22 Mind Body Therapies and Posttraumatic Stress Disorder
Post Traumatic Stress Disorder: An Overview
Discussions of the whole psychological concept of post traumatic stress disorder began when veterans returned from the Vietnam War. However, Sir William Osler, the Father of American Medicine, in his book, Aequanimitas,1 talked one hundred years ago about ordinary illnesses being due to the stress and strain of daily life. Hans Selye later brought to our attention the fact that virtually all illness is the result of stress.2 Indeed, having worked with over 30,000 individuals who had failed conventional medicine, many of them with chronic pain and all of them with chronic depression, it is my impression that virtually all illnesses are ultimately the result of unresolved stress, which frequently began in childhood. In other words post traumatic stress appears to be the root cause of illness. Situations that were perceived as either childhood abuse or abandonment impact an individual for life. Abuse tends to cause anger and abandonment leads to depression in adulthood. The extent of anger or depression varies significantly among individuals.
Posttraumatic stress disorder is generally considered a more serious reaction that can occur almost instantly after major trauma or disaster. The most striking features of PTSD are flashbacks, recurrent memories and reliving of specific traumatic experiences. These same features appear to be in most patients with chronic depression or anxiety. These individuals can have rapidly developing emotional outbursts and often extremely bizarre behavior sometimes leading to rampages of murder or suicide. Indeed, it is these extremes that are the sine qua non of PTSD. If we look at the number of symptoms that are often part of posttraumatic stress disorder, they include3:
PTSD Diagnosis
The difficulty in establishing the diagnosis of PTSD has led to the development of a PTSD checklist (PCL). This checklist was developed from a population of 40 motor vehicle accident victims and sexual assault victims.4 The Iraq and Afghanistan wars have led to a striking increase in the number of soldiers diagnosed with PTSD.
As one might expect, not everyone exposed to what appears to be the same intensity of trauma develops posttraumatic stress disorder. In one small study, 51 individuals who suffered a physical injury due to a traumatic event were assessed 1 week and 6 months after the trauma. Only 13 of these 51 (25.5%) met the posttraumatic stress disorder diagnostic criteria at follow-up. Those who did develop PTSD, had “higher levels of peritraumatic disassociation and more severe depression, anxiety, and intrusive symptoms” at the 1 week assessment. This peritraumatic disassociation at that initial week was a major factor in whether they later developed PTSD.5 In another study of 72 female rape victims versus 86 female victims of nonsexual assault, there were two patterns of posttraumatic symptoms, one being characterized as posttraumatic stress disorder and the second as a phobic reaction.6
Positron emission tomography (PET) has allowed perhaps the most clinically relevant view of brain function in PTSD. In 16 women with histories of childhood sexual abuse, 8 had current PTSD and 8 did not. When asked to recall or mentally recreate a traumatic event, both groups exhibited regional cerebral blood flow increases in the orbital frontal cortex in the anterior temporal poles. However, those with PTSD had a much greater increase in cerebral blood flow in those areas and those without PTSD had a greater decrease in cerebral blood flow in the left inferior frontal cortex. The non-PTSD had greater increases in the anterior cingulate gyri.7 Single photon emission computed tomography (SPECT) scans also have offered some insights into the physiologic changes apparent in PTSD patients. Fourteen veterans with PTSD, 11 combat control subjects and 14 normal subjects were all studied with the SPECT scans in sessions at least 48 hours apart. In one exposure, the individuals experienced white noise and in the other, they experienced exposure to combat sounds. Activation in all three groups occurred in the anterior, cingulate, and middle prefrontal gyri but activation in the region of the left amygdala and nucleus accumbens was found only in PTSD patients. Deactivation was found in all three groups in the left retrosplenic region.8
It appears that the PTSD individuals have regional differences in brain activity, at least during recall of their trauma. As one might expect, those individuals diagnosed with PTSD have a high incidence (80%) of having at least one other comorbid psychiatric diagnosis.9 It may be that the total lifelong cumulative stress to which individuals have been adversely subjected earlier in life predisposes them to PTSD. In one study of 131 Vietnam male veterans who had taken the Minnesota Multiphasic Personality Inventory (MMPI) in college had readings that were within the normal range, but no one scale predicted the development of stress from combat exposure. Hypochondriasis, psychopathic deviant, masculine femininity, and paranoia scales predicted PTSD symptoms, as did depression, hypomania, and social introversion and these effects were dominant despite the degree of combat exposure. The conclusion is similar to individuals in general. “Pre-military personality can affect vulnerability to lifetime PTSD symptoms in men exposed to combat.” This is thought to be true in individuals exposed to any trauma.10 In the author’s experience treating thousands of patients with chronic pain that failed all conventional therapy, at least 75% had elevations on depression, hypochondriasis, and hysteria, and an additional 15% had elevations on psychopathic deviant, masculine femininity, and paranoia.11 The most intense problem is the pattern of replaying many past traumatic events. Many of them can never remember a happy event from childhood. The main difference in these individuals and those with PTSD is that the chronic pain and depressed patients do not have the erratic episodes of intense emotional behavior. They are more passive.
Finally, there has been an attempt to evaluate the role of shame, anger, and childhood abuse in victims of violent crime. One hundred fifty-seven victims of violent crime were interviewed 1 month after the crime and 6 months later. It was found that shame and anger were the only independent predictors of PTSD at 1 month and shame was the only independent predictor of PTSD at 6 months. The authors conclude that both shame and anger play important roles in the development of at least crime-related PTSD and that shame is the perpetuator in the subsequent course of symptoms.12
Another study supports the thesis that it is the childhood background that may determine one’s propensity to develop PTSD. In a telephone interview survey of 4023 adolescents aged 12 to 17 years, 16% of boys and 19% of girls met the criteria for at least one diagnosis of either PTSD, major depressive episode (MDE), or substance abuse/dependence (SA/D). The 6-month PTSD prevalence was 3.7% for boys at 6 months and 3% for girls, whereas, that of MDE was 7.4% for boys and 13.9% for girls. In the 12-month SA/D, prevalence was 8.2% for boys and 6.2% for girls. PTSD was more likely to be a comorbid condition than was MDE or SA/D. These results generally support the hypothesis that exposure to interpersonal violence (i.e., physical assault, sexual assault, or witnessed violence) increases the risk of the development of these major psychiatric disorders.13
Hans Eysenck’s Work on Anger and Depression
Eysenck discovered over two decades that approximately 75% of the individuals who died of cancer were the lifelong hopeless, 15% were angry, and 9% were both. Only 0.8% of those who died of cancer were autonomous. Additionally, approximately 75% of those who died of heart disease were lifelong angry, 15% were lifelong depressed, and 9% were lifelong both. Overall, the vast majority of the individuals who died in only twenty years were chronically angry, depressed, or both.14 These findings have significant implications for PTSD patients, who suffer even more intense anger, depression, or both.
Electromagnetic Dysthymia and PTSD
Whatever the circumstances that predispose an individual to posttraumatic stress disorder, treatment for this particular difficult problem is primarily one for the field of mind-body medicine. Veterans have a high incidence of traumatic physical injury as well as psychological trauma. Thus, pain is common as a comorbid condition in these PTSD patients. In general, pain should always be treated when possible with appropriate correction of the physical or physiological cause. When such treatment does not lead to resolution of the pain within 6 months, it becomes a chronic pain syndrome. In the chronic pain syndrome, one should always consider procedures such as transcutaneous electrical nerve stimulation, acupuncture, physical exercise, and massage. In the author’s experience in working with more than 30,000 chronic pain patients, the most important long-term success have been achieved when these procedures are integrated with mind-body medicine. Many of these chronic pain patients fall into the category known as electromagnetic dysthymia. It is thought that these individual’s have brains with erratic electrical systems. Individuals with this disorder have the following characteristics15:
It is the author’s experience that PTSD patients have these abnormalities.
Mind Body Therapies and PTSD
Mind Body Medicine: History and Overview
Today’s concept of mind body medicine evolved in the early 1970s from the humanistic psychology movement. Contributors to this movement included early biofeedback work by Dr. Elmer Green and his wife, Alyce, and the meditation and relaxation studies of Dr. Herb Benson. As early as 1964, Dr. George Solomon had begun his work on psychoimmunology, but the concept did not take off until Dr. Robert Ader expanded this work to the concept of psychoneuroimmunology in 1970.16,17 It was the discovery of endorphins and the work of Dr. Candace Pert that laid a solid chemical foundation for the concept.18
Mesmerism itself was the first major development in the pre-modern prelude to today’s mind-body medicine. In the early 20th century, Emile Coue emphasized that “imagination” always wins in a conflict between “imagination and will.” Coue was famous for his statement, “Every day in every way I am getting better and better.” This statement was reported to cure thousands of people.19 The “separation” of mind and body is often said to have originated with Rene Descartes. Prior to his contributions, medicine, science, philosophy, and spirituality were commonly considered aspects of the whole person. With his influence in the 1600s, the separation of mind and body occurred—with mind being the purview of religion and metaphysics and body being the purview of science and medicine. In the late 18th century, Anton Mesmer began the trend to reexamine the connection of body and mind. Although rejected by most of his contemporaries, Mesmer’s work, said by Benjamin Franklin to be only a suggestion of the effect of the mind, spawned the concept of hypnosis, which was introduced by James Braid and James Eisdale after Dr. John Elliotson demonstrated in the 1840s that surgery could be performed on mesmerized patients. In 1872, Dr. Daniel Hack Tuke published the first major treatise on mind-body medicine in London. Tuke emphasized that the mind acts on the body through intellect, emotions, and volition. He considered that special and general sensations were influenced by mind, intellect, and volition, so he excluded these from his discussion. Conversely, he quotes Unser, who in 1771 wrote, “Expectation of the action of a remedy often causes us to experience its operation beforehand. This is also one of the earliest statements of the placebo effect.
