here must be understandable to the everyday person as well as clinically provable by any “PTSD expert”. The implications of the new and fully testable clinical evidence means that some of what is written here has to be at odds with the currently “authorised” versions of “PTSD” given in the American Psychiatric Association’s ‘Diagnostic and Statistical Manual’ (DSM 6th Edition ) and the WHO’s ‘International Classification of Diseases’. (ICD 11th Edition).
The new clinical evidence (anyone involved in PTSD can test out the clinical evidence) has emerged from a thirty year long exploratory clinical investigation into an obscure persisting visual phenomenon (a visual phenomenon meaning it was seen to exist by the person and was reported by the person). The presence or absence of the visual phenomenon can be simply tested for by a simple visual test. The persisting visual phenomenon had been reported to be always present by some psychiatric patients with an anxiety disorder following the experience of a mentally traumatic event, but it was persistently absent in other psychiatric patients with much the same anxiety disorder following the experience of a mentally traumatic event. The exploratory clinical investigation over a thirty year period was into the clinical nature of the obscure visual phenomenon and into the biological implications of the visual phenomenon. The fully testable by anyone clinical findings throw some fresh light onto the most probable neurobiological nature of post traumatic stress disorders.
SECTION ONE Introduction to “PTSD”.
1.1 A “PTSD” is what it says it is — an anxiety disorder that can follow one or more very frightening experiences. A “disorder” is “a behavioural or mental pattern that causes significant distress or impairment of personal functioning”.
It has been clinically observed over many years that some people with a “PTSD” cannot recover spontaneously. These people always report the presence of the visual phenomenon on testing. They have “PTSD” lifelong when it is not successfully cured by treatment. Until the arrival of EMDR treatment in 1989 there had been no treatment that clinically provably cured (eliminated) “PTSD”. Unfortunately, EMDR treatment cannot cure all with “PTSD”, so for some people their “PTSD” still lasts lifelong. (EMDR treatment is fully explained below in Section 4.1.)
It has also been clinically observed over many years that some people with a “PTSD” can recover spontaneously. These people never report the presence of the visual phenomenon on testing. They can respond to treatments that speeds up their full recovery. However, EMDR has no effect on these people, it does nothing to help speed up their recovery.
It seems, from the observations given in the two paragraphs just above, that “PTSD” cannot be just one disorder: there must be two different forms of “PTSD’. Following one or more very frightening experiences some people can develop one form of “PTSD”, others can develop the other form of “PTSD” from the same one or more very frightening experiences. Obviously, some people don’t develop any form of “PTSD” following the same one or more very frightening experiences.
1.2 The biological nature of post mental trauma anxiety disorders has always been a mixed-up mystery: What goes wrong inside the brain in those people with a “PTSD”? Since there must be two different forms of “PTSD” they must be clinically distinguishable one from another (and we shall see below, this is where the obscure visual phenomenon plays a part). To give names to the two forms of “PTSD”:
One form can be called PTSD-A. It has a subtle and unique visual abnormality. It cannot recover spontaneously over time.
One form can be called PTSD-B. It has no visual abnormality. It can recover spontaneously over time, but may not, depending on circumstances that might delay or otherwise hamper its recovery.
What is Complex PTSD ? (We come to this in detail in Section 1.8.) It IS NOT a third form of “PTSD”. It is the name given to the effects that having PTSD-A and or PTSD-B for many years can have on the development on a person’s personality.
1.3 The nature of PTSD-A.
PTSD-A is a ‘categorical’ anxiety disorder, meaning that it has two unique clinical symptoms that characterise the disorder. (Only if those two unique clinical features are there is the disorder there: the two unique clinical features do not occur in any other disorder.) The disorder can only be caused by the experience of a sudden traumatic mental shock — meaning, a sudden surge of intensely high anxiety (fear or disgust). A mental shock is triggered by the experience of a sudden experience of a mentally traumatic event.
PTSD -A always has the two invariant unique clinical symptoms (invariant meaning the two symptoms are always there together in PTSD-A). One symptom is an abnormal phenomenon of vision, a visual symptom; the other symptom is an abnormal form of memory, an abnormal sensorially re-experiencing ‘flashback’ memory. The two symptoms are subtle (meaning one or the other or both are not always obvious or noticed), The two symptoms are unique (meaning they are not found in any other mental or physical disorder). They are inseparable symptoms: PTSD-A comes during the moment of a “traumatic mental shock” causing the PTSD-A, and hence the two unique symptoms come together at the outset.
If and only if PTSD-A is cured by EMDR treatment (explained in detail in Section 4.1), will the two symptoms go together. When neither of the symptoms is present then the PTSD-A is completely cured, eliminated. These two unique ‘stuck together’ clinical symptoms constitute an invariant ‘complex memory and vision symptom’ unique to PTSD-A.
In the reasoned opinion of clinically involved senior geneticists — two geneticists who had PTSD-A and had been cured by EMDR treatment — the most plausible speculation is that the momentary sudden surge of very high anxiety of the “traumatic mental shock” had triggered a sudden epigenetic insertion of a chemical methyl group (CH3) into the brain DNA molecules that are involved in laying down the current memory of what was happening, what was being experienced, at that moment of traumatic mental shock. That DNA, now with a methyl group attached to it, functions abnormally. The tagged DNA can only produce a uniquely abnormal form of memory of the happenings of that moment. This abnormal form of memory “locks in” the anxiety and all the other sensorial experiences. The persistent presence of the “locked-in” anxiety is presumed to give rise to the persistent peripheral oscillopsia. When that abnormal form of memory is recalled at any time it is recalled as an abnormal re-experiencing flashback memory: all the emotional, sensory and physical experiences during the moment of mental shock are re-experienced (re-lived) in the uniquely abnormal form, an abnormal flashback of PTSD-A. (It is described in detail is Section 2.5.)
The visual symptom is called “persistent peripheral oscillopsia” (osi-lop-sia, a Greek word meaning ‘wavy vision’). The visual symptom is there for as long as the abnormal form of memory is stored in the brain, there whether or not that abnormally stored memory is currently being recalled or has been recalled recently. There is a simple visual test that is reliable, sensitive and specific for the presence or absence of this visual abnormality. Hence, the visual test is a reliable, sensitive and specific for the presence or absence of PTSD-A. (The simple test is described in detail in Section 2.3.)
1.4 PTSD-A can be diagnosed in people of any age over five or six years, people from all walks of life. For some people with PTSD-A it was caused by the experience of an event that would terrify anyone, and for some people, by experiencing an event that frightened them but probably would not have frightened anyone else. For most people with PTSD-A the event that they experienced was somewhere between those two extremes. The susceptibility of people to getting PTSD-A varies widely. The severity of PTSD-A varies widely.
1.5 There is now fully testable clinical evidence (fully described below) to strongly suggest that in PTSD-A the experience of a sudden mental shock, a sudden surge of high anxiety, physically damaged the brain. The damage was via the epigenetic insertion into the DNA currently encoding the memory of the experiences during the moment of the traumatic mental shock. The brain cannot recover from the epigenetic damage spontaneously.
[ In effect, the two locked together unique symptoms is a ‘unique symptom module’, and the ‘symptom module’ is a PTSD-A. When there are several different abnormal re-experiencing flashbacks originating from several different ‘mental shock’ experiences from several different experiences of mentally traumatic events, then there is a multi modular PTSD-A. Each separate ‘module’ will require separate EMDR treatment (see below)]
1.6 The nature of PTSD-B.
PTSD-B is a ‘dimensional’ anxiety disorder. It has no unique clinical symptom or symptoms that characterise the disorder. PTSD-B can be caused by the experience of a sudden traumatic mental shock, as can PTSD-A, but unlike PTSD-A, PTSD-B can also be caused by the experience of experiences of other forms of mental trauma, sometimes long drawn out mental trauma. The clinical evidence suggests that the experiences of mental trauma functionally but not physically damaged the brain. —- the brain can recover from the functional damage spontaneously, though it not always does, depending on circumstances that can delay or otherwise hinder recovery.
1.7 Common anxiety symptoms common to both PTSD-A and PTSD-B.
These symptoms There can be distressing traumatic memories that keep coming back distressingly, but they are memories that are not coming back abnormally, just distressingly in normal form. There can be sleeplessness, frightening nightmares of the event or of anything else (these nightmares are not limited to PTSD-), jumpiness over anything, being easily startled, being inattentive, lacking in concentration, failing to remember things, tension headaches, emotional withdrawal, frustrations, depressed moods, uncontrollable anger and sometimes violence, and avoidance of any reminders of the event that caused their PTSD. There can be dangerous thoughts of suicide.
Since PTSD-A and PTSD-B have many symptoms in common they can appear superficially clinically indistinguishable but the presence or absence of PTSD-A can be rapidly determined using the simple visual test (described in detail in Section 2.3)
Since there have to be two biologically different forms a PTSD-A and PTSD-B, then either form can be present alone, or both can be present together. One or both can be present with any other mental or physical disorders. e.g., together with a traumatic brain injury, with another mental, with a personality disorder, with a psychotic mental illnesses such as schizophrenia, and or together with ADHD.
1.8 The nature of Complex PTSD.
This is not a third form of “PTSD”. It is the effect that long-term persisting PTSD-A and or PTSD-B symptoms can have on the personality. Complex PTSD is akin to a “post-traumatic stress personality disorder” with characteristics very similar to those of Borderline Personality Disorder.
The features of Complex PTSD.
C-PTSD may or may not have followed PTSD-A and or PTSD-B.
C-PTSD usually has followed but not necessarily has followed long drawn out trauma over months, years or decades.
C-PTSD usually has but not necessarily has followed childhood trauma.
C-PTSD can follow the mental traumas of long-lasting childhood abuse, of childhood abandonment; of long-lasting relationship abuse; of sexual slavery; of living along with long-lasting combat; of being tortured; of having multiple modules of PTSD-As from multiple traumatic mental shocks as a combatant or other first responder.
C-PTSD usually has but necessarily has followed interpersonal trauma.
C-PTSD can be of any severity and duration.
C-PTSD symptoms include disturbances of self-organisation, symptoms defined as emotional dysregulation; interpersonal difficulties; negative self-concept; and can include recurrent abnormal re-experiencing memory flashbacks characteristic of PTSD-A (which have been mentioned above and are described in detail in Section 2.5. ).
(The features of Borderline Personality Disorder include impulsive and risky behavior; unstable or fragile self-image; unstable and intense relationships; fluctuating moods, sudden bursts of anger, often as a reaction to interpersonal stress; stress-related paranoia behavior or threats of self-injury; fear of being alone or abandoned, pervading sense of emptiness . . ..)
SECTION TWO. The diagnosis of PTSD-A and PTSD-B
2.1 PTSD-A and PTSD-B require very different treatments. Having the same anxiety symptoms they can appear clinically indistinguishable. Being different disorders they can both be present at the same time. Either or both can be together with other disorders, including Complex PTSD. The presence or absence of PTSD-A can only be confirmed by the presence or absence of one or other or both of the symptoms unique to PTSD-A.
2.2 Unique Symptom # 1 Persisting Peripheral Oscillopsia. (osi-lop-sia, a Greek word for ‘wavy vision’)
Persistent peripheral oscillopsia is an illusory (false) perception of stationary objects that can be seen in the periphery of the field of vision appearing to be moving about — moving either up and down, or side to side . For most people with PTSD-A this visual symptom is seen to be present only when the head and eyes are held still, and only after staring at something straight ahead for 5 to 10 seconds. Once stationary objects in the periphery appear to start moving about, then they continue to appear to be moving about for as long as the head and eyes are kept perfectly still.
This symptom (this form of oscillopsia) is unique to PTSD-A. It does not occur in any other physical or mental disorder. It is always present in those PTSD-A ( i.e., in anyone with the other unique feature of PTSD-A, the recurrent abnormal re-experiencing flashbacks).
This visual symptom was first described (as far as we know) in 1946 by a London ophthalmologist, Dr Harry Moss Traquair*. It had been reported to him by ex-soldiers suffering from Traumatic Neurosis from WWII. Traumatic Neurosis was the name given by a neurologist, Hermann Oppenheim, in 1889. The name was changed to “PTSD” in 1980.
*Traquair, H.M., Introduction to Clinical Perimetry’, 5th Edition, 1946, London: Henry Kimpton. Page 121.
2.3 The simple visual test for persistent peripheral oscillopsia — i.e., the presence or absence of PTSD-A.
The visual test is a simple test that reliably, sensitively and specifically detects the presence or absence of the unique visual phenomenon, persistent peripheral oscillopsia. So, the visual test is a reliable, sensitive and specific test for the presence and absence of PTSD-A. In 2009 a paper was peer reviewed and published in the international literature*. but passed mostly unnoticed.
Tym, B., Beaumont, P., Lioulios, T. Two Persisting Pathophysiological Visual Phenomena following Psychological Trauma and their Elimination with Rapid Eye Movements: A Possible Refinement of Construct PTSD and Its Visual State Marker. Traumatology. 15(3): 22-33 (2009). ]
The person being tested sits in a chair, The examiner stands in front. At the beginning of the test examiner will have his left arm stretched out and held still and rigid for the ten seconds of the test. At the start of the test the person being tested covers his or her left eye and stares at the left eye of the examiner; he or she will maintain steady gaze at the examiner’s eye for ten seconds, without moving their eye. The examiner has his right eye covered and maintains strict eye-to-eye contact with the eye of the person being examined to ensure there is no movement of their eye. (See the diagram below). At the end of the ten seconds the eye fixation ends, the eyes are uncovered, and the examiner lowers his left arm. He then asks the person being tested to demonstrate, using their right arm, how the examiner’s left arm, hand or fingers appeared to them during the ten seconds.
Figure. How the examiner appears to the person being examined. The oval line is the outer edge of the visual field. Where the dotted lines cross is the stationary visual axis between the examiner’s left eye and the right eye of the person being examined.
The test is positive for the presence of PTSD-A if the person being examined reports any sustained rhythmical movement of any portion of the examiners arm starting within a few seconds of their steady fixation.
Note: the important detail: The examiner’s fingers must just reach the very outer edge of the right visual field of the person being examined — before the test starts the examiner must adjust his distance away so that this is exactly so.
2.5 Unique Symptom #2 The nature of the recurrent abnormal flashback. A recurrent abnormal re-experiencing form of memory recall of what was seen and felt during that moment of the mental shock that had triggered the PTSD-A.
An abnormal flashback is not a dissociative phenomenon and not a dream or a nightmare. Dreams and nightmares are not characteristics of PTSD-A or PTSD-B; they can be non-specific anxiety symptoms, regardless of their content.
Abnormal flashbacks can be of any severity, from near terrifying to a hardly noticeable twinge of anxiety that accompanies their appearance (and the same range of severity goes for PTSD-A itself).
An Abnormal flashback is a ‘flashing back’ re-experiencing, a ‘re-living’, ‘as though the event is happening over again’. There is a sudden return of all the emotional, sensory and physical sensations that had been experienced during that circumscribed moment of sudden mental shock, that sudden surge of high anxiety. With each flashback there is always an emotional, sensory and physical re-experiencing of the sudden surge of the mental and physical (shaking, sweating) anxiety that had been felt; usually, not always, a flashing-out-there-in-front vivid ‘picture’ or ‘video-replay’ of what was seen happening during that moment; usually, not always a re-hearing of the ‘sounds’ of what had been heard; usually, not always a re-feeling of the ‘pain’ that had been felt; usually, not always a re-smelling of the ‘smell’ that was there . . .. An abnormal flashback can last a few seconds or many minutes, it can come every few minutes, once an hour, once a day, once a month or much longer. It can come spontaneously, or triggered by any reminder, or it can be recalled voluntarily. It is not a ‘dissociative’ phenomenon, its abnormal form is unique to PTDD-A.
If abnormal flashbacks recur at all, then at anytime in between them the Visual Test will be positive for Persistent Peripheral Oscillopsia.AAA
3.1 Treatment of PTSD-A
PTSD-A cannot spontaneously resolve over time. Properly performed EMDR (see Section 4.1 ) has the best chance, but no certainty, or permanently eliminating (curing) PTSD-A. (EMDR has no effect on PTSD-B.) If properly performed EMDR treatment has no effect on PTSD-A and sadly it cannot be successful for everyone with PTSD, then PTSD lasts life long unless successfully treated by something else. No one knows whether a person with PTSD will or will not respond to properly performed EMDR until it has been tried and persisted with for some time. The clinical evidence is that properly performed EMDR is only effective in eliminating PTSD-A in persons of certain genotypes (genetic makeups).
Most of the people with PTSD who do not respond to properly performed EMDR can be helped considerably by reducing the severity of the anxiety and anxiety related symptoms. Talking therapies with or without medication or other anxiety-relieving medications. This includes, for some people, ‘MDMA (Ecstasy)-assisted psychotherapy’ conducted by certified therapists. As yet there is no proof that these other treatments have permanently cured PTSD. They do give some hope to those for whom EMDR has failed.
The success or otherwise of EMDR eliminating PTSD-A is easily determined by having a positive Visual Test result before treatment and a negative test result after treatment. Similarly, by having an abnormal re-experiencing form of memory recall of the moment of mental shock before treatment and a normal form of non-re-experiencing memory after treatment. The Visual Test is the quicker and more accurate of the two tests — it remains accurate regardless of the presence of other mental or physical disorders.
Following the successful treatment of PTSD-A, then PTSD-B and or Complex PTSD may remain, and in need of treatment.
3.2 Treatment of PTSD-B and Complex PTSD.
Both disorders are ‘dimensional disorders’, i.e., at the lower end of their severity they merge imperceptibly with a normal mental state and unremarkable personality. They are treated with standard short or long-term psychotherapy techniques. The ease and effectiveness of treatment is part determined by the severity of the symptoms and the duration of the disorder.
4.1 Properly Performed EMDR.
First of all one has to be sure the person has PTSD-A — that the person has persistent peripheral oscillopsia and has recurrent abnormal flashbacks. Children over the age of five or six years with proven PTSD-A can be treated with EMDR. Since the effectiveness of EMDR in eliminating PTSD-A is determined by, amongst many other factors, the person’s genome, it’s effectiveness cannot be predicted with certainty before attempting treatment. There is no proven evidence that EMDR helps with any disorder other than PTSD-A. (But it might be, but it has not been clinically proven, that it can be more than a helpful placebo treatment for other disorders).
Let us say that the person being treated is a “he”, and the person doing the EMDR is a “she”. He sits comfortably in a chair; she sits or stands in front, a metre or so away. He is asked to re-evoke one (perhaps just one of several different) abnormal experiential flashback, and then ‘hold’ that ‘visual picture’ (if there is one) or whichever sensation is the most characteristic of his flashback. This will raise his anxiety, possibly 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 saccades, i.e., a run of repeatedly moving his eyes from side-to-side. He does this by following her moving hand as she repeatedly sweeps her hand from far left to far right to far left in front of him, at one to three sweeps per second .
He is told to stop the run of his saccades, his eye movements, as soon as his abnormal experiential flashback image goes, and she stop also. This disappearance of the image may have taken a run of just several of her 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 abnormal experiential flashback image re-evoked , and each run is continued until it goes.
If EMDR is being successful, then following every few runs of saccades, he senses that, step by step, the flashback image (if there is one) and the other sensations, are degrading in intensity step by step. If and only if there is no other flashback, then on re-doing the Visual Test the persistent peripheral oscillopsia will be lessening in range over the visual field step=by-step likewise, lessening in amplitude of oscillation and or lessening in frequency of oscillation.
The runs of saccades must continue until no fragment of that flashback image can be re-evoked. It may take as few as two or three runs saccades at his first session, or it might take several once or twice per week sessions of saccades 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 had one or more other flashbacks from one or more other traumatic events, then each flashback must be treated by EMDR until eliminated before PTSD-A has been cured. Only then will there be a negative result from the Visual Test — on more peripheral oscillopsia.
If other mental disorders present at the same time, e.g., PTSD-B, Complex PTSD, then they will be left to be treated in some other way after PTSD-A has been cured.
Section Five. Addendum.
5.1 The heritability of an increased risk for developing PTSD-A in response to the experience of a mental shock.
PTSD-A cannot be inherited. There is clinical evidence to strongly suggest that people with the genome for ADHD, have an increased risk of developing PTSD-A in response to the experience of a sudden mental shock. ADHD can be inherited. This may look as though PTSD-A is being inherited when PTSD-A appears in several members of the same genetic extended-family. each of them having inherited the genes for ADHD.
5.2 No one can be born with PTSD-A. It appears that PTSD-A cannot occur in those under five or so years old. What a mental shock can or cannot do to the brain of those younger than five years and with the genes for ADHD or others susceptible to PTSD later in life is not known.
5.3 Perhaps there are also people with genes that prevent them from ever getting PTSD-A when they are experiencing a sudden surge of high anxiety from a mental shock. This is unknowable.
5.4 Oscillopsia, ‘wavy vision’, is just one of many physiological disorders that high anxiety can produce. In a panic attack ‘wildly wavy vision’ is a common symptom that is present in those without PTSD-A. It goes away when the level of the anxiety subsides at the end of the panic attack. A sudden surge of high anxiety can cause sudden death from Takotsubo cardiomyopathy — a heart atttack.
5.5 There is a lot we do not know, cannot intuitively grasp, about the patho-physiological mechanisms of anxiety.
5.6 A book, ‘Cracking the Code of “PTSD” ‘ may one day be published, giving more details of what is already known and how it became known.