STANLEY L. GOODMAN, M.D. – Qualified Medical Examiner #962948
Diplomate, American Board of Psychiatry & Neurology
in Forensic, Child, Adolescent, Adult, Addiction, and Geriatric Psychiatry
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The Use of Smartphone Technology to Objectify PTSD Criteria B Analysis
by Stanley L. Goodman, M.D.
Post Traumatic Stress Disorder (PTSD) was first described in 1980 by the American Psychological Association (APA) in its third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III). The clinicians who described this diagnosis were primarily evaluating war veterans. In 2000, the APA revised the PTSD diagnostic criteria in the fourth edition of the DSM (DSM-IV-TR). The DSM-IV revision should be considered a guide, as patients subjected to various types of stressors, ranging from children to adults, will display different clinical pictures. In civilian clinical practice, most patients are traumatized due to motor vehicular accidents, domestic violence, sexual assault, dog bites, negligence, or is caused by some negligence where the patient was severely injured. The DSM-IV diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms including intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. Intrusive recollections often manifest as nightmares in patients with PTSD.
PTSD remains a subjective disorder and there is no direct way to diagnose this disorder. In litigation, the diagnosis of PTSD may be questioned due to subjectivity. Therefore, after treating this disorder for approximately 40 years, I propose in this article a way to utilize information technology through the use of smartphones, an approach known as eHealth, to record the patient’s dreams soon after awakening, in the hope of objectifying the PTSD criteria by creating a log of the patient’s recurrent recollections. The primary objective would be for the patient to first record the dream to the best of the patient’s recollection, which frequently may be partially or completely forgotten. A record of these dreams can help both the clinician and the patient guide the management of PTSD.
To this end, I have started to enroll my patients in a preliminary study on the use of mHealth to treat PTSD and I hope that the data generated by this method will be objective and useful in litigation. Furthermore, by having patients visualize and record the traumatic dream in a timely manner, a more clear understanding of the psychiatric trauma of the dream will be obtained.
With PTSD, in the dream, the actual event of the trauma can be mentally reenacted, but at times the ending will digress from the actual event. For example, in some dreams the person will die, but in reality the patient suffering from PTSD did not die. This implies that during the course of the actual trauma, the mind was not fully aware of what was occurring. This thought may manifest itself in the dreams in the altered ending, where the person dies. Dreams may be a disguise.
Protocol for the Use of Smartphone Technology in the Management of PTSD
Disclosure to the Patient
You have told me that you have been traumatized by an accident. As you may know, after a traumatic or scary event you will probably have nightmares, some of which may wake you up. I am asking that you use an advanced smartphone (e.g: Samsung or iPhone) to visually record your moments upon wakening after such dreams. If your dream has roused you from your sleep, it is up to your discretion whether you want these dreams to be recorded and emailed to me and/or your attorney. Your dreams, whether they wake you or not, are important in understanding the emotional effects of your trauma.
I am offering you what I think is the best way to record your dreams, by using a smartphone where you can be seen and heard. These dream recordings can later, with your informed consent, be put into a DVD. Whatever you remember in a dream, the frequency of your dreams, the content of your dreams, and the effects that dreams have on you (e.g: you wake up, become nervous, have difficulty returning to sleep) help us further understand the implications of the trauma. This is completely voluntary, but if you participate in this, it would definitely help your attorney and me understand the effects of the trauma in a more profound manner. You can share with me the feelings you experience and I will document them. The information gathered through the use of smartphone technology to manage your PTSD, an approach referred to as mHealth, will help in the personalization of your care, and may also be useful in the future for research on PTSD.
Materials and Methods
The following are instructions to the patient for the recording of their dreams
1. Get a smartphone with clear resolution for video recording. (The new Samsung phone and iPhone have been ranked highly among the latest consumer reports.)
2. Keep the smartphone, fully charged, by your bedside where it can be easily accessible upon waking.
3. Record the time you retired to bed. Please also try to record approximate times of when you fell asleep, though we know it is near impossible to determine the exact time a body falls asleep.
You may record (via the smartphone or a tape recorder) thoughts that prevent you from falling asleep. If you have difficulty falling asleep, I recommend seeking the Benson-Henry Institute for Mind Body Medicine fro consultation. They have several excellent relaxation techniques.
4.Ensure there is sufficient lighting, so that upon waking your recorded video will be of decent quality.
5. Get an OMRON wrist cuff (it measures your blood pressure and pulse), to measure your BP and pulse when you wake up feeling anxious.
6. Ensure your full face and neck are shown in the video.
7. Have a clock (preferably digital) easily accessible so that you may document the date and time of your awakening.
8. If you are awakened by a scary dream, whether or not it is related to your accident or trauma, record your dreams to the best of your ability. The recording should be performed immediately upon waking as there is a significant deterioration in memory in the first moments after rousing from sleep.
Please try to recall the entire dream. Include location of the dream, who was present in the dream, what events occurred in the dream, and how you felt during the dream. If you have any thoughts regarding the dream, please feel free to explore them in the video.
9. Keep a notebook by your bedside and write down as much of your dream to the best of your recollection. Do not type it out on your phone or computer to avoid any dispute that it was truly you who documented the dream.
If you are too tired or upset from the dream to do so, try again in the morning. You may play back your videos to aid you in your memory process.
Please know that even if a dream does not wake you, you should document the dream when you wake up in the morning. Be sure to include location, who was present, events that transpired, and how you felt.