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There is a crisis in PTSD.   What is it, exactly?  There is evidence concerning PTSD that has long been ignored, because it was thought to be insignificant. When it’s paid attention, not ignored, it is highly significant in an unexpected way. It casts light on the neurobiology, its course and its prognosis.  One thing unexpected: the evidence demands two different PTSDs.  There is a PTSD group 1 (that never goes away on its own but for some people their PTSD group 1 can respond to treatment, EMDR and or MDMA plus psychotherapy).  There is a PTSD group 2, that can resolve spontaneously over time and does respond to conventional treatment. The two have in the past been, still are confused with each other clinically. To make things more complicated, group 1 and group 2 can be there together in the same person. The new evidence, easily understood by anyone, enables the two to be distinguished one from the other by anyone, and treated differently by anyone since they need to be treated differently.

Either group 1 or group 2 can affect anyone over 5 or 6 years old; either group can be very mild or very severe or anywhere in between.

Ordinary people, if involved in any way with PTSD, need to know what it is and what can be done.  PTSD is not how it is described in DSM 5 * or ICD 11 * — the new evidence has changed that.

(* ‘Diagnostic and Statistical Manual of Mental Disorders’  ** International Classification of Diseases’.)

 Dr Bob Tym, Clinical psychiatrist, formerly a/prof neurosurgeon, now retired,

Bio: drbobtym.com.  E: drbobtym@gmail.com.  See also <www.ptsd.net/blog/mdma_pt-ptsd-still-a-problem > and < www.ptsd.net/cases >.

Preamble

No one with any sort of PTSD can predict what will happen. A PTSD for some people can resolve on its own over time and they recover.  For other people a PTSD can last life long, and some people have preferred suicide from having to living with it.  PTSD is complicated; it’s not always ‘just another anxiety disorder’.

To the new evidence. It’s well known that some people, when experiencing severe anxiety, perhaps a panic attack, experience at the same time some inexplicable wild, wavy and chaotic vision — everything seems to be swaying about, making them feel dizzy.  The wavy vision all settles when the anxiety settles. The name psychiatrists and psychologists have given to this unpleasant visual sensation is ‘somatisation’ — the brain is somehow making the anxiety into a bodily experience, somehow getting some attention for the frightened person with the panic.   This new word ‘somatisation’ was there to replace the old word ‘hysterical’, which was also meant to mean somehow ‘not real’, ‘imaginary’,’not significant’ — a sensation that goes away when the anxiety settles and vision returns to normal again.  This simplistic explanation has meant that psychiatrists and psychologists don’t have to worry about explaining it to themselves and are able to tell people they can ignore it.

But: the human brain isn’t simplistic, it’s complicated. It turns out that people don’t ‘imagine it’, the ‘wavy vision’ is ‘real’ and for some people it doesn’t go away.  The neurobiological connection between wavy vision and anxiety is still unexplained, but taking notice of wavy vision can explain a lot of what the neurobiology of PTSD is.   There is a form of PTSD, the worse of the two forms, in which there is a persistent but very subtle form of ‘wavy vision’ that is related to the persisting anxiety. For some people with that form of PTSD both the wavy vision and anxiety are both very noticeable; for most people with that form of PTSD only the anxiety is noticeable and the wavy vision only noticed under certain circumstances.  There is no persistent wavy vision with the other form of PTSD, despite the anxiety being much the same. Looking for the ‘wavy vision’ tells which PTSD is which.

The subtle ‘wavy vision’ in one form of PTSD was first reported in 1946 by a London ophthalmologist, Dr Ross Traquair. Persistent wavy vision, seen in the periphery of where they were looking, was reported to him by many ex-soldiers with Traumatic Neurosis from WWII — reported whenever he was examining their vision for something else. Not being a psychiatrist he didn’t investigate it, but he did think it worth mentioning (and he did, on page 121 of  his notable 1956 text book ‘Introduction to Clinical Perimetry’, 5th Edition, London: Henry Kimpton).  The name Traumatic Neurosis, given by the Prussians in 1892, was changed to PTSD by the Americans in 1978. Those WWII ex-soldiers had PTSD in 1946.

In 1977, this same wavy vision — very noticeable and distressing all day long, and having persisted every day for the past several years since the days of frightening accidents at work — was reported to this author, by then a psychiatrist. It was reported by several different women patients, all with an anxiety disorder, and all immigrants from Southern Europe. He knew nothing about Traquair’s findings 30 years earlier. He found their complaints mystifying.  Each woman had been ‘diagnosed’ as ‘hysterical’ by their ophthalmologists and psychiatrists. Clearly, they all had Traumatic Neurosis (not renamed to PTSD until a year later). Their lawyers had been hoping to get them Workers Compensation.  This author was not able to help them, psychiatrically or medico-legally. The previous psychiatric and ophthalmic opinions prevailed, and no compensation was awarded for their ‘hysteria’.  The author,  being an ex-neurosurgeon, could not accept a diagnosis of ‘hysteria’, but couldn’t help them either. Clearly these women were not all to be indefinitely ‘hysterical’; and when he followed them up, nothing changed.  He decided to investigate ‘what’s going on?’.

The odd clinical presentation of these women sparked a 30 year long exploratory and heuristic (learning-as-you-go) clinical investigation into just what the wavy vision was and what it really meant — it was  ‘a gathering of clinical observations and a  gathering of thoughts’.  As an ex-neurosurgeon he was as interested in vision as he was in trauma.

By the end of the 30 year long clinical investigation there had been 9000 or so consecutive randomly referred patients, all of whom underwent a usual psychiatric and psychological assessment and all  also underwent a voluntarily  simple  visual examination, a simple visual test, regardless of why they had been referred to a psychiatrist.  Those patients were mostly blue-eyed Northern Europeans.  Those initial patients, women immigrants from Southern Europe, were dark-brown-eyed with olive skin.  Patients from different countries with slightly different genes often have slightly different clinical presentations of the same disorder — certainly with PTSD.   The women from Souther Europe were as disabled as much by their incessant wavy vision as by their anxiety.

But not all patients, from anywhere,  with PTSD had any wavy vision, regardless  of their genes. Finding a sometimes subtle sometimes obtrusive ,consistent and persisting visual abnormality of ‘wavy vision’ in some people with a PTSD and not in other people with a PTSD was the unexpected finding.

It turned out that there aren’t two different types of people, there are two different types of PTSD.  The two types of ‘anxiety disorder PTSD’ can look very similar, they can be virtually indistinguishable, but neurobiologically (what’s gone wrong inside the brain — something persistently affecting vision and anxiety together in one type of PTSD; only affecting anxiety, not vision, in another type of PTSD) they are very different. Each type has its different course, its different treatment and its different prognosis.

For the sake of simplicity, the two types are called PTSD type 1 and PTSD type 2. Either can be present alone, or, they can both can be there together in the same person, arising from the same or from different traumatic events; if one ‘PTSD’ is cured then the other can remain.

Introduction.

The readily-testable-by-anyone clinical evidence distinguishes a PTSD type 1 and a PTSD type 2, regardless of the circumstances under which a PTSD was caused and regardless of how severe it is.  PTSD type 1 and a PTSD type 2 together cover all ‘post traumatic stress disorders’, including  so-called ‘Complex PTSD’.  They ‘don’t fit’ the PTSD of DSM or ICD. Both PTSD type 1 and type 2 are anxiety disorders that can be triggered by experiencing mental trauma.  The two types can be clearly distinguished one from the other by anyone who knows what to look for, the specific visual disturbance.

 PTSD type 1

It can be shown to be a specific ‘categorical’* anxiety disorder. It can be instantly triggered by, and only by an experience of sudden 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.) and regardless of what was experienced to give rise to the sudden mental shock.  In addition to non-specific anxiety related symptoms it always has two invariant (always there together) unique clinical features. clinical features that are not found to be present in any other mental or physical disorder. One is an abnormal form of memory-and-memory-recall,  and one of a subtle abnormality of visual perception (to be described in detail just below).  PTSD type 1 does not resolve spontaneously over time. In some people with PTSD type 1, not all, it can be cured (‘a pathologic complete response to treatment’) by EMDR (‘eye movement desensitising and reprocessing’) (described in detail later; as to how EMDR could ‘cure’ PTSD in anyone at all baffled psychiatrists ever since it had been shown that it could by its discoverer, Dr Francine Shapiro, in 1989, so psychiatrists ignored it, or swore that it couldn’t.). PTSD type 1 can be helped palliatively by some conventional and unconventional treatments.

Categorical Disorder: An explicit, unambiguous and specific disorder – its two unique clinical features have to be present at the same time, or the disorder is not there at all.

PTSD type 2

It can be shown to be a ‘generic’ (non-specific, dimensional*) anxiety disorder, that can also be triggered by an experience of sudden mental shock and or  be triggered by an experience of any sort of mental trauma, regardless of what was experienced to give rise to the sudden mental shock or other sort of mental trauma. It can have the same anxiety-related symptoms as PTSD type 1 but it does not have either of the two unique clinical features that are unique to PTSD type 1.  PTSD type 2 can resolve spontaneously with time, and helped to resolve with conventional and unconventional treatments. There is no response to EMDR.

* Dimensional (Generic)  Disorder:  A disorder having no unique clinical features and a wide range and type of non-unique symptoms in common with other similar disorders.

(Not everyone gets PTSD type 1 or 2 from experiencing a mental shock and or experiencing any sort of mental trauma — some people can ignore mental trauma, some can build resilience from mental trauma. )

What are the two unique symptoms that distinguish PTSD type 1 from PTSD type 2? 

Unique symptom (i) of PTSD type 1A uniquely abnormally-formed and persisting memory-and- memory-recall of the circumscribed experiences during the moment of the sudden mental shock that had triggered the PTSD type 1. This symptom is a recurrent abnormally formed ‘flashback’ memory (its postulated neuro-biology is described in Section 1 below,  and illustrated in more detail in Section five, below). This is present in PTSD type 1 but not in PTSD type 2. Whenever that abnormally-formed memory is recalled it is recalled abnormally — as a ‘flashing back’ re-experiencing, a ‘re-living’, ‘as though it’s happening allover again’, with a return of the sensations that had been experienced during that circumscribed moment of sudden mental shock (a form of memory recall that cannot be subsumed by the non-specific term ‘dissociative’ *). With each recall, whether recalled spontaneously, triggered or voluntarily, there is a mental and physical re-experiencing of the sudden surge of mental and physical anxiety that had been felt; a flashing-out-there-in-front picture of what had been seen happening during that moment; re-hearing the sounds of what had been heard; re-feeling the pain that had been felt; re-smelling the smell that was there… . When PTSD type 1 is cured (i.e. after a proven pathologic complete response to treatment) the memory and its recall of the experiences at the moment of the mental shock is in normal form — it is reported to be recalled normally, without any re-experiencing of those sensations.

( * The English dictionary definition of ‘dissociative’ is ‘disruptions in aspects of consciousness, identity, memory, physical actions and/or the environment; when a person experiences severe dissociation symptoms they may be diagnosed with a  ‘Dissociative Disorder’.)

(Both disorders, PTSD types 1 and PTSD type 2,  can have one or more severely distressing intrusive memory recalls of past distressing experiences — these are normal-in-form memories and memory recalls, distressing as they may be; they can loosely mimic the abnormal in form recurrent abnormal ‘flashback’ memory recall specific to PTSD type 1.)

Unique symptom (ii) of PTSD type 1:  A subtle, persisting and consistent unique anxiety-related visual abnormality, a unique form of oscillopsia. It is called ‘persistent peripheral oscillopsia‘. (Brief and chaotic ‘wavy vision’ is common during brief high anxiety such as panic attacks but only in PTSD type 1 is it both consistent and  persistent. There are many other well recognised  forms of oscillopsia described in the neurological literature that are associated with certain neurological and inner ear disorders; this is not one of them.) This unique symptom is only found present in PTSD type 1 and not in PTSD type 2.  It is invariably present when the first symptom, (i) above, is present.  It is not always noticed spontaneously but is always noticeable with a simple visual test —  a simple eye test (Section 4 below) that anyone can perform on anyone over five or so years old, anywhere. (The simple test is described in detail in Sections Three and Four below.) When PTSD type 1 is cured then peripheral vision on testing is reported to be normal — non-oscillating. The simultaneous loss of (i) and (ii) in response to treatment confirms a pathologic complete response — a cure. 

The diagnostic criterion of PTSD type 1 is the presence of the two invariant abnormal unique anxiety-related symptoms. Finding one symptom to be present implies the other is also present.   The simple  eye test is specific, sensitive and reliable for detecting the presence or absence of  ‘persistent peripheral oscillopsia’, which means the simple visual test is a specific, sensitive and reliable test for detecting the presence or absence of  PTSD type 1 — and at any age above 5 years, and regardless of the presence of other mental, including psychotic disorders or physical disorders, including traumatic brain injury (other than the subject’s blindness or the subject’s uncooperativeness).

Despite being neurobiologically quite different disorders, but sharing many similar non-specific anxiety symptoms, they can appear superficially clinically indistinguishable.  To tell the difference between PTSD type 1 and  PTSD type 2 the presence of the two unique symptoms of PTSD type 1 must be detected.

Because PTSD types 1 and 2 are neurobiologically quite different disorders then either can arise alone, or, they can both arise together in the same person at the same time, in response to experiencing a mentally-traumatic event or events.  Curing just one disorder leaves the other still present.

(The ‘Formal Clinical Definition’ of PTSD type 1 and PTSD type 2 are given in Section 2 below.)

For the lay person  this means that anyone can diagnose the presence or absence of PTSD type 1 and start treatment — a mother for her child, a colleague for a fellow colleague, a doctor for any patient —  and that anyone can confirm whether or not any treatment for PTSD type 1 has or has not cured PTSD type 1. (‘cure’ meaning ‘a provable pathologic complete response to treatment’).  Some people, but not all people with PTSD type 1 can be cured with properly performed EMDR.   So, as with the simple diagnosis of PTSD type 1 above, anyone can properly perform EMDR for anyone, and do so with a good chance for some, though no certainty, of successfully curing their PTSD type 1. (EMDR, a treatment that has a high probability of success in curing PTSD type 1 in certain genotypes — is described in Section Six.)

This web page further defines PTSD type 1 and PTSD type 2 and provides clinical evidence-based clinical details of diagnosis and treatment, and the provenance of the evidence base of those details.

DSM and ICD  As things were in 1978, just after the Vietnam War, the American Psychiatric Association (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 at that time in DSM and ICD had inevitably to be ad hoc since there was nothing clinically specific known at the time that was 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 whether a participant might or 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, of necessity, to be part based on the objective features, nature and timing of the causal event experienced and had triggered the anxiety disorder, PTSD. It was not to be based solely on any specific subjective clinical finding in the person.  Those not satisfying the diagnostic criteria were classified under the rubric ‘other Trauma- and Stress-Related Disorders’.

Section One.

What’s gone wrong in the brain with PTSD type 1, what is it’s neurobiology?

The unique abnormally formed and persisting memory of the circumscribed experiences during the moment of the sudden mental shock that had triggered the PTSD type 1 is an incompletely processed memory. It can be called a ‘proto-memory’ of the sensory experiences during the circumscribed (momentary) period of acute anxiety of the ‘mental shock’  — the mental shock that triggered the PTSD type 1 while experiencing a mentally traumatic event.  The abnormal part-processed ‘proto-memory’, including the memory of the anxiety, is stored and recurrently recalled as the recurrent experiential (re-experiencing) abnormal ‘flashback’ memory of PTSD type 1. It is not ‘dissociative’ in the non-specific and general meaning of that term.

 The neurobiological pathological process involved in the failure to fully process the circumscribed memory, leaving just the part processed proto-memory, has been abductively-reasoned-from-the-clinical-evidence (by academic geneticists who have personally experienced PTSD type 1 and its cure by EMDR) to be due to the sudden surge of high anxiety of the sudden mental shock inducing a sudden epigenomic methyl group insertion into, and disrupting the function of, the DNA normally involved in current memory processing of experiences of a circumscribed moment.

The anxiety-related consistent and persistent peripheral oscillopsia is inextricably linked to the persistent and consistent presence of the unprocessed anxiety, the anxiety being an intrinsic inclusion of the persisting ‘proto-memory’ (there is no speculation as to how, neurobiologically, anxiety can disrupt visual perceptual stability, causing anxiety-related oscillopsia).

In some people with PTSD type 1, not all with PTSD type 1, properly performed  EMDR can cure PTSD type 1 (i.e. can, step by step, effect a pathologic complete treatment response).  It is abductively-reasoned-from-the-clinical-evidence that successful properly performed EMDR brings about a step by step demethylation – an epigenomic reversal — of that portion of DNA, allowing the demethylated DNA to complete the processing of the part-processed ‘proto-memory’.  There is then a normal non-experiential, anxiety-free memory and memory recall of the experiences of the circumscribed moment of the causal mental shock. With the processing of the and elimination of the abnormally retained anxiety there is a simultaneous step by step disappearance of the anxiety-related persistent peripheral oscillopsia, as confirmed by the visual test.

In those not responding to properly performed  EMDR their PTSD type 1 persists indefinitely. Their subjective severity of PTSD type 1 may be mitigated (but not eliminated) by time or by talking and or medication therapies — medication prescribed or non-prescribed (the latter, e.g. cannabidiol (CBD), controlled MDMA plus psychotherapy) — but the recurrent abnormal ‘flashback’ memory and the persistent peripheral oscillopsia remain.

There can be more than one proto-memory present from more than one experience of mental shock from experiencing the same event or from experiencing more than one mentally traumatic event at different times. Each seperate proto-memory requires seperate properly performed EMDR treatment before persistent peripheral oscillopsia is no longer present.

This responsiveness to properly performed EMDR by some with PTSD type 1 and not by others with PTSD type 1 may indicate, clinically:  either that there are two relevant sub-sets of human genomes — sub-sets of genomes that allow epigenomic reversal (demethylation) in response to properly performed EMDR treatment, and sub-sets of genomes that do not allow (are resistant to) epigenomic reversal (demethylation) in response to properly performed EMDR treatment, or,  this may indicate two sub-sets of PTSD type 1, each with a different epigenetic insertion of some chemical group other than a methyl group, an inserted chemical group that is not reversible by —  unresponsive to — properly performed EMDR treatment.   (See Section seven below for clinical evidence for genome-related factors in PTSD type 1.)

If PTSD type is not cured by EMDR then PTSD type 1 persists indefinitely (i.e. the ‘proto-memory’ remains evocable, never fully processed, and persistent peripheral oscillopsia persists).

PTSD type 2

A dimensional generic anxiety disorder, causally unrelated to genomics and unresponsive to EMDR.

It has non-specific anxiety symptoms similar to those of PTSD type 1 and 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’.   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 may occur at any age (but this clinical investigation did not include seeing children under five years old). It may persist indefinitely if there are indefinitely persisting mentally traumatic circumstances from, for example, persisting

The Complex PTSDs (specifically undefinable disorders).

These may be (a) or (b)

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

(b) PTSD types 1 and/or PTSD type 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 remaining, including PTSD type 2, psychotic illness  Similarly the elimination of PTSD type 2 can leave other disorders remaining, including PTSD type 1

Section Two . 

Formal Clinical Definitions of PTSD types 1 and PTSD type 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 specificallydiagnosed 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  & PTSD type 2 can include nightmares, hyper-vigilance, exaggerated startle response, avoidance of external reminders, and avoidance of thoughts and feelings associated with the traumatic event, headaches, inattentiveness, insomnia, emotional withdrawal, depressed mood, recurrent distressing intrusive memories in normal form, episodic dissociation, episodic derealisation, panic attacks…….any one or more symptoms mentioned in DSM 5 and ICD 11 diagnostic symptom criteria

Section Three    

Descriptions of Clinical Features

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 past (i.e the persistent presence of  PTSD type 1.  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 (as described) 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. From person to person 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 Four below.

Three reasons, a,b,c, 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 a person usually and instinctively immediately glances towards that movement, and with PPO there is nothing seen to be moving, so any apparent movement is ignored.

3.2  Visual Test for the presence or absence of PTSD type 1 

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. See Section four, below

3.3  EMDR – Eye Movement Desensitization and Reprocessing

Its performance in brief: One or more sessions in which a recurrent abnormal experiential flashback of PTSD type 1   i.e. a proto-memory,  is voluntarily repeatedly recalled and, each time it is recalled the patient voluntarily-performs repeated runs of rapid alternating left-to-right-to-left…. eye movements. These are alternating eye movements 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.See Section four, below.

Section Four

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 well 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 leave their therapist unaware similarly  — without the therapist’s simple test being routinely performed to confirm the presence or absence of PTSD type 1 in any patient.

It takes longer to read how to do this simple PPO visual test than the 30 seconds needed to perform it.  There are myriad ways to detect one’s own PPO.  There are myriad ways to invent more sophisticated ‘technological’ ways to test others.  There is always need to ensure  simple 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.

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 general psychiatric hospital or office practice in 1977 — and several other patients of southern European ethnic origin since) (See Section 7).

Section Five

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, are left as a ‘proto-memory’ and 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) Seeing an eidetic picture (called by some as ‘dissociative’) 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 Six

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

(See also ptsd.net/cases)

Virtually anyone anywhere can properly diagnose PTSD type 1 via 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 medication and  adjunctive talking therapies are part of the overall management of PTSD  types 1 & PTSD type 2, e.g. non-specific psychotherapy support, formal Exposure Therapy, formal Cognitive Behaviour Therapy – and with or without the help of anti-anxiety medication.  Intense anxiety even at the thought of having to re-evoke an abnormal flashback during EMDR treatment is a major reason for patients refusing a trial of EMDR. This intense anxiety of voluntarily recalling an abnormal flashback may be assuaged for some by the controlled use of  unconventional anti-anxiety agents e.g.cannabis derivatives (CBD), MDMA at the time of EMDR and or at the time of Psychotherapy.

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. As far as is known this has not been verified for PTSd type 1 via the visual test for persistent peripheral oscillopsia performed before and after treatment.

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 Seven

Heritable vulnerability to developing PTSD type 1.

At the present time there can be no data for the prevalence of PTSD type 1 (‘PTSD’ as per ICS 11) in the general population. There is the rough USA estimate that the prevalence of ‘PTSD’ as per DSM 5 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 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 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.

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.

END

 

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