Dear Roberto,

I know that especially for PTSD heart rate variability has been considered a valid marker. In fact, HRV biofeedback has been used to core post traumatic stress disorder patients.

I would suggest the readings from Hagit Cohen

http://www.biologicalpsychiatryjournal.com/article/S0006-3223%2897%2900475-7/abstract

https://www.ima.org.il/FilesUpload/IMAJ/0/61/30924.pdf

Hope this helps.

Best Regards,

Thanks for Timo and Stefano! Best regards from Buenos Aires!

PTSD is a DSM diagnosis - recently the RDoC NIMH project suggests the DSM is not real - its fictive 

Dear Avi, 

I protest against your claim! Do not believe everything you read. 

Avi has a point. If PTSD is real why does its definition change with each revision of the DSM? A study comparing PTSD in 1990 (DSM-III-R) with a study in 2005 (DSM-IV-TR) might be comparing apples with pears. If PTSD is actually a carrot it will decided by committee and appear in a future version of the DSM. If biomarkers can identify PTSD I wonder which version it will be...

 The definition changes with each revision of DSM because today we know much more. We have come a long way since Charcot and Janet pointed out the importance of traumatic experience for the origin of hysteria or

dissociative symptoms. We know so much more and every time we add something to the body of knowledge DSM diagnoses must be revised. 

If you are interested in the whole history of PTSD read:  http://yorkspace.library.yorku.ca/xmlui/bitstream/handle/10315/7854/Ray-EvolutionofPTSD.pdf By S. L.Ray from where I cite the following: 

Hysteria, melancholia, and hypochondria

were the major types of neurosis described in the

late 1gth century. At the salpetriere in Paris,

Charcot and Janet pointed out the importance of

traumatic experience for the origin of hysteria or

dissociative symptoms. Although hysteria had been

considered an affliction of women, Charcot, as well

as Briquet, described several cases ofworking-class

men, most of whose hysteria (conversion symptoms)

followed work-related accidents. Charcot

demonstrated that paralysis could result from

hypnotic suggestion and initially deduced that

there was a latent flaw in the nervous system

(although he could not demonstrate it anatomically),

Janet agreed that some of the hysteria, such as

that seen following railroad accidents, was a form

of neurosis but also noted that the shock could be

imaginary. Hysterical symptoms included paralysis,

contractions, disordered gait, tremors, and shaking.

Janet was the first to systematically study dissociation

as a critical process in the reaction to

ovenruhelming stress and subsequent symptoms

(van der Kolk & van der Hart, 1989). Beard (1869)

coined the term neurasthenia or nervous exhaustion

to cover nonspecific emotional disorders, fatigue,

insomnia, headache, hypochondriasis, and melancholia.

Neurasthenia was common in the early

1900s and was recognized to occur after emotional

trauma (Kinzie & Goetz, 1996).

Freud (1896/1962) described early childhood

sexual trauma in the Aetiology of Hysteria. He

recognized that traumatic repetitive dreams brought

the patient back to prior situations and accidents

which were in conflict with his pleasure principle

because unpleasurable subjects were recollected and

worked over in ttrc mind. Attempts by Freud to

explain this was felt by critics to be inadequate. The

rejection of his theory led him to minimize the

external events and concentrate on premorbid problems,

such as intrapsychic conflict (Miller, 1997).

Traumatic neurosis was used by Kraepelin

(189912002) to describe reactions to accidents and

other disasters. The early searches for an etiology,

first in the organic area and then in the intrapsychic

conflicts, greatly influenced subsequent research to

the detriment of other approaches to knowledge

development. One effect of the separation between

neurology and psychiatry was the insistence that

disorders were either functional (which became

synonymous with psychological) or organic in

nature. Thus, the concept of an interaction became

lost (Trimble, 1981).

World War I

Ferenczi, Abraham, Simmel, and Jones (1921)

studied World War I combat stress reactions and

applied Freud's then current theories about unconscious

conflict, rather than his original idea about

trauma. Bailey, Williams, and Kamora (1929)

published a definitive work on neuropsychiatry in

World War I which referred throughout to Freudian

psychology as a theoretical construct for their data.

Da Costa's work on effort syndrome became a

popular diagnosis during the war (Turnbull, 1998b).

The largest number of psychiaric cases in the

war involved neurosis, including neurasthenia or

"shell shock," which was coined by Myers (1915),

a British military psychiatrist.

Mott (1919) gave one of the best descriptions of

the major forms of war neurosis, hysteria, and

neurasthenia. He wrote that physical shock and

horrifying conditions could cause fear, which in

turn produced an intense effect on the mind.

Hysterical symptoms included paralysis, contractions,

disordered gait, tremors, and shaking.

Neurasthenia symptoms included lassitude, fatigue,

weariness, headaches, and particularly vivid and

terrifying dreams. Another symptom described by

Mott in detail for the first time was a startle reflex.

In 1926, the U.S. Army reported that no new

psychiatric syndrome was found in World War l.

Even the Russian literature (Ronchevsky, 1944)

listed no unique syndromes.

The Traumatic Neuroses of War by Kardiner,

White, and French {1941} and War Stress and

Neurotic lllness by Kardiner (1947) are seminal

psychological works on the evolution of PTSD,

Kardiner included the most extensive follow-up of

patients from World War l. He developed the

concept of "physioneurosis" which indicated bodily

involvement. Kardiner differentiated the normal

action syndrome from its alteration through trauma

in terms of the symptomology (Lamprecht & Sack,

2002). Symptoms included features such as fixation

on the trauma, constriction of personality functioning,

and atypical dream life. In most cases, the

organic etiology became untenable, and the syndromes

were forced into the existing nomenclature

of traumatic hysteria or traumatic neurasthenia

(Kinzie & Goetz, 1996).

World War ll

At the onset of War World ll, the skeptics

regarded shell shock 0r war neurosis as a heterogeneous

group with many factors involved including

malingering as well as psychogenic (Turnbull,

1998a). Brill (1943) commented on the many terms

used to describe the affected soldiers such asexhaustion neurosis, shell shock, fright neurosis,

and asthenia. Although the reactions were caused

by fear, shock, and physical strain, they were also

found in nonservice men and in men never exposed

to shelling in warfare.

As the events of World War ll unfolded, psychoanalytic

concepts undenruent modifications, and

multiple analytic concepts were used to interpret

war-related neurosis. These theoretical concepts

represented an attempt to explain the multiple

symptoms seen in war neurosis in terms of an

intrapsychic model, which downplayed the role of

the trauma itself.

As the war continued, more American, British,

and Canadian studies began to describe and name

syndromes found among armed services personnel

such as acute exhaustion, war fatigue, war neurosis,

and old soldier's syndrome. The sheer volume of

observations by well-known psychiatrists gave

clinical validity to these findings (Lamprecht &

Sack. 2002).

Cannon (1932) defined the fighting and escaping

principles in both the psychological and physiological

sense as a person's reaction to impending

danger and the principal of homeostasis. Saul

(1945) identified traumatic war experiences with

the term combatfatigue and incorporated Cannon's

fight-fl ight reaction.

ln 1942, the Coconut Grove fire provided the

first modern clinical descriptions of reaction to

noncombatant trauma. Lindemann (1944) found

psychological grief among survivors characterized

by overactivity, expansiveness, some psychosomatic

symptoms, irritability, avoidance of social

relationships, and hosti I ity.

Grinker and Spiegel (1945), two American

psychiatrists in the Army Air Force, wrote about

what happens to soldiers who break under the stress

of modern warfare. Sixty-five case histories were

included as illustrative material with a description of

various therapies used to treat the psychological

casualties of combat. The most interesting aspects

were the etiology of the psychoneuroses or war

neuroses stated first in psychological terms and then

in terms of neurophysiology. Some of the symptoms

included passive dependent states, guilt and depression,

aggressive and hostile reactions, and psychotic-like

states.

To summarize, during the 1gth century and into

the mid-20th century, there was an ongoing debate

as to whether the etiology of traumatic disorders

was psychological or organic. The recognition that

there was an interaction between the psychological

and neurophysiologic was not clearly identified

until post-War World ll.

Post-World War ll

Krystal (1969) edited the groundbreaking work

Massive Psychic Trauma, which looked at "concentration

camp syndrome" of Nazi Germany's

concentration camp survivors after World War ll,

Psychological Aspects of Stress edited by Harry S.

Abram (1970) is cited frequently in the trauma

literature as a mqjor contribution in the evolution of

PTSD. Abram examined the human response to

stressful events including psychological reactions to

life-threatening illness, concentration camps, emetgency

situations, combat, and the stresses of outer

space. As follow-up information on concentration

camp victims became increasingly available; a

chronic syndrome was described by many authors

with a high degree of agreement on symptoms with

both physical and psychological factors.

Selye and Fortier ('1950) introduced the "General

Adaptation Syndrome" with the three phases of

alarm, resistance, and exhaustion. As a result, the

term stress entered everyday language. Selye

(1974) introduced the concept of heterostasis,

thereby indicating the existence of an area between

maintaining a normal equilibrium and succumbing

to physical and mental breakdown. Once again the

external environment was discovered as the instigator

of threat and danger. Burgess and Holstrom

(1974) described "Rape Trauma Syndrome" noting

that the flashbacks and nightmares resembled the

traumatic neuroses of war.

The first concession to a unique syndrome was

published by the American Psychiatric Association

(APA; 1952) in the first edition of its Diagnostic

and Statistical Manual of Mental Disorders (DSMl)

which coincided with the Korean War. The

DSM-I called what is now known as PTSD

"Stress Response Syndrome" caused by gross stress

reaction under the category of transient situational

personality disorder.

The inclusion of Stress Response Syndrome

recognized that some reactions could occur in

normal persons at times of extreme physical and

emotional stress. However, it was specified that the

reactions were reversible and that the ego should

return to normal under treatment. This Freudian

view became even harder to maintain with the

follow-up studies from World War ll and the

increasing data from concentration camp victims

(Bradford & Bradford, 1947). However, this

information did not influence DSM-Il (APA, 1968)

in which the only comparable diagnosis given was

situational adjustment reaction of adult life.

The Vietnam War and PTSD ........

Many symptoms such as weakness, fatigue, and

loss of will power mentioned early on and by many

subsequent authors (Lamprecht & Sack, 2002) that

have historically been related to trauma did not find

a place in the DSM-Ill-R (APA, 1987), the DSM-IV

(APA, 1994), or the DSM-IV-TR (APA, 2000).

Headache was a common symptom reported in both

combat and concentration camp victims, as well as

multiple psychophysiological reactions, particularly

gastrointestinal disturbances (Friedhelm &

Sack, 2002) are not mentioned.

There are few descriptions of dissociative symptoms,

except amnesia operating in PTSD. This fact

is recognized by the limited dissociative symptoms

required for the diagnosis of PTSD in DSM-IV-TR

(APA, 2000). DSM-lV-TR (APA, 2000) reflects the

ongoing ambivalence of psychiatry to maintain

dissociative disorders such as dissociative identity

disorder in a separate diagnostic group while stiMany symptoms such as weakness, fatigue, and

loss of will power mentioned early on and by many

subsequent authors (Lamprecht & Sack, 2002) that

have historically been related to trauma did not find

a place in the DSM-Ill-R (APA, 1987), the DSM-IV

(APA, 1994), or the DSM-IV-TR (APA, 2000).

Headache was a common symptom reported in both

combat and concentration camp victims, as well as

multiple psychophysiological reactions, particularly

gastrointestinal disturbances (Friedhelm &

Sack, 2002) are not mentioned.

There are few descriptions of dissociative symptoms,

except amnesia operating in PTSD. This fact

is recognized by the limited dissociative symptoms

required for the diagnosis of PTSD in DSM-IV-TR

(APA, 2000). DSM-lV-TR (APA, 2000) reflects the

ongoing ambivalence of psychiatry to maintain

dissociative disorders such as dissociative identity

disorder in a separate diagnostic group while acknowledging a close relationship between psychological

trauma and dissociative symptoms (van

der Kolk, Herron, & Hostetler, 1994).

ADDITIONAL DIAGNOSTIC

CATEGORIES FOR TRAUMA

The DSM-IV field trial studied 440 treatmentseeking

patients and 128 community residents and

found that victims of prolonged interpersonal

trauma, particularly early in life, had a high

incidence of problems with (a) regulation of affect

and impulses, (b) memory and attention, (c) selfperception,

(d) interpersonal relations, (e) somatization,

and (0 systems of meaning (Roth, Newman,

Pelcovitz, van der Kolk, & Mandel, 1997).

Complex PTSD (C-PTSD) or disorders of extreme

stress not otherwise specified (DESNOS) attempted

to recognize the long-term psychological responses

of individuals exposed to prolonged periods of

violence such as various forms of captivity, childhood

physical or sexual abuse, domestic violence,

and organized sexual exploitation (Roth et al.,

1997; van der Kolk, Roth, Pelcovitz, Sunday, &

Spinazzola, 2005). However, these profound psychological

alterations that occurred among individuals

exposed to prolonged periods of captivity or

total control by another such as hostages, prisoners

of war, concentration camp survivors, and survivors

of long{erm interpersonal violence (Matussek,

1975; Niederland, '1964) were not captured in

PTSD as outlined by the DSM-IV-TR (APA, 2000).

The DSM -IV-TR (APA, 2000) listed C-PTSD or

DESNOS not as a distinct diagnosis but under the

rubric of "associated and descriptive features" of

PTSD.

I have also had the pleasure to read my father's own analyses of the traumatic experiences of shell shocks later on named PTSD and even later C-PTSD during the years 1940-1945 in the war between Finland and Russia.