Acupuncture and Post-traumatic Stress Disorder (PTSD)
Anxiety disorders are the most prevalent psychiatric illnesses in the community and may be present in up to 20% of clinic patients. Post-traumatic stress disorder (PTSD) is a syndrome characterized by anxiety following exposure to extreme traumatic events such is threat of personal death, personal injury, or death of loved ones. The reaction that occurs shortly after the trauma is called acute stress disorder but if one has a delayed or recurring response it is characterized as PTSD. Common symptoms of PTSD include:
- Loss of emotional responsivity
- Unable to recall aspects of trauma
- Recurrence of trauma in thoughts, dreams, flashbacks
- Exaggerated startle response
While the trigger for PTSD is a traumatic event, a number of risk factors including past psychiatric history, neuroticism, and genetic influence may increase a person’s risk for PTSD.
Treatments for acute stress include short-term use of benzodiazepines and supportive psychotherapy. However, treatment for PTSD is more complex and clinicians often utilize both pharmacologic and behavioral treatments. Common drugs used may include tricyclic antidepressants, selective serotonin reuptake inhibitors, sedatives and monoamine oxidase inhibitors. Psychotherapy is also commonly indicated and 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.
Acupuncture and Traditional Chinese Medicine
Acupuncture has been indicated as a potential complementary treatment for PTSD however limited data exists in the literature. Despite this, I discuss two important papers below, one prospective clinical trial of acupuncture in patients with PTSD and another that piloted the addition of acupuncture services in a pre-existing local clinic treatment patients with PTSD.
1. Hollifield M, et al. Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial.
Briefly the purpose of this study was to evaluate the efficacy of acupuncture for PTSD.
Methods: Prospective pilot RCT comparing acupuncture to group cognitive behavioral therapy (CBT) to a wait-list control. Acupuncture was conducted 2/week for one hour. CBT was conducted 1/week for 2 hours.
- Standardized acupuncture for all subjects + a few flexibly prescribed points dependant on individual patient characteristics
- Front points: PC6, HT7, ST36, SP6, yin tang
- Back points: GB20, UB14, UB15, UB18, UB20, UB21, UB23
- A group of 15 other points from which up to 3 flexibly prescribed points could be added
- Ear seeds: Shenmen, sympathetic, liver, kidney, lung
Cognitive Behavioral Therapy Intervention:
- Integration of 4 modalities that demonstrate efficacy for PTSD including:
-“Trajectory and Resource Loss Stabilization”: psycho education, behavioral activation, activity
- All sessions delivered with a standard approach of agenda setting, education, review of previous sessions and homework
Outcomes: Self-reported measures at beginning, mid, endpoint and 1 and 3 month follow up periods
- Primary: Change in PTSD based on the Posttraumatic symptoms scale-self report (PSS-SR)
- Secondary: Depression, anxiety, impairment in daily functioning and satisfaction using the Ho Symptoms Checklist-25 (HSCL-25) and the Sheehan Disability Index (SDI)
- Primary: Acupuncture (ACU) provided a large treatment effect for PTSD which was similar to cognitive behavioral therapy and both were significantly better than the wait listed control (p<0.01, p<0.01, ACU, CBT respectively). PSS-SR scores declined significant from baseline to the end of treatment in both the acupuncture and the CBT groups (p<0.01, p<0.01 ACU, CBT respectively)
- Both ACU and CBT improved significantly more that the WLC.
- ACU and CBT subjects expressed the same levels of satisfaction with care.
-ACU compared to CBT strongly agreed that they felt good about doing what they were supposed to do between treatment sessions
-CBT strongly agreed that they understood the reason for the treatment they received better than the ACU group
Conclusions: Acupuncture may be an acceptable treatment for subjects with PTSD and more trials need to be done in order to determine how acupuncture can work alone or in combination with CBT as well as its potential mechanism of action.
2. Pease M, Acupuncture for refugees with posttraumatic stress disorder: initial experiences establishing a community clinic. Explore (NY). 2009 Jan-Feb;5(1):51-4.
This article describes the establishment of an acupuncture clinic and the feasibility of providing free acupuncture treatment to refugees, asylum seekers and internationally displaced people suffering from PTSD. The background includes thorough discussion on treating PTDS from a Traditional Chinese Medicine (TCM) perspective such as the potential advantage of offering individualized treatment as well utilization of the holistic treatment tenet that addresses both physical and mental symptoms.
Feasibility and development of the PTSD model clinic
The authors describe an existing organization, a PTSD clinic for Boston-based refugees and discuss how they began conversation about implementing acupuncture treatment as a new service. An important initial concern that was raised was the appropriateness of implementing a treatment that involved needles in an already traumatized group of people. This concern was addressed by piloting acupuncture treatment in the staff members and staff education although data was not collected on how many patients denied acupuncture treatment based on fear of the needles.
TCM/Acupuncture assessments for patients
1. Phase One: Assessment that involved meeting with case /worker to review trauma history and cultural background
2. Phase Two: Intake involving reviewing of patient’s rights with caseworker, patient and translator (if necessary). TCM diagnostic intake.
3. Phase Three: Treatment plan utilizing TCM diagnosis.
4. PTSD Protocols: National acupuncture detoxification association (NADA) protocol used in all treatments. Common use of extraordinary vessel acupuncture treatment.
- 111 treatments preformed on 16 patients from 13 countries
- Most commonly reported symptoms were pain (chronic pelvic pain, back pain) followed by mental-emotional symptoms (recurrent nightmares, anxiety)
- Most common TCM diagnoses: Liver qi stagnation and Shen disturbance
- No prospective clinical measures but self-reported reduction in symptoms in 14 of 16 patients
Initial barriers to inclusion of acupuncture/TCM in an established clinic for patients with PTSD were present however, case reports and assessment of feasibility demonstrate that prospective study and continued study on set up and/or inclusion logistics are warranted.
Active services offering acupuncture for PTSD
A number of excellent examples of acupuncture services exist for organizations that treat people suffering from PTSD. For example in New York State, the 9/11 Mental Health and Substance Abuse Benefit, funded through Red Cross resources, included auricular acupuncture as a covered benefit. Patients treated under this benefit described a number of positive results following auricular treatment including:
• improved sleep
• reduction in anxiousness
• reduction in cravings for alcohol and other substances that induced relaxation or stress relief
Other initiatives related to treating people suffering from PTSD following events such as 9/11and Hurricane Katrina include a couple of groups, CRREW: Community Relief and Rebuilding through Education and Wellness and Serving Those Who Serve, a nonprofit organization dedicated to the health and well being of Ground Zero rescue, recover and relieve workers and volunteers and Acupuncturists without borders, another non-profit that aims to provide immediate relief and recovery acupuncture services to global communities that are in crisis from disaster or human conflict.
Harrison’s Principles of Internal Medicine. 17th Edition, McGraw Hill.
Hollifield M, Sinclair-Lian N, Warner TD, Hammerschlag R. Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial. J Nerv Ment Dis. 2007 Jun;195(6):504-13.
Pease M, Sollom R, Wayne P. Acupuncture for refugees with posttraumatic stress disorder: initial experiences establishing a community clinic. Explore (NY). 2009 Jan-Feb;5(1):51-4.
CRREW: http://www.crrew.org/joomla/, Viewed November 17, 2009
Serving those who serve: http://www.stws.org/, Viewed November 18, 2009
New York State 9/11 Health Benefit: http://www.nyc.gov/html/doh/wtc/html/mhb/mhb.shtml, Viewed November 18, 2009
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