The integrative management of PTSD: A review of conventional and CAM approaches used to prevent and treat PTSD with emphasis on military personnel

https://doi.org/10.1016/j.aimed.2014.10.002Get rights and content

Abstract

Post-traumatic stress disorder (PTSD) may be the most urgent problem the U.S. military is facing today. Pharmacological and psychological interventions reduce the severity of some PTSD symptoms however these conventional approaches have limited efficacy. This issue is compounded by the high rate of co-morbid traumatic brain injury (TBI) and other medical and psychiatric disorders in veterans diagnosed with PTSD and unresolved system-level problems within the Veterans Administration and Department of Defense healthcare services that interfere with adequate and prompt care for veterans and active duty military personnel. This paper is offered as a framework for interdisciplinary dialogue and collaboration between experts in biomedicine and CAM addressing three primary areas of need: resiliency training in high risk military populations, prevention of PTSD following exposure to combat-related trauma, and treatment of established cases of PTSD.

The evidence for widely used conventional pharmacological and psychological interventions used in the VA/DOD healthcare systems to treat PTSD is reviewed. Challenges and barriers to adequate assessment and treatment of PTSD in military personnel are discussed. A narrative review of promising CAM modalities used to prevent or treat PTSD emphasizes interventions that are not widely used in VA/DOD clinics and programmes. Interventions reviewed include virtual reality graded exposure therapy (VRGET), brain–computer interface (BCI), EEG biofeedback, cardiac coherence training, EMDR, acupuncture, omega-3 fatty acids and other natural products, lucid dreaming training, and energy therapies. As meditation and mind-body practices are widely offered within VA/DOD programmes and services addressing PTSD the evidence for these modalities is only briefly reviewed. Sources included mainstream medical databases and journals not currently indexed in the mainstream medical databases. Although most interventions discussed are applicable to both civilian and military populations the emphasis is on military personnel. Provisional integrative guidelines are offered with the goal of providing a flexible and open framework when planning interventions aimed at preventing or treating PTSD based on the best available evidence for both conventional and CAM approaches. The paper concludes with recommendations on research and policy within the VA and DOD healthcare systems addressing urgent unmet needs associated with PTSD.

Introduction

Post-traumatic stress disorder may be the most urgent problem the U.S. military is facing today. The personal, social and economic burden of human suffering, treatment costs, disability compensation, and productivity losses related to PTSD are major issues facing American society and, to a lesser extent, other countries that have supported the U.S.-led conflicts in Iraq and Afghanistan.

After decades of research there is still no consensus on the causes, nature or treatment of the psychological and psycho-somatic consequences of trauma [1], [2]. Different understandings of human trauma have led to different conceptual models and disparate treatment approaches. Conventional pharmacological and psychological approaches widely used to treat PTSD are based on the assumption that traumatic exposure results in chronic dysregulation in neurophysiology and maladaptive coping with stressful situations. Many therapies endorsed by mainstream psychiatry reduce the severity of some PTSD symptoms however most conventional approaches have limited efficacy. In a review of 55 studies on empirically supported treatments of PTSD high drop-out rates or non-response rates (up to 50%) were common [3]. The limitations of current mainstream approaches invite open-minded consideration of the range of promising alternative and integrative approaches aimed at preventing PTSD following exposure to trauma and treating chronic PTSD.

Section snippets

Challenges and barriers to adequate assessment, prevention and treatment of PTSD

Adequately assessing and treating the complex symptoms of PTSD calls for comprehensive screening and multi-modal collaborative treatment. In general, mental health problems among the military are probably under-reported because of concerns over confidentiality and feelings of shame, anger and guilt [4]. Conversely, some veterans may falsify or exaggerate claims of mental illness—including PTSD—when seeking disability compensation. These challenges become even greater with respect to programmes

Prevention of PTSD following trauma

Gartlehner et al. [8] compared the effectiveness and adverse effects of psychological and pharmacological interventions aimed at preventing PTSD in adults. Thirteen studies on efficacy included diverse populations including victims of sexual assault, accidents, terrorist attacks and others. Significant findings included no evidence for debriefing in preventing PTSD, some evidence for a collaborative care (CC) model combining pharmacological management and CBT, no evidence for comparative

CAM perceptions and use trends in civilian and military personnel diagnosed with PTSD

Rates of CAM use among veterans and the civilian population are comparable and range between 23% and 50% depending on the type of CAM and the population surveyed [13]. A cohort analysis of 599 individuals who had been diagnosed with PTSD and reported active symptoms of PTSD within the past year found that 39% reported using a CAM treatment to address emotional and mental problems within the same one-year period however only 13% saw a CAM practitioner for treatment [14]. Types of CAM most widely

Meditation

Research studies have evaluated mindfulness training, mantra reciting and compassionate meditation (Vipassana) for their potential beneficial effects in PTSD. A review of meditation practices addressed at preventing PTSD found more evidence supporting mindfulness meditation than mantra reciting or compassionate meditation [17]. The majority of studies on mindfulness have been done on individuals diagnosed with generalised anxiety—not PTSD—therefore outcomes may not generalise to PTSD.

Towards an integrative model for preventing and treating PTSD

Numerous conventional and CAM therapies addressing PTSD are currently used or are at various stages of investigation. Exh 1 summarises evidence for conventional and CAM therapies aimed at preventing or treating PTSD including comments on limitations of findings and safety.

Exhibit 2 is provided as a concise guide to interventions addressing the three target populations of interest:

  • Groups who are at high risk of exposure to trauma because of the nature of their work including active duty

Recommendations on policy and research

Challenges interfering with access to care and quality of care within the VA and DOD healthcare systems include inadequate funding, delays in funding allocation to new programme development efforts, difficulties recruiting qualified mental health professionals, and slow progress around implementation of specialised PTSD programme and clinics. Such system-level problems directly impact on the timely implementation of adequate, appropriate, cost-effective evidence-based services and resources

Conflicts of interest

The author has no financial conflicts of interest to declare.

References (87)

  • C.S. North et al.

    Toward validation of the diagnosis of posttraumatic stress disorder

    Am J Psychiatry

    (2009)
  • Van der Kolk et al.

    What is PTSD Really? Surprises, twists of history, and the politics of diagnosis and treatment

    J Clin Psychol

    (2013)
  • M.A. Schottenbauer et al.

    Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations

    Psychiatry

    (2008)
  • P. Corrigan

    How stigma interferes with mental health care

    Am Psychologist

    (2004)
  • S. Mohamed et al.

    Pharmacotherapy of PTSD in the S. Dept of Veterans Affairs: diagnostic and symptom-guided drug selection

    J Clin Psychiatry

    (2008)
  • B. Capehart et al.

    Review managing posttraumatic stress disorder in combat veterans with comorbid traumatic brain injury

    J Rehabil Res Dev

    (2012)
  • E. Hermes et al.

    Recent trends in the treatment of posttraumatic stress disorder and other mental disorders in the VHA

    Psychiatr Serv

    (2012)
  • G. Gartlehner et al.

    Comparative Effectiveness Review No. 109, Interventions for the prevention of post-traumatic stress disorder (PTSD) in adults after exposure to psychological trauma. AHRQ Pub. No. 13-EHC062-1-EF

    (2013)
  • A. Adler et al.

    J Consult Clin Psychol

    (2009)
  • M.B. Hamner et al.

    Adjunctive risperidone treatment in post-traumatic stress disorder: a preliminary controlled trial of effects on comorbid psychotic symptoms

    Int Clin Psychopharmacol

    (2003)
  • D.P. Sniezek

    Guest editorial: community-based wounded warrior sustainability initiative (CBWSI): an integrative medicine strategy for mitigating the effects of PTSD

    J Rehabil Res Dev

    (2012)
  • M.A. Micek et al.

    Complementary and alternative medicine use among Veterans Affairs outpatients

    J Altern Complement Med

    (2007)
  • D.J. Libby et al.

    Complementary and alternative medicine use among individuals with posttraumatic stress disorder

    Psychol Trauma: Theor Res Pract Policy

    (2013)
  • D.J. Libby et al.

    Complementary and alternative medicine in VA specialized PTSD Treatment Programs

    Psychiatr Serv

    (2012)
  • VA Research Currents

    Meeting seeks to expand VA's study of complementary, alternative therapies for PTSD, May–June 2011

    (2011)
  • A.J. Lang et al.

    The theoretical and empirical basis for meditation as an intervention for PTSD

    Behav Modif

    (2012)
  • R.A. Bryant et al.

    A randomized controlled trial of exposure therapy and cognitive restructuring for posttraumatic stress disorder

    J Consult Clin Psychol

    (2008)
  • L. Stankovic

    Transforming trauma: a qualitative feasibility study of integrative restoration (iRest) yoga Nidra on combat-related post-traumatic stress disorder

    Int J Yoga Therap

    (2011)
  • S.H. Kim et al.

    Mind-body practices for posttraumatic stress disorder

    J Investig Med

    (2013)
  • Y. Kim et al.

    Acupuncture for posttraumatic stress disorder: a systematic review of randomized controlled trials and prospective clinical trials

    Evid Complementary Alternative Med

    (2013)
  • D.J. Libby et al.

    The use of yoga in specialized VA PTSD treatment programs

    Int J Yoga Therap

    (2012)
  • E.M. Seppälä et al.

    Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. Military veterans: a randomized controlled longitudinal study

    J Trauma Stress

    (2014)
  • J.K. Staples et al.

    A yoga program for the symptoms of post-traumatic stress disorder in veterans

    Mil Med

    (2013)
  • M.A. Grodin et al.

    Treating survivors of torture and refugee trauma: a preliminary case series using qigong and t’ai chi

    J Altern Complement Med

    (2008 Sep)
  • J. Shepherd et al.

    Eye movement desensitization and reprocessing in the treatment of post-traumatic stress disorder: a review of an emerging therapy

    Psychol Med

    (2000)
  • K.M. Hertlein et al.

    A systematic research synthesis of EMDR studies: implementation of the platinum standard

    Trauma Violence Abuse

    (2004)
  • G.H. Seidler et al.

    Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study

    Psychol Med

    (2006)
  • F.W. Jeffries et al.

    What is the role of eye movements in eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder (PTSD)? A review

    Behav Cogn Psychother

    (2013)
  • T. Karatzias et al.

    A controlled comparison of the effectiveness and efficiency of two psychological therapies for posttraumatic stress disorder: eye movement desensitization and reprocessing vs. emotional freedom techniques

    J Nerv Ment Dis

    (2011)
  • D.P. Wood et al.

    Lessons learned from 350 virtual-reality sessions with warriors diagnosed with combat-related posttraumatic stress disorder

    Cyberpsychol Behav Soc Netw

    (2010)
  • G.M. Reger et al.

    Effectiveness of virtual reality exposure therapy for active duty soldiers in a Military Mental Health Clinic

    J Traumatic Stress

    (2011)
  • V. Vakili et al.

    Lessons learned from the development of technological support for PTSD prevention: a review

    Stud Health Technol Inform

    (2012)
  • Cited by (17)

    • The efficacy of virtual reality exposure therapy for PTSD symptoms: A systematic review and meta-analysis

      2019, Journal of Affective Disorders
      Citation Excerpt :

      With the development of VR technology, more and more families or individuals have the opportunity to experience or own this new technology, and its usage becomes more and more extensive. Furthermore, 15 of the 18 eligible studies were published within the last decade, which might reflect the VR technology development and the increased research interest in using VR technology to improve mental health (Lake, 2015). The main analysis of 10 RCTs found that VRET had a moderate positive significant effect (g = 0.327) on PTSD symptoms, with relatively small heterogeneity and no indication of publication bias.

    • PTSD and surgical residents: Everybody hurts… sometimes

      2017, American Journal of Surgery
      Citation Excerpt :

      Battlemind debriefing is a group approach designed to teach soldiers coping skills to address anger management, insomnia, and social isolation while reframing PTSD symptoms. Mindfulness training is a form of meditation that promotes increased control over intrusive thoughts or memories.18 As such, the authors advocate for the incorporation of similar interventions into residency training.

    View all citing articles on Scopus
    View full text