PTSD TYPE 1, OSCILLOPSIA, EMDR & PTSD TYPE 2
(Something unexpected and new about PTSD, a web page for anyone to read)
In 1946 a London ophthalmologist, Dr Harry Moss Traquair, reported that some of his patients, ex-soldiers from WWII with Traumatic Neurosis, were reporting ‘…a stammering of perception in the periphery of their visual fields…’ whilst their vision was being examined. Dr Traquair appears not to have mentioned it again, and just left his observation at those eleven words! Traumatic Neurosis was not renamed PTSD until 1978. In 1977, and knowing nothing of Dr Traquair or his finding, a psychiatrist (who had previously been a neurosurgeon), an ophthalmologist and a neuropsychologist — started to investigate a persisting visual abnormality reported by several women patients. The women were all recent immigrants from southern Europe and the Middle East. They were all suffering from Traumatic Neurosis that had followed frightening accidents at work several years before. Their visual abnormality had been diagnosed by their eye specialists and psychiatrists alike as ‘hysterical’, ‘not real’, ‘of no significance’. This strange visual abnormality didn’t look ‘hysterical’ to an ex-neurosurgeon, the psychiatrist (the author), to whom they had been referred by their compensation lawyers. He thought it too odd a visual abnormality to be dismissed as hysterical and started to investigate it. He eventually called on two colleagues for some help. After 30 years of joint investigation this odd visual abnormality has been identified. It is certainly a very ‘real’ abnormality, and certainly not ‘hysterical’ — but for most people who have the visual abnormality it is certainly very subtle, and is not detected in them until their vision is being tested. This appears to have been the case for those WWII ex-soldier patients of Dr Traquair with Traumatic Neurosis in 1946. Unexpectedly, the investigation has revealed a ‘three-legged-stool evidence base’ for there being two distinct types of ‘PTSD’, a type 1 and a type 2 — a type 1 with a subtle visual abnormality, likely to respond to EMDR and only to EMDR, and a type 2 — with no visual abnormality, that does not respond at all to EMDR, but does respond to conventional treatments,
Most mentally traumatic circumstances, and other adverse events in life, can be coped with. Some traumas can even build up one’s resilience, toughen one up. But for some people their experiences of mentally traumatic circumstances and adverse events in life cannot all be coped with, and not because of any human weaknesses on their part. Soldiering is first amongst many occupations where severe and acute mental trauma in many forms is all too common, taking a heavy toll of persisting mental distress and disorder. Post Traumatic Stress Disorder, ‘PTSD’, is ‘a special case’ of mental distress and disorder. The nature and course of ‘PTSD’ has always been difficult to understand and predict. Much the same disorder was called Traumatic Neurosis in 1898, and for a thousand years before that it had many different names and always difficult to understand and predict. For some people, their ‘PTSD’ can slowly fade away over time; for others their ‘PTSD’ can remain unfaded and last life-long. ‘PTSD’ can be there but concealed amid other mental disorders. ‘PTSD’ can occur in people of any age above 5 or 6 years anywhere. At the present time ‘PTSD’ is said to affect one in fourteen of the Western World.
This webpage presents a new ‘three legged stool’ evidence base that ‘PTSD’ must be a disorder of two distinct types, PTSD types 1 and 2. In the absence of a simple, reliable and sensitive visual test it can at times be hard, often impossible, to tell the two types of ‘PTSD’ apart. For some people — and just to show how things can be more complicated — both types can be there together from experiencing just one traumatic event or from experiencing many. One form, PTSD type 1, used to last life-long for everyone, but now has a very good chance, a 9 or so out of 10 chance, of being cured, eliminated, by a treatment called EMDR. It is never cured by talking and or medication treatments. The other form. PTSD type 2, does tend to fade away slowly over time, does respond to talking and or medication treatments, but does not respond to EMDR at all.
The webpage describes the accidental finding of a subtle and abnormal visual oddity, ‘persistent peripheral oscillopsia’, not previously fully described or recognised. It is a distinctly different form of ‘oscillopsia’ from those of neurological disorders such as multiple sclerosis. It is found to be always subtly present when there are also recurrent uniquely ‘abnormal’ memory flashbacks of the moment of a mentally traumatic event. The presence of these two abnormal features, a subtle abnormality of vision and a very unsubtle abnormal form of recurrent ‘flashback memory, has been found to be unique to PTSD type 1 — neither feature is found in PTSD type 2 or in any other mental or physical disorder. The recurrent abnormal memory flashbacks are different from the other unpleasant but not abnormal intrusive memories of mentally traumatic events, there is now a simple visual test that detects the presence or absence of the ‘oscillopsia’. Hence this same simple test detects the presence or absence of PTSD type 1. This simple tests enables appropriate EMDR treatment to start without delay.
But eliminating both PTSD types 1 and or 2 does not necessarily eliminate all aspects of other mental distress that can follow mental trauma. Mentally traumatic circumstances, including physical trauma, can give rise to endless mental distress — inconsolable grief, anger, resentment, loss of irreplaceable relationships, unemployability — and endless depressed mood and anxiousness because of endlessly depressing post-traumatic circumstances. Getting rid of PTSD types 1 and 2 is not always a panacea for future contentment, but it can certainly help.
All this material has been published in the peer reviewed international journal Traumatology 15(3) 2009. It has been mostly ignored by ‘authority’, the same fate of much that is both new and as counterintuitive as the idea that PTSD type 1 can be diagnosed by a simple visual test. But the miserable lives of those with ‘PTSD’ of either or both types demand open and honest approaches and knowledge of how, if possible, they can be recognised and helped. If this web page, here for all to question, test and dispute, furthers that cause then it will have done its job.
A quick and simple Q & A to get started — all the details are in the webpage
Q. What’s all this about? Whatever is oscillopsia? How’s it pronounced? Why should we know about it?
A. It’s pronounced ‘osi-lop-sia’, a Greek word for ‘wavy vision’. There’s a subtle visual abnormality in which stationary objects in the periphery of vision appear to be waving about all the time when keeping one’s head and eyes still and staring straight ahead. It’s called ‘Persistent Peripheral Oscillopsia’. It’s quite unlike other forms of ‘oscillopsia’ that can occur multiple sclerosis and inner ear disease where the oscillopsia is only present during head or eye movements.
Q. Whatever has this peripheral oscillopsia got to do with ‘PTSD’?
A. It’s unique in that it’s only to be found in one form of ‘PTSD’ and not in another form of ‘PTSD’ or in any other disorder.. This type has to be called PTSD type 1 to distinguish it from the other PTSD type 2. Most people with PTSD type 1 don’t notice any peripheral oscillopsia until it’s tested for, and most but not all of those who do notice it can ignore it. If it wasn’t so subtle it wouldn’t have taken us 30 or so years and seeing and testing 9000 or so patients to sort it all out. There is now a very simple but very accurate visual test to detect the presence of this peripheral oscillopsia. One more thing that is unique to PTSD type 1, and vastly more noticeable and obtrusive than the oscillopsia is for most — it is the uniquely abnormal recurrent ‘re-experiencing’ memory flashbacks of the moment of the event which caused the PTSD type 1. This is an abnormal form of recurrent intrusive memory. The other type of ‘PTSD’, which has to be called PTSD type 2, has neither of these unique features, but can have the rather similar but normal form of recurrent intrusive memories, as can PTSD type 1 in addition to abnormal flashbacks. PTSD type 2 can be virtually indistinguishable from PTSD type 1 most of the time unless one looks for the subtle peripheral oscillopsia.
Q. So why are oscillopsia and abnormal flashbacks there with PTSD type 1?
A. God hasn’t told anyone why, it’s just God’s ‘nomological law’ ‘… persistent peripheral oscillopsia and recurrent ‘re-experiencing’ abnormal flashback are always there together in PTSD type 1 — this something that is neither logically necessary nor theoretically explicable but it’s just so…’. ( It is true that in any branch of medicine ‘nothing is always and nothing is never’ but if one of these two abnormal features is there then the other is always there, and when successful EMDR gets rid of PTSD type 1 then neither is there, as sure as anything ever is ‘always’ in medicine.). We have an abductive speculative reason as to why the two are always there together. It is to be found in Section 2 of the webpage.
Q. OK then: So what difference does it make if peripheral oscillopsia is there but it’s hardly ever noticed?
A. Before treating ‘PTSD’ one must know which ‘PTSD’ is which. PTSD type 1 does not go away on its own, nor does it respond to talking therapies or to medication, but PTSD type 1 can be cured completely in 9 cases out of 10 by EMDR. We’ll get to EMDR in a moment, below, and EMDR is all explained in the web page. PTSD type 2 can go away on its own, slowly, but by no ways always, and may be helped along with talking therapies and medication or both, but PTSD type 2 does not respond to EMDR at all. Getting the treatments mixed up can be fruitless and frustrating, and many people who don’t distinguish the two end up saying “…EMDR doesn’t work for ‘PTSD’…it’s a waste of time…”
Q. So now: just what on earth is EMDR?
A. EMDR was serendipitously discovered by the brilliant psychologist Francine Shapiro in 1989. EMDR stands for Eye Movement Desensitization and Reprocessing. It sounds a lot more complicated than it is. It’s a peculiar, very simple treatment. It can be successful in eliminating PTSD type 1 for 9 or s0 out of 10 people with PTSD type 1. As we shall see below, anyone can learn how to correctly recognise PTSD type 1 and how to correctly perform EMDR. There’s a God’s nomological law for EMDR ‘…the success of EMDR in eliminating PTSD type 1 in many people who have it, but not all who have it, is neither logically necessary nor theoretically explicable but it is just so…’. God hasn’t provided any explanation as to why EMDR works or why it only works for 9 out of 10, and we provide no speculation as to why either, but we suspect that geneticists will be able to explain it one day. Nine out of 10 is better than none out of 10 as it was before 1989.
Q. So how to tell the difference between PTSD type 1 and PTSD type 2?
A. How to do the simple eye test that specifically, reliably and sensitively detects the presence or absence of peripheral oscillopsia is all explained in the web page below. If the eye test is ‘positive’ for persistent peripheral oscillopsia then PTSD type 1 is there, regardless of what other mental disorder may be there, and so EMDR treatment can get started asap. If the test for peripheral oscillopsia is negative then PTSD type 1 is not there, and treatment for PTSD type 2 can get started asap. Only if and when PTSD type 1 has been fully eliminated by EMDR is the test for peripheral oscillopsia ‘negative’. Getting things mixed up can lead to treatment chaos. If PTSD type 1 is not eliminated then it’s there life long — and that can be very tough for the quality of life of children and anyone else with PTSD type 1, and may well cost them their lives in the long run.
Q. So what other differences are there between PTSD type 1 and PTSD type 2?
A. PTSD type 1 can only follow a sudden mental shock, and it comes on instantly. A mental shock is defined as ‘experiencing damaging intense fear or horror triggered by experiencing a sudden, unexpected and out-of-control event’. PTSD type 2 can follow a mental shock or any sort of not so sudden mental trauma and can come on straight away or after a day or two. PTSD types 1 and 2 can be there together in the same person from the same traumatic event or from separate events at separate times, giving rise to a ‘complex PTSD’. Both PTSD type 1 and 2 can be of any severity. The spectrum of severity for both types is from ‘horrendous’ to ‘just noticeable and tolerable’ and of any intensity in between. Both PTSD type 1 & 2 can be diagnosed at any age over 5 or 6 years old.
Q. That’s not how ‘PTSD’ described in the books, why?
A. True, and that’s why the American Psychiatric Association’s description of ‘Post Traumatic Stress Disorder’ in their ‘psychiatrists’ bible’, the Diagnostic and Statistical Manual of Mental Disorders, the DSM 5, cannot be left as it is. DSM 5 doesn’t distinguish between the two type of ‘PTSD’ and they have a mixture of other disorders that follow mental trauma that aren’t their ‘PTSD’ but cannot be distinguished from their other disorders — and this causes confusion. We have to try to get the APA to change it. We have to get ordinary people as well as ‘experts’ able to do the simple visual test and look for PTSD type 1 and type 2, and able do EMDR for those with PTSD type 1.
Q. How is it going to be changed? How come no one knows about all this oscillopsia test stuff?
A. ‘All this’ comes from the 30 year long investigation into persisting subtle visual abnormalities in people who had been mentally traumatised. And ‘all this’ has been published by us in the peer-reviewed international scientific literature. But the ‘PTSD authorities’ around the Western World — the APA, the psychiatrists and psychologists of academia and of the armed services and emergency services — don’t countenance such a counter-intuitive idea as a unique visual abnormality following purely mental trauma that distinguishes between two types of ‘PTSD’. This then prevents them from finding EMDR to be reliable. They shun EMDR, and that leaves many with PTSD type 1 untreated, and sadly, many with PTSD type 1 left untreated commit suicide. Those not wanting to believe in persistent peripheral oscillopsia must avoid looking for it, just as Galileo’s good friend, the philosopher Cremonini, refused to look through Galileo’s telescope because he didn’t want to believe in the moons of Jupiter.
So we take our assurance from Thomas Huxley, the 19th Century biologist, the man known as ‘Charles Darwin’s bulldog’ — he reminded all sceptics that ‘…the ultimate court of appeal is to observation and experiment, not to authority….’ So for us the combination — the ‘observation’ of oscillopsia, the ‘observation’ of abnormal flashbacks, and the ‘experiment’ of eliminating PTSD type 1 with EMDR, and in so doing making the ‘observation’ of the elimination of oscillopsia and abnormal flashbacks at the same time — provides a ‘three-legged-stool evidence base’ for the two types of ‘PTSD’ and the appropriate place for EMDR.
The full story of the ups and downs during the 30 years of the investigation, together with many descriptive case histories, and details of the many mental health issues entangled with PTSD types 1 and 2, is all in a book soon to be published by Austin Macauley, London. It is entitled ‘The Ladies with Stammering Vision’. The title of the book (the words ‘stammering vision’ are in deference to Dr Traquair, who is mentioned in the Synopsis above) refers to the women first seen by us in 1977 who had ‘Traumatic Neurosis’, the earlier name for ‘PTSD’. They were recent immigrants from southern Europe. They each had what was then a peculiar ‘oscillopsia’ — they had wavy vision everywhere they looked. They had been told at the time by their top eye doctors and top psychiatrists who had examined them that their ‘oscillopsia’ was all ‘hysterical’, ‘not real’, ‘all in the head’. As an ex-neurosurgeon and new to psychiatry, I was sceptical of the label ‘hysterical’ and decided to investigate it, and did so, eventually with the help from the two colleagues, an ophthalmologist and a neuropsychologist. The investigation lasted 30 years. The peculiar ‘oscillopsia’ proved not to be ‘hysterical’ at all but a not previously fully recognised and described ‘real’ visual abnormality of ‘persistent peripheral oscillopsia’. It is a form of oscillopsia unique to PTSD type 1, and quite different from other forms of oscillopsia of neurological disorders such as multiple sclerosis.
Understandably, people can let any term mean whatever they want it to mean. The term ‘PTSD’ is used world over — in armies, in emergency services, in law courts, in media, in workplaces, in pubs, even in parliaments. Each psychiatrist and psychologist more or less has his or her own idea of what it means. ‘PTSD’ is used as though people are all talking about the same thing. Which they mostly are, but each meaning little more precise than ‘…very unpleasant persisting mental distress-and anxiety-related symptoms together with very unpleasant memories, all triggered by one or more experiences of mental trauma…’. With no agreed precise description of ‘PTSD’ there has been no agreed precise treatment of ‘PTSD’. And most must agree that the long description of ‘PTSD’ given in the APA’s DSM 5 is far from precise and gives rise to a lot of unresolvable problems.
–Dr Robert Tym (psychiatrist, formerly a neurosurgeon, now retired)
- Preface: A brief story of how all this came about over the 30 years.
- Section 1: Some of the problems with DSM 5 and ‘PTSD’.
- Section 2: What is the new ‘PTSD’ — the formal paradigms of PTSD types 1 and 2.
- Section 3: Persistent peripheral oscillopsia unique to PTSD type 1, and The Visual Test.
- Section 4: The re-experiencing abnormal flashback memories unique to PTSD type 1.
- Section 5: The severities of PTSD type 1 and PTSD type 2.
- Section 6: EMDR treatment of for PTSD type 1 and the treatment for PTSD type 2.
- Section 7: Can PTSD type 1 be heritable?
A brief story of how it all came about over the 30 years.
The name Traumatic Neurosis came from Prussia in 1889. In the thousand or so years before that there were many vague and unflattering terms for those with persisting distress following frightening events, and nothing to show on the outside to account for the persisting distress. The new name PTSD came from the American Psychiatric Association in 1978.
Our investigation started in 1977 — a year before the name changed to PTSD. Some women patients had been referred by their compensation lawyers. The women were complaining of high anxiety and distress following very frightening accidents at work some years before. The women all happened to be immigrants from southern Europe and the Middle East. They certainly had Traumatic Neurosis. But they complained also of an unpleasant visual difficulty that had persisted unchanged from the time of their accidents. Previous doctors, including their psychiatrists and eye specialists, had told them, and told me, that their odd visual complaint was “…all hysterical…it’s all in the mind…it’s not real…it’s caused by their anxiety…it’ll go away after the compensation is settled one way or another,,,.” Since this odd visual complaint had always been dismissed as ‘hysterical’ it had never been investigated by anyone as far as anyone can tell. However, these patients were now my patients. To an ex-neurosurgeon, relatively new to psychiatry, it seemed to me to be an odd visual complaint to be dismissed as ‘hysterical’. What is more, it didn’t go away when their compensation cases were settled. Two colleagues and I wondered ‘what is it, truly?’ We thought that perhaps ‘that truth’ was worth hunting. Galen, in Greece 2000 or so years ago, had told us all even then that ‘…we must be bold and go hunting for the truth…even if we don’t come right up to it, at least we’ll get closer than we are now…’ The investigation, hunting for ‘the truth’ went on and off for 30 years. The clinical clues were few and far between and initially hard to find. The human brain doesn’t yield up its secrets readily.
The investigation finally revealed that this visual abnormality was not ‘hysterical’ but a subtle form of ‘oscillopsia’ (‘osi-lop-sia’, a Greek word for ‘wavy vision’). This form of oscillopsia had never been fully described anywhere before, as far as we can tell. The full name is ‘persistent peripheral oscillopsia’ (and is fully described in Section 3). It is very obtrusive in some people who have it — as it was with the women patients I first saw — but is very subtle and hardly noticed until tested for in most other people who have it. When present, for most people it is apparent only after a second or two when the head and eyes are held perfectly still and the eyes are staring at a stationary object. Most people who have it can ignore it and do ignore it. It is not exactly an earth shattering visual abnormality, but it is there all the same in some people. In most people it is important for what its presence on testing indicates, not for what trouble it gives in everyday life. Its form is distinct from all the other forms of previously described oscillopsia, those that can be associated with some neurological and vestibular disorders such as multiple sclerosis, in which the oscillopsia is only present and troublesome when the head or the eyes are moving about.
We devised a simple but sensitive and reliable eye test to detect the presence or absence of persistent peripheral oscillopsia. From the outset in 1977 virtually every patient I saw, regardless of why they were coming to see me, was asked to have one or other very simple and quick eye test. Now ‘upgraded’ in form it is called The Visual Test. It is non-invasive, needs no apparatus, is applicable to anyone over 5 or 6 years, and takes 30 seconds at the most to do. It is a specific, sensitive and reliable test to detect the presence or absence of persistent peripheral oscillopsia of any degree. When confined to the peripheral visual field then the oscillopsia is there but only seen after staring with one eye at a stationary object for up to five seconds, and it only persists for as long as staring at a stationary object persists. On shifting gaze it goes immediately and only reappears after another five seconds of staring at a stationary object. As we shall come to below — why it is called persistent peripheral oscillopsia is because The Visual Test always — persistently — gives a positive test result for its presence when PTSD type 1 is present, and always — persistently — gives a negative test result for its presence when PTSD type 1 is absent. For the patients whom I first saw, the women of Middle East genotype, and for a few patients since, their persistent peripheral oscillopsia was present all over their visual field, not just confined to the periphery. It was there with no delay no matter where they looked, and present all day every day. They didn’t need testing for it. It certainly was troublesome and couldn’t be ignored by them. This wide spectrum of the obtrusiveness and the extent over the visual field of persistent peripheral oscillopsia in those with Traumatic Neurosis, later PTSD type 1, appears to be a spectrum of obtrusiveness that is determined by the person’s genotype.
It was in 1990 that we came across the 1946 textbook written by the London ophthalmologist, Dr Harry Moss Traquair. In it he had reported that some ex-soldier patients of his, fresh from WW II and suffering Traumatic Neurosis had “… a stammering of perception in the periphery of the visual fields…” During Dr Traquair’s eye examinations of their visual fields the ex-soldiers had to keep their head and eyes perfectly still and stare for a few seconds, with one eye at a time, at a black dot. Traquair didn’t pursue this visual abnormality. He certainly didn’t suggest there was anything ‘hysterical’ about those ex-soldiers from WWII with Traumatic Neurosis. We were certainly encouraged by Traquair’s finding. We realised there and then that the Old Testament Book of Ecclesiastes 1: 9 was always right: ‘what has been done is what will be done, and there is nothing new under the sun’.
Our investigation subsequently revealed that there were two unique abnormal clinical features always occurring together, two abnormal clinical features not found to occur in any other mental or physical disorder. It was consistently found that when persistent peripheral oscillopsia is present to any degree with the simple visual test i.e. when the visual test gives a positive test result in that person, then that person always experiences one or more constantly recurring abnormal flashback memories — either mentioned spontaneously or on being specifically asked. These are ‘recurrent abnormal experiential (re-experiencing) flashing-back memories of aspects of the sensations experienced during the moment of the mental shock that triggered the PTSD type 1’. They can be voluntarily evoked, but only reluctantly, and are always come in abnormal experiential form. They are always in the form of re-experiencing, or re-living the unpleasant visual and other sensory and physical experiences of what had been experienced during a moment of mental shock. That moment of mental shock is the momentary ‘experiencing damaging instant and intense fear or horror triggered by experiencing a sudden, unexpected and out-of-control event’. It always appeared that it had been a sudden mental shock that had triggered, given rise to, the patients’ Traumatic Neuroses / ‘PTSDs’.
It surprised us and still surprises us that The Visual Test, simply done conscientiously and strictly as described, remains so consistently reliable, specific and sensitive for detecting the presence or absence of peripheral oscillopsia of any degree And, as became apparent later below, it remains consistently reliable, specific and sensitive for detecting the presence or absence PTSD type 1 of any degree. Anyone can do the test on anyone. One can even test oneself. Nothing magic about the test.
It was then consistently found that persistent peripheral oscillopsia is ‘persistent’ in that some degree is always to be found on testing at any time as long as there is even a fragment of an abnormal flashback that comes spontaneously or can be evoked voluntarily, and found on testing regardless of how long since any abnormal flashback or any fragment of one was last evoked. There seemed little doubt that the ‘nomological law’ of PTSD type 1 applies: ‘persistent peripheral oscillopsia and recurrent abnormal flashback are always there together — this is neither logically necessary nor theoretically explicable, but is just so’ .
The Visual Test gives a consistently negative test result for persistent peripheral oscillopsia in people with a disorder of distress and anxiety following mental trauma who have only normal forms of unpleasant intrusive memories of one or more aspects of a mentally traumatic event or events. One intrusive memory, often many intrusive memories, certainly all unpleasant and emotionally upsetting, but recurrent intrusive memories that are in normal form.
So there is a significant difference between a ‘recurrent abnormal flashback’, which intrudes quite abnormally, and a normal ‘recurrently intrusive traumatic memory’, which can intrude quite normally, albeit unpleasantly, after experiencing a traumatic event. (Abnormal flashbacks, and how they differ from normal recurrent unpleasant intrusive memories are described in further detail in Section 4)
By 1989 there appeared to us to be two different types of ‘PTSD’. Both are post-mental-trauma i.e ‘post mental stress’, so they both warrant being called post traumatic stress disorders — both ‘PTSD’, hence there are two forms of ‘PTSD’. But there are very significant differences between the two ‘PTSDs’
- One form now called here PTSD type 1 — an acute distress and anxiety disorder caused by a mentally traumatic experience that had triggered mental shock. It has persistent peripheral oscillopsia, and has recurrent abnormal flashbacks — both as defined. The person may or may not have many additional quite normal but unpleasant and upsetting ‘recurrent intrusive traumatic memories’ of many aspects of the traumatic events and experiences that had triggered the PTSD type 1. It does not fade in intensity with time and does not respond curatively to medication and or talking therapies, helpful though they may be otherwise. Unless eliminated by EMDR it will persist indefinitely.
- One form now called here PTSD type 2 — an acute distress and anxiety disorder caused by a mentally traumatic experience or many experiences, perhaps or perhaps not triggering a mental shock. It can be virtually indistinguishable from PTSD type 1 except that it has no visual abnormality, and has no recurrent abnormal flashbacks of the trauma or traumas that triggered the disorder. There may or may not be many quite normal unpleasant and upsetting ‘recurrent intrusive traumatic memories’ of many aspects of the traumatic events and experiences that had triggered the PTSD type 2. It tends to slowly fade in intensity and resolve in time, and it can be helped curatively and in other ways by medication and or talking therapies, but it does not respond at all to EMDR.
- It also became clear that PTSD type 1 and PTSD type 2 can be present in the same person at the same time from the same event or from separate events, recent or long passed, giving a Complex PTSD.
Until EMDR came along, we are coming to EMDR treatment, then for those with PTSD type 1 there appeared to be some temporary palliative response to talking and medication treatments, but no curative response to any form of treatment — PTSD type 1 appeared to last life long. For those with PTSD type 2 there was slow spontaneous recovery and some useful curative response to talking and medication treatments.
In 1989 the American psychologist, Dr Francine Shapiro, serendipitously discovered ‘EMDR’, Eye Movement Desensitisation and Reprocessing, a ‘treatment for PTSD’ (details of EMDR are in Section 6). From our treatment trials in 1990 it became apparent that properly performed EMDR has a high probability of permanently eliminating, in 9 or so cases out of 10, properly diagnosed PTSD type 1, but properly performed EMDR has no effect on properly diagnosed PTSD type 2.
We found that if EMDR successfully eliminated PTSD type 1 over serial sessions of EMDR then both the persistent peripheral oscillopsia and the recurrent abnormal flashback were, serially bit by bit together, and simultaneously, changed to normal peripheral vision and a normal form of memory recall. The patients could certainly remember the awful moment of the mental shock but the memory of it was now a ‘recurrent intrusive traumatic memory in normal form’ — no longer abnormally ‘experiential’, i.e. no longer a physical and sensory re-experiencing memory of the event. Their anxiety and distress also resolved, but usually somewhat more slowly. EMDR reinforced the difference between PTSD type 1 and PTSD type 2. It reinforced the understanding that there was something unique and specific about PTSD type 1 and something unique and specific about EMDR. The one appeared to be uniquely different in form from all other mental disorders and the other a treatment different from all other mental disorder treatments.
Sadly, it soon became clear that when EMDR is properly performed for those with properly diagnosed PTSD type 1, then it is effective for only 9 out of 10 or so. For some patients for whom this treatment is ineffective the reason is clearly related to factors associated with very high anxiety and or multiple trauma with multiple abnormal flashbacks. But for some patients for whom this treatment is ineffective the reason is not at all clear and possibly related to factors associated with their genome. Genes appear to have a part to play in the PTSD type 1 puzzle (discussed in Section 7).
The Visual Test turns out to be a specific, sensitive and reliable test for the presence or absence of persistent peripheral oscillopsia, and ipso facto, turns out to be a specific, sensitive and reliable test for the presence or absence of PTSD type 1, regardless of the presence of any other mental disorder or mental illness or physical disorder other than blindness being present at the same time.
In effect The Visual Test detects the presence or absence of PTSD type 1, of any degree of severity and regardless of whether or not some other mental disorder is there at the same time, e.g. when there is PTSD type 2 present at the same time, when there is some degree of traumatic brain injury present at the same time, when there are mental illnesses such as schizophrenia present at the same time. The simple test for PTSD type 1 applies to anyone above the age of 5 or 6 years — children get the same PTSD type 1 and or PTSD type 2 as adults.
The presence of persistent peripheral oscillopsia together with a recurrent abnormal flashback memory before EMDR, and the absence of both immediately after successful EMDR, provides ‘the three legged stool’ evidence base for the effectiveness of EMDR in eliminating PTSD type 1 in that person.
Based on our novel clinical findings, this new paradigm of PTSD type 1 and 2 has to be at odds with the DSM 5 paradigm of the American Psychiatric Association. Just how and why it is at odds with ‘PTSD’ in DSM 5 is explained. (Section 1 & 2). This is our David and Goliath battle with the APA. The battle is only over their DSM 5 ‘PTSD’. The rest of their DSM 5 is an excellent ‘bible’ for psychiatrists. Our paradigm of ‘PTSD’ can be judged as more or less reasonable than any other paradigm vis-a-vis the observational consequences and any impartial reasoning. (See Section 1.)
Problems with the DSM 5 description of ‘PTSD’
The American Psychiatric Association, the APA, publish details of their ‘PTSD’ in their Diagnostic and Statistical Manual of Mental Disorders. It is now in its 5th edition, DSM 5, 2013. But ‘PTSD’, replacing the vague term Traumatic Neurosis, does not describe a specifically defined psychiatric or psychological entity.
The APA had added a few extra ‘distress and anxiety disorders’ that can follow ‘traumatic-stress’ that are ‘not PTSD’ (even though they are obviously ‘post traumatic stress’ disorders). They include ‘Acute Stress Disorder’, ‘Adjustment Disorders’, and some others. But from the descriptions given by the APA for these extra disorders it is still not always possible to distinguish them from the DSM ‘PTSD’ itself. Distinguishing one from another can certainly be impossible in the earliest stages following the mentally traumatic event that triggered them — or at any other time when the anxiety and distress levels are very high.
What is more, the APA authors stipulated in their DSM 5 that there can be no ’PTSD’ unless the mentally traumatic event triggering it had been “…an exposure to actual threatened death, serious injury or sexual violence …. in various specified ways……” In other words, in DSM 5 terms: it is the nature of the mentally traumatic event that is important in the diagnosis of ‘PTSD’, not how the person was actually affected by the mentally traumatic event, regardless of its nature. This is rather like saying: it’s a broken leg if it happened in a violent road accident; but it’s not a broken leg for an old lady with osteoporosis if it happened while she was just turning over in bed. True, all broken legs have x-rays to show there is a break ….. There is now a simple, reliable and sensitive visual test to show that PTSD type 1 is there. People of any age above 5 or 6 years have different susceptibilities and vulnerabilities to the development of PTSD type 1 and or PTSD type 2 in response to experiencing a mentally traumatic event of any severity.
In 2013 Dr Allen Frances, an APA member who had worked for many years on the ‘DSM’ task force, published his book ‘Saving Normal’, a critique of the DSM. He has a Chapter entitled ‘Fads of the Present’. This chapter contains his section on ‘PTSD’, a section headed ‘Hard to get it right’. He comments ‘The diagnosis of PTSD is imprecise because it’s based exclusively on the person’s self-report — there is no laboratory test or objective measure’.
There is still ‘no laboratory test or objective measure’ for PTSD type 1. Nor is there one for practically any other psychiatric disorder except for, perhaps, porphyria. But there is now a simple, specific, reliable and sensitive Visual Test for PTSD type 1. There is no visual test for any other psychiatric disorder, including PTSD type 2. The Test Visual Test is there for anyone taking trouble enough to use it. It detects the presence or absence of a precise and specific PTSD type 1, and regardless of the nature of the traumatic event that triggered it and regardless of the severity of the PTSD type 1, and regardless of the presence of any other mental or physical disorder other than blindness.
There is also an imprecise, amorphous, and nonspecific PTSD type 2 to replace the mixture of those other equally amorphous ‘trauma and stressor related disorders’ listed in DSM that can follow mental trauma, those disorders that in DSM are supposedly ‘not PTSD’.
The women who were referred to me in 1977 with Traumatic Neurosis, who also had the odd visual abnormality, had certainly been very frightened by their accidents at work. But they had not been in very serious accidents otherwise. And if there is a compensation issue over any form of ‘PTSD’ then it surely has to be settled on the subjective severity of the mental effect the traumatic event had on the person, regardless of the objective severity of the causal traumatic event. It can no longer be the case that ‘…you can’t have ‘PTSD’ because the traumatic event you experienced wasn’t bad enough…’.
The formal paradigm of PTSD types 1 and 2
(cf. The ultimate court of appeal is to observation and experiment — not authority)
The paradigms of PTSD types 1 & 2 conform with the parsimony demanded by the 14th Century philosopher, William of Ockham — Ockham’s Razor. The paradigm for PTSD type 1 alone also conforms with demands for falsifiability of the 20th Century philosophers of science, Popper and Kuhn, and conforms with a necessary ‘three legged stool’ evidence base — i.e. the constant presence from the outset of its two unique clinical features that can be eliminated simultaneously with EMDR.
In retrospect, and with 20/20 hindsight, all that was needed by the APA in their dividing up of the old paradigm ‘Traumatic Neurosis’ in 1978 was a more parsimonious division. A division of ‘Trauma- and Stressor-related Disorders’ conflated into a joint PTSD of two types 1 and 2. The two types are at times clinically indistinguishable from each other except for the two unique clinical features of PTSD type 1.
PTSD type 1:
- PTSD type 1 is a Unitized disorder ( Koch’s 19th Century postulates for a specific ‘disease’ entity. i.e. the disorder is either all there or it is not there at all.).
- PTSD type 1 is a disorder of persisting anxiety and distress. The intensity of amorphous anxiety and distress symptoms ranges from the most horrific to the much less so.
- 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 (e. a momentary experience of instant fear or horror triggered by experiencing a sudden, unexpected and out-of-control mentally traumatic event).
- PTSD type 1 has no necessary condition of the objective dimension of the event (how big or small or how bad) that triggered the mental shock.
- PTSD type 1 has two ‘necessary-and-sufficient’ conditions: Two unique clinical abnormalities present from the outset: (a) A unique abnormality of vision — a subtle and mostly unnoticed persistent peripheral oscillopsia — this is unique to PTSD type 1 (described in detail in Section 3); (b) A unique abnormality of memory, an all-too- noticeable recurrent abnormally flashing back memory of the moments of the mental shock event. This form is also unique to PTSD type 1. (It is described in detail in Section 4).
- PTSD type 1 has no necessary condition of the subjective severity or obtrusiveness of either of the two unique abnormal clinical symptoms (see Section 5).
- PTSD type 1 has no necessary condition for the subjective severity or obtrusiveness of associated non-unique mental distress, anxiety or depressed mood-related symptoms (Section 5).
- [One cannot define a disorder by its response to treatment, but — PTSD type 1 does not fade in severity over time spontaneously, nor is it eliminated in response to medication or talking therapies, helpful as those treatments may be otherwise. It has a probability, but no certainty, of permanent elimination by EMDR (or its equivalents) (Section 6) during which the two unique abnormal clinical symptoms are simultaneously degraded and then permanently eliminated step by step and in step. The simultaneous elimination of these two unique clinical symptoms by EMDR (or its equivalents), confirmed by visual testing, supplies the falsifiability of the evidence base for the PTSD type 1, and, the treatment effectiveness of the EMDR for that particular person. There may be two or more abnormal flashbacks from two or more mental shocks coming at different times, each requiring separate elimination by EMDR.
[PTSD type 1 is a ‘unitized’ disorder (as opposed to a ‘dimensional’ disorder): it is either there or not there — it doesn’t ‘fade away over time’ or ‘merge at the edges’. Its form is unlike that of any other mental disorder: (i) It is either there from the moment of mental shock — together with its two uniquely abnormal clinical features, one of vision and one of memory — or it is not there at all; (ii) From case to case the symptom severity of all its clinical features remains more or less constant from the outset; (iii) From case to case the symptom severity of all its clinical features varies from being extremely obtrusive to being hardly noticeable; (iv) It does not resolve spontaneously; (v) It may be permanently eliminated with EMDR (or its equivalents) but it is not permanently eliminated with other treatments.]
[Herewith a speculative jump — going abductively from observation to a theory of PTSD type 1 — ‘the simplest and most likely explanation’. It is as if the sudden and momentary surge of high anxiety of a mental shock had instantly caused an epigenetic change somewhere in the brain — perhaps a methyl group dislodged from some protein configuration at some specifically vulnerable ‘switching’ site of a susceptible person’s brain. Sudden malfunction at that site leads to an instant cascade of malfunction in three functionally-unrelated sites of the brain — one related to ‘processing of the specific memory of the experiences of that moment of mental shock’, one related to ‘an appropriate resting anxiety level’, and one related to ‘visual image stability’. This multiple malfunctioning remains until there is a reversal of epigenetic change.]
[There can be no speculative jump, no ‘simplest and most likely explanation’ for EMDR’s effectiveness. Pragmatically: during EMDR treatment, there appears a probability, but no certainty, of a reactivation of an epigenetically modified ‘switch’ via some epigenetic modifier, allowing a simultaneous return of normal functioning in those functionally unrelated sites. Elimination of PTSD type 1 by EMDR is sometimes quickly effective in ten seconds of treatment, sometimes very slowly and only after several months of repeated sessions, usually over some time in between those two extremes, and for some people EMDR is totally ineffective in eliminating PTSD type 1. Every aspect of PTSD type 1 has a spectrum, going from extreme to extreme of severity, obtrusiveness, complexity and responsiveness. ]
PTSD type 2:
- PTSD type 2 is a Dimensional (non-unitised) Disorder.
- PTSD type 2 has amorphous symptoms of anxiety and distress. The intensity of the symptoms of anxiety and distress ranges from the most horrific to the much less so. These amorphous symptoms of anxiety and distress can be indistinguishable from those same symptoms of PTSD type 1.
- PTSD type 2 has a necessary condition of having been caused by experiencing one or more events giving rise to mental trauma or traumas (fear and or distress), with or without mental shock. Its onset may be sudden, slow or delayed.
- PTSD type 2 has no unique abnormal features of vision and no abnormal forms of memory — perhaps many horrible and intrusive memories in normal form, but not in the form of abnormal flashbacks.
- PTSD type 2 can slowly fade away spontaneously over time; it can respond to talking and medication treatments, but EMDR treatment has no effect. .
[PTSD type 2 is a ‘dimensional disorder’. Its form is similar to many other anxiety disorders: (i) From case to case its symptom severity at the outset varies from very severe to hardly noticeable and can fluctuate over time; (ii) It can spontaneously resolves from the time of outset — its symptom severity slowly fading away over time; (iii) It has no unique clinical features; (iv) It does not respond to EMDR; (v) It can respond to medication and to talking therapies.
[A ‘speculative jump’ going abductively from observation to theory: In PTSD type 2 it is as though there has been a subconscious ‘once bitten, twice shy’ learned mental disorder of anxiety and or depressed mood triggered immediately, or with a delayed onset, by the experience of mental trauma(s). It takes time and re-learning to diminish in intensity. It may not fully recover over time if other sources of mental trauma continue to be present, e.g. from persisting lameness, deprivation, persisting grief, persisting drug and or alcohol abuse, or from the development of other mental illness or disorder.]
- PTSD types 1 & 2 can arise alone or rise together in the same person following the same traumatic event.
- PTSD types 1 & 2 can persist together, and can be present together with other mental illnesses and physical injuries and disorders.
- The simple visual test detects the presence or absence of PTSD type 1 amongst other mental and physical disorders which may be present, including PTSD type 2. If and when PTSD type 1 is eliminated by EMDR then the other comorbid disorders, including PTSD type 2, remain to be treated.
- Attempts at any treatment for Complex PTSD, not knowing which mental disorder is which, or that both are there together, can lead to frustration and discouragement, fostering scepticism about the effectiveness of any treatments for ‘PTSD’.
Mental shock (as defined — a momentary experience of instant fear or horror triggered by experiencing a sudden, unexpected and out-of-control mentally traumatic event) may cause nothing at all, may increase resilience, but may cause PTSD type 1 (of any degree of severity), may cause PTSD type 2 (of any degree of severity) and may cause both PTSD 1 & 2 together (of any degree of severity). Mental trauma without mental shock may cause nothing at all, may increase resilience, and may cause PTSD type 2 (of any degree of severity), but cannot cause PTSD type 1.
The Visual Test to detect the presence or absence of Persistent Peripheral Oscillopsia, unique to PTSD type 1 — and hence The Visual Test is a test to detect the presence or absence of PTSD type 1.
(It takes a lot more time to read how to do this simple visual test than the 30 seconds it takes to do it).
Persistent peripheral oscillopsia is ‘persistent’ in that it is always to be found at any time if there is even a fragment of an abnormal flashback of PTSD type 1 that is spontaneously evocable or can be evoked voluntarily. Its presence is regardless of how long since any abnormal flashback or fragment of an abnormal flashback was last evoked. The abnormal flashback does not have to be present at the time of The Visual Test.
For the sake of this description of The Visual Test let us suppose that the subject being examined here is a ‘he’, the examiner here is a ‘she’. If possible a friend or relative of the subject will be present also, looking on to reassure him.
- 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 English there will need to be an interpreter.
- 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 panic are well passed.
- Throughout the test he remains seated. He must hold his head and eyes perfectly still throughout the ten seconds of the test.
- One of his eyes must be covered (let us say his left).
- He is asked to focus with his right eye on her left eye. She stands a metre or so in front. She has her right eye covered.
- Her left arm is then held out, and held rigid and horizontal. The fingertips of her left hand must just reach the outer periphery of his right visual field. He can just see the examiner’s finger tips but no further out. This is an essential detail.
- She fixates her left eye on his 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 (patient’s eye fixation to examiner’s eye fixation) is thereby held rigid.
- During the ten seconds of the test he is asked not to shift his fixation of his right eye from her 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 focussed on her left eye.
- After 10 seconds she lowers her left arm and asks him to demonstrate with his right arm, how her left arm appeared to him during the 10 seconds of keeping his right eye fixed on her left eye.
- The test is positive for ‘persistent peripheral oscillopsia’ when he 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 move up and down, or round and round — to 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 persistent peripheral oscillopsia vary from subject to subject:
- For any one person the oscillations may appear to be there, at each test, from the outset or only appear after a few seconds — a constant delay in onset which may be from 1 to 6 or 7 seconds of steady fixation.
- For any one person the oscillations, at each test, have a constant frequency — of about one to three or more waves or cycles per second.
- For any one person 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 person the oscillation, at each test, has a constant extent over the visual field — the extent of apparent movements may have been just in the periphery of the visual field, 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’s whole arm appearing to oscillate.
- There may be an apparent very brief ‘jerk’ or two, up or down, of the examiner’s arm during the ten seconds. These are normal illusions. They do not persist and are not abnormal oscillations.
- During successful EMDR — i.e. as EMDR continues and there is a steady step by step degradation of the details of the abnormal flashback — there is a simultaneous steady step by step and in step degradation of all features of the oscillopsia seen on serial testing.
- Some degree of persistent peripheral oscillopsia is ‘persistent’ in that it is always to be found at any time if there is even a fragment of an abnormal flashback of PTSD type 1 that is revocable spontaneously or can be evoked voluntarily, and regardless of how long since any abnormal 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 treatment for PTSD type 1 and gives a negative visual test result immediately after properly-performed EMDR has successfully permanently eliminated the PTSD type 1 — no oscillopsia and no abnormal flashback. This negative 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 not all that uncommon in a psychotic illness and EMDR is no more or less effective in the presence of psychosis.)
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 every day, with their head and eyes held perfectly still and with head and eyes moving about (this had been the case with those first patients of Middle East and southern Europe ethnic origin who had been referred to me in 1977 — and several other patients of southern European ethnic origin since) (Section 7).
A recurrent abnormal experiential flashback of PTSD type 1.
People who have PTSD type 1 always have this unique clinical feature. It is a recurring abnormal re-experiencing iconic flashback memory recall of the sensory and physical experiences during the moment of mental shock — the momentary experience of instant fear or horror triggered by experiencing a sudden, unexpected and out-of-control mentally traumatic event— the mentally traumatic event that had triggered the PTSD type 1.
- It is an abnormal form of iconic memory-recall, a ‘re-experiencing’ or ‘re-living’ of the physical and sensory sensations that had been experienced during the moment of the mental shock at the time of the event that triggered the PTSD type 1… ‘as though it is all happening again’.
- The features, briefly or not so briefly, that are re-experienced are (i) The sensations of the emotion felt during that moment e.g. the fear, anxiety, panic; (ii) Of what was seen during that moment e.g. a coloured, often detailed still picture or constantly re-running 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 murder site or in a burnt out building. The room where one was listening to a frightening phone call, or where one was having a panic attack. A vehicle just prior to an unavoidable collision. A smashed windscreen immediately after an accident. A dead white face in a coffin. A colleague who was standing next to one now bleeding to death after being shot ,…there is myriad unique possibilities of what’s ‘seen’ in people’s real life abnormal flashbacks. (iii) Of what was heard during that moment e.g. the words spoken, the screams, the screech of brakes, the crumbling metal, the gunfire…. (iv) Of what felt physically during that moment e.g. the pain, the penetration, the choking, the falling…. (v) Of what was smelled during that moment e.g. the petrol, the putrefaction, the faeces, the smoke…..
- The abnormal flashback is NOT a dream. It is experienced only whilst wide awake. When coming in the middle of the night perhaps triggered by a nightmare of similar frightening events.
- The abnormal flashback can occur spontaneously, can be triggered and can be voluntarily re-evoked.
- There may be several different abnormal flashbacks from several different moments of mental shock from one traumatic event or from many different traumatic events which may be separated in time from minutes to days to decades ago.
- Abnormal flashbacks may recur from many times a day to once or twice a year.
- Abnormal flashbacks last from a few seconds to several minutes.
- Attempts are usually made to get rid of an abnormal flashback by distraction, by a violent action, e.g. 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, etc.
- Abnormal flashbacks recur each time with the same intensity of distress. The distress may be extremely severe, may be relatively unobtrusive or anywhere in between.
- Abnormal flashbacks must be distinguished from recurrent normal intrusive distressing memories of traumatic events, from distressing dreams and nightmares of traumatic events — any or all of which may be intermingled with abnormal flashbacks pf PTSD type 1
- When an abnormal 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, distressing as it may well be.
Severity of PTSD type 1 and or PTSD type 2
There is a spectrum of subjective severity for both PTSD type 1 and PTSD type 2. Either can be hideously severe with terrible anxiety, frustration and depressed moods that destroy relationships and shorten lives. Either type can be not very severe, just noticeable. Most are somewhere in between in terms of severity. Only in PTSD type 1 is there always present persistent peripheral oscillopsia, very subtle and not noticed until tested for, or, very obvious and there all the time, or, anywhere in between. In PTSD type 1 only there are always abnormal flashbacks, lots and lots of different ones or just one or just a few. They are severely distressing or they are hardly noticeable or they are anywhere in between in number. Only in PTSD type 1 there is a high chance but no certainty of it being permanently eliminated by EMDR. PTSD type 1 is there with its two unique features or it is not there at all.
There is a spectrum of the objective severity of the events which triggered the PTSD type 1 or type 2 — how big and terrible and frightening the event was or how small but frightening the event was. The objective severity of experience that can trigger mental shock or mental trauma differs very widely from person to person.
Some firefighters, soldiers, paramedics and other emergency workers of either sex, amongst many others of either sex, can get horrendously severe PTSD type 1 and or PTSD type 2 from horrendously traumatic experiences that are endlessly distressing, relationship-destroying and life shortening. And some of them can get only mildly distressing PTSD type 1 and or PTSD type 2 from a frightening personal confrontation or a frightening reprimand at work or at school.
Some 5 and 6 year old boys and girls can get horrendously severe PTSD type 1 and or PTSD type 2 from experiencing horrendously collateral trauma in war or child abuse at home that are endlessly distressing, relationship-destroying and life shortening. And some of them can get mild PTSD type 1 and or PTSD type 2 from being frightened by a teacher shouting at them in the classroom or being bullied by a classmate in the playground.
EMDR Treatment of PTSD type 1, and the treatment of PTSD type 2
The aim of EMDR is to deconstruct the abnormal iconic form of the abnormal flashback memories, leaving only a normal form of memories of the moments of mental shocks, and to eliminate persistent peripheral oscillopsia. Properly-performed EMDR is effective in eliminating correctly-diagnosed PTSD type 1 for about 9 out of 10 cases. EMDR is a lot simpler than the wording of its long title would suggest. Virtually anyone anywhere can properly diagnose PTSD type 1 with The Visual Test and then virtually anyone anywhere can perform proper EMDR for anyone who has PTSD type 1. Either or both can be done just behind the battlefield or in the living room at home. EMDR is as equally effective for children aged 5 to 6 years with PTSD type 1 as it is for adults. There appear to be genetic factors in certain races militating towards a greater severity of their persistent peripheral oscillopsia and towards greater difficulties over their response, if any response at all, of their PTSD type 1 to EMDR.
Adjunctive talking therapies, with or without the help of anti-anxiety medication, e.g. a tricyclic or SSRI antidepressant, must be part of the overall management of PTSD of either type.
Let us say that that the subject being treated with EMDR here is a ‘he’, the therapist here is a ‘she’. If possible a friend or relative of the subject will be present and looking on, to reassure him. For those not understanding English there will need to be an interpreter.
- He sits comfortably in a chair. She sits or stands in front, a metre or so away.
- At the commencement, he is asked to re-evoke one (perhaps of several) abnormal flashback, and then ‘hold’ the re-experience of the instant fear or horror and the re-experience of the visual and other sensations that had been triggered by the experience of a sudden, unexpected and out-of-control event.
- This may raise his anxiety to an almost unbearable level, and he will need reassurances that his anxiety will only be at its most severe with the first session or two of EMDR, and he must do whatever he can to tolerate the beginning of the EMDR.
- Whilst the abnormal flashback is being ‘held’, he has a run of repeatedly moving his eyes from side to side by following the moving hand of the therapist, as she repeatedly sweeps her hand from left-to-right-to-left at one to three sweeps per second in front of him.
- He is told to stop the run of eye movements as soon as his abnormal flashback goes — the therapist’s hand-sweeps then stop too. This may have taken a run of just several of her hand-sweeps before the abnormal flashback goes, 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 with his abnormal flashback re-evoked each time and each run continued until his abnormal flashback goes each time.
- If EMDR is being effective, then following each run, or every few runs of side to side eye movements, he senses that the repeatedly re-evoked abnormal flashback is, step by step, degrading in its intensity of sensation — his anxiety is less, the visual detail and colouring of the ‘picture’ of his flashback is less, the hearing detail is less, his pain is less …..
- The runs of eye movements must continue until no fragment of his abnormal flashback can be re-evoked. It may take as few as two or three runs of eye movements at his 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 before no fragment of his abnormal flashback can be re-evoked and is permanently eliminated.
- If he has other abnormal flashbacks — 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.
- She can only be sure that EMDR has been effective in permanently eliminating his PTSD type 1 when his visual test gives a negative test result — free from any degree at all of his previously-present persistent peripheral oscillopsia, and, he cannot re-evoke any fragment of any of his previously-present abnormal flashbacks.
The presence of (1) persistent peripheral oscillopsia and (2) his abnormal flashbacks before his EMDR, and (3) their total absence after his EMDR, together, is the independent ‘three legged stool’ evidence base for the effectiveness of EMDR in having eliminated his PTSD type 1 — regardless of PTSD type 2 or any other post-mental-trauma issue or mental illnesses he may have and which may well still persist after the successful EMDR elimination of his PTSD type 1.
There are other ‘EMDR-equivalent’ treatments said to be effective for ‘PTSD’ but ??? are they for PTSD type 1 (probably yes). The success of those treatments is not yet confirmed by The Visual Test (they probably will be tested eventually). One such treatment is with alternate left side, right side tapping instead of alternate left to right eye movements. One treatment is with evoking the visual image and other details of the abnormal flashback and then ‘mentally rewinding’ the details of the event which triggered the PTSD type 1. This last mentioned treatment is called ‘Rewinding’.
The treatment for non-specific PTSD type 2 symptoms is numerous sessions of talking therapy with or without the help of anti-anxiety medication, e.g. a tricyclic or SSRI antidepressant. EMDR is ineffective for PTSD type 2.
There is an EMDR Institute and an EMDR International Association, with memberships limited to certain selected psychologists worldwide. Neither establishment shows willingness to acknowledge the evidence base given here for the two abnormal pathophysiological findings that characterise PTSD type 1, nor the evidence base for the specific effectiveness of EMDR in the elimination of PTSD type 1 in certain people. It is purported by these two establishments that there is a wide range of ill-defined mental states and mental phenomena that ‘respond’ to EMDR — but they provide no evidence base for their purported ‘responses’ that is comparable to the evidence base given here for the response of PTSD type 1 to EMDR. However, 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 highly effective for some people within that wide range of ill-defined mental states and mental phenomena they speak of.
Is PTSD type 1 heritable?
There cannot be data as to the prevalence of PTSD type 1 in the general population, yet. There is the rough USA estimate that the prevalence of ‘PTSD’ 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 is born with PTSD type 1. However, it appears that one can inherit an enhanced predisposition to the development of PTSD type 1 in response to experiencing a mental shock.
It has been our clinical experience that amongst any one hundred of the one in fourteen or so of the general population of any age with ‘PTSD’ of any severity, and attending for treatment for PTSD type 1 of any severity, about 40 of that hundred with PTSD type 1 were found to have in addition, ‘confirmed’ ADHD impairments of any severity — but only when ADHD impairments of any severity were routinely looked for in all, and confirmed. Those 40 confirmed with ADHD impairments were confirmed as well as ADHD impairments 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 ten 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 tested for in all. The 70 others were tested and found not to have PTSD type 1. Those 100 confirmed with ADHD impairments of any severity were confirmed as well as ADHD impairments can ever be confirmed.
If having ADHD were independent of having PTSD type 1, then finding the two together would have a probability of 1/140 or so. But finding PTSD type 1 with ADHD in those attending for treatment of ADHD impairments appears to have a probability of 3/10 or so, and finding ADHD with PTSD type 1 in those attending for treatment of PTSD type 1 appears to have a probability of 4.2/10 or so.
The onset of PTSD type 1 and or type 2 may trigger ADHD impairments in someone with the genome for the susceptibility to ADHD impairments when no impairments had been evident before that onset of PTSD type 1 and or type 2. The co-occurrence of ADHD impairments and PTSD type 1 and or type 2 is a form of ‘Complex PTSD’. The persistence of ADHD impairments following 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 genetically determined schizophreniform illnesses, bipolar disorder illnesses or other major psychiatric illnesses, and then remain. The Visual Test will detect the PTSD type 1 in these patients with mental illnesses. EMDR will have some probability of eliminating PTSD type 1 in these 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 with mental illnesses.
In conclusion: It seems virtually certain 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.
For some therapists, alas, it appears that it is easiest of all not to bother looking for either PTSD type 1 of any severity or ADHD impairments of any severity, let alone both. It appears that all too often therapists will diagnose only ‘Depression and Anxiety’ on the basis of the commonest symptoms of each, and treat with medication and or talking therapies.