Debra Gibson, ND

Docere

PTSD: it’s an acronym that doesn’t need explaining these days, as it seems that every week another horrific event occurs for which posttraumatic stress disorder may be either a cause, a probable effect, or both at once. The “irritable heart,” “hysteria,” “shell shock,” and “battle fatigue” of earlier times – that later reappeared as a long-festering wound of the Vietnam War, associated with ruined lives of drug and alcohol abuse, troubled relationships, and social alienation – has now entered mainstream awareness. In the wake of 9/11 and the many-place-names of homegrown violent tragedy; with increasing acknowledgement of pandemics of childhood, sexual, and domestic abuse; and as waves of modern warriors have returned home to the stresses and strangeness of “normal” life, awareness of the aftereffects of trauma has, over time, seeped into our daily lives and our cultural consciousness.

Maybe that’s not entirely a bad thing – because, after all, traumatic stress has been with us for as long as violence, war, and catastrophe have intruded upon the illusory safety of human existence. But for society to learn to recognize the downstream consequences of trauma on mind, spirit, and body, and to begin to identify paths to recovery and wholeness – to recognize that there are paths to recovery, and to explore, illuminate, and broaden access to them – is what may set apart our time (era), with its particular mix of seemingly senseless tragedy and psychic pain, from those that have gone before (times past).

The qualities and common practices that naturopathic physicians bring to patient interactions – an innately holistic perspective; a thorough and in-depth intake interview; appointments more extended than is typical for physician visits; empathic attunement; an active commitment to “first, doing no harm” – make us unusually well-equipped among healthcare providers to discern, enquire about, and make space for sensitive exploration of the potential role of trauma in our clients’ health issues, and where possible, with permission, to gently open conversations around options for support and healing.

Posttraumatic Stress: Disorder or Injury?

In recent years, a movement originally started by a retired Army general has sought to remove from the diagnosis “Posttraumatic Stress Disorder” the word “disorder” (due to its stigmatizing potential) and to replace it with “injury” (deemed to be more accurate, given what is now known about the physiology of posttraumatic stress).^1,2

Because the reasoning behind this nomenclature change makes sense to me, and also because many common life experiences have the potential to engender more symptoms on the spectrum of posttraumatic injury than meet criteria for a PTSD diagnosis (such as chronic illness, ongoing financial challenge, or repeated loss), after discussion of formal diagnostic criteria, and except as the term “PTSD” is used in quotation, this article will use the designation PTSI (posttraumatic stress injury) to refer to posttraumatic stress-related health issues.

Diagnosis: A Work in Progress

The formal psychiatric definitions of posttraumatic stress disorder are evolving. In the most current diagnostic manual for psychiatry (DSM-5), PTSD moved from the category of anxiety disorders to a new category of trauma- and stressor-related conditions, a change that implicitly acknowledges its complexity and distinctness from the anxiety disorders. This new grouping of stress-induced psychological issues includes Acute Stress Disorder, or ASD, which shares some characteristics of PTSD but which resolves after a relatively short period of time.

According to DSM-5, posttraumatic stress effects may follow a life-threatening, terrifying, and/or horrific event or events. Posttraumatic stress symptoms lasting for 1 month are considered a posttraumatic stress disorder; beyond 3 months, PTSD is considered chronic (c-PTSD).3 ICD-11 (International Classification of Disease, the 11^th Revision of the medical coding system generated by the World Health Organization), due to be finalized and released in 2018, reportedly includes in its draft document criteria for “complex PTSD” (CPTSD) a variant of PTSD which follows multiple traumas that may be experienced over extended periods of time (such as with domestic abuse or genocide), and with a different, expanded symptom profile (compared to DSM-5 criteria).⁴

Common symptoms of adult PTSD [in childhood it presents somewhat differently], organized for clinicians as the CAPS-5 (clinician-administered PTSD scale),⁵ include re-experiencing the precipitating trauma(s), avoidance behaviors, negative changes in mood and brain function, and hyperarousal. These may be expressed as:

• Intrusive, recurring, and distressing memories, thoughts, images, dreams, or flashbacks of the traumatic event
• Emotional numbness or deadness, feelings of detachment from others, and possibly difficulty experiencing loving feelings. Feelings of guilt, shame, or blame (of self or others) are common.
• Avoidance of thoughts, conversations, places, people, activities, or anything which may trigger memories of the trauma and cause distress or anxiety. Common “tools” for avoidance include numbing behaviors, such as self-abuse with alcohol and other substances.
• Apathy toward formerly pleasurable activities. In general, a pessimistic view of the future; it may be difficult to make future plans.
• Attraction to risk-taking and behaviors reckless, or destructive to self and/or others
• Problems in getting to sleep or staying asleep; irritability, possibly accompanied by anger and volatility; difficulty concentrating; increased vigilance; an increased startle reaction. Chronic hyperarousal may manifest as depression.

Gender differences and similarities in the experience of trauma,⁶ as well as factors contributing to the increased incidence of PTSI in women (approximately twice that in men), are now beginning to be investigated.7,8 Multiple traumas increase vulnerability to PTSI, as does greater intensity, duration, or scope of the precipitating event (the so-called “dose-response” effect).⁹ Correlations with childhood neglect and abuse (“developmental trauma”¹⁰⁾, family traumatic history (“intergenerational transmission of trauma”¹¹), genetic and epigenetic influences,¹² and preexisting or comorbid anxiety and depression, mental health issues, substance abuse, and sleep disorders, are adding depth and dimension to the understanding of the difficult landscape of PTSI.

The Neurobiology of Fear

The defining characteristics and behaviors of PTSI have been explicated over time as external manifestations of internal effects of trauma on mind, body, and spirit through activation of “fear circuitry”:  patterns of reaction and interaction within the brain (the medial prefrontal cortex, limbic system, memory centers involving the amygdala and hippocampus, and the hypothalamic-pituitary axis) and the body (adrenal glands, sympathetic and parasympathetic nervous systems) in response to severe stress and trauma.¹³ The natural process of fear extinction, by which normal responses to fear-inducing stimuli attenuate over time, is disrupted. The brain is “hijacked”¹⁴: the fear switch, once flipped on, can’t be shut off, and the sufferer swings between traumatic memories of the past and apprehension of potential threats in the future, unable to find a place in the present. In the words of Bessel van der Kolk, MD, a pioneering research clinician in posttraumatic stress disorder and the neurobiology of trauma:

People with PTSD lose their way in the world. Their bodies continue to live in an internal environment of the trauma. We all are biologically and neurologically programmed to deal with emergencies, but time stops in people who suffer from PTSD. That makes it hard to take pleasure in the present because the body keeps replaying the past.

(van der Kolk, 2009)¹⁵

Traditional Trauma Treatment

Treatment of PTSI can do more harm than good. Traditional talk therapies and widely used “desensitization” therapies, such as cognitive processing and prolonged exposure (despite their amenability to the randomized controlled trial model), carry risk of re-traumatization and have rates of success that are at best modest (about 50%); they are also qualified by high drop-out rates that are not factored into much of the trial data.^10,16 Pharmacologic strategies (primarily SSRIs, SNRIs, and benzodiazepines) may manage, to varying degrees, the depression, anxiety, insomnia, anger, and substance abuse that often accompany posttraumatic stress; however, none of these effectively engages with the deep and interconnected wounds to mind, body, and spirit of complex PTSI. A possible exception is the psychedelic drug MDMA (aka ecstasy), which has shown promise, particularly when combined with psychotherapy.^17,18 (A comprehensive review of MDMA has been previously published in NDNR.¹⁹)

The mixed results of standard treatment contribute to a misperception – not just by the public but also by much of the healthcare community, including many mental health professionals – that PTSI is a tough nut to crack, so sufferers had best just learn to live with it. As Belleruth Naparstek, a psychotherapist who has developed guided imagery for prevention and treatment of traumatic stress disorders, observes:

You can recover from posttraumatic stress. Certainly, you can significantly reduce – not just manage – its symptoms. But – and here’s the thing – not with traditional treatment. The problem is, a lot of my colleagues don’t know this yet. So they go about it in traditional ways and pronounce the condition incurable, based on the results they get.

(Naparstek, 2010)²⁰

In Part 2: Trauma treatment is evolving to a multidisciplinary, holistic, stage-based care model that appears to improve outcomes while reducing risk of harm. Naturopathic treatment approaches (both fundamental and those more specific to healing the neurobiologic wounds of PTSI) can be integral to this emerging standard of care.

References:

1. Ochberg F. An Injury, Not a Disorder. Military Review. 2013; March-April:96-99. Available at: https://usacac.army.mil/CAC2/MilitaryReview/Archives/English/MilitaryReview_20130430_art014.pdf. Accessed March 11, 2018.
2. PTSD vs PTSI. Available at: http://globalptsifoundation.org/ptsd-vs-ptsi. Accessed March 10, 2018.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth Edition. Washington, DC: American Psychiatric Publishing; 2013.
4. Complex Posttraumatic Stress Disorder. Available at: http://traumadissociation.com/complexptsd. Accessed March 10, 2018.
5. Weathers FW, Bovin MJ, Lee DJ, et al. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and Initial Psychometric Evaluation in Military Veterans. Psychol Assess. 2017 May 11. doi: 10.1037/pas0000486. [Epub ahead of print]
6. Vogt D. Research on Women, Trauma and PTSD. Last updated February 23, 2016. PTSD: National Center for PTSD. U.S. Department of Veterans Affairs Web site. https://www.ptsd.va.gov/professional/treatment/women/women-trauma-ptsd.asp. Accessed February 8, 2018.
7. Irish L, Fischer B, Fallon W, et al. Gender differences in PTSD symptoms: an exploration of peritraumatic mechanisms. J Anxiety Disord. 2011;25(2):209-216.
8. Pineles SL, Arditte Hall KA, Rasmusson AM. Gender and PTSD: different pathways to a similar phenotype. Curr Opin Psychol. 2017;14:44-48.
9. Herman J. Trauma and Recovery: The Aftermath of Violence – From Domestic Abuse to Political Terror. New York, NY: Basic Books; 1997:57.
10. van der Kolk B. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York, NY: Viking/The Penguin Group (USA) LLC; 2014:149-168.
11. Bowers ME, Yehuda R. Intergenerational Transmission of Stress in Humans. Neuropsychopharmacology. 2016;41(1):232-244.
12. Almli LM, Fani N, Smith AK, Ressler KJ. Genetic approaches to understanding post-traumatic stress disorder. Int J Neuropsychopharmacol. 2014;17(2):355-370.
13. Izquierdo I, Furini CR, Myskiw JC. Fear Memory. Physiol Rev. 2016;96(2):695-750.
14. Ford J, Wortmann J. Hijacked by Your Brain: How to Free Yourself When Stress Takes Over. Naperville, IL: Sourcebooks; 2013.
15. Yoga and Post-Traumatic Stress Disorder. An Interview with Bessel van der Kolk, MD. Integral Yoga. Summer 2009:113. Available at: http://www.traumacenter.org/clients/maginside.su09.p12-13.pdf. Accessed March 10, 2018.
16. Morris DJ. The Evil Hours: A Biography of Post-Traumatic Stress Disorder. New York, NY: Houghton Mifflin Harcourt; 2015:189.
17. Mithoefer MC, Wagner MT, Mithoefer AT, et al. The safety and efficacy of {+/-}3,4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study. J Psychopharmacol. 2011;25(4):439-452.
18. Mithoefer MC, Wagner MT, Mithoefer AT, et al. Durability of improvement in post-traumatic stress disorder symptoms and absence of harmful effects or drug dependency after 3,4-methylenedioxymethamphetamine-assisted psychotherapy: a prospective long-term follow-up study. J Psychopharmacol. 2013;27(1):28-39.
19. Zelfand E. Psychedelic science: spirituality as medicine. NDNR. March, 2017. Available at: https://ndnr.com/anxietydepressionmental-health/psychedelic-science-spirituality-as-medicine/. Accessed February 26, 2018.
20. Naparstek B. Note to Colleagues: Please Stop Saying Post Traumatic Stress is Incurable. July 1, 2010. Huff Post Web site. https://www.huffingtonpost.com/belleruth-naparstek/mental-health-note-to-col_b_553096.html. Accessed February 12, 2018.

Photo by Milada Vigerova on Unsplash

Debra Gibson, ND, graduated from the National College of Naturopathic Medicine (NCNM, now NUNM) in 1983, and has practiced for more than 30 years. The intersection of body, mind, and metaphysics is of particular interest in her work. She currently practices in Cos Cob, CT.