A Review of Select CAM Modalities for the Prevention and Treatment of PTSD

The personal, social, and economic burden of human suffering related to PTSD are major issues facing society. Conventional pharmacotherapy and psychotherapy reduce the severity of some PTSD symptoms; however, their effectiveness is limited, and many patients discontinue these pharmacological and psychotherapeutic treatments before achieving full remission. The limited effectiveness of conventional approaches and unmet treatment needs of patients provide compelling arguments for effective conventional and complementary and alternative medicine (CAM) interventions aimed at preventing PTSD and treating chronic PTSD.

[[{"type":"media","view_mode":"media_crop","fid":"25947","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7524994072267","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2455","media_crop_rotate":"0","media_crop_scale_h":"204","media_crop_scale_w":"200","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; height: 179px; width: 175px;","title":" ","typeof":"foaf:Image"}}]]CAM perceptions and use trends

Recent findings indicate that CAM therapies are used by more than 50% of patients who have PTSD.¹ CAM use among veterans and the civilian population is comparable and ranges between 23% and 50%, depending on the type of CAM and the population surveyed.²

A survey of 170 VA programs that specialize in PTSD treatment found that 96% of programs offered at least one CAM modality: mindfulness (88%), stress management/relaxation training (63%), progressive muscle relaxation (75%), yoga (63%), guided imagery (50%), or spiritual practices or therapy (50%).³ CAM therapies were typically offered in the context of ongoing conventional treatment, including psychotherapy and medication management.

These findings suggest that CAM use is widespread among veterans in specialized PTSD programs; however, they are limited by the absence of specific data (eg, number of veterans treated using particular CAM approaches, frequency of treatment, outcomes). Acupuncture and meditation are supported by the highest level of evidence; mindfulness approaches, on the other hand, have not been thoroughly investigated. Additional research to evaluate the comparative efficacy of different meditation techniques in PTSD as well as to identify CAM therapies to combine with existing pharmacological or psychological treatments to improve treatment response is needed.⁴

Meditation and mind-bodyapproaches

Mindfulness training, mantra reciting, and compassionate meditation (ie, Vipassana) have been evaluated for their effectiveness in persons with PTSD. More evidence supports mindfulness meditation than mantra reciting or compassionate meditation.⁵ The majority of studies on mindfulness have consisted of persons with generalized anxiety disorder (GAD) rather than PTSD, and the outcomes may not generalize to PTSD.

Mindfulness training may reduce symptoms of PTSD: increased control over attention permits increased control over intrusive thoughts or memories. Patients are trained to shift attention from remembered fears to problem solving focused in the present.

The therapeutic benefits of mantra meditation may be related to the effects of repetitive chanting that reduces the level of arousal and consequently permits improved emotional self-regulation. Compassion meditation may reduce symptoms of PTSD (or other anxiety disorders) by reducing negative emotions and reactivity to stressful circumstances. Improved coping is achieved through enhanced resilience, and group meditation practice provides better social connections. Veterans with PTSD who practiced transcendental meditation experienced significant improvements in overall quality of life and reductions in core symptoms.⁶

Future studies on the therapeutic effects of meditation in PTSD should more clearly define the meditation practices being studied and should use validated instruments that reliably measure targeted outcomes. Important unanswered questions remain about the physiological, behavioral, and psychological mechanisms that underlie the different meditation practices. The advantages of meditation for PTSD include ease of training, low cost, and practical implementation in group settings.

Traditional Chinese medicine

Chinese medicine and contemporary biomedicine use similar conceptual schemata to characterize the phenomenology and biological mechanisms of PTSD.⁷ Acupuncture is inexpensive, safe, and easy to provide in military field conditions. In their study of acupuncture as a treatment for PTSD, Hollifield and colleagues⁸ found statistically significant differences between the acupuncture and wait-list group but nonsignificant differences between the acupuncture and cognitive-behavioral therapy (CBT) groups. Patients who received acupuncture or CBT continued to report clinical improvements in PTSD symptoms 3 months after study end point.

A meta-analysis of pooled findings showed superiority of a combined regimen of acupuncture and moxibustion over SSRIs and superiority of acupoint stimulation plus CBT over CBT alone in reducing PTSD symptoms.⁹ Greater, but nonsignificant, improvement was also seen in PTSD patients who received acupuncture than in those who received SSRIs; more favorable responses were seen with combined acupuncture plus CBT than with CBT alone; and greater improvement was seen with acupuncture plus moxibustion than with SSRIs. These findings provide promising but preliminary evidence that acupuncture may reduce core symptoms of PTSD.

Promising results were seen for acupuncture in reducing the severity of symptoms that are often comorbid with PTSD (eg, headaches, anxiety, fatigue, sleep disturbances, depression, chronic pain) in active-duty military personel.¹⁰ Other findings suggest that acupuncture may be a practical and effective treatment of PTSD in emergency department settings.¹¹ In contrast to conventional pharmacological therapy, the adverse effects of acupuncture are mild and infrequent.¹²

Large sham-controlled trials and comparative studies of acupuncture and CBT or SSRIs are indicated before acupuncture can be generally recommended to treat PTSD. To date, the results have been restricted by inclusion criteria that have limited the number of study participants, the absence of sham-controlled studies, the use of different study designs across trials, and poor study design.

Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is a psychological approach widely used to treat PTSD; however, research findings are mixed. Studies of EMDR treatment for PTSD show promising results.^13,14 Symptom severity decreased after 3 months of treatment. Efficacy was comparable to exposure therapy and superior to relaxation training.

Persons with PTSD who were randomized to EMDR or emotional freedom technique experienced equivalent significant improvements at study end and at the 3-month follow-up.¹⁵ Although more studies are needed to verify these findings and help determine when it is appropriate to refer patients with PTSD to EMDR, these outcomes justify large sham-controlled trials.

Virtual reality exposure therapy

Considerable research efforts are ongoing to develop virtual reality tools for assessing, preventing, and treating combat-related PTSD. Virtual reality exposure therapy (VRET) uses high-end computer graphics, 3-dimensional displays, and multisensory feedback to create a computer-generated environment that results in intense feelings of immersion and presence.

Sessions are guided by a therapist who regulates the virtual scenario to achieve the appropriate intensity of arousal for the patient. Repeated exposure results in habituation to a particular fear-inducing environment (ie, reduced autonomic arousal), extinction of fear response, and reduction in severity of PTSD symptoms.

Results from a study on combined multisensory exposure and VRET showed significant reductions in severity of PTSD symptoms in active-duty military personnel who had failed to respond to other forms of exposure therapy.¹⁶ Several patients in the study reported significant improvement following only 5 VRET sessions. However, there was considerable variability in the number of sessions needed to reduce symptom severity to a similar level in other study participants.

In addition to uses of VRET for the treatment of established PTSD, virtual reality applications are being developed to assess the risk for PTSD as well as mental resilience training to prevent PTSD.¹⁷ Preliminary findings suggest that combining virtual reality environments with real-time feedback based on neurophysiological responses to stress may permit each patient to optimize the level and type of exposure to enhance resiliency training and speed the rate of recovery from PTSD.¹⁸

Cardiac coherence training and EEG biofeedback

Promising findings are emerging in 2 specialized types of biofeedback used to treat PTSD: cardiac coherence training based on heart rate variability monitoring and electroencephalographic (EEG) biofeedback. Abnormal low heart rate variability is associated with deficits in attention and short-term memory in combat veterans. In EEG biofeedback, or neurofeedback, the individual is rewarded only when specific EEG frequencies corresponding with a more regulated mental or emotional state take place. Participants who received training in heart rate variability monitoring while undergoing relaxation training had improvements in attention and short-term memory.¹⁹

Heart rate variability biofeedback may reduce symptom severity in chronic PTSD; however, results from the two studies completed to date are inconsistent.^20,21 In a small pilot study, 7 veterans with treatment-refractory PTSD who received regular EEG biofeedback reported significant reductions in symptom severity.²² Recent research findings suggest that neurofeedback at frequencies between 0.02 and 0.2 Hz is associated with rapid dramatic reductions in the severity of PTSD symptoms.^23,24

Omega-3

The pathogenesis of PTSD may be related to neural processes that underlie the consolidation of fear memories of trauma in the hippocampus.²⁵ Symptoms of PTSD may develop when consolidation of intense fear memories takes place in the absence of neural mechanisms that permit extinction. Increasing hippocampal neurogenesis soon after trauma may result in more rapid clearance of fear memories and interfere with consolidation of immediate posttrauma memories into long-term memories. Daily supplementation with omega-3 fatty acids may significantly reduce the severity of PTSD symptoms resulting from accidental injury.^26,27

Dehydroepiandrosterone

Dehydroepiandrosterone (DHEA) is a prohormone that may protect against cortisol-induced hippocampal atrophy.²⁸ Increased severity of PTSD is correlated with reduced blood DHEA levels.²⁹ In a small open-label study (N = 5), women with treatment-refractory PTSD related to early childhood abuse experienced decreases in numbing, re-experiencing, hyperarousal, and other core symptoms, as well as improved sleep and improved libido with DHEA at dosages between 25 and 100 mg/d.³⁰

Multinutrient supplements

Emerging findings suggest that taking a multinutrient supplement containing vitamins, minerals, amino acids, and antioxidants before exposure to trauma may increase emotional resilience and reduce the severity of PTSD symptoms following exposure. Adults enrolled in a study on a proprietary micronutrient formula for ADHD at the time of a major New Zealand earthquake reported feeling significantly less anxious and stressed than matched adults not taking the supplement.³¹ Measured outcomes using micronutrient formulas were found to be comparable to those observed with conventional medications, behavioral therapy using an earthquake simulator, and eye movement desensitization and reprocessing, but with fewer adverse effects and better retention rates.^32-35 However, these findings are limited by small study size and the absence of a placebo group, blinding, and randomized protocols.

Lucid dreaming training

Training in lucid dreaming methods involves 4 to 6 weeks of daily dream journaling and weekly sessions for training in lucid dream induction techniques that focus on insights related to themes of recurrent nightmares. Lucid dreaming techniques, including “dialoguing with” or “physically embracing” dream characters, are designed to reduce feelings of helplessness and terror and help the patient learn that he or she can control frightening images or experiences that are associated with past trauma.

Lucid dreaming is a unique state of consciousness in which an individual is self-aware while dreaming and is able to change or control dream content.³⁶ Trauma survivors frequently have recurring vivid nightmares that may represent a dream-anxiety syndrome. Lucid dream induction techniques have been found to reduce the frequency and intensity of nightmares related to memories of trauma and to lessen the severity of PTSD symptoms.^37,38

“Energetic” and spiritual approaches

Spiritual and energy healing methods used to treat PTSD include thought field therapy, emotional freedom technique, healing touch, qigong, Reiki, specific spiritual methods in Ayurvedic and Tibetan medicine, and shamanic ritual healing. The therapeutic mechanism of these methods has not been established; however, numerous psychological, biological, and possibly subtle energetic processes may be associated with these approaches to provide beneficial outcomes. Quantum mechanics may help explain postulated subtle effects of energy healing or directed human intention on health and illness.³⁹

Energy psychology is a rapidly growing field based on conventional psychological theory and Chinese medical theory. It is based on the assumption that energetic imbalances in the meridians manifest as emotional or mental symptoms. Thought field therapy and emotional freedom technique are specific approaches used in energy psychology to treat a range of mental health problems.

In thought field therapy, the patient is asked to invoke a “thought field” associated with a traumatic memory after which the thought field therapy practitioner reattunes energetic imbalances manifesting as persisting memories of trauma by gently tapping on specific acupuncture points. Emotional freedom technique is a simplified version of thought field therapy that uses only one routine for stimulating acupuncture points. Limited evidence from case reports suggest that emotional freedom technique may have beneficial effects.

Emotional freedom technique has been evaluated in the treatment of phobias, GAD, and PTSD that may be poorly responsive to exposure therapy. The technique is manualized and can be easily self-administered following a brief training session. An advantage of emotional freedom technique over conventional exposure therapies is avoidance of the risk of retraumatization through in vivo exposure.

Few controlled studies have evaluated emotional freedom technique as a treatment of PTSD, and findings are limited by the absence of sham arms in most studies, small study size, methodological flaws, and inconsistent outcomes.⁴⁰ During several 6-week retreats, veterans with PTSD and their spouses (many of whom also had PTSD) participated in a multimodal intervention involving emotional freedom technique and other energy psychology approaches together with a range of CAM approaches for stress reduction.⁴¹ The participants experienced significant reductions in PTSD symptom severity as measured by the PTSD checklist, and these gains were maintained by veterans-but not spouses-on follow-up.

In a 2-week study, veterans with PTSD who underwent craniosacral therapy and somatoemotional release experienced significant improvements in symptoms of physical distress, depressed mood, anxiety, guardedness, and behavioral isolation.⁴² These findings, however, are limited by the small study size, the absence of a sham treatment arm, absence of follow-up, and nonstandardized outcome measures.

References:

1. Libby DJ, Pilver CE, Desai R. Complementary and alternative medicine use among individuals with posttraumatic stress disorder. Psychol Trauma. 2013;5:277-285.

2. Micek MA, Bradley KA, Braddock CH 3rd, et al: Complementary and alternative medicine use among Veterans Affairs outpatients. J Altern Complement Med. 2007;13:190-193.

3. Libby DJ, Pilver CE, Desai R. Complementary and alternative medicine in VA specialized PTSD treatment programs. Psychiatr Serv. 2012;63:1134-1136.

4. VA Research Currents. Meeting convened by VA R&D seeks to expand study of complementary, alternative therapies for PTSD. May-June 2011. http://www.research.va.gov/resources/pubs/docs/va_research_currents_mayjune_11.pdf. Accessed June 10, 2014.

5. Lang AJ, Strauss JL, Bomyea J, et al. The theoretical and empirical basis for meditation as an intervention for PTSD. Behav Modif. 2012;36:759-786.

6. Rosenthal JZ, Grosswald S, Ross R, Rosenthal N. Effects of transcendental meditation in veterans of Operation Enduring Freedom and Operation Iraqi Freedom with posttraumatic stress disorder: a pilot study. Mil Med. 2011;176:626-630.

7. Hollifield M. Acupuncture for posttraumatic stress disorder: conceptual, clinical, and biological data support further research. CNS Neurosci Ther. 2011;17:769-779.

8. Hollifield M, Sinclair-Lian N, Warner TD, Hammerschlag R. Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial. J Nerv Ment Dis. 2007;195:504-513.

9. Kim YD, Heo I, Shin BC, et al. Acupuncture for posttraumatic stress disorder: a systematic review of randomized controlled trials and prospective clinical trials. Evidence-Based Complement Altern Med. 2013. http://www.hindawi.com/journals/ecam/2013/615857/. Accessed June 10, 2014.

10. Lee C, Crawford C, Wallerstedt D, et al. The effectiveness of acupuncture research across components of the trauma spectrum response (TSR): a systematic review of reviews. Syst Rev. 2012;1:46.

11. Fleckenstein J, Schottdorf J, Kreimeier U, Irnich D. Acupuncture in emergency medicine: results of a case series [in German]. Anaesthesist. 2011;60:854-862.

12. White A, Hayhoe A, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ. 2001;323:485-486.

13. Shepherd J, Stein K, Milne R. Eye movement desensitization and reprocessing in the treatment of post-traumatic stress disorder: a review of an emerging therapy. Psychol Med. 2000;30:863-871.

14. Hertlein KM, Ricci RJ. A systematic research synthesis of EMDR studies: implementation of the platinum standard. Trauma Violence Abuse. 2004;5:285-300.

15. Karatzias T, Power K, Brown K, et al. A controlled comparison of the effectiveness and efficiency of two psychological therapies for posttraumatic stress disorder: eye movement desensitization and reprocessing vs. emotional freedom techniques. J Nerv Ment Dis. 2011;199:372-378.

16. Reger GM, Holloway KM, Candy C, et al. Effectiveness of virtual reality exposure therapy for active duty soldiers in a military mental health clinic. J Trauma Stress. 2011;24:93-96.

17. Vakili V, Brinkman WP, Neerincx MA. Lessons learned from the development of technological support for PTSD prevention: a review. Stud Health Technol Inform. 2012;181:22-26.

18. Repetto C, Gorini A, Vigna C, et al. The use of biofeedback in clinical virtual reality: the INTREPID project. J Vis Exp. 2009;12:1554.

19. Ginsberg JP, Berry ME, Powell DA. Cardiac coherence and posttraumatic stress disorder in combat veterans [published correction appears in Altern Ther Health Med. 2010;16(5):11]. Altern Ther Health Med. 2010;16(4):52-60.

20. Tan G, Dao TK, Farmer L, et al. Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): a pilot study. Appl Psychophysiol Biofeedback. 2011;36:27-35.

21. Lande RG, Williams LB, Francis JL, et al. Efficacy of biofeedback for post-traumatic stress disorder. Complement Ther Med. 2010;18:256-259.

22. Nelson DV, Esty ML. Neurotherapy of traumatic brain injury/posttraumatic stress symptoms in OEF/OIF veterans. J Neuropsychiatry Clin Neurosci. 2012;24:237-240.

23. Legarda SB, McMahon D, Othmer S, Othmer S. Clinical neurofeedback: case studies, proposed mechanism, and implications for pediatric neurology practice. J Child Neurol. 2011:26:1045-1051.

24. Othmer S. Psychological health and neurofeedback: remediating PTSD and TBI. EEG Institute. January 2, 2012. http://www.eeginfo-europe.com/fileadmin/images/research/anxiety/RemediatingPTSD_TBI.pdf. Accessed June 10, 2014.

25. Ressler KJ, Mayberg HS. Targeting abnormal neural circuits in mood and anxiety disorders: from the laboratory to the clinic. Nat Neurosci. 2007;10:1116-1124.

26. Matsuoka Y, Nishi D, Yonemoto N, et al. Omega-3 fatty acids for secondary prevention of posttraumatic stress disorder after accidental injury: an open-label pilot study. J Clin Psychopharmacol. 2010;30:217-219.

27. Matsuoka Y, Nishi D, Yonemoto N, et al. Potential role of brain-derived neurotrophic factor in omega-3 fatty acid supplementation to prevent posttraumatic distress after accidental injury: an open-label pilot study. Psychother Psychosom. 2011;80:310-312.

28. Sapolsky RM. Glucocorticoids and hippocampal atrophy in neuropsychiatric disorders. Arch Gen Psychiatry. 2000;57:925-935.

29. Rasmusson AM, Vasek J, Lipschitz DS, et al. An increased capacity for adrenal DHEA release is associated with decreased avoidance and negative mood symptoms in women with PTSD. Neuopsychopharmacology. 2004;29:1546-1557.

30. Sageman S, Brown RP. 3-acetyl-7-oxo-dehydroepiandrosterone for healing treatment-resistant posttraumatic stress disorder in women: 5 case reports. J Clin Psychiatry. 2006;67:493-496.

31. Rucklidge J, Johnstone J, Harrison R, Boggis A. Micronutrients reduce stress and anxiety in adults with attention-deficit/hyperactivity disorder following a 7.1 earthquake. Psychiatry Res. 2011;189:281-287.

32. Onder E, Tural U, Aker T. A comparative study of fluoxetine, moclobemide, and tianeptine in the treatment of posttraumatic stress disorder following an earthquake. Eur Psychiatry. 2006;21:174-179.

33. Basoglu M, Salcioglu E, Livanou M. A randomized controlled study of single-session behavioural treatment of earthquake-related post-traumatic stress disorder using an earthquake simulator. Psychol Med. 2007;37:203-213.

34. Konuk E, Knipe J, Eke I, et al. The effects of eye movement desensitization and reprocessing (EMDR) therapy on posttraumatic stress disorder in survivors of the 1999 Marmara, Turkey, earthquake. Int J Stress Manag. 2006;13:291-308.

35. Abbasnejad M, Mahani KN, Zamyad A. Efficacy of “eye movement desensitization and reprocessing” in reducing anxiety and unpleasant feelings due to earthquake experience. Psychol Res. 2007;9:104-117.

36. LaBerge S, Rheingold H. Exploring the World of Lucid Dreaming: A Workbook of Dream Exploration and Discovery That Will Help You Put the Ideas in Lucid Dreaming Into Practice. New York: Ballantine Books; 1990.

37. Brylowski A. Nightmares in crisis: clinical applications of lucid dreaming techniques. Psychiatr J Univ Ott. 1990;15:79-84.

38. Brylowski A. Lucid dreaming as a treatment for nightmares in posttraumatic stress of Vietnam combat veterans. Paper presented at: Meeting of the Southern Association for Research in Psychiatry; April 1991; Tampa, FL.

39. Hankey A. Are we close to a theory of energy medicine? J Altern Complement Med. 2004;10:83-86.

40. Herbert JD, Gaudiano BA. The search for the holy grail: heart rate variability and thought field therapy. J Clin Psychol. 2001;57:1207-1214.

41. Church D, Brooks AJ. CAM and energy psychology techniques remediate PTSD symptoms in veterans and spouses. Explore (NY). 2014;10:24-33.

42. Zonderman R. The Upledger Foundation Vietnam Veteran Intensive Program. Palm Beach, FL: The Upledger Institute; 2000.