Post-Traumatic Stress Disorder

What is Post-Traumatic Stress Disorder?

Post-traumatic stress disorder (PTSD) is a mental health condition in which distressing symptoms persist after a person experiences or witnesses a traumatic event. It involves re-living the event, avoiding reminders, negative changes in mood and thinking, and heightened arousal, and it can disrupt daily life and relationships.^{[1, 2]}

For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Common symptoms

PTSD symptoms fall into four groups. They are intrusive memories such as flashbacks and nightmares, avoidance of reminders, negative changes in mood and thinking, and arousal symptoms such as being on guard, irritability, poor sleep and trouble concentrating.^[1]

• Flashbacks, nightmares and distressing memories
• Avoiding places, people or conversations that bring the event back
• Guilt, hopelessness, emotional numbness or loss of interest
• Being easily startled, tense or irritable, with sleep trouble

Causes and risk factors

PTSD follows exposure to a traumatic event, but not everyone who is exposed develops it. About one third of people who experience a severe traumatic event develop PTSD.^[3] Factors linked to higher risk include a family history of psychiatric disorder, a history of physical disease, repeated exposure to traumatic experiences, and the severity of the trauma.^[3]

How it is diagnosed and treated conventionally

A trained clinician diagnoses PTSD based on a history of trauma exposure and symptoms lasting more than a month, causing distress or impairment.^[1] Treatment centers on trauma-focused psychotherapy, and a meta-analysis of 65 trials found exposure therapy had large effects compared with waitlist or usual care.^[4] Medicines, such as SSRI antidepressants, are also used, and treatment response is often incomplete, so care is individualized.^{[1, 2]}

Why Post-Traumatic Stress Disorder calls for a whole-person approach

PTSD affects the body as well as the mind. A state-of-the-art review describes chronic PTSD as a systemic disorder with a high allostatic load, meaning prolonged strain on the body's stress systems.^[2]

Care that supports sleep, stress and physical tension is a reasonable addition to the trauma-focused treatment your clinician provides.

Stress and an overactive alert system

Hyperarousal, such as being easily startled and always on guard, is a core feature of PTSD and is linked to changes in the brain's fear and stress circuits.^[1]

Sleep

Sleep trouble and nightmares are common in PTSD. In a trial of veterans with persistent sleep disturbance after mild traumatic brain injury, two thirds also had PTSD, and those with PTSD had more clinically significant sleep difficulties at baseline.^[5]

Mood and coexisting conditions

Depression, substance use, emotional dysregulation and suicidality often complicate PTSD and can make treatment response weaker.^[2]

Physical symptoms and pain

PTSD is often accompanied by physical symptoms. In a trial of service members with PTSD, acupuncture was linked to improvements in depression, pain and physical functioning along with PTSD scores.^[6]

Acupuncture as supportive care in Post-Traumatic Stress Disorder

What the research shows

Research suggests acupuncture may reduce PTSD symptoms, but the studies are few and mostly small. A 2018 meta-analysis of 7 randomized trials (709 participants) found very low-quality evidence that acupuncture reduced PTSD symptoms right after treatment, and low-quality evidence for PTSD and depression symptoms at longer follow-up. It found no clear effect on anxiety or sleep.^[7]

The best sham-controlled trial enrolled 93 combat veterans with PTSD. Real acupuncture lowered clinician-rated PTSD severity more than minimal-needling sham acupuncture, although the sham group also improved. Participants had up to 24 one-hour sessions over 15 weeks.^[8] In a trial of 55 service members, 8 sessions of acupuncture on top of usual PTSD care improved PTSD scores more than usual care alone, but the trial was small and had no sham group.^[6] An earlier pilot trial found acupuncture comparable to group cognitive behavioral therapy and better than a waiting list.^[9]

For sleep, a sham-controlled trial of 60 veterans with mild traumatic brain injury and disturbed sleep, two thirds of whom had PTSD, found real acupuncture improved sleep scores more than sham.^[5] A review of ear acupuncture after disasters found limited evidence of benefit, with generally low-quality trials.^[10]

A systematic review of emerging PTSD interventions rated acupuncture among those with moderate-quality evidence from small to moderate trials, and noted most emerging approaches lacked enough evidence.^[11]

How acupuncture may work

How acupuncture might help PTSD is not settled. In the veteran trial, real acupuncture was linked to better fear extinction, a laboratory measure of how the brain unlearns fear responses, which suggests a possible mechanism.^[8] This remains a proposed explanation.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the body, and sometimes the ear, usually left in place for about 20 to 40 minutes. Trials have used from 8 to 24 sessions, often twice a week.^{[6, 8]} We reassess after a short course of visits to see whether stress and sleep are improving. If lying still, being touched or being in a closed room is difficult after trauma, tell your practitioner so the session can be adjusted.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, pain or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[12] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Post-Traumatic Stress Disorder

The Ayurvedic view

Ayurveda does not have a category matching PTSD. Traditionally, fear, startle, poor sleep and restlessness after a shock are described as aggravated Vata, the principle said to govern movement and the nervous system. These are traditional categories used to choose supportive measures, not biomedical diagnoses.

Therapies that may be used

Supportive care is chosen for the individual and may include:

• Daily routine and diet, with regular meals and steady sleep and waking times
• Warm oil massage of the body or scalp, if touch is comfortable for you
• Breathing practices, yoga and meditation, adapted to trauma-sensitive needs
• Herbs such as ashwagandha (Withania somnifera), which has been studied for stress and anxiety^[13]

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, or when someone is in acute distress or crisis.

What the research shows

We found no trials of Ayurvedic medicine for PTSD. Evidence for related practices is limited. In a trial of 64 women with chronic, treatment-resistant PTSD, a weekly trauma-informed yoga class for 10 weeks led to more women no longer meeting PTSD criteria than a health education class (52% versus 21%). Yoga is part of the wider Indian tradition, but it is not Ayurvedic medicine.^[14]

A meta-analysis of 12 randomized trials found lower stress and anxiety scores with ashwagandha than placebo in adults, though the certainty of evidence was low and results varied. These trials were not in people with PTSD.^[13]

Herbal medicine as supportive care in Post-Traumatic Stress Disorder

Herbs and formulas that have been studied

Herbal research for PTSD is sparse. A literature review of herbal medicine after large-scale disasters found two randomized trials of PTSD and a few case series on symptoms such as dizziness, pain and psychosomatic complaints.^[15]

What the research shows

The evidence is very limited. The disaster review concluded that herbal medicine has been used to treat trauma and PTSD symptoms, but that few high-quality studies exist and more research is needed.^[15] We did not find systematic reviews or large trials of any herb for PTSD.

Safety and herb-drug interactions

Herbs can interact with the medicines used for PTSD and related conditions. Reports describe kava causing a semicomatose state when combined with the sedative alprazolam, and St John's wort causing serotonin syndrome when combined with SSRI antidepressants, and lowering the levels of several other drugs.^[16] People taking SSRIs, benzodiazepines, prazosin or other prescribed medicines need a practitioner's review before using any herb.

Ashwagandha supplements have been linked to rare cases of liver injury, usually with jaundice and itching appearing 2 to 12 weeks after starting.^[17] Tell us if you have liver disease. In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[18] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine describes the aftermath of shock and fear through patterns such as heart and kidney disharmony, liver qi stagnation or disturbed spirit. Researchers studying acupuncture for PTSD look at ideas that loosely parallel this, such as fear extinction and the stress response.^{[2, 8]}

Ayurveda's aggravated Vata describes fear, restlessness and poor sleep. This resembles the hyperarousal described in PTSD.^[1] No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

PTSD needs diagnosis and treatment by a physician or mental health professional. Our care is supportive and does not replace trauma-focused therapy, psychiatric care or medicines. Do not stop or change prescribed medicines, including SSRIs, without your prescriber. We do not diagnose or manage PTSD.

Please bring your diagnosis, a list of your medicines and supplements, and the contact details of your treating clinician. We ask that your treating team knows you are receiving complementary care.

When to seek urgent medical care

PTSD can involve a risk of suicide and of harm from substance use.^[2]

• Thoughts of suicide or self-harm; call or text 988 (Suicide and Crisis Lifeline)
• Thoughts of harming another person
• Feeling unsafe, or being in danger from violence or abuse
• Severe flashbacks with loss of touch with reality, or seeing or hearing things that others do not
• Heavy alcohol or drug use to cope, or withdrawal symptoms

If any of these are an emergency, call 911 or go to the nearest emergency department.