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Cochrane review

Multiple session early psychological interventions for prevention of post-traumatic stress disorder Doc James (talk ·contribs · email) 23:16, 15 February 2011 (UTC) [acted upon 2011.04.27]]

Re: moving of last section of lede

I have moved this recently added sentence - "Standardized screening tools such as Trauma Screening Questionnaire[4] and PTSD Symptom Scale[5] can be used to detect posttraumatic stress disorder" - from the end of the lede to theAssessment section of the article. This worthy addition to the article (which indicates the existence of validated screening instruments for PTSD) is neverheless not lede material, as it is specific rather than overview material. Furthermore, we already have a meager Assessment section where this material fits right in. Thus, the move seemed well justified.

I also edited the sentence a bit. No screening instrument detects PTSD. It merely indicates than an individual has a high-probability of having the disorder, and is therefore a good candidate for further examination - i.e., a formal diagnostic assessment. People diagnose PTSD, not instruments. I'm sure the author knows this, and I'm only clarifying his intended meaning. I hope this change is welcome.

Tom Cloyd (talk) 22:03, 27 April 2011 (UTC)

Terms in the lead

IMO this "post-traumatic stress disorder" is not needed as a synonym. Doc James (talk · contribs · email) 19:44, 30 September 2011 (UTC)

Interesting that you would say that, given that you can fairly be characterised as an unusually well-informed person. This indicates to me the need for better documentation, which need I will meet. As it turns out the hyphenated version isICD-10 nomenclature, while the nonhyphenated is DSM-IV. This can be made clear. I need to find my DSM to locate a correct page number...
I'm not sure of the best way to make this clarification in the article itself. Certainly it can be made in theterminology subsection. What I'd like to do is put in the lede something like "(see variant terms)", but I'm unsure if that's the way to do it. Can you advise me? (talk)
UPDATE - OK, I have placed a note immediately after the term in the lede, directing the reader to a note about terminological variants. The note itself, however, needs some help. I'd like to put a direct link to "Terminology" in the note but have not been able to figure out how to do it. Do you know? And what do you think of my solution? Tom Cloyd (talk) 16:45, 3 October 2011 (UTC)
It is not that we do not have the two spellings of the term it is that it is not significantly important IMO to belong in the lead. Maybe mention it under diagnosis?--Doc James (talk · contribs · email) 17:11, 3 October 2011 (UTC)
You have to admit that what I'm about to say is a bit funny, given that I'm fro the US and you're Canadian (!): My concern, which I have expressed in more detail in my outline for proposed article revision, at the top of the Talk page, is that the article in general, from title down, is overly DSM-centric. While this may be somewhat justified, given that this is theEnglish WP, it could well be argued (and I cannot lay my hands on the reference just now) that even there the ICD is used in treatment (though not in research) contexts in significant preference to the DSM - at least in general. More to the point, what is entered into charts, at least in hospitals, is more likely to be ICD codes than DSM codes, and I say this as one who used to run the admission department of Portland, Oregon's major mental hospital.
My long goal is that the article be more "internationalized", or at least more conspicuously diverse. The terminological difference is now made very clear in the Terminology subsection of the History section - but that's literally the very tail of the article. The single little footnote I placed in the lede is simply an attempt on my part to avoid the charge that the article is overly USA-centric. Personally, I don't think it's enough, but I can live with it, for now.
My other concern is that people coming here will be confused because they didn't expect to see "posttraumatic" - a single word. Given the frequency with which we have to revert 'corrections' to this spelling, this surprise happens rather often. I'm a little worried (possibly needlessly so) that people will come here and think "oh, this isn't the article I was looking for..." and try to go elsewhere.
The issue of being "USA-centric" is a real one, for me. For the English WP in general, this is too often a problem, I think. I'd just like it not to be here. Am I making sufficient sense? Tom Cloyd (talk) 20:19, 3 October 2011 (UTC)

Re: addition of Goya's No quieren (They do not want to) as lede illustration

I am far from unconcerned about the objections to the Ficherelli painting used previously. I was in fact, eager to see it improved upon. I'm sorry that the objections to the previously used painting were not more reasonably laid out; they would have been more useful and persuasive had they been.

But, the discussion led me ultimately to this print series by Goya, an artist of unquestioned aesthetic and moral power. Had he known about PTSD, he surely would have been interested, sympathetic as he would appear to be to the issue of psychological traumatization. Thus, it is particularly fitting that we should use art by him for this article. I am grateful to editorRoscelese for in effect leading me to this illustration. Unless I have missed something, all objections to the previous illustration are met by this one. We should (I hope) be at peace now, and free to devote our efforts to improving the substance of the article.Tom Cloyd (talk) 20:01, 3 October 2011 (UTC)

File:Goya-Guerra (09).jpg Nominated for Deletion

An image used in this article, File:Goya-Guerra (09).jpg, has been nominated for deletion at Wikimedia Commons in the following category: Deletion requests November 2011
What should I do?

Don't panic; a discussion will now take place over on Commons about whether to remove the file. This gives you an opportunity to contest the deletion, although please review Commons guidelines before doing so.

  • If the image is non-free then you may need to upload it to Wikipedia (Commons does not allow fair use)
  • If the image isn't freely licensed and there is no fair use rationale then it cannot be uploaded or used.

This notification is provided by a Bot --CommonsNotificationBot (talk) 08:26, 7 November 2011 (UTC)

Since the only objection to the image is that it is in-use here, I've copied said objections below:

  • An image of a rape scene on a page that will be viewed by people with PTSD is unnecessary, cruel and triggering. I am certain that I am not the only person who has visited this page and now has to face days -or more- of violent flashbacks. 76.22.65.199 08:18, 7 November 2011 (UTC) Commons:Deletion_requests/File:Goya-Guerra_(09).jpg
  • Posting an image of a rape scene on a PTSD page, which of course will be visited by individuals with PTSD, is cruel, unwise, and in poor taste. I now will be facing days -if not more than that- of horrific flashbacks, and I'm certain that I'm not the only one. I've submitted a deletion request. Perhaps this is a page where imagery ought to be generally omitted, given the triggers and symptoms of the demographic that is most likely to visit. This is a landmine. commons:File talk:Goya-Guerra (09).jpg

--Kramer Associates (talk) 22:04, 7 November 2011 (UTC)

Wikimedia Commons location of discussion of proposed deletion

See this page. However, that is not the place to discuss the matter, as the issue is not the image itself but its use here. For that, see the next section. Tom Cloyd (talk) 06:37, 8 November 2011 (UTC)

Discussion of proposal

A rape scene? - The allegation that the Goya illustration is of a rape scene is unsubstantiated. The image itself does not indicate this, and could be as well an illustration of a soldier being caught breaking into a home, attacking the mistress of the house, who discovered him, while her father launches a counter attack. The notion that it is a rape is but an interpretation. Goya himself does not say, although the title might be taken as suggestive. The illustration itself is ambiguous at best.

Why illustrate at all? - It is reasonable and customary to illustrate medical, psychiatric, and psychological articles with fine art which may be related to the article. It is commonly done on the cover of the Journal of the American Medical Association, for example. There are also numerous examples of such illustration in Wikipedia itself (I can provide links, if needed). Illustrations create visual interest and variety and simply make an article more attractive. In addition, this illustration subtly makes a point, as I have already said, above, in a related thread: Most victims of PTSD are not male soldiers, but female civilians. This point bears making, as it is not the common perception at all.

Should we expunge all triggers? - Are we to attempt to remove everything from the article that might be triggering? Words, phrases, allusions, references to situations? I think this is neither possible nor a reasonable proposal. (And yes, I realize that a general sweep of the article for triggers is NOT being proposed, but if we remove one, why not go after the others? A good answer follows...)

Can triggers even be predicted? - As someone who treats PTSD professionally, I assert that it is difficult if not impossible to predict what will be triggering to someone. For some people, merely going through the diagnostic protocol for PTSD is triggering. Should we remove that? The range of triggering stimuli is amazingly diverse. I once had a male trauma victim triggered by a simple relaxation exercise I was taking him through. One just doesn't know what will do it. What research exists which relates possible post-trauma triggers to the responses of trauma victims, AND gives us effect size statistics? (This would tell us the likelihood that a stimulus would be triggering for a particular sort of victim.) Let's not make gratuitous assumptions about what might and might not be triggering. I rather think certain predictions might be reasonable, but I also expect that the power of the prediction would not be great. However, I don't think we really know. For some rape victims, for example, the word "rape" would do it. For others, any image of physical assault, or anything having to do with sex, or with certain smells that remind them of their attacker, and on and on. There is simply no end to the possibilities.

What is the audience for this article? - This article is not written for people diagnosed with PTSD, but for the general public, the vast majority of whom do not have and never will have PTSD. It is reasonable to write for THAT audience. I obviously do not want anyone triggered by anything in this article. On the other hand, a person who knows they have this problem has a substantial obligation to pursue treatment to resolve the problem, rather to ask that the public sanitize the media to protect them from themselves. PTSD is decidedly treatable and curable. I've done it with hundreds of people.

A request for article censorship is not a rational response to finding something in the article which is triggering. Seeking treatment, which will remove the triggering response, is. I strongly encourage THAT response.

Finally, a personal note to the author of the deletion request. - Are you formally diagnosed? Do not assume you have PTSD unless this has occurred. Having a posttraumatic response, such as flashbacks, suggests PTSD, but is far from a confirmation. Second, if you think you even might have PTSD, why have you not sought professional treatment? The cost is typically less than that of getting a tooth crowned. If you cannot afford treatment, it is available through public health services in many places. If you don't know where to start in seeking help, begin with your personal or family physician, or with the physician at a low-cost public health clinic. Just seek help. It IS generally available, but they won't come looking for you. You have to take the initiative.

Tom Cloyd (talk) 06:37, 8 November 2011 (UTC)

Responses to "Discussion" below

(I have inserted my responses into your extended comment below, in order to address specifics. Tom Cloyd (talk) 17:01, 18 November 2011 (UTC)

A rape scene? -
Regardless of what exactly is happening in the picture, it is inappropriate for the reason that it is unclear what is happening in the picture, therefore it has no relevance in this article. It could be interpreted that the man is an alcoholic and the woman has hidden a bottle of whisky about her person, whilst the elder is a passerby-would-be-hero who has misinterpreted the situation.

You can't have it both ways: If the illustration is explicit (which I argue it is not) you say it's unacceptable because it's explicit. If it isn't, it's unacceptable because it isn't. Huh? That leaves us with nothing.
The exact nature of the act in the picture may be open to multiple interpretations (and I argue that it is), but the violence of it surely isn't. The research on PTSD epidemiology, with which I am familiar, and which is well cited in the article, tells us that the major cause of PTSD is, in women, sexual violence, and, in men, physical violence. Sexual violence mayat hand in the Goya, and physical violence surely is. I don't find your assertion of inappropriateness at all persuasive.
If we used an image of warfare, I doubt that there would have been any comment at all. But that kind of image misrepresents the disorder, so the image must at least have woman as a central figure, and not be explicitly about warfare, if it is to be minimally epidemiologically correct. [TC]

Why illustrate at all? This is not the Journal of the American Medical Association or any other psych rag, it is wikipedia – designed for the common man- therefore what is the norm for psych rags, should stay within them. I fail to see the need to insert imagery which bears no correlation to the actual subject matter. We CAN insert an appropriate image, that has to do with the subject as opposed to one of many events that may or may not cause the psychological problem to appear. We also need data to prove female civilians outweigh male soldiers as PTSD patients, however I may like to point out that not all soldiers are male, and that not all civilians are female. Both need adequate respresentation. PTSD sufferers may also end up with secondary PTSD because of the victim blaming culture, and the law of diminishment.

Articles in Wikipedia are encouraged to have illustrations. It one of the aspects on which "Good article" and "Feature article" candidates are evaluated. That alone is sufficient reason to illustrate the top of the article. Most other articles here on major mental illness diagnoses have such illustrations. We are not setting a standard here, only trying to meet one.
Your reference to the Journal of the American Medical Association is doubly inaccurate. It is not a psychology journal, and it is not a "rag". That reference is just plain disrespectful, It is one of the most respected professional journals in the world, and with very good reason, and it does publish front line psychiatry articles, including ones on PTSD. It is also widely read by people who are not physicians. I myself receive frequent summaries of the current issue (it comes out weekly) and I am not a medical professional.
If you have a more appropriate image, great. Bring it here so we can consider it. And...the event(s) in the Goya definitely DO cause PTSD in vulnerable individuals. (Of course, nothing causes PTSD deterministically...)
The 2 to 1 prevalence of female civilian PTSD victims over male military ones is well known, but only among those who have bothered actually to study the epidemiological reports, which are referenced in the article, and available online. You should examine the article's references instead glibly questioning one of its well-sourced assertions. [TC]

Should we expunge all triggers? See next paragraph. Nobody is trying to remove the whole article (I presume), just one picture.

I was addressing the notion that we should remove something from a general article, targeted to a non-clinical population, because something in it purportedly triggered someone.Everything triggers someone, I suspect. There are many potential triggers in this article. Seeking to remove then all would gut the article, be without precedent, in my professional experience, and would be without rational justification. Someone who is experiencing triggering is receiving a signal of illness - "dis-ease" - and should seek resolution of the problem, rather than literary censorship. I think that's a reasonable, justifiable request. [TC]

Can triggers even be predicted? If it is difficult if not impossible to predict what could be a trigger, then considering what may be a trigger then perhaps more time should be spent choosing an appropriate image. As a professional in the field surely you must have considered this?

I've already related how difficult it has been to find an image for this article. Considerable time HAS been spent. We have more valuable matters to invest our time in with this article (see my change outline proposal at the top of this talk section, please). [TC]

I’m sure we all appreciate the point about your patient, his relaxation exercise and response, but the point here is that it is all within his, or the patient’s, mind. There will have been a reason why that exercise or the words you chose etc would have caused a reaction. If most people were triggered by a relaxation exercise would you then insert an image of someone undergoing a relaxation exercise? And what would you expect the response to be? This is all very well when it happens in the physicians office, however the article will be accessed by the general public (who will include sufferers, either before (ie those presenting symptoms, whom are later diagnosed) or after diagnosis) away from a place where a professional may be able to help. It is possible that a sufferer will have a negative reaction to the article itself (for example realising for the first time , however this cannot be helped, appropriate selection of imagery can.

Please present us with research on what triggers whom, how often, and under what conditions of exposure. I will not consider modifying the article merely on some vague supposition. As I've said before, once we start this, where do we stop? [TC]

What is the audience for this article? Is it not reasonable to consider that the majority of the general public will not seek out this article.

On the assumption that you meant to say "the majority of the general public will not seek out", I say: Correct. Also irrelevant. We're concerned not with the general public at large, but with that portion of the general public which DOES come to Wikipedia wanting to know more about PTSD, which will always be a minority of the general public, I suspect. Who else might we be writing for? And we are NOT writing for a professional or clinical population. Writing does exist which is targeted to those audiences, but it will not be found in Wikipedia. [TC]

I surmise that the majority of readers will be friends and relatives of those who are, or appear to be suffering from the illness, or will be the patients (or potential patients) themselves.

On what basis do you assume this? I see no reason at all to assume this. But even if you're right, we still write, correctly, for a general audience. Is the article on geological strata written primarily for geologists? How about the article on T. S. Eliot - is it primarily for poets or people who have one in the family? People DO come for some reason, I grant you. It seems reasonable that they come because they want to learn more about the subject. What motivates this desire for more knowledge is what we really don't know. How can we, in the absence of research on the subject? Have you any? I would agree with you that it's likely that more people coming here have PTSD, whether they know it or not, than are found in the general public, but we still are correct in writing for a general, non-clinical reader. [TC]

The stereotypical general public will always choose the easiest option, that of whatever the media tells them. Ergo they will not be reading this article. However, the point is to make it easy to read, understand and find ways of encouraging that general public to understand it (along with many other misunderstood psychological diagnoses).

I totally agree! [TC]

Treatment may remove or diminish the triggering response. It may or may not improve a patients quality of life, over time.

I have never failed with a client suffering from PTSD, if they can remember how they got it, and are willing to complete the treatment, which can be challenging, but is generally less challenging, I think, than chemotherapy is for cancer. Success of treatment is measured in good part by extinction of triggering responses. I have always been able to extinguish triggering IF the client has decent memory of the traumatic events. Always. How can that not improve a client's quality of life - and immediately, at that? My clinical experience tells me that it does, without question. One can virtually always see the improvement in quality of life in the week following resolution of a traumatic memory. Consider how cognitively and behaviorally disruptive the symptoms of PTSD are (please review them, as stated, in the article). Now, remove those disruptions. How can that not improve quality of life? [TC]

I do however question that you have eradicated it completely from all your patients, a few perhaps, but not all.

Doubt my assertion all you want, but I have the records to back it up, and I was there when it occurred. I always take measurements, and record the result, to document the extinction of the triggering, as well as the removal of symptoms. When the symptoms are gone, one can no longer assert that PTSD is present. Very simple, yes?. My results are far from unusual, in the community of psychotherapists who are trauma treatment specialists. I find it very sad that more people don't KNOW how treatable PTSD generally is. I have no idea why you seem so confident that complete treatment of PTSD is a rare event. It isn't.
By the way, none of the people I work with are "patients". Physicians have patients, non-physician psychotherapists have "clients"). When I first started editing this article, I corrected this usage, and other editors, including a physician, supported this change, as it reflects usage in the clinical world.

Did you consider that these patients displayed evidence of more likely being ASD patients?

All people with PTSD first have ASD (Acute Stress Disorder). But you cannot have both. If you meet the criteria for PTSD (see article) you cannot meet the criteria for the less severe ASD diagnosis. When assessing for PTSD, one first rules out the presence of ASD. I have treated ASD, of course, and the treatment is the same as for PTSD, and is equally effective. [TC]

Finally, a personal note to the author of the deletion request. - "Are you formally diagnosed? Do not assume you have PTSD unless this has occurred. Having a posttraumatic response, such as flashbacks, suggests PTSD, but is far from a confirmation. Second, if you think you even might have PTSD, why have you not sought professional treatment? The cost is typically less than that of getting a tooth crowned. If you cannot afford treatment, it is available through public health services in many places. If you don't know where to start in seeking help, begin with your personal or family physician, or with the physician at a low-cost public health clinic. Just seek help. It IS generally available, but they won't come looking for you. You have to take the initiative."

Bear in mind that not all psychotherapists/psychiatrists are ‘professionals’. And all potential patients should consider they may end up with a diagnosis of something other than PTSD, based on the Doctor’s own beliefs. I DO however actively encourage anyone to seek professional help – this is what sufferers should ideally do, or be encouraged to by those around them. It is more likely to improve with them than without. MagicalThinking (talk) 13:14, 17 November 2011 (UTC)

If a psychotherapist/psychiatrist is practicing, and licensed (and they have to be, to be legal), they are professionals. If they are not behaving in a professional many, they are guilty of practicing in an unethical or incompetent manner. All professions have bad apples. Ours is no different. Quality of service varies. Surely this is no surprise to anyone.
A diagnosis of PTSD is not made on the basis of "belief". (Please read the article's "diagnosis" section.) In my experience, the main reason a diagnosis of PTSD is not made when it could is that other things get diagnosed first, and the professional thinks they have found the problem. They therefore do not continue looking for other causes.
For example, most PTSD will present itself clinically as depression, not as a trauma-related problem. One usually has to explicitly screen for trauma-related problems to find them, and too many professionals do not do this. I have seen several pieces of research validating this problem, and have seen a lot of it in my practice. Until I was properly trained in trauma treatment, I made this mistake myself, I'm sorry to say, as I was part of the general population of psychotherapists who fail to realize the importance of routinely screening for PTSD, regardless of the client's clinical presentation.
NOW, can we please devote out energies to substantive improvement of the article? This endless quibbling about the imperfections a single illustration is simply not wise use of our limited time and resources.
Tom Cloyd (talk) 18:33, 18 November 2011 (UTC)

Agreed.

If you dont mind I was just, hmmm, filling for whoever wrote the original and failed to respond.


With your response I surmise that you have covered points.

However I cannot speak for anyone else.
~ — Preceding unsigned comment added byMagicalThinking (talk •contribs) 13:33, 22 November 2011 (UTC)

MEDRS

[NOT ARCHIVED - is an unresolved issue to which response is needed. Tom Cloyd (talk) 00:19, 24 February 2011 (UTC)]

An overreliance on primary sources, and relative absence of secondary reviews, is present in this article, and typically results in original research. I see we have one practitioner particularly active here, and although that may be helpful, Wiki medical articles depend upon reliable medical sourcing. Please upgrade this article to correctly use primary sources and include secondary reviews; how to find them in PubMed is explained at Wikipedia:Wikipedia Signpost/2008-06-30/Dispatches.

There are over 2,000 review articles in PubMed, and some of them, such as:

  • Ehlers A, Bisson J, Clark DM; et al. (2010). "Do all psychological treatments really work the same in posttraumatic stress disorder?". Clin Psychol Rev. 30 (2): 269–76. doi:10.1016/j.cpr.2009.12.001. PMC 2852651. PMID 20051310. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

even have free full-text available, which is an added benefit to our readers. SandyGeorgia (Talk) 22:52, 14 August 2010 (UTC)

The following contains some info that appears to contradict some of the text here and might warrant review:

SandyGeorgia (Talk) 02:55, 16 August 2010 (UTC)

More secondary reviews with full text freely available:

SandyGeorgia (Talk) 00:28, 17 August 2010 (UTC)

response
  • "...overreliance on primary sources, and relative absence of secondary reviews..." - yeah, and it was noted many months ago. See next two sections for details. I'm too tired to repeat myself. You're late to the party.
  • "...I see we have one practitioner particularly active here, and although that may be helpful..." - yes, it just might be helpful, after 8 years, to finally have someone working on the article who actually treats PTSD professionally. Or, it might take us off a cliff. I'll leave it to others to decide. In any case, this is an ad hominem proposition, and thus beside the point. Article quality derives from other considerations, control of which might indeed be related to such things as education, clinical experience, professional commitment, etc.
  • pointing people to PubMed is always helpful, I think. This article certainly does need better use of review articles (as has been previously noted months ago, I again point out). Selection of such articles needs to be representative and well thought out. I would argue that achieving that goal is significantly dependent upon good judgment, the very judgment development of which is so emphasized in graduate training programs in psychotherapy. I don't expect to see it achieved by a tweener with a keyboard (although they're welcome to try!).
  • deficits in the article - I agree that there are many, which is why some time ago I sketched out a carefully thought out plan for article revision and improvement, and pleaded for critique of the plan. I have seen only a little result from this. We don't need someone to point out what has already been noted. We need more people to work seriously on the article.
Tom Cloyd (talk) 06:48, 21 August 2010 (UTC)

Article "B" class or "C" class???

[NOT ARCHIVED - is an unresolved issue to which response is needed. Tom Cloyd (talk) 00:19, 24 February 2011 (UTC)]

I cannot make sense of this and would appreciate some help. At the top of the article proper appear the words "A B-class article from Wikipedia, the free encyclopedia", yet on the Talk page, it is declared that for both the Psychology and the Medicine Portals, "This article has been rated as C-Class on the project's quality scale."

Why the inconsistency? I'd like to get this cleared up.

Here, we see that it IS rated a "C" class on the psychology portal, but WHY? It's surely at least a "B" class, I would think, but I cannot find the criteria.

Tom Cloyd (talk) 07:40, 21 August 2010 (UTC)

Brain Stimulation subsection: ECT, TMS, and etc., treatments

[NOT ARCHIVED - is an unresolved issue to which response is needed. Tom Cloyd (talk) 00:19, 24 February 2011 (UTC)]

This sections was just added today. Help collect the rest of the info and touch it up as I'm not an expert in touch up. —Preceding unsigned comment added by 173.162.221.82 (talk) 00:17, 9 November 2010 (UTC)

I have removed the following new section from the article, for several reasons. First, it hardly seems inappropriate to take up this topic in the article, BUT, what was inserted was only a proposal and a list of references, coupled with a plea for help. Legitimate as this appears (to me), I don't think it belongs in the article, but rather on this Talk page. The topic needs to be researched, written, THEN entered. That has yet to be done. I, personally, will not be taking this topic up at this time, simply because there are more urgent matters to attend to here, and I'm attending to them. Later, if no one else has responded, I well may.
Brain Stimulation Treatments: Electroconvulsive therapy, Transcranial magnetic stimulation, and others
Few studies exist on on Brain Stimulation Treatment for PTSD. Recent promising studies include:
JOURNAL: Brain Stimul. 2010 Jan;3(1):28-35
DATE: 2009 May 27
ARTICLE TITLE: Efficacy of ECT in chronic, severe, antidepressant- and CBT-refractory PTSD: an open, prospective study
AUTHORS: Margoob MA, Ali Z, Andrade C.
BACKGROUND: Treatment options are limited in patients with severe, chronic, posttraumatic stress disorder (PTSD). There is little information on the use of electroconvulsive therapy (ECT) for PT
CONCLUSIONS: ECT may improve the core symptoms of PTSD independently of improvement in depression, and may therefore be a useful treatment option for patients with severe, chronic, medication- and CBT-refractory PTSD.
JOURNAL: J Anxiety Disord. 2009 January; 23(1): 54–59
ARTICLE TITLE: Repetitive TMS combined with Exposure Therapy for PTSD: A preliminary study
AUTHORS: Elizabeth A. Osuch, Brenda E. Benson, David A. Luckenbaugh, Marilla Geraci, Robert M. Post, and Una McCann
JOURNAL : J ECT. 2007 Jun;23(2):93-5
ARTICLE TITLE: Electroconvulsive therapy for comorbid major depressive disorder and posttraumatic stress disorder
AUTHOR: Watts BV
CONCLUSIONS: Electroconvulsive therapy may be an effective treatment for patients with refractory depression and co-occurring PTSD.
Tom Cloyd (talk) 17:01, 9 November 2010 (UTC)

FROM THE ADDDER: PLEASE ADD IT AS I HAVE PTSD and am in a support group for it and we are researching but confused over ECT and brain stimulation treatments and our drug and talk theraphy is failing. We are doing the best we could to add this information. We need the true information. —Precedingunsigned comment added by74.10.198.135 (talk) 22:29, 9 November 2010 (UTC)

I am sorry to hear of your struggle with PTSD. While this is not the place to commence a discussion of treatment options relevant to individuals contributing to Wikipedia, I will offer a few brief thoughts, as someone who specializes in the treatment of PTSD (consult my WP user page for more info.):
Group therapy, talk therapy, and drug therapy are all interventions which have NOT been shown to be effective in resolving the symptoms of PTSD. Your "support group" is, at best, just that - support, not treatment.
Effective treatments DO exist. I know this from my years of PTSD-treatment experience, and from the published reviews of treatments for PTSD, at least some of which are summarized in the "Management" section of the WP PTSD article. You would do far better to pursue these treatments than to look at treatment reports which, at best, are exploratory, preliminary, and so forth.
I want to do more than simply state the obvious, as I think I have done above. So, I will try - repeat, try - to find time today or in the next few days to assess the state of our knowledge of the brain stimulation treatments (not quite a correct characterization, I suspect) to which your reference list refers, and write into the article a summary of what I find. I can certainly say, without additional work, that I have never used such methods, and know of no one who ever has. What this means is that the odds of their being effective for randomly chosen individual are small, at best. Why not look at treatments which almost alway work, like those involving exposusre (CBT, EMDR, etc.). THOSE are good bets.
Tom Cloyd (talk) 16:38, 10 November 2010 (UTC)
UPDATE - This topic is still on my short list to receive at least a minimal review and report, as soon as I can find a little time. I have not forgotten. Tom Cloyd (talk) 20:10, 23 November 2010 (UTC)

New topic to develop: trend in the justice system to recognize PTSD as mitigating factor

[NOT ARCHIVED - is an unresolved issue to which response is needed. Tom Cloyd (talk) 00:18, 24 February 2011 (UTC)]

I have removed from the main article this content, which was just added:

===Criminal Sentencing=== PTSD in veterans is increasingly a reason for judges to mitigate sentencing for criminal offenses.<ref[http://www.nytimes.com/2010/03/16/us/16soldiers.html]</ref>

Problem

There are several problems with this edit:

  • It creates a new section with a single sentence. This strongly suggests an underdeveloped topic. If that's the case, let's develop it here, THEN move it into the article, else the article becomes a patchwork of content "stubs".
  • As we move the article (hopefully) ever closer to GA, then FA status, we need to maintain and improve quality at all levels, and not allow the erosion easily comes from opportunistic or casual editing.
  • The source used is primary at best. The implication is that we have a trend here. That may be so, but we need support better than this in order to bring that assertion into the article. I'm an working hard to fix this sort of problem in the article existing assertions, and to remove those that cannot be fixed. We don't need MORE of this problem. Primary reliance upon secondary sources is the launching pad for elevation of an article's status rating, and that's why I'm emphasizing this.

Solution

This is a potentially interesting and useful addition to the article. We need to locate better sources, AND develop a somewhat better exposition. I do see this fitting into a section I am about to create which will better characterize some already existing content: Public policy response. I guess I better get on with it!

An interesting question: is there evidence of this alleged trend in justice systems outside the USA?

Tom Cloyd (talk) 23:59, 1 May 2010 (UTC)

Here is another perhaps better citation for the PTSD/ law link: http://www.ncbi.nlm.nih.gov/pubmed?term=19618551 MBVECO (talk) 17:48, 6 April 2011 (UTC)MBVECO

Effective treatment in the form of meditation

This is not included in the article, but it is related and perhaps should be included: Coping Strategies—a CD-ROM distributed to US military affiliates, especially those suffering with PTSD. I will see if I can find any more good sources that cite it as a recommendation to treat PTSD. Mrtea (talk) 02:29, 25 November 2011 (UTC)

Research on meditation IS suggesting some likely real benefits for people with a number of different mental illnesses, including anxiety disorders. I'm doing a lit. review right now, and hope to bring the results to the article this week. However, none of this research (that I've yet encountered) suggests that the meditation effect is a "treatment". It does not cure, but does help to moderate symptoms, and builds the basis for improved post-treatment emotion management.
If you find those sources, do bring them here. Bear in mind, though, that what we really need is a review article, not a set of unsummarized individual research studies. I have not yet found such a review article, but, I'm only just getting started on this project.
Tom Cloyd (talk) 16:31, 28 November 2011 (UTC)
Sorry to be slow responding. Am still working on this. Have a lot on my plate, as it were, just now. Tom Cloyd (talk) 14:48, 5 December 2011 (UTC)

Name of this article (updated)

ICD 10 still very clearly calls it PTSD [1] thus moved it back until consensus can be achieved. Would need to see high quality refs that show the majority of the scientific community believes it to be an "injury" --Doc James (talk · contribs · email) 02:03, 5 December 2011 (UTC)

Absolutely correct. There is NO support in the relevant section of the scientific community (that devoted to the study and treatment of psychopathology) for changing "posttraumatic stress disorder" to "posttraumatic stress". We distinguish the two, and have for some time - the latter is the precursor to the development of the former. Both DSM-IV and the upcoming DSM-V, as well as ICD-10 have made NO change in the name of the disorder. It would have been very major news had this occurred. :Tom Cloyd (talk) 14:48, 5 December 2011 (UTC)
NOTE however -
I will be adding a note about this to the article later today. Tom Cloyd (talk) 22:31, 10 December 2011 (UTC)


"Posttraumatic stress disorder (also known as post-traumatic stress disorder or PTSD) is a severe anxiety disorder..."

[NOT ARCHIVED - is an unresolved issue to which response is needed. Tom Cloyd (talk) 22:37, 10 December 2011 (UTC)]

Are not all anxiety disorders severe? I don't know why PTSD would be categorically distinguished as a "severe" anxiety disorder. Consider revising? — Preceding unsigned comment added by 142.3.40.100 (talk) 21:49, 25 July 2011 (UTC)

No, a revision would be flatly incorrect, and could not be supported by reference to reputable sources.
"Are not all anxiety disorders severe?" Why would you think so? (I ask because I really don't know!) Most things in the real world at NOT binary (either/or) in nature, but rather are graded. We have degrees of red, in rock, or cloth, or paint, for example. Degrees of sweetness, and of hardness, and so on. Why not degrees of severity in anxiety disorders? Logically, there's no problem
Empirically (speaking as a clinician who treats anxiety disorders as a specialty), a phobia or generalized anxiety disorder (GAD) diagnosis (Dx) is not at all in the same league as PTSD or panic disorder, etc. You will see higher levels of nervous system arousal, and of behavioral agitation (or numbing), and so on, with the latter, unquestionably. There is NO mild or moderate PTSD. It's all serious. We do certainly see mild phobias and GAD.
An subjective way to measure the level of severity is in terms of self-reported anxiety levels on anxiety assessment tools, of which there are a number. An objective measure would be to observe the number of areas of life function (talked about in the Introduction to the APA Diagnostic and Statistical Manual) which are disrupted - things like work, leisure, family, social interactions, etc. Measures like these will clearly evidence that PTSD is indeed a severe anxiety disorder, and thus different from others which do not evidence such high levels of subjective distress and objective disturbance.
I hope that helps to explain the use of this adjective in the article. I believe, in fact, that "severe" is precisely how it is characterized in the DMS. There is no need at all for a revision.
Tom Cloyd (talk) 22:30, 26 July 2011 (UTC)

I don't see how this revision would be flatly incorrect at all, and although you make a strong argument, I believe you are wrong. The use of the word "severe" suggests there is such a thing as non-severe anxiety disorders, or some type of distinction or category that qualifies some type of severity within this class of disorders. Your suggestion that there are degrees of sweetness and hardness does not apply to anxiety disorders because there is simply NO degree of severity for anxiety disorders, so yes, logically, there is a problem. Refer to the DSM or the ICD-10 to see that there is no such use of the word "severe". Furthermore, all anxiety disorders are defined by significant impairment in areas of life, not simply PTSD. You make a good argument, but it simply is not supported by the DSM or the ICD-10 or our current understanding of psychopathology in general (as ALL disorders are "severe") or our conceptualization of anxiety disorders. Note that I am not against the idea of really high lighting the negatives associated with this disorder, I just don't think adding the word severe is the way to do it. I will make the revision again, and if it is changed again I hope to see a direct reference to the DSM (and a part that does not apply to other anxiety disorders) or a substantive literature that does not also apply to other anxiety disorders. PTSD is undoubtedly severe, but my point is that all anxiety disorders are. I'm not too familiar with Wikipedia discussion so I just added it here (I made the first comment as well), please move if needed!

First of all, as the edit interface says, Sign your posts on talk pages, please. This is more meaningful if you get a Wikipedia account. Second, please don't write large block paragraphs - they are hard for the visually impaired (and others) to read. Just write paragraphs of 2-4 sentences, all devoted to the same topic or assertion. Make it easy for your reader and they'll appreciate you more. Finally, this IS the correct place for your Talk page post, since it part of an ongoing discussion. You are just continuing in the discussion. All's well.
OK, let's think this through a bit more. I do like YOUR thoughtfulness, so I'm going to appeal to it. Those familiar with anxiety disorders wouldn't dream of classifying Generalized Anxiety Disorder in same group as PTSD. But I've already suggested this, and given reasons for the assertion. That's formally an argument. You didn't respond to it, by attacking either the premises or the logic, or both, so by the rules of traditional argumentation in educated human discourse, the argument stands. It may be wrong, but that isn't demonstrated until it's demonstrated, which hasn't occurred. Mere counter-assertion does not do the trick.
Surely all anxiety disorders are serious - that's why they acquire the status of a formal clinical (meaning "requires professional help in most cases") disorder, and appear in the DSM/ICD9. But THAT doesn't mean they are equivalent in their severity. There IS a rationale for what I'm saying, and it IS in the DSM. One place you can find it is with the category Acute Stress Disorder. The symptoms of ASD are essentially identical to those of PTSD. except as to duration. PTSD is more serious than ASD, for that reason. In the first 30 days of the disorder, however, they are identical, and any knowledgeable psychotherapist would agree with my assertion of this.
Another example: Compare symptom lists for GAD and PTSD. They just don't compare. PTSD is obviously more severe, there, too, but in a different way than when compared with ASD.
The point I am trying to make is simply that degrees of seriousness obviously DO exist within the group of anxiety disorders in the DSM/ICD9-10;. Not even a junior level university psychology student (who'd done their homework!) would assert that all anxiety disorders are equivalent in seriousness. To health professionals (for whom these documents are written) this is as obvious as the notion that cancer is more serious (in general) than a broken bone. Seriousness is differentiated by number of areas of life function that are impacted, by degree of impact, and by duration of the disorder. These dimensions of divergent seriousness ARE to be found in the DSM/ICD9-10, and clearly do distinguish PTSD from, say GAD. And, it is reasonable to characterize the far end of the "seriousness" scale with the word "severe". So, yes, I do make a good argument, and it IS supported by the standard reference works, whether or not they use the word "serious" in any comparative sense.
Finally, a point about argumentation: When you come here and strike "severe" from the text on the grounds that all anxiety disorders are "severe", it is incumbent upon you to support that assertion. I don't think you ever have. Your assertion is bare, without support. You do need to justify your action, and you haven't. Accordingly, I have restored the word "severe". But I'll go further, as this discussion has given me a good idea: I will work up a comparative table comparing number, severity, and duration of symptoms of PTSD relative to a fair sampling of other anxiety disorders. This would make a nice addition to the article, and would not constitute original research any more than would a verbal summary of the same information. It would nicely clarify the notion that compared to other anxiety disorders PTSD is severe. It may take me a day or two to do this, but I like the idea and will get it done.
Any thoughts on all this? I'm interested...
Tom Cloyd (talk) 23:56, 7 August 2011 (UTC)
It's fine as is. "Severe anxiety disorder" already means it's severe compared to other anxiety disorders. Doczilla STOMP! 00:47, 8 August 2011 (UTC)
I agree that it is severe, and in many cases, I agree that it is likely more severe than other anxiety disorders; however, I don't think this means we need to say in the first sentence that it is a "severe" anxiety disorder, it is confusing and misleading. Rather, I think it would be more useful to elaborate on its severity within the article and compare it to other disorders (as you finely suggest!) than to "qualify" it as a severe anxiety disorder. PTSD is usually more chronic, associated with more co-occurring health and mental problems, but this does not make it categorically severe, while other disorders get no such mention. I have seen plenty of patients with GAD, agoraphobia, panic disorder, etc. that experience far more debilitating symptoms than those with full DSM PTSD criteria. It may be more useful to say generally it is more severe, but that will require substantive literature supporting this claim (and not only mish-mashes of of quantitative info like duration). This is a relatively minor issue, though, so this is my last input. Cheers. Sorry I don't have an account, but hopefully who wrote what isn't confusing (writer of the original post).
I keep trying to understand where you're coming from, i.e., what your essential point really is. I'm not getting it.
I think we DO need to say so in the first sentence, for two reasons: (a) it's demonstrably correct, and thus immediately increases the accuracy of the summary that the lede is supposed to be; and (b) people reading this article come here for a reason, and some of the time they have PTSD and are wanting to learn more about what that means.
My experience is that many people with PTSD are not fully aware of the seriousness of their disorder. They can barely work, they have trouble in relationships, and they often bounce in and out of addictions, but they rationalize their situation in various incorrect ways. When they learn that that the root of their very real dysfunction is PTSD, pure and simple, the relief, and the clarity of sense of self that emerges is critically important.
I have great compassion for people who do NOT know either that they have PTSD, or do, but don't get it that this is VERY impactful, of necessity. There is NO mild PTSD. It's all grave, every time. It is rare that it doesn't shatter peoples lives. Let us begin, BEGIN, by telling this truth, out of compassion for these people, who, unlike us (and I speak for myself), do not have this burden. Let's tell the truth simply because we care about these people.
I certainly will disclose that it was this sense of compassion that brought me to this article. I wanted my clients to have better information than was in the article when I got here. That concern is still with me. Hence my holding out on this issue. I see it as non-trivial. Tom Cloyd (talk) 02:50, 8 August 2011 (UTC)
I am finding this mildly frustrating. My point is that there is NO mild ANY anxiety disorder. They are all grave in every circumstance, if they are not, it is not an anxiety disorder. Of course we all care for those with PTSD, but this does not make PTSD a "severe" anxiety disorder. If this was the case, it would mention SOMEWHERE in the PTSD section of the DSM its relative severity, and this addition is not even considered for the DSM-V. We are going around in circles here, and it doesn't look like you can be convinced, but hopefully you will reconsider. You have presented moving and compelling anecdotal and personal evidence, but this is not supported by any contemporary literature.

[starting new section] "They are all grave in every circumstance, if they are not, it is not an anxiety disorder." No, not at all true, and I have already addressed this by referring to four dimensions by which the relative severity of different anxiety disorders could be addressed: number of symptoms, duration of symptoms, gravity of symptoms, and number of life function areas impacted. If you wish to assert that all anxiety disorders are equivalent on all four of these dimensions, well, that is an extraordinary, and empirically unsupportable assertion. It is manifestly wrong and even absurd. And you have offered no evidence in support of the assertion, so it carries no weight.

"I just consulted with four clinician-researchers who study PTSD almost exclusively, as well as with a contributor to the actual DSM-IV on PTSD and they all agreed that the word "severe" should be undoubtedly removed." Why? One needs to support one's assertions, remember? And it is you who are taking the initiative here, so the onus falls on you, not me. This sentence of yours is but a word-of-mouth citation. I don't know if you did this consultation (which may only have involved taking a book off a shelf) or not, and without names or proper citations it is utterly unverifiable. We cite in order that others might verify, else why bother? I find their purported support for the removal hard to believe. In any case, you really should support this assertion better. It's mere rumor at this point, and quite contrary to my clinical experience.

Relative severity is not, to my recollection, considered in the DSM. It is a diagnostic manual, not a comparative analysis, so this is not surprising. I have suggested that the truth is obvious enough that mere familiarity with the diagnostic protocols should resolve the question. Actual clinical experience, which I have in abundance, surely does.

I have not proposed that PTSD is "severe", compared to other anxiety disorders, because we care more about its victims. That's a nonsense proposition. My argument in defense of the adjective is clearly stated, several times, must recently in my first paragraph above. I have said I'll assemble a table to make it very clear. So shall it be. And no, you cannot convince me. because you have yet to make a substantive argument, and because I have several decades of clinical experience which tells me your core assertion, now that it's clear, is absurd. In summary, as I've said before: all anxiety disorders are serious, else they would not be termed clinical disorders in the DSM/ICD9-10. However, NOT all are severe. It's that simple.

Because at this moment I do not have access to my professional library (I'm moving) I'm unable to quickly cite literature. Perhaps by this evening that situation will be improved. Tom Cloyd (talk) 22:32, 8 August 2011 (UTC)

I removed my comment about my colleagues, because as you say, it is unverifiable. I also believe, however, that your personal and clinical experience is anecdotal and is relatively unrelated to the issue at hand. The consensus of my lab, which is at the very international forefront of anxiety disorder research, is that the word "severe" should be removed. We explicitly study the latent structure of PTSD and other anxiety disorders, as well as their measured structures as we conceptualize them in the DSM-IV and DSM-V criteria, and we believe there is little (or no) reason to have the word severe there. In fact, when I simply read the sentence to my peers without mentioning its potential problem, all 6 of them independently called out that the word "severe" should be removed. I don't have time to (nor do I have permission, I haven't asked) to refer to our lab, so I will leave this issue at that. Like many arguments on the Internet, the loudest party often wins. In this case, it is a loud party who has authority (I see you have some sort of Wikipedia ambassadorship, congratulations) and who is defending what is already in place (opposed to making a change). I can't change your mind, because you seem to be quite firm, and because there is no reference out there that says PTSD is not "severe" relative to other anxiety disorders. It requires an in-depth understanding of the structure of anxiety-related psychopathology, something that my laboratory and colleagues have, but not something that I can expect many others to have access to. Although you are wrong, and researchers who have dedicated their careers to studying anxiety disorders and PTSD agree with me, I am very pleased to see someone cares so much about this article (and others, I'm sure). I would rather see the word "severe" remain in place and you continue to defend this article, than there be no one here who cares. I wish I could spend more time defending my point, but, I am too busy writing papers on this topic! If anything, the word severe makes this disorder sound important (which it is!), which probably helps me cause. Still, I think it should change! P.S. Libraries are online now! Cheers. P.P.S. I understand where you are coming from and my lack of presented credentials, so I am not taken aback by your position, just hope you reconsider!
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