Clarifying ‘PTSD’ What is it, exactly?
PTSD as per DSM 5 and as per ICD 11 are both ill defined and currently clinically inconsistent with new and readily-testable clinical findings. Fresh clinical evidence demands two different PTSDs — a PTSD type 1 and a seperate PTSD type 2. The two disorders can appear almost clinically indistinguishable but are neurobiologically distinctly different. They are both anxiety disorders that can be triggered by experiencing similar mental trauma. The two need to be distinguished from each other for treatment and for research purposes.
This article presents a readily testable-by-anyone clinical evidence base for distinguishing a PTSD type 1 and PTSD type 2. The nature of the new clinical evidence, and how it came about is described in detail.
The clinical features of the two clinically very similar but neurobiologically different post-traumatic stress disorders:-
(i) A categorical* PTSD type 1: an anxiety disorder that can be instantly triggered by, and only by an experience of sudden mental shock. It has two invariant (always there together) subtle and unique clinical features, two clinical features (symptoms) neither of which is found to be present in any other mental or physical disorder. They are (i) a persistently recurring and uniquely abnormal ‘flashing back’ form of memory — a sensory re-experiencing of the sensory experiences (anxiety, sight, sound, pain…) during the moment of a sudden mental shock that came in response to experiencing a mentally traumatic event. (it is defined in detail in Section Six below); and (ii) a subtle persisting and consistent anxiety-related visual-perceptual abnormality, a specific form of oscillopsia (osi-lop-sia – a Greek word for ‘wavy vision’) called ‘persistent peripheral oscillopsia’; it is always reported to be present (noticeable) on simple visual testing. (The test is described in detail in Sections Three and Five below). PTSD type 1 can also have non-specific anxiety related symptoms in common with other anxiety disorders. PTSD type 1 is unlikely to be diagnosable under the age of 5 or 6 years. PTSD type 1 is not cured by time or by conventional treatments and persists life long if not cured. (The treatment of PTSD type 1 is described in Section Seven, below.)
(ii) A dimensional* PTSD type 2: an anxiety disorder that can be triggered, at the time of or later, by an experience of sudden mental shock or by other non-specific mental trauma. It has no unique, only non-specific anxiety-related symptoms in common with other anxiety disorders.
* Categorical Anxiety Disorder: An explicit, unambiguous and specific anxiety disorder – all its unique clinical features, or symptoms have to be present at the same time, or the disorder is not there at all.
* Dimensional (Generic) Anxiety Disorder: An anxiety disorder disorder having a wide range and type of non-unique anxiety-related symptoms.
(The Formal Clinical Definitions of PTSD type 1 and PTSD type 2 are given in Section 2 below.)
PTSD type 1 and type 2 can be of any degree of severity. Both can arise alone or together in the same person in response to experiencing a mentally-traumatic event or events, regardless of the objective natures of those events — i.e. their diagnoses are independent of the objective nature of the mentally traumatic event that had been experienced and had triggered them.
Neither of the current DSM 5 and ICD 11 ‘PTSD’ definitions is prescriptive; neither has a specific anxiety-related symptoms criterion; neither can be designated as a categorical disorder. The English dictionary definitions 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’ , and the English dictionary definition of ‘Derealisation’ is ‘One of a range of symptoms that can occur when feeling anxious’. These definitions are obviously non-prescriptive.
For the diagnosis of PTSD type 1 there are two invariant specific and unique anxiety-related symptoms — finding one symptom to be present implies the other is also present. There is a simple, readily available, readily fully testable and clinical-evidence-based diagnostic Visual Test (described in detail in Sections Three and Five below) that is specific, sensitive and reliable for detecting the presence or absence of ‘persistent peripheral oscillopsia’ hence the visual test is specific, sensitive and reliable test to detect the presence or absence of PTSD type 1. The test is applicable to those of any age above 5 or 6 yrs, and is specific, sensitive and reliable for the presence or absence of PTSD type 1 despite the presence of other mental or physical disorders (other than blindness or uncooperativeness).
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 cured PTSD type 1. (The treatment for PTSD type 1 — EMDR, a treatment that has a high probability of success — is described in Section Seven.)
The web page 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.
SYNOPSIS (*With a Glossary of terms below).
The clinical finding of the two unique abnormal clinical phenomena came in an 30 year extended exploratory and heuristic investigation by a psychiatrist and ophthalmologist in a general clinical psychiatric practice. The investigation had started in 1977 (a year before the re-naming of the 1892 Traumatic Neurosis to PTSD) and had continued over the 30 years. The two clinical features had been spasmodically reported previously in the international literature but neither had been distinctly characterised clinical features, nor had they been recognised as invariant clinical features. The anxiety-related persisting visual symptom was first reported in the literature in 1946 by a London ophthalmologist, a symptom reported to him by ex-soldiers from WWII with Traumatic Neurosis.
That the two unique abnormal clinical phenomena are invariably found together or absent together was a finding of the exploratory investigation. It was also found that the two were always present only in some people who present with a ‘PTSD’, and found to be always absent in other people who presented with a ‘PTSD’. The final conclusion of the exploratory investigation was that neither DSM 5 nor ICD 10, later 11, definitions of PTSD were adequate: there must be two PTSDs, a PTSD type 1 with the two unique features and a PTSD type 2 that did not have those two unique features.
The long-term nature of the 30 year exploratory investigation had been a ‘gathering of observations, and a gathering of thoughts’: asking about, later developing and utilising a simple visual test for examining a specific aspect of vision. This was applied to each of 9000 or so consecutive psychiatric patients. The patients were of all ages over 5 years old and from all walks of life and of mixed ethnicity (though mostly Europeans), who were randomly referred to the non-specialised general psychiatric practice over the 30 year period – some referred with, most referred without any history of prior experiences of frightening mental trauma.
Pragmatically, our clinical experience suggests that the simplified differentiation of post mental trauma anxiety disorders PTSD type 1 and PTSD type 2, and a simple and reliable test for the presence or absence of PTSD type 1 greatly aids the clinical management of those presenting under the general rubric Trauma- & Stressor-Related Disorders of DSM 5, and of ICD 11.
See also < www.ptsd.net/cases > & < www.ptsd.net/blog/mdma_pt-ptsd-still-a-problem >.
(* See glossary of terms immediately below)
PTSD type 1
A categorical Anxiety Disorder triggered by an experience of mental trauma, and characterized by its two unique and invariant abnormal clinical features (i) & (ii)
(i) A persisting part-processed ‘proto-memory‘* of the sensory experiences during a circumscribed (momentary) period of acute anxiety – a ‘mental shock’* – a mental shock that had been triggered while experiencing a mentally traumatic event. The part-processed ‘proto-memory’, including the memory of the anxiety, is stored and recurrently recalled in abnormal form as a distressing ‘abnormal experiential (i.e. a re-experiencing of all the sensory experiences) flashback memory’*
(The neurobiological pathological process involved in the failure to fully process the circumscribed memory has been abductively-reasoned-from-the-clinical-evidence to be due to the sudden surge of high anxiety (of a sudden mental shock) inducing a sudden epigenomic interference with ( ? by a methyl group insertion into) the DNA involved in the memory processing of the experiences of that circumscribed moment.)
(ii) A persisting anxiety-related subtle visual abnormality of ‘persistent peripheral oscillopsia’* (persistent wavy vision) inextricably linked to the presence of a persisting ‘proto-memory’.
(iii) 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 pathological complete response (abductively-reasoned-from-the-clinical-evidence to be by effecting a step by step epigenomic reversal– ? demethylation) — resulting in the part-processed ‘proto-memory’ being fully processed by the demethylated DNA to a normal non-experiential, anxiety-free memory recall of the experiences of the circumscribed moment of the causal mental shock, and, a simultaneous disappearance of the anxiety-related persistent peripheral oscillopsia confirmed by the visual test.
The 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, e.g. by cannabidiol (CBD), controlled MDMA plus psychotherapy.
This responsiveness to properly performed EMDR by some with PTSD type 1 and not by others with PTSD type 1 may indicate, clinically, that there are two sub-sets of human genomes — a sub-set of genomes that allow epigenomic reversal (demethylation) in response to properly performed EMDR treatment, and a second sub-set 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 eight below for clinical evidence for genome-related factors in PTSD type 1.)
(iv) 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).
Other non-specific clinical features of PTSD type 1
(i) Persisting non-specific anxiety symptoms and distressing recurring memories in normal form are present also. (ii) PTSD type 1 can be diagnosed at any age over 5 years old or so, regardless of gender. (iii) There can be more than one proto-memory present from more than one experience of mental shock from experiencing more than one mentally traumatic event. Each seperate proto-memory requires seperate properly performed EMDR treatment.
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 (‘PTSD’ as per ICD 11) has no unique abnormal clinical symptoms of memory or of vision. It can be triggered by a variety of anxiety-ridden mentally traumatic experiences over time, including ‘mental shock’. It can have only normally-processed (normal in form) severely distressing memories and (normal in form) severely distressing intrusive memory recalls of the distressing experiences, but no abnormal-in-form experiential memory recalls and no peripheral oscillopsia on clinical testing.
PTSD type 2 can usually be, but not always is eliminated by time and by talking therapies and or medication treatments. There is no specific response to EMDR. It is seen to occur at any age above five years old and regardless of gender.
Complex PTSD (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.
And (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, including PTSD type 2. Similarly the elimination of PTSD type 2 can leave other disorders remaining, including PTSD type 1 (‘PTSD’ as per ICD 11).
Glossary of terms in brief
Dimensional Anxiety 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.
An explicit, unambiguous and specific disorder – either all there or not there at all.
Geneticists abductively reason from their own personal experiences of the clinical evidence (by inferring a construct of a known entity for an unknown entity) that sudden high anxiety, a ‘mental shock’*, can trigger (not always does) a sudden insertion of methyl groups into the DNA molecules of some gene mechanism for normal memory processing. As a result of this abnormal DNA the normal memory processing of what was perceived at that circumscribed moment of mental shock cannot proceed to the normal form of memory formation.
A sudden surge of intense anxiety from fear or disgust coming in immediate response to a sudden and unexpected perception of some out of control threat or other distress.
Proto-memory (or some such name)
Seemingly the brain’s initial imprint of all registered information of the experiences during a circumscribed moment of perception. Under normal circumstances this first imprint is instantly processed to normal form of memory – to permanent non-experiential information storage of the experience, and prone to decay in detail over time. The disruption of normal memory processing by the postulated epigenomic consequences of a momentary mental shock leaves the ‘proto-memory’ persisting i.e. leaving ‘the first edition’ of all that the brain had registered during the circumscribed moment of mental shock – the raw anxiety, the raw sensations and the raw detailed information – part-processed and ‘frozen’ intact and not decaying in detail over time. There is no explanation as to why this epigenomic disruption happens some times in some people in response to a ‘mental shock’ and not at other times, and appears not to happen at all in other people. There is some evidence that genomic factors can play a part in a person’s susceptibility. (See Section 6) In PTSD type 1 there may be more than one ‘proto-memory’, each having arisen at different times during one or more different circumscribed mentally-traumatic events that gave rise to mental shocks, giving rise to one or more different abnormal experiential flashbacks.
Abnormal experiential flashback
The recurrent recall of the circumscribed contents of the ‘proto-memory’. This can include a flashing-back physical experiential (re-experiencing) recall of the intact raw anxiety, the intact raw physical (rapid heart, perspiration) & sensory sensations, including the intact raw eidetic (sometimes referred to as ‘dissociative’) visual, sound, pain…. and other detailed information. The intensity of the anxiety, of the raw sensations and the eidetic visual and of other sensory detail in the proto-memory recall does not decay over time. There may be more than one ‘proto-memory’ from more than one momentary experience giving rise to Mental Shock.
A Greek word for ‘wavy vision’ – an abnormality of visual perception. Oscillopsia has many different forms and many different causes. There is no neuro-biological explanation for the occasional co-occurrence of anxiety with abnormalities of visual perception, e.g. the chaotic wavy vision occasionally experienced by some people during moments of high anxiety such as a panic attack.
Persistent peripheral oscillopsia’ (PPO)
A unique form of anxiety-related oscillopsia. It is invariably found to persist for as long as a ‘proto-memory’ persists – i.e. as long as PTSD type 1 (‘PTSD’ as per ICD 11) persists. For many with PTSD type 1 (‘PTSD’ as per ICD 11) its presence is unnoticeable until tested for via a simple visual test (see next paragraph). It must be assumed that the persistent retention of anxiety in the ‘proto-memory’ is responsible for the persistent presence of anxiety related peripheral oscillopsia. PPO is persistently found to be present on clinical visual testing whether or not the proto-memory is being recalled as an experiential flashback at the time of testing or has or has not been recalled recently. The simple, sensitive, reliable and specific visual test for the presence or absence of PPO, and hence for the presence or absence of PTSD type 1 (‘PTSD’ as per ICD 11), is given in detail in Sections 3 and 5 below. The test can be performed by anyone on anyone over 5 yrs of age anywhere & requires no apparatus. The reasons why PPO is rarely noticed in everyday life and has to be tested for: (a) The onset of apparent oscillations throughout the whole or just the periphery of the visual field is ‘seen’ either immediately or only after a delay of from 1 to 6 to 7 seconds of steady fixation on a stationary object; (b) in everyday life people rarely maintain fixation on any stationary object for more than a few seconds; (c) in everyday life whenever there is apparent movement in the periphery of the visual field there is most likely to be an instinctive immediate glance towards that movement, and with PPO there is nothing seen to be moving in central gaze, so any apparent movement in the periphery is ignored.
‘Eye Movement Desensitization and Reprocessing’, is a passive non-invasive treatment. (It is described in detail in Section 5, below) There is no explanation of how or why EMDR can, but not always does effect an epigenomic reversal (via (?) enzymatic de-methylation), allowing the currently-being-treated proto-memory of the event to be fully processed to a normal memory of the circumscribed event. EMDR can be effective in 10 seconds in one session or take as long as three months or more in many sessions or not be effective at all.
Epigenomic insertion and Reversal
Epigenomic insertion (? via methylation) and Epigenetic 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 (‘PTSD’ as per ICD 11), in response to EMDR – epigenetic reversal allows normal memory processing of the ‘proto-memory’ to proceed. EMDR is described in detail in Section 7 below.
Section Two .
Formal Clinical Definitions of PTSD types 1 and PTSD type 2
PTSD type 1
- PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) is unlikely to be diagnoseable below the age of 5 years.
PTSD type 2
- PTSD type 2 is a dimensional non-specific, generic Anxiety Disorder, having no unique clinical features.
- PTSD type 2 has a necessary condition of having been caused by experiencing one or more mentally traumatic events, with or without mental shock. Its onset may be sudden, slow or delayed.
- PTSD type 2 is a disorder of persisting anxiety and anxiety-related symptoms. The spectrum of intensity of its symptoms ranges between the most horrific to the much less so. These nonspecific amorphous symptoms of anxiety and distress can be indistinguishable from those same symptoms of PTSD type 1 (‘PTSD’ as per ICD 11).
- 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 criteria
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 (‘PTSD’ as per ICD 11). 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 (‘PTSD’ as per ICD 11) is there also.
LEGEND. The blue area is the full visual field of the right eye – the left eye closed. It is against a blank background. The image of the solid stationary black rod, held a metre or so away, extends from the centre of visual fixation (the red dot) to the outer limit of the right visual field. The right eye is held fixated centrally on the red dot. The onset of the apparent oscillation may be delayed for from 1 to 6 or 7 seconds: once present it persists for as long as steady fixation is held centrally. Glancing away or blinking immediately stops the apparent oscillations until steady fixation is resumed and again held until re-onset.
From person to person with PPO the length of the outer portion of the staff appearing to oscillate would range from between just the extreme outer tip, to, its whole length; the range of amplitude would vary from 5 degrees to 45 or more; the oscillation frequency would vary from 1 cycle per second to 10 or more . For any one person these three parameters remain constant over decades if a proto-memory remains i.e. if PTSD type 1 remains. More detail is given in Section Five below.
Three reasons why PPO is rarely noticed in everyday life and its persistent presence usually needs to be tested for:
(a) The onset of apparent oscillation of part of the image is ‘seen’ either immediately on fixation or, more usually, only ‘seen’ after a DELAY of from 1 to 6 or 7 seconds of steady fixation.
(b) In day-to-day life people rarely maintain steady fixation on any stationary object for more than a few seconds.
(c) In day-to-day life, whenever there is apparent movement in the periphery of the visual field one instinctively immediately glances towards that movement, and with PPO there is nothing seen to be moving, so any apparent movement is ignored.
3.2 Visual Test for the presence or absence of PTSD type 1 (‘PTSD’ as per ICD 11)
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 (‘PTSD’ as per ICD 11).
The examiner as seen by the subject during the clinical visual test for the presence or absence of PTSD type 1.
LEGEND. The subject holds the LEFT eye closed. The open RIGHT eye fixates the LEFT eye of the examiner. The LEFT eye of the examiner fixates the RIGHT eye of the subject. This ensures that the subject’s steady fixation is seen to be strictly maintained throughout the test – a fixed visual axis between the subject’s right pupil and the examiner’s right pupil. The examiner, standing a short distance in front of the subject, has the LEFT arm held rigid, adjusting the distance away such that the fingertips as seen by the subject reach the outer limit of the subject’s RIGHT visual field. After ten seconds of steady fixation the examiner lowers the left arm and the subject is asked to demonstrate with their own RIGHT arm and hand how the examiner’s LEFT arm appeared to be during the ten seconds. It is a simple, clinically controlled visual test that is reliable, sensitive and specific for the presence or absence of persistent peripheral oscillopsia. The test requires no apparatus and takes overall 30 seconds to perform. It can be performed anywhere by anyone on anyone over 5 years of age, i.e. anyone who is not blind or uncooperative. It cannot be performed reliably during a transient panic attack or the transient high anxiety of a near-panic attack, because of the difficulties in paying attention and the possible interference of vision by, for example, the occasional non-specific chaotic swaying about of visual perception experienced during a panic attack or near-panic attack. MORE NECESSARY DETAIL IS GIVEN IN SECTION FIVE BELOW
3.3 EMDR – Eye Movement Desensitization and Reprocessing
Its performance in brief: One or more sessions in which a recurrent abnormal experiential flashback of PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD; as per ICD 11) only when no fragment of any abnormal experiential flashback can be voluntarily recalled i.e. all one or more proto-memories have been processed to a normal memories of the circumscribed event(s) and can only be recalled normally – i.e. non-experientially. Only when all proto-memories have been processed to normal memories does the PPO Visual Test give a negative test result for the presence of persistent peripheral oscillopsia. MORE NECESSARY DETAIL IS GIVEN IN SECTION SEVEN BELOW.
Explanatory noes on the provenance of the novel paradigm PTSD types 1 (‘PTSD’ as per ICD 11) & PTSD type 2.
As things were in 1978, just after the Vietnam War, the APA changed the name from Traumatic Neurosis (TN) to PTSD, replacing TN that had been described by Oppenheim in Germany in 1889 for the ‘mental disorders following mental trauma’. The APA’s clinical criteria of ‘PTSD’ given at that time in DSM and ICD had inevitably to be ad hoc since there was nothing clinically specific known at the time sufficient to clearly distinguish any one specific post mental trauma mental disorder from any other. In the light of the many sufferers among the participants in the Vietnam War and others, there was an urgent need at the time, and since, for a way of determining who might and who might not justly qualify for compensation for a persisting anxiety disorder that was post-traumatic. The APA’s chosen option for whether or not a disorder is to be called PTSD was to be based on the objective features, nature and timing of the causal event experienced and had triggered the PTSD. It was not to be based on specific subjective clinical findings in the person.
In 1977, the year before the name ‘PTSD’ appeared, this author (then a newly trained Clinical Psychiatrist, previously an A/Prof Neurosurgeon with previous experience in neuro-ophthalmology) chanced upon patients reporting an inexplicable and long persisting subtle abnormality of ‘wavy vision’. This phenomenon was reported to be observed by several women of Middle East ethnicity suffering from Traumatic Neurosis following relatively trivial accidents at work. They were claiming Worker’s Compensation. The then ad hoc explanation was that the visual phenomenon was ‘hysterical’ and or ‘of no clinical significance’, ‘not real’. Incuriosity reigned. Certainly there was never any history of injury to the visual system or any neurological or inner ear disorder present to account for it, and it was unrelated to microsaccades. Nonetheless it was decided to investigate it. Helped occasionally by an Ophthalmologist and a Clinical Neuropsychologist, but mostly a lone wolf investigation, and a quest fellow psychiatrists deemed chimerical, the exploratory investigation continued for 30 or so years completion.
Later, in 1990, it was found that this same visual phenomenon associated with Traumatic Neurosis had been briefly mentioned in few words in a 1946 text book ‘Visual Fields’, written by a London Ophthalmologist, Dr Harry Moss Traquair. The ‘persisting wavy vision in the perimeter of the visual field’ was reported to Traquair by some WWII war veterans suffering from Traumatic Neurosis when he was examining their visual fields. The clinical ‘observation‘ made by Traquair was of hearing a series of separate individual ex-soldiers, each with Traumatic Neurosis, separately reporting to him their personal ‘observations‘ of a particular form of abnormal ‘wavy vision’. They only observed this ‘wavy vision’ during Traquair’s routine testing and mapping of their visual fields i.e. with one eye covered, the other kept open and held fixated on the central dot of the visual field chart.
Our clinical ‘observations‘ in 1977 had been hearing a series of female patients with Traumatic Neurosis reporting to us their personal ‘observations‘ of a particular form of abnormal ‘wavy vision’ persisting all day. We then deliberately tested iteratively for its presence or absence in all other referred patients, regardless of the reason for their referral. When found to be present in any degree we asked about the presence of any invariant clinical correlates that were personally ‘observed’ by those patients. We have no evidence to suggest that the reports of observations by the #1 ‘observers‘ (the WWII soldiers and our patients) were being influenced in any way by the #2 ‘observers‘ (Dr Traquair and us) who were observing them.
In 1989 Dr Francine Shapiro published her serendipitous EMDR findings re- ‘A treatment for PTSD’. It was initially based on her own personal observation. A first trial of EMDR on our patients in 1990 had a dramatic permanent treatment effect on some with – what is now called – PTSD type 1 (‘PTSD’ as per ICD11). During EMDR there was reported by patients a step-by-step and in-step simultaneous permanent elimination of persistent peripheral oscillopsia together with the abnormal experiential flashback memory, and a there-and-then significant and permanent diminution in the levels of anxiety and anxiety related symptoms. These patients had been followed for 10 years and hitherto found unresponsive to all other treatments and to time, the clinical features of persistent peripheral oscillopsia and abnormal experiential flashback memory had remained unchanged since first seen 10 yrs previously. For some patients with exactly the same clinical picture and same persistent peripheral oscillopsia and abnormal experiential flashback memory was no response at all to EMDR. Nor did EMDR have any demonstrable treatment effect on patients who had only a PTSD without persistent peripheral oscillopsia or abnormal experiential flashback memory.
It has been our clinical experience that different human genomes predispose to different susceptibilities to the development of PTSD type 1 (‘PTSD’ as per ICD 11) in response to the exposure to sudden ‘mental shock’, and, to the ease or otherwise of PTSD type 1 (‘PTSD’ as per ICD 11) responding to properly performed EMDR. (See Section Eight below)
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’ as per ICD 11). PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11), 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) and gives a negative PPO visual test result immediately after properly-performed EMDR has successfully permanently eliminated the PTSD type 1 (‘PTSD’ as per ICD 11) – 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) have oscillopsia of all stationary objects throughout their whole visual field persistently, with no delay in onset and present all day everyday, with their head and eyes held perfectly still and with their head and eyes moving about (this had been the case with those first patients of Middle East and southern European ethnic origin who had been referred to the psychiatric practice in 1977 — and several other patients of southern European ethnic origin since) (See Section 7).
Abnormal experiential flashbacks of PTSD type 1 (‘PTSD’ as per ICD 11), 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.
EMDR (Eye Movement Desensitization and Reprocessing) Treatment of PTSD type 1 (‘PTSD’ as per ICD 11) , and the ( non-EMDR) treatment of PTSD type 2.
(See also ptsd.net/cases)
Virtually anyone anywhere can properly diagnose PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) . 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 (‘PTSD’ as per ICD 11) as for adults. There appear to be genetic factors in people with PTSD type 1 (‘PTSD’ as per ICD 11) 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’ as per ICD 11) & 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11), 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.
Heritable vulnerability to developing PTSD type 1 (‘PTSD’ as per ICD 11).
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 (‘PTSD’ as per ICD 11)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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) of any severity, about 40 of that hundred with PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) of any severity — but only when PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) then finding the two together would have a probability of 1/140 or so. But finding PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) in those attending for treatment of PTSD type 1 (‘PTSD’ as per ICD 11) appears to have a probability of 4.2/10 or so.
The onset of PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) and or type 2. The co-occurrence of ADHD impairments and PTSD type 1 (‘PTSD’ as per ICD 11) and or type 2 is a form of ‘Complex PTSD’. The persistence of ADHD impairments following successful EMDR elimination of PTSD type 1 (‘PTSD’ as per ICD 11) and or treatment of PTSD type 2 complicates post treatment recovery.
PTSD types 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) in patients with mental illnesses. EMDR will have some probability of eliminating PTSD type 1 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) 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 (‘PTSD’ as per ICD 11) of any severity or for ADHD impairments of any severity, and diagnose ‘Depression and Anxiety’ on the basis of the commonest symptoms of each, and treat with non-specific antidepressant/anti-anxiety medication and or talking therapies.
Dr Robert Tym (clinical psychiatrist, retired from active clinical practice; formerly an a/prof neurosurgeon)