Post-Traumatic Stress Disorder: Treatment and Case Studies, Part 2 of 2
Kelly Green Jennings, ND, MSOM
It is estimated that more than 25 million Americans suffer from some form of anxiety disorder, including panic, social phobia, obsessive-compulsive disorder, generalized anxiety and post-traumatic stress disorder (PTSD) (U.S. Dept. of Veterans Affairs, n.d.). PTSD is a severe anxiety disorder characterized by a persistent pattern of re-experiencing trauma through flashbacks, recurring dreams or intense fear. People who experience these trauma-related memories often have little or no conscious identification with the original event, and frequently experience sensory elements of the trauma without being able to make sense out of what they are feeling or seeing. This may happen through exposure to circumstances that are either reminiscent of the trauma, or seemingly have no relation at all. Furthermore, fear-related trauma is commonly associated with poor memory. Even more than just an inability to recall the specific traumatic event, PTSD patients are often forgetful, have a short attention span and have difficulty sustaining focus (Bremner, 2006).
Patients with PTSD usually develop a pattern of actively avoiding situations that may prompt the traumatic event. While this article series focuses primarily on trauma’s effect on the brain, it is important to note that the physical body also retains a memory of traumatic events. This manifests in a wide range of symptoms, such as increased muscular tension, high blood pressure, restlessness, tendency to startle easily and a hypersensitivity to environmental stimuli like noise or bright lights. During a traumatic event, the body usually reacts quickly while the cognitive mind goes blank.
Brain Activity of PTSD Patients
Neuroimaging can help us understand what is going on in the post-traumatic brain. Neuroimaging can include magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), functional MRI (fMRI), positron emission tomography (PET) and single-photon emission computed tomography (SPECT). In patients with PTSD, we see an exaggerated activation of the amygdala in response to an emotionally charged experience. Generally, the greater the sensitivity of the amygdala to these events, the more severe the symptoms of the syndrome (Shin et al., 2006). The medial prefrontal cortex, the part of the brain associated with rational thought and that can act to calm the amygdala, seems impaired. In fact, the medial prefrontal cortex has been shown to be less responsive in PTSD patients during emotional events, and there is evidence that this region of the brain is actually smaller than normal. The same is true of the hippocampus; its volume is often decreased, and the integrity and function of its neurons seem to be impaired (Shin et al., 2006). This corresponds with the idea that post-trauma the hippocampus may be less capable of generating memories of safety in the present moment, and is furthermore hindered in storing new information. Thus, the PTSD brain might be described as an overly-sensitive amygdala that is not properly comforted or kept in check by the other brain regions.
Studies have shown that key hormones of the body are altered in people with PTSD. Cortisol may be abnormally high or low and adrenaline levels are often higher than normal. Hormones produced to shunt the feeling of pain are often elevated. People with PTSD often have disturbed sleep patterns and altered brainwaves. What is not known is whether these differences reflect a genetic or familial predisposition to PTSD, or whether the changes occurred as part of an adaptive response in the brain post-trauma.
PTSD and Chronic Illness
In a naturopathic clinic, we routinely see very challenging patients. Often, these individuals present with a chronic illness that has remained uncured or whose condition has worsened with conventional medical care.
Clinical experience and contemporary literature suggest that the etiology of chronic disease is repeatedly associated with traumatic events (Scaer, 2005). This calls for an approach to treating chronic illness that includes trauma as a likely etiology. Given the association of PTSD with a dysfunction of the amygdala and limbic system, particular attention should be given to these imbalances, as well as addressing the various associated manifestations for the patient.
Drainage is a naturopathic modality particularly suited for individuals coping with the aftermath of trauma. Drainage describes the use of various homeopathic, botanical, mineral and flower essence formulations designed to assist the pathways of detoxification in the body. One of the functions of drainage is to open the emunctories or tissues that are involved in the excretion process, and then facilitate the discharge of these toxins. Toxins can be physical, mental or emotional. In this way, drainage aids the proper functioning of all organs, and serves to restore normal function of an overloaded system. This therapeutic approach is well suited for the patient who has become stuck emotionally and/or physically. When there is no longer a natural flow of energy in the body, cellular debris begins to accumulate and the normal processes of elimination are hindered. As the body and mind typically store and bear the burden of a traumatic event, drainage can be used to facilitate and release this trapped energy. This can further serve to balance or modulate hypersensitivities, especially relevant for healing an overexcited amygdala. Drainage can be used to aid the processing and integration of life’s events, promote the ability to deal with the information and substances we encounter, and support the body’s capacity to recover from physical illness, emotional distress or spiritual disturbance (Thom, 2006).
While a formulaic prescription for treating PTSD and other chronically ill patients with drainage does not coincide with the principles of naturopathic medicine, some road maps can be offered with some of the typical presentations of PTSD. This system borrows heavily on various connections described in classical Chinese medical theory, between energetic organ systems and their paired emotions.
Table 1 provides a loose guideline with which to connect signs, symptoms and emotions of a patient with therapeutic drainage. The prescriptions chosen are only a small representation of remedies available (Thom, 2006).
Importance of Patient History
Though patients may have similar diagnoses of PTSD, their presentations may vary greatly. Great care must be taken to attend to the specific symptoms of an individual. In the words of Canadian physician William Osler, “it is much more important to know what sort of a person has a disease than what sort of a disease a patient has” (Cushing, 1925). This reiterates the basic naturopathic tenet of Tolle Totem.
Several key questions are relevant in ascertaining the organ systems to be treated. The patient’s history is vital to this decision. Often, we will construct a timeline, highlighting major developmental mile-markers in an individual’s life. Key questions may include the following:
- Were there any significant changes or events that impacted them in a negative way?
- What are their memories of childhood?
- At what age did they experience a traumatic event?
- Was their mother’s pregnancy or birth process difficult?
- What was their relationship like with their primary caregiver?
- When did their present illness begin?
The answers frequently provide a significant structure upon which to build an assessment. On occasion, the patient may have no memory of any of these events. However, continued work with drainage therapies will likely open these areas to recall. This requires a certain amount of patience as the memory begins to unfold. As a clinical tool for follow-up visits and as a means to evaluate therapeutic efficacy, it is helpful to monitor the basic functions that affect quality of life. The SEAMMMS questions were developed by Dr. Dickson Thom to gauge these areas, and are useful as a mnemonic to provoke questions about them: Sleep, Energy, Appetite, Mood, Menses, Musculoskeletal, and Sense of purpose/Stress.
Given our study of PTSD, it is important to assess the mental capacities of a patient as well as any physical indications of unresolved trauma. These will further determine an appropriate diagnosis and direction of treatment. What signs and symptoms is the patient presenting with? Is digestion difficult with a lot of flatulence and bloating, or does the patient experience palpitations and anxiety? Do they frequently suffer muscle tension or joint pain? How many hours do they sleep, and is it restful? Do they wake feeling refreshed? How are they physiologically coping with their daily experience of living? What is their emotional outlook? The way a patient has internalized stress and trauma and how he or she relates to the world can provide a window into the energetic organ systems that have been most affected by the trauma.
During monthly clinic visits, patients are engaged to mindfully observe the interplay of their perceptions, emotions, movements, sensations, impulses and thoughts. This is a process that borrows heavily from body-oriented psychotherapy. In the act of noticing their bodily experience and thought process both in the moment and while recalling significant events, patients become more aware of their own capacity to regulate their physiology. The ND can facilitate this observation by cueing the patient towards recognition of, for example, body posture or respiratory patterns. The patient begins to develop an increased sense of empowerment over his or her bodily processes, and this often reveals associated thought patterns or emotional states.
The case study of Rich (see Case Study 1) demonstrates that the body can be an ally and a catalyst in the process of healing from trauma. Such physical changes often help to resolve the habitual trauma-related responses and provide improved stability to handle future stressors (Ogden et al., 2006). This concurs with the thought that meditative practices can serve to ameliorate and calm an overexcited nervous system. By providing the feedback that the present is a safe place via calming the nervous system with deep breathing and guided imagery, brain networks can be significantly altered. This can specifically target and affect the amygdala through its connection to the autonomic nervous system via the brainstem. This is powerful evidence of the adaptability and flexibility of the brain. Not only are we able to record new memory but we also can, in a sense, re-record over old memory. The implications of this for a patient’s sense of control and purpose in life are profound. This is probably the best and most effective means of treatment for an individual, to facilitate progress away from the victim mentality to a realization of empowerment and personal responsibility. This is our ultimate goal.
A traumatic incident can become the center around which a person reorients his or her life. It can provide greater existential and spiritual clarity – defining, perhaps for the first time, who they are and what their purpose is in life. Using trauma as a transformative experience – to grow strong at the broken places – is our greatest challenge and, potentially, our greatest reward.
The clinical use of drainage and body-oriented therapeutics is an approach that appreciates the interrelatedness of mind and body. As representative of a holistic, energetic medicine, these modalities take into consideration the physical symptoms of unresolved trauma while ultimately attempting to bring the body back into a state of balance. Drainage encompasses a whole-systems approach to health, addressing how trauma is stored in the physical, mental and emotional layers of an individual.
Our particular focus on the amygdala serves to enhance the awareness of what imbalances underlie PTSD. This knowledge allows a window into the mechanistic understanding of why someone continues to suffer from the repercussions of a traumatic experience. Given the importance of development on the function of the amygdala, this further implicates the vital aspect of emotional stability in early childhood. It also stresses the importance – a very real need in our society – of taking time to process and resolve emotional and physical suffering. This need is becoming more and more evident as our world expands and global conflict ensues, increasing our exposure to violence and trauma. It is perhaps most relevant to a culture that shows no signs of slowing down, a culture speeding up at a pace that perpetuates anxiety, stress and little time for family or self.
Coexisting Diagnoses Often Occurring with PTSD
Psychotherapists who work with survivors of psychological and physical trauma recognize the almost inevitable clinical complexity of trauma-related disorders. As described, traumatized individuals do not just suffer memories of a tragic and horrifying experience, they demonstrate a number of complicated and debilitating signs, symptoms and difficulties. Increased sweating, poor memory and palpitations are possible outcomes of a physiology that has become the victim of a chronically frightened mind. These physical reactions are often not recognized by the patient or the conventional medical community as being correlated with or having a clear connection to the initial traumatic event.
Most traumatized individuals fulfill the criteria for a number of coexisting diagnoses that usually include mood disorders, anxiety disorders, substance abuse and dependence disorders, eating disorders and physical ailments that are seemingly inexplicable (Ogden et al., 2006; Herman, 1992; Foa and Rothbaum, 1998). In a large-scale study, 88% of men and 79% of women with PTSD met criteria for another psychiatric disorder. The coexisting disorders most prevalent for men with PTSD were alcohol abuse or dependence (51.9%), major depressive episodes (47.9%), conduct disorders (43.3%), and drug abuse and dependence (34.5%). The disorders most frequently paired with PTSD among women were major depressive disorders (48.5%), simple phobias (29%), social phobias (28.4%) and alcohol abuse or dependence (27.9%; National Center for PTSD, n.d.). These complications are reflected in the Diagnostic and Statistical Manual of Mental Disorders by the inclusion of more than 12 associated features of PTSD (American Psychiatric Association, 2000). The formal diagnosis of PTSD contains three diagnostic post-traumatic symptom groupings: 1) symptoms indicative of the usually unprompted and invasive reliving of the trauma – termed intrusive memory; 2) avoidance of memory-invoking triggers and dissociation or “numbing” during these events; and 3) symptoms of a generalized and increased sympathetic and autonomic arousal. The episodic fluctuation between the avoidance and reliving of symptoms “is the result of dissociation: Traumatic events are distanced and dissociated from usual conscious awareness in the numbing phase, only to return in the intrusive phase” (Chu, 1998). Triggered by stimuli reminiscent of the trauma, these disassociated fragments of past experience return unsolicited in the form of psychological symptoms (memory loss, sense of worthlessness, invasive images, mood swings and uncontrollable emotions) and bodily symptoms (physical pain, physical numbing, intrusive sensations, and uncontrolled and random nervous system arousal; Brewin et al., 1996). The long list of complications following PTSD explains why this condition has been historically difficult not only to diagnose, but also to treat.
Case Study 1
Rich, a 57-year-old male, was eventually able to observe that the perpetual slump in his spine had served to maintain his feelings of inferiority, helplessness and passivity. This patient had been emotionally abused by his family throughout childhood; he described himself as constantly being picked on by his parents and siblings because he was a “C-grade” student in a family of overachievers. He slouched for as long as he could remember.
As this component of his early abusive experience was addressed through drainage and awareness of his body, his posture gradually became more erect. In shifting his physical relationship to the world, he transformed a physical liability to a physical resource that supported his newfound sense of well-being and competency.
His thoughts correspondingly started to become less negative, and his emotions more lighthearted. He had an increased sense of his “place in the world” and a “sense of belonging in it.” In this way, his body became (for him) the medium through which his perspective and self observation changed.
Case Study 2
John is a 45-year-old male with hyperthyroidism. Upon his initial consultation, he manifested all of the common signs and symptoms of an overly aroused sympathetic nervous system: His upper body continuously trembled, and he had to hold his body and jaw tightly to be able to answer any questions. He was extremely fatigued, confined to the house because he no longer had the endurance to participate in any activities. Tennis and dancing, major components of his social outlet, were out of the question. His heartbeat was rapid and irregular. His body was tense, tendons and sinews tight, with upper body and head held rigidly. Everything about him seemed apprehensive and on edge. His memory of early childhood was very poor, though he recalled a continuing difficult relationship with his father.
Throughout my two years of seeing John, he made some profound emotional and physical shifts with regard to his illness. Treatment centered on treating his extreme state of arousal via the limbic and central nervous system, and included customized homeopathic remedies which consisted of a combination of plant remedies in homeopathic dilution designed to detoxify and remove emotional and physical cellular debris from several energetic organ systems, as well as deep relaxation and breathing techniques. Organ systems of note include the kidneys (associated with hyperarousal and fear states), the central nervous system (to address memory loss and trauma) and the lungs (paired with the grief and developmentally associated with a particularly difficult time in John’s life).
Throughout the months of treatment, he significantly improved his recall of childhood. He remembered a very dramatic shift in his upbringing when he was 10 years old: His sister was born and, with his mother occupied, his father took over the household. He remembers suddenly becoming very introverted and shy, afraid of his father’s rigid and overly controlling dominion. Once popular and sociable, John turned timid and withdrawn. He remembered this period as being “very stressful.” Over the course of a year of treatment, John began to see how this pattern was repeating itself in his present life: a failed marriage, strained relations with his two children, poor physical health and a psychological need to be in control. He began to see a link between those stressors in his adult life; how each one was a reflection of his internal struggle with control and was now manifesting in body symptoms that he could not keep in check.
While becoming increasingly aware of these emotional patterns, John also noticed a significant increase in energy and endurance. He now can play tennis for two hours a week. He no longer has to hold his body in tightly; his trembling has consistently and vastly improved. He speaks much more comfortably and openly about his progress, and now is able to smile and laugh. His affect has become much lighter.
His work is not yet finished, however. His endurance is not at the level he would like it to be, his heart continues to beat irregularly and his thyroid levels are still elevated.
This case study illustrates several key points about chronic disease and the drainage process. It is essential that patients using a drainage type of treatment be seen on a regular basis. This both assists the process of assessment and serves to develop a deep and trusting doctor-patient relationship. For the PTSD patient, this relationship is paramount. Typically, patients are seen monthly and over a lengthy period. In addition, clinical success depends in large part on the patient’s motivation and sense of responsibility for their own health.
Table 1. Therapeutic Drainage Prescriptions
1) Fear: An emotion associated with the energetic kidney system.
- Asparagus officinalis 4X, Berberis vulgaris 4X, Genista tinctoria 4X, Juniperus communis 4X, Petroselinum sativum 4X, Rhamnus frangula 4X, Thlaspi bursa-pastoris 4X, Argentum metallicum 12X: Effective for opening the doors of drainage from the kidney; facilitating the filtration and removal of toxins from the body. This remedy also can aid the restoration of metabolic and hormonal activities, as well as aid the body’s defense system.
- Equisetum arvense6X, Gentiana lutea 6X, Salvia officinalis 6X, Saxifraga granulata 6X, Spiraea ulmaria 6X: A kidney remedy that will serve to stabilize and reverse a demineralization process in the body.
- Arctostaphylos uva-ursi4X, Genista scoparia 4X, Inula helenium 4X, Juniperus communis 4X, Solanum dulcamara 4X, Stigmata maïdis 4X, Argentum metallicum 12X, Aurum metallicum 12X: Occasionally can be used as a deeper-acting kidney remedy, particularly if there are any chronic inflammatory conditions of the urinary tract or bladder, or kidney stones with inflammation. Enhances urinary excretion of toxins.
2) Memory loss: May indicate treatment of the central nervous system.
- Melissa officinalis4X, Mentha piperita 4X, Salvia pratensis 4X, Thymus vulgaris 4X, Valeriana officinalis 4X, Aurum metallicum 12X, Plumbum metallicum 12X: An effective remedy whenever there hasbeen prolonged mental strain and conflict, or where there is nervous exhaustion, anxiety, insomnia or depression. This number supports the elimination of toxins that might create degenerative disorders in the nervous system. It helps to coordinate all actions and give meaning to life activities.
- Arnica montana 6X, Artemisia absinthium 6X, Jatrorrhiza palmata 6X, Rosmarinus officinalis 6X, Thymus vulgaris 6X, Valeriana officinalis 6X, Aurum metallicum 12X, Antimonium metallicum 15X: Indicated for cerebral spasms, headaches and vertigo. It is a deep-acting remedy for any degenerative condition of the nervous system, including Alzheimer’s and Parkinson’s disease. It can function to repair neurons in the central nervous system, or assist in chronic or difficult-to-control hypertension, which may create cerebral vascular vulnerability or insufficiency.
3) Grief: Associated with the energetic lung organ system.
- Adiantum capillus veneris 4X, Drosera rotundifolia 4X, Glycyrrhiza glabra 4X, Grindelia robusta 4X, Inula helenium 4X, Potentilla erecta 4X, Tussilago farfara 4X, Argentum metallicum 12X, Cuprum metallicum 12X: For emotional losses and external communication problems. Grief can get stuck in the lungs and act as a toxin, interfering with one’s ability to communicate with the outside world. This remedy allows for the restoration of the harmonious breath that allows for ease of internal and external communication.
- Condurango marsdenia 5X, Hypericum perforatum 5X, Ocimum basilicum 5X, Aurum metallicum 12X, Plumbum metallicum 12X: Used for degenerative lung conditions due to past grief or loss. It offers deep-acting support to the lung and may be indicated particularly if the patient is experiencing any skin conditions.
4) Anger, irritability, headaches, hypertension: Often linked with liver pathology.
- Achillea millefolium 4X, Angelica archangelica 4X, Arctostaphylos uva ursi 4X, Equisetum arvense 4X, Larix decidua 4X, Lycopodium clavatum 4X, Valeriana officinalis 4X, Argentum metallicum 12X: For general drainage affecting the liver. Has a potent antitoxin function and aids the liver in the removal of toxins from the body, directing them towards excretion. It supports kidney elimination as well.
- Jatrorrhiza palmata 4X, Combretum raimbaultii 4X, Peumus boldus 4X, Ricinus communis 4X, Argentum metallicum 12X: For overload of the liver, when the liver is overwhelmed and not able to sort toxins properly as part of its natural function. This remedy is stronger than the remedy listed just prior.
- Calendula officinalis 4X, Condurango marsdenia 4X, Jacaranda caroba 4X, Juniperus sabina 4X, Robinia pseudacacia 4X, Aluminum metallicum 12X, Argentum metallicum 12X, Arsenicum album 12X, Aurum metallicum 12X: This remedy also helps the liver to sort wastes, facilitating proper nutrition and elimination. It is a very useful remedy to initiate the drainage process when combined with the first remedy mentioned in this section.
- Combretum raimbaultii 4X, Lycopodium clavatum 4X, Peumus boldus 4X, Podophyllum peltatum 4X, Cholesterinum 12X: A hepatic cell drainer that rapidly cleans and eliminates the effects of liver intoxication and relieves hepatic congestion. Often used with the first and third remedies mentioned in this section.
5) Insomnia, anxiety, palpitations, indecision: Related to the energetic heart organ system.
- Achillea millefolium 4X, Cactus grandiflorus 4X, Crataegus oxyacantha 4X, Equisetum arvense 4X, Hamamelis virginiana 4X, Mercurialis perennis 4X, Thlaspi bursa-pastoris 4X, Cuprum metallicum 12X: Useful for all cardiac disorders, facilitating arterial and venous circulation. This remedy can help to regulate routine and rhythm in a patient’s life, as well as serve to enhance one’s internal communication. This is particularly indicated for any patient with palpitations, which is a sign of an inability to internally regulate coordinated rhythm of the heart.
- Crataegus oxyacantha 4X, Gelsemium sempervirens 4X, Hamamelis virginiana 4X, Spiraea ulmaria 4X, Valeriana officinalis 4X, Magnolia glauca 4X, Argentum metallicum 12X, Stannum metallicum 12X: This remedy is used in all pathology with heart involvement, such as hypertension, palpitations, murmurs, chest pain or cardiovascular insufficiency. It can be used with the other remedies listed in this section.
- Allium cepa4X,Anacardium orientale4X,Jatrorrhiza palmate4X,Peumus boldus4X,Tilia europaea4X,Viola tricolor4X, Aluminum metallicum12X: For hypertension due to stress, poor circulation and degenerative states of the cardiovascular system.
- Aesculus hippocastanum 5X, Crataegus oxyacantha 5X, Rheum officinalis 5X, Stigmata maïdis5X, Strophanthus gratus 5X: Modulates and harmonizes blood pressure. This remedy is indicated when the organism is extremely tense, as it can help to rebalance and harmonize.
- Crataegus oxyacantha 4X, Magnolia glauca 4X, Passiflora incarnata 4X, Strophanthus gratus 4X: Used for drainage of the heart and vasculature. If there is any evidence of tachycardia, arrhythmia or disturbances of the aortic circulation, this remedy is indicated. Used in combination with the first remedy mentioned in this section and specifically addresses toxicity of the heart muscle.
Kelly Green Jennings, ND, MSOM is a graduate of NCNM and has a masters degree in classical Chinese medicine. She sees patients at Urban Wellness Group in Portland and in her private practice in New York City. She specializes in helping people break old patterns and realize their greater purpose. She has extensive experience working with cancer patients and is working on a breast cancer manual for holistic practitioners. Her therapies are a combination of Chinese theory, herbal medicine, acupuncture and biotherapeutic drainage, and incorporate principles of systems biology, neuroscience and cellular signaling pathways.
U.S. Dept. of Veterans Affairs web site: www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_epidemiological.html
Bremner JD: The relationship between cognitive and brain changes in posttraumatic stress disorder. In Yehuda R (ed), Psychobiology of Posttraumatic Stress Disorder: A Decade of Progress. Oxford, 2006, Wiley-Blackwell. Short papers from Ann NY Acad Sci 1071:80-86, 2006.
Shin LM et al: Amygdala, medial prefrontal cortex, and hippocampal function in PTSD, Ann NY Acad Sci 1071:67-79, 2006.
Scaer R: The Trauma Spectrum: Hidden Wounds and Human Resiliency, Philadelphia, 2005, Haworth Medical Press.
Thom D: UNDA NUMBERS: An Energetic Journey to Homeostasis and Wellness, Portland, 2006, JELD Publications, p.10.
Cushing H: The Life of Sir William Osler. Oxford, 1925, Oxford Press.
Clinical practice and conversations with Dr Dickson Thom, Natural Health Center. Portland, 2006-2007.
Ogden P et al: A sensorimotor approach to the treatment of trauma and dissociation, Psychiatr Clin North Am 29(1):263-79, March 2006.
Herman J: Trauma and Recovery. New York, 1992, Basic Books.
Foa EB and Rothbaum BO: Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD, New York, 1998, Guilford Press.
National Center for PTSD web site: www.ncptsd.va.gov/ncmain/index.jsp
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed), revised. Washington, DC, 2000, APA.
Chu JA: Rebuilding Shattered Lives: The Responsible Treatment of Complex Post-Traumatic and Dissociative Disorders. New York, 1998, John Wiley & Sons.
Brewin CR et al: A dual representation theory of posttraumatic stress disorder,Psychol Rev 103:670-686, 1996.