PTSD Diagnosis

The difficulty in establishing the diagnosis of PTSD has led to the development of a PTSD checklist (PCL). This checklist was developed from a population of 40 motor vehicle accident victims and sexual assault victims. The Iraq and Afghanistan wars have led to a striking increase in the number of soldiers diagnosed with PTSD.

As one might expect, not everyone exposed to what appears to be the same intensity of trauma develops posttraumatic stress disorder. In one small study, 51 individuals who suffered a physical injury due to a traumatic event were assessed 1 week and 6 months after the trauma. Only 13 of these 51 (25.5%) met the posttraumatic stress disorder diagnostic criteria at follow-up. Those who did develop PTSD, had “higher levels of peritraumatic disassociation and more severe depression, anxiety, and intrusive symptoms” at the 1 week assessment. This peritraumatic disassociation at that initial week was a major factor in whether they later developed PTSD. In another study of 72 female rape victims versus 86 female victims of nonsexual assault, there were two patterns of posttraumatic symptoms, one being characterized as posttraumatic stress disorder and the second as a phobic reaction.

Positron emission tomography (PET) has allowed perhaps the most clinically relevant view of brain function in PTSD. In 16 women with histories of childhood sexual abuse, 8 had current PTSD and 8 did not. When asked to recall or mentally recreate a traumatic event, both groups exhibited regional cerebral blood flow increases in the orbital frontal cortex in the anterior temporal poles. However, those with PTSD had a much greater increase in cerebral blood flow in those areas and those without PTSD had a greater decrease in cerebral blood flow in the left inferior frontal cortex. The non-PTSD had greater increases in the anterior cingulate gyri. Single photon emission computed tomography (SPECT) scans also have offered some insights into the physiologic changes apparent in PTSD patients. Fourteen veterans with PTSD, 11 combat control subjects and 14 normal subjects were all studied with the SPECT scans in sessions at least 48 hours apart. In one exposure, the individuals experienced white noise and in the other, they experienced exposure to combat sounds. Activation in all three groups occurred in the anterior, cingulate, and middle prefrontal gyri but activation in the region of the left amygdala and nucleus accumbens was found only in PTSD patients. Deactivation was found in all three groups in the left retrosplenic region.

It appears that the PTSD individuals have regional differences in brain activity, at least during recall of their trauma. As one might expect, those individuals diagnosed with PTSD have a high incidence (80%) of having at least one other comorbid psychiatric diagnosis. It may be that the total lifelong cumulative stress to which individuals have been adversely subjected earlier in life predisposes them to PTSD. In one study of 131 Vietnam male veterans who had taken the Minnesota Multiphasic Personality Inventory (MMPI) in college had readings that were within the normal range, but no one scale predicted the development of stress from combat exposure. Hypochondriasis, psychopathic deviant, masculine femininity, and paranoia scales predicted PTSD symptoms, as did depression, hypomania, and social introversion and these effects were dominant despite the degree of combat exposure. The conclusion is similar to individuals in general. “Pre-military personality can affect vulnerability to lifetime PTSD symptoms in men exposed to combat.” This is thought to be true in individuals exposed to any trauma. In the author’s experience treating thousands of patients with chronic pain that failed all conventional therapy, at least 75% had elevations on depression, hypochondriasis, and hysteria, and an additional 15% had elevations on psychopathic deviant, masculine femininity, and paranoia. The most intense problem is the pattern of replaying many past traumatic events. Many of them can never remember a happy event from childhood. The main difference in these individuals and those with PTSD is that the chronic pain and depressed patients do not have the erratic episodes of intense emotional behavior. They are more passive.

Finally, there has been an attempt to evaluate the role of shame, anger, and childhood abuse in victims of violent crime. One hundred fifty-seven victims of violent crime were interviewed 1 month after the crime and 6 months later. It was found that shame and anger were the only independent predictors of PTSD at 1 month and shame was the only independent predictor of PTSD at 6 months. The authors conclude that both shame and anger play important roles in the development of at least crime-related PTSD and that shame is the perpetuator in the subsequent course of symptoms.

Another study supports the thesis that it is the childhood background that may determine one’s propensity to develop PTSD. In a telephone interview survey of 4023 adolescents aged 12 to 17 years, 16% of boys and 19% of girls met the criteria for at least one diagnosis of either PTSD, major depressive episode (MDE), or substance abuse/dependence (SA/D). The 6-month PTSD prevalence was 3.7% for boys at 6 months and 3% for girls, whereas, that of MDE was 7.4% for boys and 13.9% for girls. In the 12-month SA/D, prevalence was 8.2% for boys and 6.2% for girls. PTSD was more likely to be a comorbid condition than was MDE or SA/D. These results generally support the hypothesis that exposure to interpersonal violence (i.e., physical assault, sexual assault, or witnessed violence) increases the risk of the development of these major psychiatric disorders.

Hans Eysenck’s Work on Anger and Depression

The work of Hans Eysenck explores two other aspects of childhood emotional reaction and resultant lifelong depression and/or lifelong anger. He and colleagues studied over 13,000 adults over a 20-year period. Initially psychometric testing revealed the following four primary types of individuals:

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  Lifelong hopelessness. Individuals who craved love and had felt abandoned

  
  
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  Lifelong anger. Individuals who felt abused and carried a grudge

  
  
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  Both lifelong depression and anger

  
  
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  Autonomous individuals. These are well adjusted individuals who would probably be considered self-actualized. Essentially they say, “Happiness is an inside job. No one else can make me happy or unhappy.”

Eysenck discovered over two decades that approximately 75% of the individuals who died of cancer were the lifelong hopeless, 15% were angry, and 9% were both. Only 0.8% of those who died of cancer were autonomous. Additionally, approximately 75% of those who died of heart disease were lifelong angry, 15% were lifelong depressed, and 9% were lifelong both. Overall, the vast majority of the individuals who died in only twenty years were chronically angry, depressed, or both. These findings have significant implications for PTSD patients, who suffer even more intense anger, depression, or both.

Electromagnetic Dysthymia and PTSD

Whatever the circumstances that predispose an individual to posttraumatic stress disorder, treatment for this particular difficult problem is primarily one for the field of mind-body medicine. Veterans have a high incidence of traumatic physical injury as well as psychological trauma. Thus, pain is common as a comorbid condition in these PTSD patients. In general, pain should always be treated when possible with appropriate correction of the physical or physiological cause. When such treatment does not lead to resolution of the pain within 6 months, it becomes a chronic pain syndrome. In the chronic pain syndrome, one should always consider procedures such as transcutaneous electrical nerve stimulation, acupuncture, physical exercise, and massage. In the author’s experience in working with more than 30,000 chronic pain patients, the most important long-term success have been achieved when these procedures are integrated with mind-body medicine. Many of these chronic pain patients fall into the category known as electromagnetic dysthymia. It is thought that these individual’s have brains with erratic electrical systems. Individuals with this disorder have the following characteristics :

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  A focus of excess electrical activity in one area of the brain. It is in the right frontal cortex 60% of the time, but it may be located in any area.

  
  
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  A failed response to photostimulation. When presented with flashing lights at 10 Hz, they may have an increase in 3-cycle or 30-cycle activity, but not 10-cycle activity.

  
  
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  A deficiency in one to seven essential amino acids, the building blocks for various neurochemicals. Deficiencies in taurine, an amino acid that regulates electrical charge on nerve cells, are found in 80%.

  
  
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  A deficiency (100% of patients) in intracellular magnesium, which also regulates cell membrane potential.

  
  
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  A wide spectrum of essential neurochemical abnormalities, especially norepinephrine, serotonin, melatonin, beta endorphin, and cholinesterase.

  
  
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  A low or deficient levels (always found) of DHEA (dehydroepiandrosterone).

  
  
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  An elevated production of cortisol.

It is the author’s experience that PTSD patients have these abnormalities.

Mind Body Medicine: History and Overview

Today’s concept of mind body medicine evolved in the early 1970s from the humanistic psychology movement. Contributors to this movement included early biofeedback work by Dr. Elmer Green and his wife, Alyce, and the meditation and relaxation studies of Dr. Herb Benson. As early as 1964, Dr. George Solomon had begun his work on psychoimmunology, but the concept did not take off until Dr. Robert Ader expanded this work to the concept of psychoneuroimmunology in 1970. It was the discovery of endorphins and the work of Dr. Candace Pert that laid a solid chemical foundation for the concept.

Mind-body medicine is a term that demonstrates physical, chemical, mental, and spiritual interconnectedness, and currently encompasses a wide variety of techniques. These include biofeedback, relaxation training, autogenic training, psychosynthesis, meditation, guided imagery, spiritual healing, prayer, Logotherapy, Gestalt therapy, and many other short-term psychotherapeutic interventions.

Mesmerism itself was the first major development in the pre-modern prelude to today’s mind-body medicine. In the early 20th century, Emile Coue emphasized that “imagination” always wins in a conflict between “imagination and will.” Coue was famous for his statement, “Every day in every way I am getting better and better.” This statement was reported to cure thousands of people. The “separation” of mind and body is often said to have originated with Rene Descartes. Prior to his contributions, medicine, science, philosophy, and spirituality were commonly considered aspects of the whole person. With his influence in the 1600s, the separation of mind and body occurred—with mind being the purview of religion and metaphysics and body being the purview of science and medicine. In the late 18th century, Anton Mesmer began the trend to reexamine the connection of body and mind. Although rejected by most of his contemporaries, Mesmer’s work, said by Benjamin Franklin to be only a suggestion of the effect of the mind, spawned the concept of hypnosis, which was introduced by James Braid and James Eisdale after Dr. John Elliotson demonstrated in the 1840s that surgery could be performed on mesmerized patients. In 1872, Dr. Daniel Hack Tuke published the first major treatise on mind-body medicine in London. Tuke emphasized that the mind acts on the body through intellect, emotions, and volition. He considered that special and general sensations were influenced by mind, intellect, and volition, so he excluded these from his discussion. Conversely, he quotes Unser, who in 1771 wrote, “Expectation of the action of a remedy often causes us to experience its operation beforehand. This is also one of the earliest statements of the placebo effect.

John Hunter, of syphilis fame, had observed ‘mesmeric magnetism’ and came to the conclusion that “attention and expectation played a major role” in outcomes. James Braid took mesmerism to its more rational explanation, hypnosis. Hypnosis was highly controversial for more than 100 years, but led to the beginning of modern psychiatry. Sigmund Freud is said to have been such a poor hypnotist that he retreated to psychoanalysis.

Jan Smuts, former Prime Minister of South Africa, wrote in the 1920s the most elegant integration of all aspects of science, philosophy, and psychology in his book, Holism and Evolution . This was essentially the foundation of what is now termed Holistics . William James discussed ‘mind cures’ extensively in his landmark book, The Varieties of Religious Experience , perhaps still the most in-depth study of religion and spirituality.

Relaxation for Stress Illnesses

In 1929, Dr. Edmund Jacobsen published his landmark book, Progressive Relaxation , in which he demonstrated physiologic homeostasis with his practical technique of focused systematic muscle contraction and relaxation. He demonstrated that 80% of patients with “psychosomatic illness” were cured with this approach. It was never embraced by the medical profession.

In 1912, Dr. J.H. Schultz of Germany had begun a specific form of self-hypnosis called autogenic training . His first book was published in 1932. By 1969, the six volumes on autogenic therapy were published by Schultz and Luthe. With some 2800 scientific references, they reported that 80% of “psychosomatic” illnesses were adequately treated with autogenic training. Additionally, athletes, business people, and students who practiced autogenic training markedly improved performance.

Dr. Hans Selye demonstrated in the first half of the twentieth century the major effect of stress on health in general and maladaptation to stress as the basis of most disease. He emphasized the physiologic similarities of physical, chemical, and emotional stress.

In 1954, the American Society of Psychosomatic Medicine was founded. It was, and remains, primarily a psychiatrically oriented concept. Unfortunately, the term psychosomatic , which should be called mind-body, has been considered by most patients and physicians to mean “all in the head.” Stress medicine would be a preferred term. Meanwhile the term placebo , which has been the standard since the beginning of modern scientific medicine, has been used and abused and is poorly understood by physicians and the public. The majority of drugs are only a few percent better than placebo, which in most controlled studies averages 35% efficacy. Few drugs are 70% efficacious.

In the 1960s, Dr. Abraham Maslow and Dr. Carl Rogers began the reintegration of spirit and mind, founding humanistic psychology. Dr. Roberto Assagioli meanwhile had integrated all of his concepts, as well as Carl Jung’s concepts of symbology, into his technique of psychosynthesis. In 1970, Dr. Elmer Green and his wife, Alyce, introduced the concept of autogenic feedback training which has since become the foundation for biofeedback training. Their earliest work demonstrated that 84% of migraineurs and 80% of patients with hypertension were remarkably improved and adequately controlled with temperature biofeedback training. Since that time, it has been demonstrated that most physiologic responses, which can be measured and fed back to the patient visually or audibly, are capable of being brought under voluntary control.

In the 1970s, Dr. Herbert Benson first reported on the physiologic homeostatic benefits of transcendental meditation and later recognized that the basic benefit was deep relaxation, soon to become known as the “relaxation response.” Benson’s work replicated what Jacobson had shown 50 years earlier. Most striking was Benson’s demonstration that individuals who performed 20 minutes of deep relaxation twice a day had a 50% decrease of catecholamine production and insulin requirement for the entire 24-hour period.

In the early 1980s, George Solomon became one of the leading proponents of psychoneuroimmunology, which has provided the greatest evidence of the complete interconnectedness of body, mind, and attitude. Most remarkable is the finding that virtually every neurochemical produced in the brain is also produced in white blood cells and usually in the intestines. To some extent, the field of psychoneuroimmunology has suggested that the “mind” is part of every cell. Dr. Candyce Pert’s discovery of beta-endorphin, the natural opioid, was the first major step in demonstrating what Buryl Payne had introduced in Getting There Without Drugs in the 1970s. It now appears that the mind can produce a wide variety of mind-altering chemicals, ranging from anandamide to neurotensin with analgesic, neuroleptic, and hallucinogenic effects. Ultimately, mind-body medicine is the foundation for virtually all complementary and alternative medicine modalities.