Lets Create A Ptsd Diagnosis - Off-topic Discussion

[anthony]

Everything off-topic, yet of value or purpose at some point, for the diagnostic discussion can go in here.

 

[Mammasalt]

I believe there is a 'Complex Post Traumatic Stress Disorder' and 'Post Traumatic Stress Disorder' personally I have PTSD in that I had one type of trauma multiple times but still the one type. I think of CPTSD when you get say a war vet with 'shell shock' plus on a separate occasion been sexually assaulted.

 

[Sideways]

Fragmentation of personality (as distinct from DID).

Does not seem to be adequately covered, but is very common. "Being a different person in different situations" to a degree that it causes significant distress and can impact functioning to a significant degree.

 

[Chava]

There is no evidence to support PTSD at present. We have the problem, just no idea what the problem really is or how it occurs

There is some evidence in terms of brain imaging and bits and pieces regarding trauma behavior in captivated animals. But we also don't know what causes autism spectrum disorders, for example, yet we have a decent symptom set and know how to help those people (can't cure it, but can greatly increase functioning if recognized early). So we can have a disorder with a symptom set (and criterion A) is extremely helpful to narrow things down...differential diagnosis list too huge without a trauma (and where the trauma seems a little gray, then you measure it against the symptoms and triggers, I suppose).

I do think we'd find better treatments for PTSD if we could understand more about how/why it occurs. The trauma experts who are taking the neuroscience angle seem to be going somewhere, but there hasn't been enough research to 100% understand what happens in the brain...and then the difference between PTSD and CPTSD, or early trauma that would be more like attachment disorders or presenting with many similar symptoms). What we do know is that it affects the fear-driven amygdala very badly, as well as even our cognitive processes (especially when triggered). For nearly intractable symptoms of early trauma, Siebern Fisher is using a combination of regular talk therapy along with neurofeedback. Some therapists mix CBT with stronger trauma-oriented focus on the behavioral aspect. Others use body or "bottom-up" techniques integrated with processing on a cognitive level. But we aren't researching all of these options thoroughly because it's like we have too much of a huge banquet of treatment options. At best we find a therapist who understands trauma as well as anyone can understand trauma right now, and is able to take a multi-faceted approach, brining in though processes but also working with the fear and automatic responses.

Anyway, with so many options and not enough research around any of them, we still feel like PTSD isn't treatable. That the treatments themselves vary so much points to our lack of understanding of what trauma really does to the brain and body. We have the brain scans and trauma experts like Van Der Kolk can point to how these lead to dissociative or hypervigilant states. We even know why and how our nervous system gets flooded in life-threatening trauma. We don't clearly understand why some nervous systems get stuck there (PTSD), but most closely linked to extremely strong procedural memories that were burned into our brains. And it's not like we can fully see all of this on a scan anyway, or afford to brain scan everyone.

So, to make a long story short, like Autism spectrum, I think PTSD is a deeply neuro-atypical situation that we don't fully understand. Actually we can know "why" in terms of having a trauma to point too...even more clear cut if followed by PTSD symptoms. So really, if we keep criterion A, it's a lot easier to diagnose, because we can assume that as the "why". We don't know exactly what is happening in the brain-body or why the nervous system gets stuck and can't reregulate after trauma (and why that differs between individuals), and worse yet, we don't seem to have a good canon of methods for helping the nervous system restore original balance. But based on what we do know, I think the diagnosis that exists is pretty good (need criterion A), but we need to research more methods, not just CBT, because that isn't working for everyone.

Also, we could research trauma symptoms where no clear criterion A is available and be sure we have some good list of stress disorders to choose from. A developmental trauma is not quite like PTSD, for example, but the abandoned baby's nervous system wires itself poorly. That might end up a personality disorder, attachment disorder, or some separate trauma disorder that is not yet in the DSM (I suspect these are the kids who come to school with a sad laundry list of other diagnosis: oppositional defiant disorder, ADD, anxiety disorder, sometimes aspergers....how does a kid rack up 4-6 separate diagnosis that relate back to the nervous system but we haven't found the cause yet? I just feel so bad for all the labels they carry and ending up usually in special education even if they are plenty smart, but have trouble regulating their attention, emotions, and behaviors.

So I vote to keep it as it is but invest more in the neuroscience research around trauma and possible therapies (likely multi-faceted).

 

[Chava]

In the meantime, however, I really like where Joey was going here, with subtypes.

This could be helpful for treatment purposes. Right now, PTSD is loosely connected to anxiety and panic disorders. Well, you could loosely connect it to dissociative disorders, mood disorders, and a load of other things. A separate traumatic stress disorder major category, with sub-types of more classic PTSD, CPTSD, and DTD (developmental) might help. I'm not sure how it would help, though after reading Siebern Fishers book about developmental trauma, really early abuse and neglect sets the stage for what can sometimes look like really anti-social behavior. The re-experiencing is not really the same as adult PTSD. But in all forms of major trauma there is basic dysregulation of the autonomic nervous system. We say there is no cure, but we've only begun to scratch the surface on the major connection to the ANS. Therapies that rely primarily on talking offer little systemic relief for the damage done to the ANS (what Van Der Kolk, Fisher, Heller, Ogden, and Rothschild are all telling us). But we haven't sorted out any one-size-fits-all response yet....very hard to research because the most helpful therapies are multi-faceted and tailored to the complexities of the individual traumas.

 

[Deleted member 28740]

Throwing out a woofy thought. What makes some dogs gun hunting dogs, and those that run to a cave to get away from fireworks? Genes and breeding to adapt, sensitization? My dog and I have two violent gun shooting traumas in common. Many dogs don't react to gun shots or fireworks at all, others have fight flight panic, wanting to dig a hold under your bed to get to safe, no ability to calm until noise is gone, and then days weeks, forever noise shy.

Studies on dogs might have some correlation. Having to get away from 4th July, New Years, sport wins. Have tried many different avenues to help calm my dog. Some veterinary practices give human benzo type meds. New thoughts are that is traumatizing, because the dog is then crashed out only on certain physical mental levels and is incapable of physically of seeking safety. Suddenly legless drunk and in full on panic.

 

[Chava]

I meet criteria for classic DSM PTSD, as well as proposed DESNOS, CPTSD, and DTD or developmental trauma described by Laurence Heller (earliest trauma). But this actually covers all of it as well (taking out the numbered bullet points to keep it brief since Anthony already posted above):

DSM V (Current Version)

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note:In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidence by one or both of the following:

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

F. Duration of disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

So, this covers all of those sub-types. But in intake, narrowing to a subtype, or understanding if the trauma was very early, or chronic through childhood (or otherwise complex, like longterm captivity), would help inform treatment. I see nothing wrong with the criteria here. They cover all of our major symptoms. And like other disorders related to the brain and nervous system (Autism, and even going out to things like MS) we can't always pinpoint exactly what is happening based on things like imaging or blood tests. The diagnostic criteria are important. These encompass a lot, for any level of trauma. What we need to separate it from other issues is the Criterion A. If someone has most of these symptoms, but no Criterion A, it could possibly be a memory thing, extreme early trauma, and could be labeled DESNOS, I suppose. I think of extreme grief, where maybe many symptoms cross over but there is no Criterion A...in that case, I wouldn't think of it as PTSD because there is likely no threat happening at the brainstem level, but all kinds of other symptoms and even lowered levels of functioning. If it's the kind of grief that isn't resolving over time maybe it's become depression. Or maybe it's something like DESNOS. ??

If clinicians followed this, I think it would work really well. The problem is diagnosing people with PTSD who had a bad break up. I don't understand how that is even helpful. But beyond that, we just need more research to define what exactly is going on so we can treat it...the diagnostic symptoms and criteria are well established. Okay, I've sort of been saying the same thing over and over...time to switch my brain to a new gear :):eek:

 

[Chava]

Therapies that rely primarily on talking offer little systemic relief for the damage done to the ANS (what Van Der Kolk, Fisher, Heller, Ogden, and Rothschild are all telling us).

Forgot to add Peter Levine here. All of these theorists are working very currently, all talking about varied arrangements of "top-down" and "bottom-up" methods working together, understanding newer neuroscience on how trauma damages the autonomic nervous system. Our cognitive brain can help us manage somewhat, but it's fundamentally not a cognitive disorder. And that's why we don't have a perfect grip on it yet...since the birth of psychotherapy we have depended upon declarative and episodic forms of memory and being able to just talk it out. So we are left thinking PTSD is untreatable, but we just haven't found the right treatments yet, though I believe getting closer. More neuroscience research, less traditional talk therapy...?

 

[lostforgottensoul]

There is no evidence to support PTSD at present. We have the problem, just no idea what the problem really is or how it occurs.

Anthony, in aspect to this, do you know of any sort of brain mapping type testing comparing PTSD and non-PTSD to see how PTSD effects the brain?

As to the question, the Criterion stuff confuses me. Sorta makes me wonder why I faught this diagnosis for so long and only after long discussions of each symptom in I believe the DSM 4, it was maybe 3 or 4 yrs ago, did I accept it.

But I do agree we need to know why for any issue or problem to be able to get the how in fixing it.

 

[UnKnown-Self]

First I question the purpose of a diagnosis.
Is it for the patient or medical professionals, including the front line therapists, psychiatrists, general practitioners, the insurance companies and pharmaceutical companies.
There is a firm line drawn between doctors who treat the body and those who treat the mind as if there is no connection between the two which is ridiculous. When visiting a GP for the first time the initial questionnaire will ask about family history regarding mental illness and addiction but not once have my answers been addressed, so why ask? When the topic of physical symptoms arises during therapy, it is suggested a GP visit is in order. Never do the two consult each other.

There has been research regarding how the brain reacts and develops when stressors are severe and on a regular basis but also unpredictable. The switch to be turned on in the brain so it can send the chemicals for handling stressors never turns off. After a while it is turned on so often it malfunctions and the switch is stuck in the on position. Those with PTSD are constantly flooded in varying doses with the chemicals causing toxins to be absorbed in the brain and rest of the body affecting synapses, cognition, gray matter along with other things and creating the physical symptoms or somatization. The interesting thing about this is it can happen to someone who has been in a war, a child who has been repeatedly physically and or sexually abused or the child who is under repeated emotional attack by a critical parent, siblings or the bully at school. The brain does not differentiate between "levels" of trauma. It's the consistency and unpredictability.

Levels of dissociation are diagnosed separately from PTSD even though without the trauma there would be no dissociation and is just as much a part of PTSD as depression and generalized panic disorder, actually more so because one can be depressed or have GAD and not have PTSD. One cannot have a dissociattive disorder and not have PTSD.

Where I see the a helpful difference in treatment is in the use of more professionally run group therapies. Vets are known to feel more comfortable sharing with other vets who also live with images of the women and children in war, the survivors guilt and the multitude of other horrors.
Those who don't know a time before trauma developed so they think and process the world differently. Being able to share with others who understand would make a difference.
Just as those who are plagued with parts. There is so much shame, fear and denial going on. What all people need and especially those with PTSD is connection with others who understand and they feel heard, validated and not all alone.
Let's start with us treating each other and the professionals can moderate the groups but also learn from the real experts. Those of us who survived and live with it.
The rest... The DSM whatever version is all about money, control and ass covering for corporations. Our diagnosis makes us a cash cow or a financial threat and that is how our treatment is decided upon today. Focusing on changing the DSM ... maybe ....
Maybe I'm seeing things wrong. I'll keep watching the thread and hope I learn.

 

[lostforgottensoul]

Being able to share with others who understand would make a difference.

This right here couldnt be more true.

I have never really identified with sexual abuse victims and never got why until I watched Steven Stayner's movie and learned that i identify very much with kidnapped victims. Unsure why as i wasnt technically kidnapped though my mother was in contempt of court.

I have forever been trying to find a place online like this for those that have survived a cult and have yet to find one.

I also seek out victims of human trafficking though im still, a year later after asking my therapist is that what happened to me, im still trying to wrap my brain around it.

On this site and the other one there are a few ive met that was in a cult but its very few. Ive learned to stop looking for whom can identify and support the whole and seek support the symptoms but it is so good to speak to someone that gets brainwashing or programming and why im so compeled to redue the rituals; besides my therapist. Makes me feel so not alone with it.

 

[Deleted member 28740]

A followup on Canine PTSD. http://canineptsdblog.blogspot.com

I'm researching the criteria for canine PTSD. Curious about diagnosis and treatment.

Exerpts, the whole site is informative.

Meanwhile, a study published in June of 2012 (“Link Removed”) re-capitulates this connection between body, mind, stress and unresolved emotion. In it the authors write, “When we look at the human psychophysiological (mind/body) system from a thermodynamic perspective, the dichotomy between mind and body states cease to exist and they become one energy system governed by the law of entropy.” A system they say behaves “like a magneto-electro-mechanical system.”

Behan writes that the biological connection he sees between thermodynamics, emotion and stress “is the only model that can smoothly encompass the phenomena of learning, sexuality, personality, memory, neoteny, evolution and domestication [in dogs].”
……..

Then, one day I came across a study showing that oxytocin can sometimes re-awaken and even strengthen memories of past abuse. (“Fear-enhancing effects of septal oxytocin receptors;” Nature Neuroscience, 2013.)

“Oxytocin is usually considered a stress-reducing agent based on decades of research,” said Yomayra Guzman, the study's lead author. “With this novel animal model, we showed how it enhances fear rather than reducing it, and where the molecular changes are occurring in our central nervous system.”
…….
The Dogs of War
If you’re interested in understanding or learning more about Canine PTSD, there’s a wonderful film about post-traumatic stress in military dogs called Dead Link Removed, produced and directed in 2013 by Kristen Kiraly. Kiraly was a student filmmaker at the time and she did a fabulous job. You should definitely take the time to watch it. [1]

Two things stood out for me when I watched the film. The first is that the main dog profiled—a retired military detection dog named Bix—seemed to always be carrying a tennis ball around in his mouth. [2] According to his adoptive owner, this helped calm his nerves. The other thing that stuck out was that the military’s top expert on PTSD in dogs, Dr. Walter Burghardt, former chief of behavioral medicine and military working dog studies at Holland Air Force Base in Lackland Texas (now retired) says in the film that PTSD in dogs can only be treated, it can’t be cured.

In a December 1, 2011 New York Times article Dr. Nicholas Dodman said the same thing to reporter James Dao. “Asked if the disorder could be cured, Dr. Dodman said probably not. ‘It is more management,’ he said. ‘Dogs never forget.’”

……..