创伤后应激障碍 PTSD - POST TRAUMATIC STRESS DISORDER

ABSTRACT

Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that develops after exposure to a terrifying event in which grave physical harm occurred or was threatened. PTSD can occur in people of any age, including children and adolescents, and more than twice as many women than men following exposure to trauma. Depression, substance abuse and alcohol, or other anxiety disorders frequently occur along with PTSD. The diagnosis requires that symptoms be present for at least a month, and that they seriously interfere with leading a normal life. Symptoms may be individual or in conjunction with each other.^[1]

This case study describes the acupuncture and Chinese herbal and biomedical integrative treatment of a 37-year-old male with PTSD, veteran of the Iraq war. The patient underwent treatment with TCM for a period of four years, and during that time he was able to overcome the symptoms to a 95% recovery that allowed him to eliminate the use of pharmaceuticals, and to continue treatment with Chinese medicine for maintenance and other minor unrelated ailments. Chinese medicine offers a cogent theoretical basis for assessing and clinically managing patients presenting with mental health issues. TCM principles integrate well with other systems, including Western medicine.

INTRODUCTION

Among circumstances that may cause PTSD are violent personal assault, torture, sexual assault, natural or human-caused disasters, accidents, unexpected life-altering events, immigration after fleeing violence, arrests, incarceration, sudden forced separation from loved ones ─especially children, people who witness traumatic incidents, or military combat.

Common physical indexes of PTSD include, but are not limited to, reliving the event through upsetting thoughts, nightmares, or flashbacks, avoiding activities, thoughts, feelings or conversations that remind the person of the experience; being unable to remember details of the episode, or obsessing over minutes details of it, inability to feel normal emotions; loss of interest, feeling all alone, or having feelings of hopelessness; feeling that one can never relax and must be on guard all the time to protect oneself. Suffering from headaches, gastrointestinal distress, trouble sleeping, immune system vulnerability, dizziness, irritability, chest pain, and trouble concentrating. Patients are often treated without connecting their symptoms to PTSD.

Treatment may be through cognitive-behavioral therapy, group therapy, and/or exposure therapy, in which the patient gradually and repeatedly re-lives the frightening experience under controlled conditions to help the person work through the trauma.

Several types of medication, particularly the selective serotonin reuptake inhibitors (SSRIs) and Complementary medicine, such as Chinese medicine, meditation, yoga, Qigong, can help relieve the illness.^[2]

CHINESE MEDICINE PERSPECTIVE

In classical Traditional Chinese medicine theory (TCM), assessing and treating spiritual disharmonies is fundamental for dealing with emotional disorders, and Traditional Chinese medicine  and acupuncture provide a wide range of therapeutic applications. Thus, TCM principles are applicable to the treatment of psychiatric disorders. 

References to the application of TCM to psychiatric disorders date to the Su Wen of the Huang Di Nei Jing or Fundamental Questions of the Yellow Emperor’s Inner Classic. The Nei Jing asserts that the nature of any entity, living or not, is determined by the intrinsic balance between opposing states. Yin & Yang disturbances in balance result in changes in nature, often expressed in living systems in the form of signs and symptoms of disease. TCM treatments are intended to restore balance, and this is accomplished by influencing Qi, or vital energy.

In the TCM paradigm, Qi flows through channels in the body and in the spaces between muscles and the skin. Qi has many functions including warming, moistening, and nourishing; promoting normal function of the organs; providing energy for different processes; regulating and protecting the body and ensuring that organs remain in their proper positions. The role of Qi is to course unencumbered and maintain balance, and in this sense, it is a homeostatic mechanism by which the body can heal itself and establish a state of wellness.

If Qi encounters a YinYang imbalance, it corrects it by transforming one to the other, thus restoring balance and harmony. If, however, a blockage exists that impedes the flow of Qi, or a factor is present that is interfering with the Qi, or if there is a Deficiency of Qi, this healing transformation of Yin & Yang does not take place. Acupuncture techniques then opens the meridians for Qi to course unencumbered and expel pathogenic factors interfering with normal processes; and for boosting Qi in cases of Deficiency.

In TCM, psychiatric disorders frequently relate to energetic disharmonies involving the Five Spirits. These are the Hun or noncorporeal spirit, the Po or corporeal spirit, the Zhi or will, the Yi or intellect, and the Shen or mind and the connecting spirit.

The Five Spirits

HUN: The Hun is associated with the Liver Qi. Hun is called noncorporeal, because it is not dependent upon the physical being for existence and continues after death. This spirit is responsible for benevolence ─loving kindness, awareness of suffering, empathy, compassion, and tolerance; and serves as a reservoir for ideas that bring meaning into life. Disharmonies that affect the Hun may lead to anger, frustration, resentment, unkindness, and feeling “cut-off” from the meaning of life.

PO: The Po exists only during physical life. It is associated with the Lung Qi, the Po animates the being, is responsible for sensation and for emotional and physical responses to circumstances; it promotes justice and fairness. Disharmonies of the Po may lead to complicated grief, sadness, a blunted affect, a tendency to overreact, or unjust/immoral behavior.

ZHI: The Zhi is the will, i.e., the force that determines the basic trajectory in life. Zhi is the spiritual aspect that resides in the Kidneys. The Yang, or active Zhi provides the motivation for self-determination and the Yin, or passive Zhi leads one down the path to an unknowable fate. Disharmony may cause illogical fears or, the opposite, reckless behavior.

YI: The Yi is the intellect. It is the platform for conscious reasoning. The Yi enables proper courses of action. The Yi is associated with the Spleen, and disharmonies may lead to worry and overthinking ─perseverance.

SHEN: By allowing the inner being to connect with the outer world, and the outer world to connect with the inner being, the Shen might be considered the “connector spirit.” In that sense, it is responsible for both inward and outward expressions of spiritual nature and for the establishment of meaningful relationships. It is also the mind, where thoughts and feelings are experienced. Associated with the Heart Qi, disharmonies of the Shen may lead to edginess, shyness, social awkwardness or, in extreme cases, agitation and delusions.

ETIOLOGY AND PATHOGENESIS

Chinese medicine views PTSD as caused primarily by recurring stimulation of the Seven Emotions.

THE SEVEN EMOTIONS

The Suwen states that “The five Yin organs of the human body produce five kinds of essential Qi which creates joy, anger, grief, worry and fear.” Traditional Chinese medicine teaches that certain organs are related to emotional activities, i.e. the Heart is related to joy, the Liver to anger, the Lungs to anxiety, the Spleen to pensiveness, and the Kidneys to fear.^[6]

The emotions are considered the major internal causes of disease in TCM. Emotional activity is seen as normal, internal, and physiological response to stimuli from the external environment; and within limits emotions are key components of a balanced human being. However, if they become overwhelming and possess the individual, they can weaken the internal organs and open the door to disease, but it is not the intensity as much as the endurance of the emotion that causes damage. While Western medicine stresses the psychological aspects of psychosomatic ailments, TCM puts stock on the pathological damage to the internal organs caused by excessive emotions.

The Yin-Yang energy imbalances caused by excess emotions include wild aberrations in the flow of blood, Qi blockages in the meridians, and impairment of function of the vital organs. Once physical damage begun, merely treating the symptoms to effect a cure is not enough; and the longer the permanence, the more organs will be influenced and there will be an evolution of symptoms.

Thus, the Seven Emotions in TCM are Joy, Anger, Anxiety, Grief, Pensiveness, Fear, and Fright.^[6]

Joy: “… When one is excessively joyful, the spirit scatters and can no longer be stored,” states the Lingshu. In TCM, Joy refers to a state of agitation or overexcitement, rather than the notion of deep contentment. The organ most affected is the heart. Over-stimulation can lead to problems of Heart-Fire connected with such symptoms as feelings of agitation, insomnia and palpitations.

Anger: Described in TCM as covering the full range of associated emotions including resentment, irritability, and frustration. An excess in rich blood makes one prone to anger. Anger thus affects the liver, resulting in Liver Qi Stagnation. This can in turn lead to liver Qi rising to the head, resulting in headaches, dizziness, and confusion. Sustained Liver Qi rising will eventually cause full-fledged high blood pressure, and stagnation of Liver Qi will, over time, affect the function of the stomach and spleen organs.

Anxiety: When one feels anxious, the Qi is blocked and does not move. Anxiety injures the lungs, which controls Qi through breathing. Symptoms of anxiety are retention of breath; shallow, rapid and irregular breathing. Anxiety also injures the lung’s coupled organ, the large intestine.

Grief: This emotion involves mostly the lungs as well. Apart from normal sorrow, grief that remains unresolved becomes chronic and can create disharmony in the lungs, weakening the lung Qi and impeding the lung’s function of circulating Qi throughout the body, damaging thus the Wei Qi ─Protective Qi.

Pensiveness: Excessive mental and intellectual stimulation and lack of  physical activity is defined in TCM as pensiveness. Activities that involve a sustained mental effort run the risk of causing disharmony. The organ most affected is the spleen. This disharmony can lead to Spleen Qi Deficiency, causing in turn worry, fatigue, lethargy, and inability to concentrate.

Fear: This protective and desirable human emotion, if out of control and with unknown causes, will likely lead to disharmony. The organs most at risk are the kidneys. In cases of extreme fear, the kidneys ability to hold Qi may be impaired causing involuntary urination. This is a common problem in children.

Fright: This is an emotion not related to a specific organ. It is distinguished from fear by its sudden and unexpected nature. Fright primarily affects the heart, especially in the early stages, but if it persists, it becomes fear and moves to the kidneys.^[8]

BIOMEDICAL PERSPECTIVE

Posttraumatic Stress Disorder, better known by its acronym, PTSD, is a severe anxiety disorder that can develop after exposure to any event which results in psychological trauma.^[3] This event may involve the threat of death to oneself or to someone else, or to one’s own or someone else’s physical, sexual, or psychological integrity, overwhelming the individual’s psychological defenses.

PTSD is a less frequent and more enduring consequence of psychological trauma than the more frequently seen acute stress response. PTSD has also been recognized in the past as railway spine, stress syndrome, shell shock, battle fatigue, traumatic neurosis, or post-traumatic stress syndrome.

Diagnostic symptoms include re-experiencing the original trauma, by means of flashbacks or nightmares; avoidance of stimuli associated with the trauma, and increased arousal, such as difficulty falling or staying asleep, anger, and hyper-vigilance. Formal diagnostic criteria, both DSM-IV and ICD-9, require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning, e.g. problems with work and/or relationships.^[4]

EPIDEMIOLOGY

The National Comorbidity Survey has estimated that the lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives. On average, 25% of individuals who experience one or more traumas develop PTSD; symptoms, however, occur in approximately 98% of individuals; of those, roughly 80% recover and do not develop PTSD, and about 20% do not recover and develop PTSD.^[5]

Case Study

HISTORY

A 37-year-old male, married with a 3 year old child; suffering from depression and high anxiety with agitation for the past year after returning from the war theater; accounts horrendous events during combat in Iraq. At the initial consultation in 2005, the patient has not worked for 6 months and was unable to hold a job due to PTSD. He was diagnosed at Walter Reed Army Medical Center.

SYMPTOMS

Complains of obsessive re-run of events in his mind with inability to stop, the images of the events are constant, and his attempts to avoid and suppress them make him frustrated and angry; does not want to talk about the events, experiences haunting nightmares, he says he thinks he loves his family, but feels detached from them, has trouble falling asleep and wakes up startled when he does, has terror stiff nightmares, feels constantly irritable, angry and withdrawn. He also reports he has no feeling on the sole of his left foot. There is constant pain (7/10 on the Visual Analog Scale) posterior to the lateral malleolus on the left –UB60 area- Pain worsens with movement, and has severe back pain as well. Patient is on medication.

RxMed:
Sertraline: effectively reduces symptom clusters of PTSD, such as hyperarousal, avoidance, intrusion.
Clonidine and Propranolol: decrease symptoms of nightmares, insomnia, hypervigilance, startle reactions, and angry outbursts.
Oxycodone: for foot and back pain.
OTC Self-Med:
Saint John’s Wort: antidepressant.
Prilosec: antacid.
Tylenol: painkiller

General Gait: Patient is quiet, withdrawn, but aware and edgy; and easily startled.

Pulse: (L) CUN slippery, rapid; GUAN rapid, wiry; CHI big, rapid, slippery.
            (R) CUN rapid, slippery; GUAN wiry; CHI rapid, slippery.
Tongue: slight purple, swollen, teeth marks, yellow, greasy coating, with red tip, significant sub-stasis.

CHINESE MEDICAL DIAGNOSIS AND TREATMENT

In Chinese medical terms, in the acute phase, he exhibited a pattern diagnosis of Phlegm-fire disturbing the Heart-Mind, and LV Heat. After several months of treatment the pattern changed to LV Qi Stagnation, HT Qi and Blood Deficiency, SP Qi Deficiency, HT Blood Stasis, and Yin Deficiency.

PATTERN DIFFERENTIATION

Heart Phlegm-Fire Disturbing the Heart-Mind (acute phase):

Symptoms: mental restlessness, palpitations, fidgety, insomnia, vivid dreams that disturb sleep, easily frightened, bitter taste, confusion, harsh behavior, laughing, singing, or crying, talking to self, depression, flushed red face, dark urine, constipation with dry stools, hallucinations.

LV-Heat (acute phase):

Symptoms: outbursts of anger, dream-disturbed sleep, irritability, stress and anxiety, thirst.

Heat leading to LV Qi stagnation (chronic phase):

Symptoms: poor appetite, depression, irritability, fatigue, anger, and restlessness.

Heart Qi and Blood Deficiency (chronic phase):

Symptoms: palpitations, dizziness, trouble falling asleep, vivid dreams, poor memory, numbness in the limbs, forgetting words and simple routine things in everyday life, like where keys were placed; anxiety, easily startled, fatigue, pale dull complexion, pale lips, may have dry and/or itchy skin, shyness, sense of vulnerability, withdrawn.

SP Qi Deficiency (chronic phase):

Symptoms: sallow complexion, fatigue, anorexia, four limbs feel tired and heavy, abdominal and epigastric distention after eating, maybe acid regurgitation or vomiting, loose stools, shortness of breath.

HT Blood Stasis (chronic phase):

Symptoms: palpitations, stabbing pain, constriction, or oppression in the heart region that may radiate to the left shoulder, to the medial aspect of left arm, or through to the back, and this pain becomes more severe at night; shortness of breath, fatigue, cyanotic lips and nails, cold hands for lack of circulation to the limbs, feeling of impending doom. This may be caused by, or complicated with Phlegm manifesting as overweight, expectoration of sputum, greasy tongue coating, nausea; or Yin type Cold Obstruction, i.e. HT Yang Deficiency, when blood can not move in the chest, thus causing sudden attacks of severe pain, cold limbs, and intolerance to cold.

Phlegm Accumulation leading to Yin Deficiency (chronic phase):

Symptoms: palpitations, irritability, dream disturbed sleep, easily startled, falls asleep with only slight difficulty, but sleeps shallow or wakes often during the night; vivid dreams sometimes to the point of disturbing the sleep, five center heat sensation, anxiety, jumpy, fidgety, restless, flighty, malar flush, night sweats, tidal fevers, dry mouth, throat, and lips, cankers of the tongue, tendency to quick and hasty words, poor memory. ^[9]

Acupuncture Points used alternately during the acute phase: LV3, PC5, ST40, CV12, CV17, HT3, HT7, LI11, LV12, LV13, GB21, CV15, PC7, YinTang, Ear-Shenmen, Anmian. Zhu Scalp Acupuncture for back pain, numbness of left foot, and head issues.

Acupuncture Points used alternately during the chronic phase: HT7, PC6, SP6, ST36, UB15, DU20, KD3, KD7, UB23, ST40, SP6, SP9, LV8, SP10, LV3, LI4, CV17, UB15. UB16. Zhu Scalp Acupuncture for back pain, numbness of left foot, and head issues.

Herbal Formula

XIAO YAO SAN: CHAI HU, DANG GUI, BAI SHAO, BAI ZHU, FU LING, ZHI GAN CAO, modified.

Modifying herbs used over a four year period: HUANG LIAN, HUANG QIN, ZHI SHI, BAN XIA, ZHU RU, FU SHEN, YUAN ZHI, DAN NAN XING, CHUAN XIONG, LONG DAN CAO, HE HUAN PI, HUAN QIN, ZHI ZI, MU DAN PI, SHENG JIANG, BO HE, HUANG QI, LONG YAN ROU, SUAN ZAO REN, MU XIANG, REN SHEN, XUAN SHEN, BAI ZI REN, SHENG DI HUANG, ZHI MU, GUA LOU, LONG GU, HUANG BAI, DAN SHEN, CHI SHAO, TAO REN, HONG HUA, ZHI KE, XIANG FU, YU JIN, LONG CHI, HU PO.

INTEGRATIVE APPROACH

First and foremost recommendation given to this patient was to return to his primary care physician for more than just drug refilling, and to explore Cognitive and Exposure therapies, and family counseling suggested by his primary.

Cognitive-Behavioral and Exposure Therapy

Cognitive therapy consists of:

-Identifying thoughts about the world and self that make one feel afraid or upset.

-Learning to replace those thoughts with more accurate and less distressing ones.

-Helping the patient to understand that the traumatic event lived through was not one’s fault.

Exposure therapy consists of:

-The goal is to have less fear about one’s memory.

-Repeated confrontation of feared stimuli through imagination, or virtual reality setup.

-Systematic desensitization: is a form where the patient repeatedly imagines anxiety-arousing stimulus until the stimulus loses ability to evoke anxiety.^[10]

PATIENT EDUCATION

Over a period of four years this patient did a lot towards his recovery and has accomplished much by following almost all suggestions given to him. Among the many, the most critical were:

Art
At the onset we strongly recommended he takes up painting, or printmaking, or woodcarving, or drawing, so that he may be able to give creative expression to his shattering and disturbing emotions, and he did so immediately at his local community college.

Nutrition
The patient followed a meticulous food regimen devoid of dairy, simple sugars and carbohydrates we prepared for him. It consisted of animal protein, except beef – unless certified organic, fresh fruits and vegetables, whole grains, and some nuts. For night sweet snacks, the diet had dried apricots, raisins, or prunes.

Six months from the beginning of treatment, of his own accord, he attended a semester on nutritional contents of foods, healthy eating and food preparation; he also become a personal trainer, and after the second year of continuous treatment, he enrolled in nursing school.

Exercise
As part of the intake, we discussed the critical importance of exercising in pursuit of a full recovery; and moreover suggested a realistic long-term exercise routine consisting of cardio, weight lifting, and TaiChi, yoga, or Qigong daily practice.

Meditation
We prescribed the daily practice of DeepMeditation and he did it twice a day as indicated. His life changed and continues to evolve for the better.

MEASURING RECOVERY

The recovery plan was based on: safety, reconnection, remembrance and mourning, a healing relationship, and commonality. ^[11]

Safety
–Establishing safety begins by focusing on control of the body: regulation of bodily functions such as sleep, diet and exercise, management of post-traumatic symptoms, and control of self-destructive behaviors.

–Instituting safety with the control of one’s environment: the building of a safe, clean, and organized living situation, financial security, and a plan for self-protection.

Reconnection
–A survivor faces the task of creating a future; mourning the old self that the trauma destroyed, and developing a new self.

–A survivor can establish an agenda and recover some of the aspirations from the time before the trauma.

–With peers, now needs to seek mutual friendships.

Remembrance and Mourning
–A story of the trauma is reconstructed.

–Reconstructing the trauma story begins with a review of the patient’s life before the trauma.

–The telling of the trauma story will inevitably plunge the survivor into profound grief. The descent into mourning is at once the most necessary and the most dreaded task of this stage of recovery.

A Healing Relationship
–The core experiences of psychological trauma are disempowerment and disconnection from others. Recovery, therefore, is based upon the empowerment of the survivor and the creation of new connections.

–The first principle of recovery is the empowerment of the survivor. The survivor must be the author and arbiter of his own recovery.

Commonality
–Traumatic events destroy the sustaining bonds between individual and community. Those who have survived learn that their sense of self-worth, and of humanity, depends upon a feeling of connection to others.

–The solidarity of a group provides the strongest protection against terror and despair, and the strongest antidote to traumatic experience.

–The restoration of social bonds begins with the discovery that one is not alone.

–Nowhere is this experience more immediate, powerful, or convincing than in a group. Because traumatized people feel so alienated by their experience, survivor groups have a special place for the recovery process.

–The encounter with others who have undergone similar trials dissolves feelings of isolation, shame, and stigma. ^[12]

Outcome/Quality of Life: Through a four year college degree in nursing, the patient made a dramatic improvement on all subjective, quality of life measures, including a better relationship with his spouse and parental responsibilities in all fronts.

Outcome/Disability: Patient returned to work and is now working at a hospital that treats veterans for PTSD, but continues family counseling, and regular individual therapy with a psychotherapist without the use of prescription drugs, and he continues with a once a week acupuncture treatment.

DISCUSSION
The points used were a combination of standard acupuncture points and Zhu’s scalp acupuncture regions. Zhu’s scalp acupuncture doesn’t have specific points as it has zones on the scalp that represent specific areas of the anatomy. The regions needled on the scalp were the head area, the right foot area, and the back area. On the first visit before the interview, the patient was also given one session of Qigong treatment to gather and stabilize his Qi.

This was the first case of PTSD I treated and as such, from day one I researched it in depth to learn everything there was available about it for treatment. The parameters and implications of PTSD continue to evolve, but there are new therapies being implemented with optimistic results; and the latest in integrative care was carried out with this patient.

Studies show that regular exercise improve physical and psychological well-being and accordingly, this person engaged in active and strenuous physical exercise in the form of cardio and mild weight lifting.

He also participated in TaiChi and Qigong classes at his local YMCA, and to his credit he continued classes at a community college and later with a Sifu in China Town.

The remarkable results arrived at with this patient were mostly due to his intense commitment to a full recovery. The stage at which he finds himself at this time could be considered a full recovery. He is currently not on medication and is now helping other vets with PTSD.

CONCLUSION
PTSD is a complex condition that is still being investigated. In the majority of cases symptoms can be debilitating and patients often need high doses of medications to cope with the devastating disease, and even more medication to ameliorate the side effects of the original medication. Chinese medicine offers PTSD patients a valid treatment option for palliation of symptoms and in this particular case, coupled with biomedicine, an absolute betterment of the whole person, even allowing him to live fully without prescription drugs.

 

MISCELLANEOUS AILMENTS

TREATMENTS OFFERED

__________________________________________________________________________________________________________________________REFERENCES
[1]National Center for PTSD Staff. (2000, March 18) What is PTSD. Retrieved April, 2005, from the U.S. Department of Veterans Affairs website: http://www.ptsd.va.gov
[2]National Center for PTSD Staff. (2000, March 18) PTSD Fact Sheet: Frequently asked Questions. Retrieved April, 2005, from the U.S. Department of Veterans Affairs website: http://www.ptsd.va.gov
[3]David Satcher et al. (1999). “Chapter 4.2”. Mental Health: A Report of the Surgeon General. http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html.
[4][12] American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association. ISBN 0890420610
[5]Kesslet RC, Sonnega A, Bromet E, Hughes M, Nelson CB (December 1995). “Posttraumatic stress disorder in the National Comorbidity Survey”. Arch Gen Psychiatry 52 (12): 1048-60. PubMed 7492257.
[6]Veith, Ilza. The Yellow Emperor’s Classic of Internal Medicine. Berkeley: University of California Press, 1972, p. 28.[7] Veith, p. 25.
[8][9] Maciocia, Giovanni. The Foundations of Chinese Medicine. New York: Churchill Livingstone, Inc. 1989.
[10][11] Richard A. Kulka et al., Trauma and the Vietnam War Generation: Report of findings from the National Vietnam Veterans Readjustment Study (NEW York: Brunner/Mazel, 1990; ISBN 0-87630573-7)

-Above Article Written by Dr. Osorio, Gloria DAOM, L.Ac. 2011.