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

 A definitive clinical evidence based paradigm for the two different anxiety disorders of ‘PTSD’ – two that can appear clinically very similar but are neuro-biologically distinct: a categorical PTSD type 1 and a dimensional PTSD type 2.

What is new about all this:  A clinical evidence-based means of certain diagnosis of the presence or absence of PTSD type 1  as distinct from PTSD type  2  i.e. a simple visual test.  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 PTSD type 2, and, for (ii) assessing the effectiveness of EMDR (or of any other treatment) in any particular patient with PTSD type 1.
SYNOPSIS (In combination with the Glossaries of terms a few paragraphs below)
 
Applying Occam's razor (applying minimum essentials only) to the clinical implications of finding two invariant (invariably present) unique clinical features - i.e. finding a constant relationship between two complex clinical phenomena - a clinical finding present only in some people, not present in all people, who were presenting with an anxiety disorder that had been triggered by one or more mentally traumatic (anxiety provoking) experiences.
 
The clinical findings (published in 2009*) arose from a 30 year clinical investigation into the nature of a subtle hitherto-undefined visual perceptual abnormality (called persistent peripheral oscillopsia).  It was a visual perceptual abnormality that had been persistently reported by some people but not by all people presenting with an anxiety disorder that had been triggered by one or more mentally traumatic experiences.  And later, finding that recurrent abnormal flashbacks were only present in people with the visual perceptual abnormality, and vice versa - the constant relationship found only in some people with an Anxiety Disorder triggered by mentally traumatic experiences and not in others. 

Finding this constant relationship between two unique and complex clinical phenomena suggested a novel and definitive clinical evidence-based paradigm for two different anxiety disorders that can be triggered by one or more mentally traumatic experiences a PTSD types 1 and a PTSD type 2.  This novel evidence based clinical paradigm of anxiety disorders PTSD types 1 and 2 is necessarily at odds with the clinically ad hoc paradigm of one anxiety disorder 'PTSD' as described in DSM 5 and ICD 11. 

These exploratory evidence-based clinical findings were published anecdotally in Traumatology 15(3) 22-33 (2009).

The diagnosis of the anxiety disorder 'PTSD' in both DSM 5 and ICD 11 relies on the specific objective natures of the causal mentally traumatic experiences. The diagnosis of anxiety disorders PTSD types 1 & 2 relies on the presence of two specific subjective clinical symptoms in some people (with the anxiety disorder PTSD type 1) but not in all people (with the anxiety disorder PTSD type 2) following in response to mentally traumatic experiences, and regardless of the objective nature of those mental traumatic experiences.      
 
The  implications of the clinical findings are that both the infinitely complex human genomics and the infinitely 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 clinical differentiation of anxiety disorders PTSD type 1 and PTSD type 2 significantly aids clinical management. The formal 'paradigm PTSD types 1 and 2' is given in Para (V)'Formal Clinical Definitions' below.

*Traumatology 15(3) 22-33 (2009)

PTSD type 1.  A categorical Anxiety Disorder, characterized by two unique and invariant abnormal clinical features: (i) A persisting epigenomic-engendered unprocessed ‘proto-memory’ (or some such name for it) of the circumscribed experiences of an event giving rise to sudden anxiety, a ‘mental shock’. The unprocessed ‘proto-memory’, including the anxiety,  is stored and is recalled only as a distressing recurrent ‘experiential (re-experiencing) flashback’.  (ii) A persisting  anxiety-related subtle visual  abnormality of ‘persistent peripheral oscillopsia’ (persistent wavy vision) inextricably linked to the persisting ‘proto-memory’. Non-specific anxiety symptoms can be present also. PTSD type 1 is seen to occur at any age over 5 years.

GLOSSARY IN BRIEF

Categorical Disorder: An explicit, unambiguous and specific disorder.
Traumatic Stress: Awareness of exposure to possible danger.
Anxiety: An emotional response acting as a warning of present or imminent danger of some degree.
Mental Disorder: Having persisting inappropriate level(s) of emotion(s), belief(s), behaviour(s) and or cognition.
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.
Experiential means 'sensorially re-experiencing' or 're-living all the sensations of the experience'. 
 
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 the sudden insertion of methyl groups into the DNA of the 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. 

'Proto-memory'(or some such name). 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 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 all unprocessed, all '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 below and Section 7 of the web page.)].
In PTSD type 1 there may be more than one 'proto-memory', each having arisen at different times from different circumscribed mentally-traumatic events that gave rise to mental shocks, giving rise to one or more different experiential flashbacks. 

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 (see below) - epigenetic reversal allows normal memory processing of the 'proto-memory'to proceed, 

 Experiential flashback is the recurrent recall of the circumscribed contents of the 'proto-memory'. There is a flashing-back physical re-experiencing of the intact raw anxiety, the intact raw sensations and the intact raw eidetic visual 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) is a Greek word for 'wavy vision' - an abnormality of visual perception. There are many causes.(See 'Clinical Definitions' a few paragraphs below, and in Section 3 of the web page below.) 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 during moments of high anxiety such as a panic attack. Oscillopsia has many different forms and many different causes. 

Persistent peripheral oscillopsia' (PPO) is a unique form of anxiety-related oscillopsia (wavy vision). It is invariably found to persist for as long as a 'proto-memory' persists - i.e. as long as PTSD type 1 persists.  It must be assumed that the persistent retention of anxiety in the 'proto-memory' is responsible for the persistent presence of peripheral oscillopsia. PPO is persistently found to be present on clinical 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 been recalled recently.  

(Hence: PTSD type 1 is clinically characterised by two invariant subjective clinical criteria and not by any objective criteria related to the nature of the causal event. I.e. these clinical criteria are necessarily at odds with the APA's ad hoc criteria for 'PTSD' given in DSM 5 and ICD 11.) 
 .

PTSD type 1 may be helped (but not eliminated) by time, talking and or medication. For some but not all people with PTSD type 1, each ‘proto-memory’ can respond, one at a time, to EMDR treatment.  EMDR can effect epigenomic reversal, allowing each proto-memory to be normally processed to normal memory form and normal form of memory recall. With all ‘proto-memories’ fully processed, and hence no experiential flashbacks remaining, persistent peripheral oscillopsia is no longer present. This implies permanent elimination of the PTSD type 1.  At present, for those not responding to EMDR their PTSD type 1 persists indefinitely.

GLOSSARY (Cont'd) 

EMDR 'Eye Movement Desensitization and Reprocessing', is a passive non-invasive treatment. (It is described in detail in Section 5 of the web page below.) There is no explanation of how or why EMDR can, but not always does effect epigenomic reversal (via enzymatic de-methylation), allowing the 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 in many sessions or not effective at all. 

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 has only normally-processed distressing memories and distressing normal memory recalls of the distressing experiences.   It can usually be, but not always is eliminated by time and by talking therapies and or medication treatments. There is no response to EMDR. It is seen to occur at any age above five years.

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.

PTSD types 1 and 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.

Further Research. The urgent problem facing 'PTSD' world wide is the need for a dedicated scientific research effort to find an alternative mode of permanent epigenomic reversal for those with severe PTSD type 1 not responding to properly performed EMDR treatment. Available talking and or medications therapies may help to ameliorate but cannot eliminate PTSD type 1. The discovery of EMDR was serendipitous. Reports in the literature of the treatment effectiveness of 'EMDR', 'PTSD Exposure Therapy' and other talking therapies, and medication, do not distinguish between PTSD types 1 & 2 - the therapies can help most with PTSD types 1 and or 2 but with no clear clinical evidence base given so far to confirm that they can permanently eliminate PTSD type 1. The clinical results given here can be clinically reproduced by anyone.

FORMAL CLINICAL DEFINITIONS

(i) An  experiential flashback (See  Section 4 of the web page below for details and examples.)                    An abnormal form of undecaying recurrent experiential (re-experiencing) flashing back memory recall of a proto-memory of the emotional and other sensory experiences during the circumscribed moment of a mental shock. (Normal forms of memory recall of a traumatic experience are not experiential and can decay in information content and emotional intensity over time. Normal forms of memory of a traumatic experience are not associated with persistent peripheral oscillopsia.)

(ii) Persistent peripheral oscillopsia (PPO).                                                                                                             It is a persisting manifestation of the persisting presence of a proto-memory of the circumscribed moment of a mental shock.  (See Section 3 of the web page below) 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.  This form of oscillopsia is a distinctly different form from those chaotic forms of non-oscillating 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.  We find no persistent peripheral oscillopsia (PPO) in Panic Disorder unless experiential flashbacks (i.e. PTSD type 1) is there also.

LEGEND. The blue area is the full visual field of a right eye – 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 left eye is held closed.  The right eye is held fixated centrally on the red dot. The apparent oscillation, once present, 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.

Three reasons why PPO is rarely noticed in everyday life and needs to be tested for:                                  1. 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 up to 6 or 7 seconds of steady fixation.                                             2. In day-to-day life people rarely maintain steady fixation on any stationary object for more than a few seconds.                                                                                                                                                               3. 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.

From person to person with PPO the length of the outer portion of the staff appearing to oscillate would range from 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.

(iii)  The clinical Visual Test for the presence or absence of persistent peripheral oscillopsia, hence for the presence or absence of PTSD type.

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 maintained throughout the test. The examiner, standing a short distance in front of the subject, has the LEFT arm held rigid, adjusting the distance away such that the finger tips as seen by the subject reach the outer limit of the subject’s RIGHT visual field.  After ten seconds of steady fixation 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. (See Section 3 of the web page below for a more detailed description of the procedure.)

(iv) EMDR – ‘Eye Movement Desensitization and Reprocessing‘ treatment and its performance’ (See Section 6 of the web page below for details).                                                                                                 Its performance in brief: An abnormal experiential flashback of PTSD type 1 ( i.e. a proto-memory) is voluntarily recalled and, whilst held present, is subjected to voluntarily-performed repeated runs of rapid alternating left-to-right eye movements. 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 are recalled normally – i.e. non-experientialy.   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.

There is 'no rhyme nor reason' known as to why or how EMDR can effect an epigenetic reversal for anyone with PTSD type 1, let alone why it cannot do the same for all with PTSD type 1.

(v) The formal paradigm of PTSD types 1 and 2  :

'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.

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

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), a form that is unique to PTSD type 1 (described in detail in Section 3); (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  – or of the non-specific amorphous anxiety and distress symptoms.

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.

(vi) Sources of possible clinical confusion .                                                                                                        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 (clearly clinically distinct from the recurrent abnormal experiential 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 superficially clinically indistinguishable – but clinically indistinguishable ONLY IF the two unique clinical features of PTSD type 1 are not first looked for and recognised.

In PTSD type 1 and or PTSD type 2 – from person to person there is a wide spectrum (a varying ‘dimension’) of the objective severity of the causal traumatic event  (from extreme to hardly noticeable by others) and of the subjective clinical severity of the disorder (from persistently severely disabling to hardly noticeable day to day). Successfully eliminating PTSD type 1 usually leaves some aspect of PTSD type 2 remaining and requiring treatment. If PTSD type 1 does not respond to EMDR there may still be PTSD type 2 and or other disorders present that may respond to other treatments, but leaving PTSD type 1 remaining indefinitely.  See also <ptsd.net/cases >

(vii) ‘Complex PTSD’- it cannot be a diagnosis of a specific entity.                                                          There are many ways that clinical presentations of PTSD types 1 and or 2 can be there together with other post trauma or other mental and or physical disorders.

(viii) 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 if it clusters in extended families when clearly it cannot happen. The persisting high anxiety of PTSD type 1 and or PTSD type 2 may effect other non-specific heritable or non-heritable epigenetic changes to the DNA of sperm in a male and to the fetus in a female.

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 epigenomic change to some other aspect of brain function in some genome-susceptible children, e.g. to an autism spectrum disorder, though this may be the case.

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 PPO and a much lower chance of successful elimination of their PTSD type 1 with EMDR, than those of northern European ethnicity phenotype.

(ix) Prognosis of PTSD type 1.                                                                                                                           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 support. 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.

………………………………………………….

Introduction to web page.

(1)  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.  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…’. ‘PTSD’ of any sort can be of any severity. Most want to get rid of it as soon as possible, regardless. Each psychiatrist and psychologist has his or her own idea of what exactly ‘PTSD’ means to them.  All 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 soldiers to five and six year old girls and boys. Mental trauma does not discriminate.

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

As things were in 1978, just after the Vietnam War, the APA changed the name from Traumatic Neurosis to PTSD.  They described the new 'PTSD' in DSM, and for it to be an improvement on ‘Traumatic Neurosis' described in Germany in 1892 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 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 might and who might not 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' and might be compensable was to be based on the objective features, 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 a definition  '... it can be a broken leg in a healthy young man if it happened in a violent 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.... . i.e., not accepting that different people have different vulnerabilities.

(ii) 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 1946 text book called ‘Visual Fields’, written by a London ophthalmologist, Dr Harry Moss Traquair.   The ‘wavy vision in the perimeter’ was reported to him by his patients when examining the vision of war veterans from WWII suffering from Traumatic Neurosis (‘Shell Shock’).   This observation was reported in his book but not investigated by Traquair, and seemingly all but forgotten.

(iii) In 1977, the year before the name ‘PTSD’ appeared, we (a psychiatrist, helped occasionally by 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 investigate it. Mostly a lone wolf investigation, and a quest fellow psychiatrists deemed chimerical, it took 30 or so years to complete.

* 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 i.e. whilst one eye, the other covered, was held fixated on the centre of the visual field chart.  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 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 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.

(iv) The clinical investigation.   The observation of Traquair in 1946 has turned out to be the unique persistent peripheral oscillopsia perception of a ‘proto-memory’ of one ore more moments of mental shock from some out-of-control threat(s) or other acute distress.   Most clinicians told of this visual abnormality by their patients have considered it to be a ‘hysterical’ symptom, somehow attributable to ‘anxiety’ and best ignored: certainly there is never any history of injury to the visual system or any neurological or inner ear disorder present to account for it, and is unrelated to microsaccades.  Traquair, did not refer to it as a ‘hysterical’ symptom in those ex-soldiers with Traumatic Neurosis from WWII .

(v) There was no understanding of any of this at the outset of our investigation in 1977.  The investigation had initially involved the brief asking about, later developing the simple PPO visual test for testing 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 the subsequent 30 year period. Abnormal clinical findings that are rare and subtle require a large sample, a lot of people, to search through.

(vi) 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. There is no clinical evidence base for properly performed EMDR treatment having any long term beneficial effect on PTSD type 2.

(vii) 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 >

Contents

  • Section 1  Problems with DSM 5 / ICD 11 and ‘PTSD’.
  • Section 2 Severity of PTSD type 1 and or PTSD type 2
  • Section 3  Persistent peripheral oscillopsia (PPO) and  The PPO Visual Test for its presence.
  • Section 4  The experiential abnormal experiential flashback  (unique to PTSD type 1).
  • Section 5  EMDR treatment for PTSD type 1 and the treatment for PTSD type 2.
  • Section 6  Heritable vulnerability to developing PTSD type 1.

Section 1

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

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 given here 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. This allows a clear demarcation from PTSD type 2 – the wide spectrum of non-specific, generic ‘post-mental trauma’, ‘post mental stress’ anxiety disorders.

Section 2 

The varying vulnerability to PTSD type 1 and or PTSD type 2

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 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 elsewhere.

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 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 3

The  PPO 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 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 Europe 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 4

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 5

EMDR (Eye Movement Desensitization and Reprocessing) 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 in those of northern European genotype, perhaps fewer in other genotypes.  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 (See Section 6).

Adjunctive talking therapies must be 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 an 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 6

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 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.

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.

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 medication and or talking therapies.

END

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

ptsd.net@hotmail.com