By Jiang Liu, Diplomate of Oriental Medicine
AR Licensed Acupuncturist and Herbalist
Acupuncture & Chinese Medicine Clinic
2024 Arkansas Valley Dr., Suite 402
Little Rock, AR 72212
Post Traumatic Stress Disorder (PTSD) is a prevalent anxiety disorder, which develops following the experience of a traumatic event and may result in multiple disabling symptoms. About 70% of people will experience a traumatic event in their life, but not all will develop PTSD. According to a report published in 2004, PTSD has affected 18% of Operation Iraqi Freedom veterans. The median time to care for most veterans is 12 years. Therefore, getting treatment as soon as possible after PTSD symptoms develop may prevent PTSD from becoming a long-term condition.
- Frequently having upsetting thoughts or memories about a traumatic event. Having recurrent nightmares.
- Acting or feeling as though the traumatic event were happening again, sometimes called a “flashback.”
- Having strong feelings of distress when reminded of the traumatic event.
- Being physically responsive, such as experiencing a surge in your heart rate or sweating, to reminders of the traumatic event.
- Making an effort to avoid thoughts, feelings, or conversations about the traumatic event.
- Making an effort to avoid places or people that remind of the traumatic event.
- Having a difficult time remembering important parts of the traumatic event.
- A loss of interest in important, once positive, activities.
- Feeling distant from others.
- Experiencing difficulties having positive feelings, such as happiness or love.
- Feeling as though your life may be cut short.
- Having a difficult time falling or staying asleep.
- Feeling more irritable or having outbursts of anger.
- Having difficulty concentrating.
- Feeling constantly “on guard” or like danger is lurking around every corner.
- Being “jumpy” or easily startled.
Traumatic events that can lead to post-traumatic stress disorder (PTSD) include:
- Combat or military exposure
- Child sexual or physical abuse
- Terrorist attacks
- Catastrophic accident (e.g., auto, airplane, mining)
- Violent sexual or physical assault
- Medical procedures (especially in kids)
- Natural disasters (fire, tornado, hurricane, flood, or earthquake)
- There is evidence that susceptibility to PTSD is hereditary
Treatment for PTSD is more complex and clinicians often utilize both cognitive-behavioral therapy and medication. Psychological treatment strategies are often aimed at disarming avoidance behaviors via focusing on the experience of the traumatic event as well as employing practices that help the patient to overcome demoralization and fear of recurrence; Sertraline (Zoloft) and paroxetine (Paxil) are selective serotonin reuptake inhibitors (SSRI) that are the first medications to have received FDA approval as indicated treatments for PTSD. While some of these therapies appear promising, there is no definitive treatment and no cure for the condition.
Acupuncture is very effective in the treatment of persons who have been traumatized as a result of emotional and/or physical damage. Multiple studies have shown that acupuncture can relieve pain; Improve sleeping quality; Eliminate anxiety; Reduce stress and worry; Improve emotional fluctuations; Improve depression; Improve memory; Improve tachycardia; Reduce cravings for alcohol and other substances; Attenuate inflammation and regulate immune function. To date, research supports using acupuncture for treating PTSD symptoms, including insomnia, anxiety and depression, in addition to some pain disorders.
PTSD is a complex disorder, which is a combination of emotional, cognitive, behavioral abnormalities. Clinical symptoms and manifestations are various from person to person. In my clinical practice, the following types of PTSD are commonly observed.
Classifications of PTSD by Chinese medicine
- Liver qi stagnation
- Yin deficiency and fire domination
- Deficiency of kidney essence
- Dominant damp restraining spleen
- Phlegm fire disturbing interiors
- Deficiency of both heart and spleen
- Disharmony of heart and kidney
- qi deficiency of both heart and gallbladder
Chinese medicine is individualized medicine. Experienced Chinese medicine practitioners will make accurate diagnosis according individual’s symptoms, signs, pulse, tongue, as well as individual’s life style and individual’s constitution. The choice of accupoints, herbal components, as well as some other modalities of Chinese medicine such as TuiNa, Gwasha, or electric stimulation, is highly individualized and there is no one who has exactly same accupoints or herbal formula. Acupuncture is often given to PTSD patients twice per week, total 10-12 times per one course. The courses to be given depend on individual’s situation or response to acupuncture. Often, after one course, the patients get dramatic improvement. Acupuncture can be combined with herbal formula or some other modalities of Chinese medicine, which can get better results.
Scientific evidence of acupuncture
Scientific evidence of acupuncture for PTSD: Various studies have approached the mechanisms of acupuncture to improve PTSD symptoms. It seems that acupuncture and/or Chinese herbal medicine could regulate the most abnormalities involved in the mechanisms of PTSD.
Amygdala, a structure in the brain, is involved in the expression of emotion, especially fear, autonomic reactions (e.g., increased heart rate and blood pressure, the startle response), and emotional memory. Dysfunction in this structure may produce symptoms of PTSD. Studies have shown that acupuncture can regulate this region of brain.
- Acupuncture produced extensive deactivation of the limbic-paralimbic-neocortical system in the medial prefrontal cortex, the temporal lobe (amygdala, hippocampus, and parahippocampus) and the posterior medial cortex and activates sensorimotor cortices, thalamus and occasional paralimbic structures.
- Acupuncture evoked short-term and long-term increases in MOR binding potential and sensory processing regions including amygdala.
- Acupuncture changes amygdala-specific brain network into a functional state that underlies pain perception and pain modulation, including anti-nociceptive, memory, and affective brain regions.
Hypothalamic-Pituitary-Adrenocortical (HPA) axis
Reactions to stress are regulated primarily via the HPA axis. When a healthy person is faced with a stressor, the activation of the hypothalamus results in the secretion of corticotropin-releasing hormone (CRH) and arginine vasopressin. These hormones quickly trigger pituitary release of adrenocorticotropin-releasing hormone (ACTH), which acts on the adrenal glands to prompt release of glucocorticoids into the bloodstream. Glucocorticoids (along with norepinephrine and epinephrine, released by the sympathetic nervous system) are primarily responsible for changes that occur in the body during a stressful situation to maximize one’s ability to deal with the stressor at hand. While glucocorticoids (notably, cortisol) are the main output of the human stress response, they are also critical for the termination of that response. Recognition of adequate glucocorticoid release results in a negative feedback loop whereby the hippocampus signals the hypothalamus to halt glucocorticoid release, thus ending the cascade.
- HPA axis: Studies have demonstrated that PTSD is associated with functional abnormalities of HPA axis and acupuncture regulates HPA axis.
- CRH and cortisol: PTSD patients have baseline high levels of corticotrophin releasing hormone (CRH) in CSF and low levels of cortisol in plasma and 24 h urine. Acupuncture decreases CRH23 and increases cortisol level.
- Norepinephrine and epinephrine: PTSD patients have elevated plasma norepinephrine and 24-hour urinary norepinephrine, which may be related to increased heart rate, increased startle reaction, and increased blood pressure as responses to traumatic slides, sounds and scripts. Studies demonstrate that acupuncture reduces plasma norepinephrine and epinephrine contents.
Serotonin (5-HT) system: connection of amygdala and HPA axis
Studies show that PTSD is associated with HPA axis dysfunctions and other brain-related structures, including amygdale. The amygdala is known to modulate the function of the HPA axis but the mechanism of this effect is still not clear. The studies suggest a mechanism by which the amygdala may modulate the function of the HPA axis via the serotonin (5-HT) system.
The brain 5-HT system is involved in the regulation of stress and anxiety and has been linked to the neurobiology of PTSD. Serotonin depletion may result from repeated exposure to severe stress and trauma, which may be a factor in the development of irritability and violent or angry outbursts in people with PTSD. Studies have shown that acupuncture increases plasma serotonin and stimulates the release of serotonin of brain.
Inflammation and dysfunction of immune function
PTSD is associated with inflammatory-related medical conditions. Studies suggest an excess of inflammatory actions of the immune system in individuals with chronic PTSD. High levels of inflammatory cytokines have also been linked to PTSD vulnerability in traumatized individuals. There is also evidence that excessive inflammation is in part due to insufficient regulation by cortisol. Following a trauma, the HPA axis is activated. In PTSD, the HPA axis is often dysregulated, resulting in altered cortisol activity and levels. A dysregulated HPA axis may result in excessive inflammation through insufficient regulation of immune function. Multiple studies have demonstrated that:
- Acupuncture reduces or eliminates inflammation
- Acupuncture regulates dysfunction of immune system
Hypothalamus-Pituitary-Thyroid (HPT) axis
HPT axis is stress-responsive, especially to traumatic stress. Studies show that PTSD patients have low level of plasma thyrotropin (TSH) and elevated total and the free fractions of triiodothyronine (T3) and thyroxine (T4), indicating HPT axis might be dysregulated in PTSD patients. Studies demonstrate that Chinese herbal formula, Ahnjeonbaekho-tang, reduces the levels of serum T3 and T4 and increase TSH level. Acupuncture or/and moxibustion can decrease prominently serum value of thyroxine.
Clinical studies of acupuncture and herbal medicine on PTSD
Acupuncture Improves Symptoms of PTSD. Wendling P. Family Practice News. 2009;39(4):17. Brief exposure to acupuncture significantly improved the symptoms of PTSD when this treatment was compared with usual care, in a randomized controlled trial in 55 veterans. 55 active-duty personnel with PTSD were randomized to usual care (medication or psychosocial therapy) or eight 90-minute of acupuncture sessions delivered twice weekly for 4 weeks, plus usual care. The acupuncture sessions, which included needling and patient-practitioner interaction, were standardized for the first four sessions and individualized for the second four sessions.
Compared with usual care, acupuncture was associated with significantly greater decreases in PTSD symptoms on Clinician-Administered PTSD Scale (CAPS) and PTSD Checklist-Civilian Version (PCL-C), and these improvements were maintained through the 12-week follow-up. The mean PCL-C decreases were 19.4 at the end of treatment and 19.8 at the 12-week follow-up in the acupuncture group, compared with 4.0 and 9.7 in the usual care group. Symptoms of depression and pain also significantly improved in the acupuncture group, compared with the usual care group. The 36-Item Short Form Health Survey (SF-36) scores for mental functioning improved significantly with acupuncture. There was a trend toward improvement in physical functioning on the SF-36, but it likely didn’t reach significance because the sample was fairly healthy physically and didn’t have much room to improve.
Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial. Hollifield M et al. Journal of Nervous & Mental Disease. 2007;95(6):504-13. The purpose of the study was to evaluate the potential efficacy and acceptability of acupuncture for posttraumatic stress disorder (PTSD). People diagnosed with PTSD were randomized to either an empirically developed acupuncture treatment (ACU), a group cognitive-behavioral therapy (CBT), or a wait-list control (WLC). The primary outcome measure was self-reported PTSD symptoms at baseline, end treatment, and 3-month follow-up. Repeated measures MANOVA was used to detect predicted Group X Time effects in both intent-to-treat (ITT) and treatment completion models. Compared with the WLC condition in the ITT model, acupuncture provided large treatment effects for PTSD (F [1, 46] = 12.60; p < 0.01; Cohen’s d = 1.29), similar in magnitude to group CBT (F [1, 47] = 12.45; p < 0.01; d = 1.42) (ACU vs. CBT, d = 0.29). Symptom reductions at end treatment were maintained at 3-month follow-up for both interventions. Acupuncture may be an efficacious and acceptable nonexposure treatment option for PTSD. Larger trials with additional controls and methods are warranted to replicate and extend these findings.
Developing a traditional Chinese medicine diagnostic structure for post-traumatic stress disorder. Sinclair-Lian N et al. Journal of Alternative & Complementary Medicine. 2006;12(1):45-57. BACKGROUND: Post-traumatic stress disorder (PTSD) is a common, disabling condition with many diverse symptoms including anxiety, depression, insomnia, and body pain. These symptoms are likely to be helped by treatment with Traditional Chinese Medicine (TCM); however, PTSD is not yet a recognized disorder (bing ming) in Chinese medicine. In preparation for a phase II clinical trial comparing TCM and cognitive behavioral therapy (CBT) treatment of PTSD symptoms, a TCM diagnostic pattern framework for persons who meet the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) definition of PTSD was sought. METHODS: Three approaches were used to identify the most likely TCM pattern differentiations for PTSD: an English-language TCM textbook review on the conditions “depression,” “anxiety,” and “insomnia”; a survey of 20 experienced practitioners of TCM; and TCM assessments of 21 individuals affected by PTSD. Two TCM practitioners synthesized the information into a list of pattern differentiations. RESULTS: The most likely pattern differentiations for PTSD were Heart Shen disturbance caused by Heat, Fire, or a constitutional deficiency; Liver Qi stagnation; and Kidney deficiency. Secondary patterns identified were outcomes of long-term Liver Qi stagnation-Liver overacting on Spleen/Stomach, Liver Fire, Phlegm Fire, Phlegm-Damp, and Heart Fire-and constitutional deficiencies in the Heart, Kidney, and Spleen organ systems. CONCLUSIONS: The use of extant literature, expert knowledge, and clinical TCM diagnoses contributed to the development of a TCM diagnostic structure for PTSD. The results can inform the clinical practice of TCM. The method can be used to guide research design involving different diagnostic systems.
Integrating complementary therapies into community mental health practice: an exploration. Collinge W et al. Journal of Alternative & Complementary Medicine. 2005;11(3):569-74. OBJECTIVES: To (1) describe the integration of massage and energy-based therapies with psychotherapy in a community mental health center, (2) to present qualitative feedback on the service, and (3) to present pilot data from a sample of long-term clients with persistent mental health concerns. DESIGN: A noncontrolled pilot study was conducted using interview data before and self-report instruments after completing a brief program of complementary therapy accompanying ongoing psychotherapy. SETTINGS/LOCATION: The program took place at a comprehensive community mental health center in southern Maine and in the private offices of massage therapists and energy healing practitioners who contracted with the program. SUBJECTS: Subjects were 20 women and 5 men, with mean age of 42 years and a mean history of 7.4 years of mental health treatment. All had histories that included trauma, 10 of which involved sexual abuse. The Diagnostic and Statistical Manual of Mental Disorders IV Axis I diagnoses were PTSD (10), major depression (nine), anxiety disorder (three), and dual diagnosis (three). INTERVENTIONS: Clients receiving ongoing psychotherapy were assigned to one modality of complementary therapy based on clinical judgment, availability of practitioners, and client interest. Modalities used were massage, acupuncture, Reiki, and Healing Touch. The mean number of sessions was five. OUTCOME MEASURES: Clients completed an investigator-generated instrument with Likert-scaled ratings of satisfaction and perceived changes in four dimensions of trauma recovery: perceived interpersonal safety, interpersonal boundary setting, bodily sensation, and bodily shame. RESULTS: Clients reported high levels of satisfaction with the service and significant levels of perceived (self-rated) change on each outcome measure. Qualitative results included enhanced psychotherapeutic outcomes reported by mental health clinicians. CONCLUSIONS: The integration of complementary therapies into community mental health practice may hold promise of enhancing mental health outcomes and improving quality of life for long-term users of mental health services.
Free and Easy Wanderer Plus (FEWP), a polyherbal preparation, ameliorates PTSD-like behavior and cognitive impairments in stressed rats. Wang HN et al. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2009;33(8):1458-63. Free and Easy Wanderer Plus (FEWP) is a well-known traditional Chinese medicine that has been shown to be effective in treating various mood disorders. The purpose of the present study was to determine whether FEWP could ameliorate stress-associated behavior in rats. Following the exposure to enhanced single prolonged stress (ESPS) paradigm, consisting of 2-hr constraint, 20-min forced swimming, ether-induced loss of consciousness, and an electric foot shock, animals were administered orally with FEWP (2.5, 5, or 10mg/kg daily) or vehicle for 2 weeks. Animals were then tested in the open field, elevated plus-maze, and Morris water maze. ESPS exposure resulted in pronounced anxiety-like behavior, without impairing locomotor activity, as indicated by significant decreases of time spent and number of entries into open arms in the elevated plus-maze test, and unaltered distance traveled in the open field test compared to unexposed animals. ESPS-exposed animals also displayed marked cognitive impairments, with significant increases of distance traveled and the escape latency to the underwater platform, and a striking decrease of time spent in the target quadrant with and without the removal of the platform in the water maze test. However, repeated treatment with FEWP, particularly at higher doses, reversed the aforementioned behavioral values in the elevated plus-maze and water maze tests to the levels similar to unexposed animals. These results indicate that FEWP possesses anxiolytic and cognition-improving effects and may be an effective herbal preparation for the treatment of stress-associated conditions, such as posttraumatic stress disorder (PTSD).
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