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                                    CRACKING THE CODE OF “PTSD”

    Fresh clinical evidence telling us about the nature of “PTSD”.

Understanding, managing and treating “PTSD” rationally.

Dr Bob Tym, Clinical Psychiatrist, formerly an Assistant Professor  of   Neurosurgery — now retired from active clinical practice.

This website is of extracts from the book of this same title, awaiting publication.

The reason for the book:

Understanding the  nature of post mental trauma anxiety disorders, “PTSDs”, has always been a problem. How can a ‘traumatic mental shock’ damage the brain and the brain cannot recover: what did the ‘traumatic mental shock’ do to the brain?   For some people the brain does eventually recover on its own from a ‘traumatic mental shock’, why not for all people?  Why does a ‘traumatic mental shock’ damage the brain just for some people and not for all people?  Mental trauma without a mental shock can also damage the brain, and the brain can recover, why?  Why all the differences in the nature of a “PTSD” from one person to another?

Unexpectedly, new clinical evidence  has emerged.  Taking notice of the new clinical evidence demands a new clinical nomenclature, a clinical nomenclature that fits in with the new clinical evidence.  The old nomenclatures for “PTSD” has to be replaced with new nomenclature that makes more practical clinical sense.

So, what is written in this book has to be at odds with the currently “authorised” versions of “PTSD” given in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) and the WHO’s  International Classification of Diseases. (ICD).

It confirms  the most recent, but as yet unauthorised nomenclature of  “a PTSD and a Complex PTSD”.

The book is written for the everyday person. What is written must be understandable to the everyday person. What is written must also be credible to, and provable by, any “PTSD expert”.

An abstract of the book.

The book itself tells of a thirty year long exploratory clinical investigation, and its eventual unexpected findings.  The investigation was into a mystifying subtle visual phenomenon (a phenomenon is some unexplained thing experienced by the senses).  The phenomenon, a subtle visual symptom, was reported by some people as having appeared  and persisted following a mentally traumatic experience.  Some people were still noticing it long after they’d been traumatised. When they asked their eye doctors or their psychiatrists about it they were always  being told that it was nothing to worry about, just a “hysterical” symptom, of no significance.

The author of the book, an ex-neurosurgeon just starting out in psychiatry, had several of these people referred to him. He felt that their visual abnormality could not be “just hysterical”, but did.not know what it was or what it signified clinically, if it signified anything at all.  He decided to investigate this odd visual phenomenon, to ask about visual symptoms in all the psychiatric patients he would be seeing over his forthcoming years of psychiatric practice. The investigation lasted thirty years, seeing 9000 of so patients, patients  of all ages over five years, from all walks of life.

Unexpectedly, this visual phenomenon that had been ignored for so long, thought to be too insignificant to warrant any attention, has eventually thrown fresh light on the nature of “PTSD”.

Whenever this subtle abnormal visual phenomenon, a visual symptom, is present in a patient, then it is always there together with another abnormal phenomenon, an abnormal memory symptom. This abnormal memory symptom is a constantly recurring re-experiencing flashing-back memory of a very frightening moment during the event that had triggered their PTSD.

Some patients with “PTSD” have these two abnormal symptoms. But some people with “PTSD” have neither of the two symptoms.   So, the clinical evidence tells us that there must be two different “PTSDs” – two “PTSDs” that are superficially very similar clinically but must be very different neuro-biologically.   Those with “PTSD” and with the two abnormal and unique symptoms, the symptoms  provide evidence for what, most plausibly, has damaged their brain in response to their experience of traumatic mental stress, a “mental shock”.  Those with “PTSD” but without the two abnormal and unique symptoms symptoms did not have the same damage to their brain in response to their experience of traumatic mental stress, a “mental shock”, but they did have a “PTSD”.

So, one “PTSD”, now simply called PTSD, has two unique and subtle clinical features, one of which is the abnormal visual feature.  it is caused by the experience of a sudden “mental shock”, a sudden surge of high anxiety from experiencing a sudden and unexpected mentally traumatic event. PTSD-A cannot resolve on its own, it stays life long if it’s not cured. In the opinion of involved senior geneticists, the most plausible speculation is that the sudden surge of high anxiety of the “mental shock” has triggered a sudden epigenetic insertion into the brain.    An epigenetic insertion means here, a sudden attachment of a chemical group onto one part of the brain’s DNA: specifically that DNA currently concerned with forming the memory of the traumatic event. Given the clinical evidence, the involved geneticists consider this to be the most plausible explanation for PTSD, and some plausible explanation for why and how properly performed EMDR can cure PTSD in some people but not in all people with different genomes.

The other “PTSD”, called Complex PTSD,  has no unique clinical features.  It, too, can be caused a sudden mental shock, but in Complex PTSD there has been no epigenetic insertion. It is more often caused by more long-drawn-out mental trauma that can accrue over the long term, for some people over the very long term — from long term child abuse, adult torture, repeated relationship abuse.  Complex PTSD can slowly resolve on its own over time, but it not always does.

The two different  “PTSD’s”require very different treatments.   There is a simple visual test to detect the presence or absence of the visual phenomenon, so, the visual test for the visual phenomenon is a reliable, sensitive and specific test for the presence and absence of PTSD. The simple test, that anyone can perform, is described in Section Two

[In 2009 a scientific paper was written, peer reviewed and published in the international literature*. but mostly unnoticed.

Tym, B., Beaumont, P., Lioulios, T.  Two Persisting Pathophysiological Visual Phenomena following Psychological Trauma and their Elimination with Rapid Eye Movements: A Possible Refinement of Construct PTSD and Its Visual State Marker. Traumatology. 15(3): 22-33 (2009). ]

SECTION ONE.  What the clinical evidence and its implications have told us.

There are two forms of “PTSD”.  There is an anxiety disorder of  PTSD and an anxiety disorder of Complex PTSD.   Both PTSD and Complex PTSD are different and distinct disorders. The two different anxiety disorders can look very much alike superficially, but they are not alike neuro-biologically.  The anxiety disorder, PTSD, is only caused by a sudden ‘mental shock’, a sudden and unexpected surge of high anxiety (from fear or disgust). There is evidence of some ‘physical’ damage, some molecular change in the brain caused by the sudden surge of high anxiety.

The anxiety disorder Complex PTSD is more like any other long-lasting Anxiety Disorder, with nothing ‘physical’ having gone wrong inside the brain. There are no abnormal

The anxiety disorder, PTSD, is only caused by a sudden and unexpected surge of high anxiety (fear), a sudden ‘mental shock’.  Obviously, not everyone who has experienced a sudden surge of high anxiety, a sudden ‘mental ‘shock’ has  a PTSD, just some unfortunate people have. (Anxiety, in one form or another, can cause many different forms of damage to the physical workings of the body, all in ways we do not understand.)

PTSD has two invariant (meaning they are always there together in PTSD) abnormal symptoms.  The two are subtle (meaning not always obvious or noticed) and unique (meaning they are not found in any other mental or physical disorder). They are inseparable symptoms: PTSD comes during the moment of  the “mental shock” causing the PTSD — the two symptoms are there together from the outset. As PTSD is gradually cured, step by step, e.g., with EMDR (see below)  then the two symptoms go together step by step and in step. When neither of the symptoms is present the PTSD is completely cured.The two together constitute an invariant ‘complex memory and vision clinical symptom’.

The two invariant symptoms:

The first of the two invariant abnormal symptoms is a subtle but abnormal visual symptom.  It is called ‘persistent peripheral oscillopsia‘ (osi-lop-sia, is a Greek word for ‘wavy vision’). Persistent peripheral oscillopsia’ is described in Section Two, just below.

The second of the two invariant abnormal symptoms is usually more obvious: a constantly recurring abnormal form of memory-recall, an abnormal reliving, re-experiencing, of what had been experienced during the moment of the frightening event that had caused PTSD-A This is described in detail in Section Three.

Both of these abnormal symptoms are directly caused by that ‘something  physical’ that went wrong in the brain, triggered by the sudden surge of high anxiety.  The most plausible explanation for that ‘something physical that went wrong in the brain, and how it give rise to the two symptoms’, is explained in Section Five.

PTSD can occur in people of any age over five or six years, people from all walks of life. For some people with PTSD-A  it was caused by the experience of an event that would terrify anyone, and for some people, by experiencing an event that frightened them but probably would not have frightened anyone else. For most people with PTSD-A the event that they experienced was somewhere between those two extremes.  The susceptibility of people to getting PTSD-A varies widely.  The severity of PTSD-A varies widely.

Both anxiety disorders PTSD and Complex PTSD can have the same ‘ordinary’ anxiety symptoms. The anxiety symptoms vary widely in number and severity from person to person in both disorders (which is why the two different disorders so often look so alike clinically):

Common anxiety symptoms common to both PTSD and Complex PTSD. There can be distressing traumatic memories that keep coming back distressingly, but they are memories that are not coming back abnormally, just distressingly in normal form.   There can be sleeplessness, frightening nightmares of the event or of anything else (these nightmares are not limited to PTSD-), jumpiness over anything, being easily startled,  being inattentive,  lacking in concentration,  failing to remember things,  tension headaches, emotional withdrawal, frustrations, depressed moods, uncontrollable anger and sometimes violence,  and avoidance of any reminders of the event that caused their PTSD. There can be dangerous thoughts of suicide.

The presence or absence of PTSD can be specifically, sensitively and reliably diagnosed clinically by the simple visual test. (See Section Two below.)

The test detects the presence or the absence of  ‘persistent peripheral oscillopsia’. Because ‘persistent peripheral oscillopsia’ only occurs in PTSD, the simple Visual Test detects the presence or absence of PTS in anyone over five or six years old.  It is a simple test that can be performed by anyone on anyone who is over five or six years old. The test is sensitive, reliable and specific for the presence or absence of PTSD despite the possible presence or absence of any other mental disorder.  If that test is ‘positive’ before PTSD is treated, and changes to negative after PTSD then PTSD  has been successfully treated, eliminated: PTSD has been permanently cured. (A description of the visual symptom and the simple test for it are in Section Two.)

Treatment of PTSD

PTSD cannot get better on its own over time, it requires very special treatment, e.g., properly performed EMDR is the treatment most likely to be successful.. (See Section Four for a description of EMDR treatment.)  If EMDR treatment is not successful, and sadly it cannot be successful for everyone with PTSD, then PTSD lasts life long unless successfully treated by something else. EMDR is explained and explained how anyone can try it on anyone over five or six who has PTSD, in Section Four.   No one knows whether a person with PTSD  will or will not respond to properly performed EMDR until it has been tried and persisted with for some time.

Most of the people with PTSD who do not respond to properly performed EMDR can be helped considerably by talking therapies and some medications (including for some people, ‘MDMA (Ecstasy)-assisted psychotherapy’, a not-to-be-tried-by-one’s-self treatment and not likely to be readily available for most people at present). As yet there is no proof  that these other treatments have permanently cured PTSD. They do give some hope to those for whom EMDR has failed.

Complex PTSD

Complex PTSD is caused by either experiencing a sudden mental shock, as is PTSD, or more commonly by experiencing recurring mental trauma, the effects of which accrues over the long term.  Repeated physical and mental child abuse, repeated physical and mental relationship trauma, repeated physical and mental torture

PTSD can  resolve, get better, on its own over time, but it not always does, depending on the circumstances.

PTSD and Complex PTSD can both present together.

Because PTSD-A and PTSD-A are similar but biologically different disorders, either can be there alone, or, both can be there together in the same person, having been caused by the same sudden mental shock. In which case: if just one of the two disorders is cured by treatment, the other will still be there, and needing to be treated next.  Several different mental disorders  can be present at the same time.

Treatment of Complex PTSD.

Complex PTSD is treated with long term talking therapies and or with anxiety-relieving medication. Care must be taken not to miss PTSD and other disorders being there (i.e., the presence of one or more abnormal re-experiencing flashbacks of PTSD that need properly performed EMDR treatment, and possibly ADHD.  PTSD is more common in those with ADHD than in those without, and families with many having ADHD are more likely than those without to have members who develop Complex PTSD.

 

SECTION TWO.  (No one expected a subtle visual symptom to be part of  any PTSD.)  Persisting Peripheral Oscillopsia, and the visual test for PTSD.

The visual symptom called ‘Persistent Peripheral Oscillopsia’ (osi-lop-sia, a Greek word for ‘wavy vision’).

It  is an illusory (false) perception of stationary objects that can be seen in the periphery (the outer part) of the field of vision appearing to be moving about –either up and down, or side to side .  For most people with PTSD this visual symptom is seen to be present only when the head and eyes held still, and only after staring at something straight ahead for 5 to 10 seconds.  Once things in the periphery start to appear to move about, then they continue to appear to move about for as long as the head and eyes are kept perfectly still.

This symptom is unique to PTSD (it does not occur in any other physical or mental disorders), and, it is always present in those PTSD, i.e., in anyone with unique recurrent abnormal re-experiencing flashbacks, These two unique symptoms arise together at the moment of the ‘mental shock’ that triggered the PTSD, and they stay together until PTSD has been eliminated (e.g., by successful properly performed EMDR) then they go together.

The simple visual test for persistent peripheral oscillopsia is a specific, sensitive and reliable for detecting the presence of PTSD, regardless of whether other mental disorders are present.

(This visual symptom was first described (as far as we know) in 1946 by a London  ophthalmologist, Dr Harry Moss Traquair*.   It had been reported to  Dr Traquair by ex-soldiers who were all suffering from with Traumatic Neurosis from WWII.  Traumatic Neurosis was the name given by a neurologist, Hermann Oppenheim, in 1889.  The name  was  changed to PTSD in 1980.

*Traquair, H.M., Introduction to Clinical Perimetry’, 5th Edition, 1946, London: Henry Kimpton. Page 121.

This abnormal visual phenomenon was reported but not investigated by  Dr Traquair. The same abnormal visual phenomenon was reported to the author in 1977.  The author at the time was unaware of Traquair’s report.  The author, intrigued by the mysterious visual abnormality, had independently embarked upon an exploratory investigation into the visual phenomenon.  The investigation continued  throughout  his clinical psychiatric practice from 1977 to 2012. The  final result of the clinical finding of the investigation are that  persistent peripheral oscillopsia only occurs in people with PTSD not in any other disorder.

 The Visual Test for PTSD-A  (i.e., a test for persistent peripheral oscillopsia, unique to PTSD)

The person being tested sits in a chair, The examiner stands in front and at the beginning of the test will have  his left arm stretched  out and held rigid and still for the ten seconds of the test.  At the start of the test the person being tested covers his or her left eye and stares at the left eye of the examiner; he or she maintains steady gaze at the examiner’s eye for ten seconds, without moving their eye. The examiner has his right eye covered and maintains strict eye-to-eye contact with his or her eye to ensure there is no eye movement. (See the diagram below).  At the end of the ten seconds the examiner lowers his left arm and asks the person being tested to demonstrate, using their right arm, how the examiner’s left arm, hand or fingers appeared to them during the ten seconds.

Figure One.  How the examiner appears to the person being examined. The oval line is the outer edge of the visual field. Where the dotted lines cross is the stationary visual axis between the examiner’s left eye and the right eye of the person being examined.

Note the important detail: the examiner’s fingers must just reach the very outer edge of the right visual filed of the person being examined — before the test starts the examiner must adjust his distance away so that this is exactly so.

 

SECTION THREE.   The exact nature of the recurrent abnormal flashback.  A recurrent abnormal re-experiencing form of memory recall of what was seen and felt during that moment of the mental shock that had triggered the PTSD-A.

It is a ‘flashing back’ re-experiencing, a ‘re-living’, ‘as though the event is happening over again’. There is a sudden return of all the sensations that had been experienced during that circumscribed moment of sudden mental shock. With each flashback there is always a mental and physical re-experiencing of the sudden surge of the mental and physical (shaking, sweating) anxiety that had been felt; usually, not always, a flashing-out-there-in-front vivid ‘picture’ or ‘video-replay’ of what was seen happening during that moment; usually, not always a re-hearing of the ‘sounds’ of what had been heard; usually, not always a re-feeling of the ‘pain’ that had been felt; usually, not always a re-smelling of the ‘smell’ that was there . . .. [An abnormal flashback  is not a dream or a nightmare. Dreams and nightmares are not characteristics of PTSD-A or PTSD-B; they are non-specific anxiety symptoms, regardless of their content.]  An abnormal flashback can last a few seconds or many minutes, it can come every few minutes, once an hour, once a day, once a month or longer.  It can come spontaneously, or triggered by any reminder, or it can be recalled voluntarily.  It is not a ‘dissociative’ phenomenon, its abnormal form is unique to PTDD-A.

If abnormal flashbacks recur at all, then at anytime in-between them the Visual Test will be positive for Persistent  Peripheral Oscillopsia.

During successful properly performed EMDR (s see Section Four, below), as the picture of flashback goes bit-by-bit during the EMDR, then the peripheral oscillopsia, if it is tested for in between sessions of EMDR, goes bit-by-bit likewise. Once the abnormal flashback has gone for good then the  peripheral oscillopsia has gone for good. They come together, stay together and go together simultaneously: what had gone wrong with the brain has been (somehow, and inexplicably) corrected with EMDR.

SECTION FOUR

Properly Performed EMDR.

First of all one has to be sure the person has PTSD-A — that they have persistent peripheral oscillopsia and have recurrent abnormal flashbacks. There is no proven evidence that EMDR helps with any  disorder other than PTSD-A (but it might be, but it has not been clinically proven that it can be more than a helpful placebo treatment for other disorders).

Let us say a ‘he’ is the person being treated,  and a ‘she’ is the person doing the EMDR.  He sits comfortably in a chair; she sits or stands in front, a metre or so away.  He  is asked to re-evoke one (perhaps just one of several different) abnormal experiential flashback, and then ‘hold’ that ‘visual picture’ (if there is one) or which ever sensation is the most characteristic of his flashback.  This will raise his anxiety, possibly to a near-unbearable level, and he will need reassurances that his anxiety will  be at its most severe only with the first trial or two of EMDR, and he must do whatever he can to tolerate the discomfort at the beginning of the EMDR.

As soon as the abnormal experiential flashback image is ‘held’, he has a run of repeatedly moving his eyes from side-to-side by following her moving hand as she repeatedly sweeps her hand from far left to far right to far left in front of him, at one to three sweeps per second .

He is told to stop the run of his eye movements as soon as his abnormal experiential flashback image goes, and she stop also.  This disappearance of the image may have taken a run of just several of her hand-sweeps, or a run of ten or twenty or thirty or more of her hand-sweeps.

The procedure is repeated.  Each repeated run of eye movements has the abnormal experiential flashback image re-evoked , and each run is continued until it goes.

If EMDR is being successful, then following every few runs of side to side eye movements, he senses that, step by step, the flashback image (if there is one) and the other sensations are degrading in intensity step by step.  If and only if there is no other flashback, then on re-doing the Visual Test the persistent peripheral oscillopsia will be lessening in range over the visual field step=by-step likewise, lessening in amplitude of oscillation and or lessening in frequency of oscillation.

The runs of eye movements must continue until no fragment of that flashback image 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 of repeated sessions before no fragment of his abnormal experiential flashback image can be re-evoked and is permanently eliminated.

If he had one or more other flashbacks from one or more other traumatic events, then each flashback must be treated by EMDR until eliminated before PTSD-A  has been cured. Only then will there be no more peripheral oscillopsia on testing for it.

If there are other disorders are present at the same time, the  they will be left to be treated in some other way after PTSD-A has been cured.

EMDR is, for some inexplicable reason, never successful for some people with exactly the same sort of PTSD-A.  It appears that peoples’ genes somehow or other determine whether it is to be successful or not.

 

SECTION FIVE.  What is the most probable explanation for what has gone wrong in the brain in PTSD-A.

These suggestions are from some senior geneticists who have had PTSD-A themselves. They have been cured, after many decades of having their PTSD-A,  by properly performed EMDR. They are fully aware of the nature of all the new clinical evidence about PTSD-A and PTSD-B.

The geneticist’s most plausible speculation.

In some people, they themselves included, a sudden momentary surge of high anxiety can trigger an epigenetic insertion into the DNA molecules, the genes, while they are forming, laying down, the memory of what is happening at that moment.  What gets inserted into the DNA genes are methyl groups, a simple chemical group (CH 3) that tags itself onto those molecules and disrupts their normal functioning.  Having been tagged, they function abnormally.  They form the recurrent re-experiencing  abnormal flashback of PTSD-A instead of a normal form of memory.  This epigenetic change is not passed on to the next generation.  PTSD-A cannot be inherited.

(PTSD-A cannot be inherited. There is, however,  provable clinical evidence to strongly suggest that some people, particularly those people with the genes for ADHD, have an increased risk of developing PTSD-A in response to the experience of a sudden mental shock.   ADHD can be inherited. This sometimes makes it look as though PTSD-A is inherited when PTSD-A appears in several members of the same genetic extended-family. each of them having inherited the genes for ADHD.  No one can be born with PTSD-A.  It appears that PTSD-A cannot occur in those under five or so years old.)

When PTSD-A successfully responds to properly performed EMDR, it is suggested that, in some equally inexplicable way, the methyl group goes back to wherever it came from — an epigenetic reversal — and the brain DNA can then continue forming that memory into a normal form of memory:  and from then on it is remembered normally, without re-experiencing what is remembered.

It appears that the chances of PTSD-A not responding to properly performed EMDR depends on the person’s genes, their genetic makeup..  There appear to be certain genotypes for whom the visual symptoms are more likely to be obtrusive and for whom there is a greater chance of EMDR being totally ineffective. 

Perhaps there are also people with genes that prevent them from ever getting PTSD-A when they are experiencing a sudden surge of high anxiety from a mental shock.  This is unprovable.

Oscillopsia, ‘wavy vision’, is one of many bodily disorders that anxiety can produce. In a panic attack ‘wildly wavy vision’ is a common symptom that is present. It goes away when the level of the anxiety subsides at the end of the panic attack.  Since the time of Hippocrates, anxiety symptoms that fade away when the anxiety fades away have always been regarded as “hysterical symptoms”, of no clinical importance. More recently they are called ‘somatoform symptoms’, bodily-like symptoms. In the past, when wild wavy vision was there together with Traumatic Neurosis, it confirmed in the minds of many people that Traumatic Neurosis, later called PTSD, was a ‘hysterical’ condition itself..

Persistent peripheral oscillopsia of PTSD-A appears to be caused by the anxiety that is persistently ‘locked-in’ with the abnormal form of memory of the frightening mental shock that caused the PTSD-A.   This  abnormally ‘locked in’ anxiety gives rise to the sudden extra surge of anxiety that comes when the flashback suddenly comes.   That ‘locked-in’ anxiety only goes when that abnormal form of memory goes to normal form in response to EMDR and persistent peripheral oscillopsia reverts to normal vision in the periphery.

There is a lot we do not know, cannot intuitively grasp, about the  patho-physiological mechanisms of anxiety — except that the word ‘hysteria’ isn’t a good word to apply to any of its clinical manifestations.

The book:  ‘Cracking the Code of “PTSD” ‘ is shortly to be published.  It explains in detail the way the fresh clinical evidence came from different sources and slowly coalesced, eventually cracking the code.

THE END