Short Communication, J Trauma Stress Disor Treat Vol: 6 Issue: 3

Managing Post Trauma Reactions-Changing the Dialogue and Protocols

Joanne Patti Munisteri^*

New Zealand School of Acupuncture and Traditional Chinese Medicine, USA

*Corresponding Author : Joanne Patti Munisteri
New Zealand School of Acupuncture and Traditional Chinese Medicine, Level 10, 57 Willis street, CBD, Wellington, USA
Tel: 04 473 9005
E-mail: js334@georgetown.edu

Received: August 11, 2017 Accepted: September 04, 2017 Published: September 11, 2017

Citation: Munisteri JP (2017) Managing Post Trauma Reactions-Changing the Dialogue and Protocols. J Trauma Stress Disor Treat 6:3. doi: 10.4172/2324-8947.1000177

Abstract

Keywords: Post traumatic; Trauma spectrum response; Acupuncture

Background

In the last decade there is an increasing awareness in conflict zone hospitals, in military hospitals and clinics in a number of countries, that acupuncture and traditional Chinese medicine treatments are efficacious and time/cost effective for treating post-traumatic stress and what is labelled as TSR or Trauma Spectrum Response and the recently listed condition of ASD (Acute Stress Disorder) and GAD (General Anxiety Disorders).

The immediate and subsequent symptoms can include: insomnia, residual pain, aphasia, appetite changes, numbing, personality changes, depression, manias, flashbacks, anxiety, muscular skeletal weakness, digestive disorders, tinnitus, temporary paralysis, myopia, fatigue, impulse control problems, filters, triggers, sexual dysfunction, aggressive denial, phobias, cognitive difficulties, ahedonia, hyper arousal, and other ‘qi/chi’ and/or ‘shen’ disturbances which cause suffering in the patients, as well as impact their family, friends, colleagues, communities and their wider society.

Patients have presented with physical, emotional/mental and even ‘spiritual’ distress from being a victim, witness and/or perpetrator of trauma. These symptoms and possible treatment protocols were described by traditional Chinese Medicine practitioners in their literature since 240 B.C., when the Inner Cannon of the Yellow Emperor by Huang Di, known as the Nei Jing, was written. The Song of the Ghost Points by Sun Si Miao, was transcribed into written text in the 7^th century.

“In classical Acupuncture terms-pathologies of ‘Qi’ (are) objective disharmonies that generate physical and emotional symptoms simultaneously. In the Acupuncture paradigm, resonant with the term ‘soldier’s heart’; all emotions affect the Heart, the vessel of Shen, spirit. Thus a Heart Shen disturbance participates in every case of PTSD and TBI (Traumatic Brain Injury) which manifest commonly as exhaustion of Heart Fire (concentration and memory problems, anxiety, depression, disturbed sleep). Stagnant Liver Qi escalating into Liver Fire accounts for some of the most distressing symptoms (muscle tension, hyper vigilance, irritability and outbursts of rage) and both Heart and Liver disturbances are coupled with Kidney Yin and Yang depletion (fatigue, fear and helplessness) [1].

In western medicine these symptoms are clustered together and generally labelled as PTSD (Post-Traumatic Stress Disorder) or less commonly as TSR (Trauma Spectrum Response).

“In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The diagnostic criteria are specified below.

Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and, the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. Two specifications are noted including delayed expression and a dissociative subtype of PTSD, the latter of which is new to DSM-5. In both specifications, the full diagnostic criteria for PTSD {Post-Traumatic Stress Disorder} must be met for application to be warranted. “Co-existing symptoms (for example: chronic pain, depression, anxiety, and fatigue) are common in military fighters who have experienced physical and/or psychological trauma. These overlapping conditions cut across the boundaries of mind, brain and body, resulting in a common symptomatic and functional spectrum of physical, cognitive, psychological and behavioural effects referred to as the ‘Trauma Spectrum Response’ (TSR).” [2]

In addition there is another diagnostic label possible if a practitioner is treating patients afflicted with symptoms within a specified time frame after the trauma happened. “Acute stress disorder (ASD) is a new diagnostic category that was introduced in 1994 to differentiate time- limited reactions to trauma from posttraumatic stress disorder (PTSD)” [3].

Dialogues

Dis is a prefix which originates from Roman mythology, Dis Pater (Hades in Greek myths). Dis was the god of the underworld. Dis means ‘against’, as a prefix, so the word/term ‘disorder’ can simply be understood as being- against the order of ‘normal health’. However the somatic and psychic responses of human beings to violence, horrific events, abuse, sudden life threatening natural disasters, torture, murder, rape, prolonged deprivation, imprisonment; are essential features of our human health signalling systems. They are embedded indicators which dispatch warnings to our physical, emotional and even spiritual essence to be uniquely alert to the changes that have arisen due to trauma.

Diagnosing a patient with language which condemns her or him to a seemingly long term, immutable health disturbance can adversely affect patients as well as health practitioners in the treatment environment. Words used therapeutically by psychiatrists, psychologists, nurses, care takers, healers can make considerable difference between short and long term recovery. We know from neuroscience imaging research how important encouraging words/ text/ imagery and stimulation are to growth, repair and resilience in human beings and in animals. Therefore promoting a shift in perspective and diagnostic label replacement from “disorder” (acute stress disorder, post-traumatic stress disorder) to a “response” or “reaction” is the first step for all involved in post-trauma management and care. It is significant to report that health practitioners in countries where I have worked, and where English is not the national language (for example Armenia, Ukraine, Afghanistan, Pakistan, Israel, Russia, Morocco, Italy) do not call, label or diagnose post traumatic responses as post-traumatic stress ‘disorder’. This is also the case for Indigenous populations in Australia (Aboriginal), New Zealand (Maori) and certain First Nation tribes in the continent of North America. Officially, health practitioners may label these collections of symptoms- ‘Post-Traumatic Stress’ or Trauma Stress Reactions, but in addition they have other more poetic descriptions such as: “maemae” (hurts/pains-Maori) ‘katipo’ (poisonous spider- Maori) ‘talking ghosts’, (translated from Mandarin texts) ‘wind evils’, Iktomi (Lakota), and so forth. These psycholinguistic distinctions are crucial to changing the attitude and to de- stigmatizing these conditions.

Treatment Protocols

The usual prescriptions in western medicine approaches to post trauma involve the administration of pharmaceutical medicine and perhaps the addition of CBT Cognitive Behavioural Therapy (CBT) and exercise. There are few other possibilities offered to someone suffering from Post-Traumatic Stress (PTS) or Post-Traumatic Stress Response (PTSR) in conflict zones or in military hospitals at present. There are a number of studies presenting the efficacy of using guided imagery, GMI (Graded Motor Imagery) visualization, EMDR(Eye Movement Desensitization and Reprocessing) [4], medical qigong and meditation- to shift the paradigm of suicidal, self-harming or aggressive actions to more life affirming, less agitated behaviours. These methods are also part of successful pain management tools. “Neuroscientist Vilayanur S. Ramachandran argued that chronic pain can be reinforced by a learned reorganization of neural circuits. To prove this, he created a treatment known as the mirror box. All it consists of is two mirrors in a box which, when viewed from an angle, give an amputee the illusion of having two functional limbs. The visualization tricks the brain, ends the maladaptive feedback loop, and relieves the pain. The mirror box changed the way we look at chronic pain, and mirror therapy is now one of the main components of a treatment called graded motor imagery. Patients can assuage symptoms on the neuronal level using GMI, in addition to using physical therapy to promote functional movement. Lifestyle changes like diet and exercise can also work to provide relief” [5].

These techniques are introduced to the patient by a health practitioner who will choose when to initiate these modalities. All of these are possible with limited resources and in confined spaces, but they require consistent guidance from a skilled practitioner and regular practice on the part of the patient. Complementary strategies for post trauma management may be done in conjunction with Acupuncture and Traditional Chinese Medicine (TCM).

Acupuncture and Traditional Chinese Medicine

Acupuncture used for Integrated Stress Management (ISM)and Traditional Chinese Medicine (TCM) meridian points needled on thousands of patients, in both civilian and military clinics/hospitals, has proved effectual in a number of randomized, controlled medical investigations arising from varying circumstances and happening to diverse population groups [6-8].

Military Medicine Applications

“Acupuncture for the treatment of concussions, insomnia, dizziness, headaches, and PTSD is used in the US military. Stars and Stripes published an article on this topic by Dr. Stuessi, a Navy sports medicine physician who works in a special concussion care center. He notes, “I’ve found phenomenal, off-the-charts results doing acupuncture for sleep, for dizziness and headaches.” [9]. There are a numbers of commonly used points such as Zu San Li (Stomach 36) which hearken back to Chinese dynasty military campaigns, when due to depletion or injury soldiers needed to go “3 miles more” on little sleep or with little food. They applied moxa (heat with mugwort) to the point(s) and/or needled bilaterally on the leg meridian points for quick reaction response to “keep on going” until they were able to re supply and recuperate. There is an entire body of literature and case studies in TCM (Traditional Chinese Medicine) concerning application of the “Ghost Points” for treating symptoms similar to those described in western medicine diagnosis as PTS or TSR. American military uses of acupuncture date back to the 1960s. Army, Navy, Air Force and Marine doctors have utilized meridian points for post trauma, pain relief and emotional resiliency. “The US military has documented the usefulness of acupuncture since 1967, when an Army surgeon wrote an article on the efficaciousness of acupuncture in Military Medicine magazine. Since that time, doctors at the Walter Reed Army Medical Center in Washington recommend acupuncture for the treatment of physical pain due to injuries. Col. Richard Niemtzow, an Air Force physician, first offered acupuncture in 1995 at McGuire Air Force Base (New Jersey). Later, he founded the Air Force acupuncture clinic at Andrews Air Force Base (Maryland). In addition to clinical care for patients, there is training for doctors to bring acupuncture therapy to war zones in Iraq and Afghanistan. The focus is on the treatment of pain and PTSD. The Navy has an acupuncture training program for doctors at Camp Pendleton (San Diego, California). Dr. Ronald White, as director of pain services at Landstuhl Regional Medical Center, commented on acupuncture, “There’s no risk; it gives you benefit. Our goal — my end result — is function. If you come to me complaining that you can’t play with your kids, you can’t sleep at night, you can’t work, and six months later, I have you playing, sleeping and back to work….” [10]. While working on Ascension Island, South Atlantic with the British military, I treated a number of returning soldiers who were reintegrating after being wounded on active duty. I used acupuncture and moxa for: phantom pain after amputations, insomnia, anxiety, muscular skeletal injuries and residual pain from back, shoulder and neck injuries. The reaction of the doctors and patients on the island was one of initial disbelief, then surprise and curiosity since acupuncture (Traditional Chinese Medicine) was so effective. “Acupuncture has been widely applied in the treatment of anxiety disorders and statistically significant effects have been observed.” [5]. On the NATO hospital HKIA base in Kabul, in collaboration with USAF doctors we treated not only muscular skeletal injuries of the back, neck, ankle and shoulders but also insomnia using the NADA bi lateral auricular protocol, plus Yintang (MN-HN-3) and/or Heart 7 (Shen Men on the arm). If the patients were receptive, I also demonstrated the medical qigong movements from the Ba Gua/Nei Jia Guan series as a therapeutic means of calming the nervous system before trying to sleep.

Auricular Acupuncture

What was originally known as NADA protocol (National Acupuncture Detox Association) is now known as Auricular Trauma Protocol (ATP) as well as ISM (Integrated Stress Management) treatment point’s protocol.

Initially points in the ear were stimulated with electricity however research at Lincoln Recovery Center in New York City, proved over time that needles retained for 30-45 minutes provided longer symptomatic relief for patients. The auricular points for this protocol are: sympathetic nervous system, shen men, kidney, liver, lung with additional bilateral points such as point zero and heart. “Recovery from chemical addiction mirrors the recovery path for individuals suffering from post-traumatic stress syndrome, which is why the NADA protocol is now being used to treat the effects of trauma [11]. “Translating the Louisiana experience into on base clinics has demonstrated that the NADA 5 Needle protocol is an effective tool for treating the stresses and wounds of war.” [12]. When these reports mention “5 Needle Protocol” they refer to 5 needles in each ear. The Korean made sijouk needles, as well as the specially manufactured NADA protocol needles, can be used on all ages and body types, are cost effective and easily transportable. An integral part of treatment in clinics at Lincoln Hospital in the Bronx, New York, USA, Ballymead clinics in Northern Ireland, and on Maori maraes in New Zealandfor example- is the involvement of patients in the preparation of their own treatment. This collaborative process supports personal empowerment in the therapeutic steps necessary for symptom relief and ultimately for healing. The patient fills out their own form each time they return for a session, rates their own progress or tells a practitioner so their progress can be recorded Patients are expected to wash their own hands before being seated. Patients are instructed on how to swab their own ears before treatment, seat themselves comfortably and raise their own hand when they are ready for a practitioner to come over to treat them. Patients are responsible for disposing of the needles used for their treatment in a centrally placed sharps container. The actions the patients complete as part of their own treatment, reinforces their independence and capability with conditions (such as addiction and post trauma reactions) which previously or unpredictably may have overwhelmed them and led to a loss of self-confidence, feeling of powerlessness, reduced capabilities and dependency. “The treatment methods include body acupuncture and ear acupuncture, with the common selected points of Baihui (DU-20), Shenmen (HE-7), Neiguan (P-6), and Sanyinjiao (SP-6), which is based on traditional Chinese Medicine (TCM) theory of Zang-Fu organs. Based on the integration of TCM with biomedical knowledge of brain regions related to anxiety disorders, we designed and located two new stimulation areas on the scalp with electric stimulation, and this treatment protocol for anxiety disorders has shown remarkable immediate and long-term effect in our clinical practice.”

Scalp Acupuncture

Scalp acupuncture is another treatment possibility for practitioners. While there are not specific points designated just for post trauma (PTS) or GAD; depending on the symptoms and physical health of the patient, the following points may be administered: Du 20 (Baihui) “4 Directions points” (scalp), Du 23,(Shangxing) Du 24 (Shenting) M-HN-9 (Taiyang), GB 8(Tianchong) GB 9 (Shuaigu).

“The unique aspect of our scalp acupuncture treatment protocol is in selecting points on the Governing Vessel and local points on the head to locate the two scalp stimulation areas with electric stimulation in order to regulate and balance the function of the corresponding brain regions related to anxiety disorders. The demonstration of remarkable immediate and long- term effects of this treatment protocol reveals new and developing prospects of scalp acupuncture for the treatment of anxiety disorders.

Stimulation area one: The line between Yintang (M-HN-3) and Shangxing (DU-23) and Shenting (DU-24).

Stimulation area two: The line between Taiyang (M-HN-9) and Tianchong (GB-9) and Shuaigu (GB-8).

Low voltage electric current is passed between the pair of needles to stimulate the amygdala and hippocampus regions to regulate the neural activity of fear and anxiety” [13].

Scalp acupuncture may be administered while the patient is seated or lying prone depending on the situation and facilities available. In combat and conflict zones, ‘battlefield acupuncture’ has proven to be effective for immediate symptomatic relief. This may involve a combination of sijouk and Serian (or other brand TCM needles) of varying length and width depending on body types, thickness of muscles, skin type, etc.

New Zealand TCM practitioner, Peter Larking at the Om Clinic in Wellington, uses Tang scalp acupuncture points and he contributes the following:

In the Tang style acupuncture there is a location called ‘the calm line’ which is used for anxiety or linking Du 24 and Bl 3 (upper jiao line) back into Du 22 to make a triangle shape. This is now my goto technique for chronic insomnia. Doctors, aid workers, medical practitioners in high stress situations may also benefit themselves from 30-45 minutes acupuncture treatments on site. A number of Ukrainian medical doctors working with US agencies in Kiev and Ternopil in 2015, were suffering post trauma after the events they witnessed during the Maidan demonstrations. I administered the 5 point bi lateral auricular protocol and a few extra points (Baihui- Du 20) the 4 Gates (Tai Chong-Liver 3, and Hegu-Large Intestine 4) as well as Lung points for grief. These proved effective in relieving their symptoms after only two treatments. They were able to return to their high level functioning and demanding practice without the need for sleeping or anti-depressant medication.

Herbal Remedies

In addition to the above stipulated modalities for treating PTSR, PTS, GAD, ASD - supplementing ISM with Bach Flower Rescue Remedies in lozenge or liquid form has been helpful for many patients (between treatments) in reducing anxiety, stress, triggers, depression and agitation symptoms. The liquid form is more concentrated but more problematic to transport in field/combat situations. Pills and lozenges are easy to transport but less concentrated and patients may need to take more for the same effect as a few drops on the tongue. “The result of this independent study is not only welcome news for those of us who encounter stressful situations every day, but particularly for the 40 million Americans who suffer from physiciandiagnosed anxiety,” said Ronald Stram, MD, who regularly prescribes Rescue Remedy to his anxious and stressed patients. “Stress compromises your ability to fight off disease and infection. It can even rewire the brain, making you more vulnerable to everyday pressures and problems.” [11]. Traditional Chinese Medicinal herbs may also be prescribed depending on the overall health condition of the patient and the availability of the herbs on site or nearby the clinic, hospital or private practice rooms.

Natural Disaster Trauma Response Utilizing Acupuncture

“In related research, acupuncture is found more effective than paroxetine (Aropax, Paxil, Sereupin) for relief of PTSD due to earthquake trauma. Researchers from the Chengdu University of Traditional Chinese Medicine and the Chengdu Military General Hospital conducted a randomized controlled clinical investigation of 138 patients with earthquake induced PTSD. Electro acupuncture was applied to the treatment group at GV20 (Baihui), Sishencong (Ex- HN 1), GV24 (Shenting) and GB20 (Fengchi). The medication group received oral administration of paroxetine. The medication group showed improvement. However, the reduction scores of PTSD including specific scores for anxiety and depression reduction were better in the electro acupuncture group than the paroxetine group.” [10]. Unfortunately medications such as paroxetine, SSRIs (anti-depressants) and prescription sleeping medications have side effects such as long term liver and kidney damage as well as the following short term symptoms: “drowsiness, nausea, dry mouth, insomnia, diarrhea, nervousness, agitation or restlessness, dizziness, sexual problems, such as reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction), headaches, blurred vision, weight gain and hallucinations” [14].

The Hippocratic Oath all western medical practitioners take -Primum Non Nocere- ‘to above all do no harm’ -is more easily followed with the use of the therapies outlined in this article. Those who come to us, are sent to us or live among us seeking relief should be able to access comprehensive, non-addictive, effective remedies which are easily affordable, to cope with the pain and suffering that sudden and violent trauma inflicts.

“Complementary and IM (Integrative Medicine) modalities include tools that induce permanent healing in a whole person. Better and more-holistic approaches are needed for healing the wrTSR. (War related Traumatic Stress Reactions) In addition, there needs to be greater emphasis on research and implementation of whole-person healing practices. Finally, it is necessary to recognize the importance of healing as much as curing.” [15].

All the treatments mentioned may be expanded upon with more research, observation and implementation. Those who are already trained and skilled TCM practitioners can work together with western medicine trained practitioners to offer patients a range of healing strategies and treatments. This is already being done on a limited scale when doctors in clinics, hospitals and in the field have open minds about different approaches for physical and psychic pain relief. This article was written to share information and spur discussion of these healing modalities.

Acknowledgements

Thank you to all the TCM, Western medical doctors and tribal healers who have trained and worked with me over the last few decades, especially: Doc Ron Rosen, Dr. Lillian Oh, Dr. Xiao Tian Shen, Chief Archie Fire Lame Deer, Auntie Jesse Williams of the Gumbayngirr People in New South Wales, Australia , Canon Wi Te Tau Huata- Ngati Kahungunu, Peter Larking at the OM Clinic NZ, Dr. Robert Calhoun (USAF) and all those who were my teachers and colleagues at the New Zealand School of Acupuncture and Traditional Chinese Medicine between 2003- 2006. Special thanks to Dr. Debra Betts, who was not only an inspiring teacher at the New Zealand School of Acupuncture and Traditional Chinese Medicine in Wellington, but an encouraging mentor and rigorous taskmaster who gave generously of her personal time and expertise. I am extremely grateful for the many patients I have had over the years in various places and in often challenging conditions.

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