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



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 integrative management of PTSD: A review of conventional and
CAM approaches used to prevent and treat PTSD with emphasis on
military personnel
James Lake
International Network of Integrative Mental Health, United States
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 compensa-
tion, 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
Advances in Integrative Medicine 2 (2015) 13–23
Article history:
Available online 20 January 2015
Post-traumatic stress disorder
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 inde xed 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.
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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.
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 collabo-
rative 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 compen-
sation. These challenges become even greater with respect to
programmes aimed at preventing or treating PTSD in active duty
combatants or veterans because of delays in screening or obtaining
prompt treatment following exposure to trauma, the high
frequency of comorbid psychiatric, substance use and medical
disorders, and the high incidence of severe or refractory PTSD
symptoms in military patients [5]. A significant and unknown
percent of OIF/OEF veterans diagnosed with PTSD have mild to
moderate traumatic brain injury (TBI) that has not been diagnosed
or treated. TBI is also frequently associated with depressed mood,
mood swings, psychosis, insomnia and chronic pain and increased
risk of substance abuse. Recently revised VA/DOD guidelines
address assessment and treatment of complex cases of PTSD that is
co-morbid with other psychiatric and medical disorders including
cpg_PTSD-FULL-201011612.pdf; [6]). Historically the DOD and
VA have emphasised the treatment of established cases of PTSD
however, in order to provide more adequate care for military
personnel, a high priority must also be placed on both pre-
deployment resiliency training and prevention of full-blown PTSD
in active duty combatants at high risk for exposure to trauma, or
recently deployed combat veterans who have been exposed to
trauma but have not yet developed symptoms of PTSD.
Barriers to allocation of resources for adequate and timely
assessment and treatment of PTSD among both active duty
military personnel and combat veterans are related to system-level
issues in a complex multi-tiered federally managed healthcare
system. System-level challenges include inadequate funding,
delays in funding allocations for new programme development
efforts, difficulties recruiting qualified mental health professionals,
and slow progress implementing specialised PTSD programme and
clinics. Funding for specialty PTSD programmes in the Veterans
Healthcare Administration has recently been increased however
many veterans are not receiving adequate or prompt care for PTSD
and other serious mental health problems [7]. A recent study
examined ‘treatment intensity’ defined as the total number of
visits per veteran addressing PTSD—among veterans receiving
mental health services for PTSD at VA outpatient clinics. The
findings suggest that returning veterans are receiving fewer than
the optimal number of psychotherapy sessions (i.e., a minimum of
9–15 sessions) needed for PTSD to respond. A June, 2014 report by
the Institute of Medicine concluded that it is impossible to
determine whether veterans or active duty service members
receiving treatment for PTSD are experiencing improvements.
Although both the DOD and the VA are committed to treating PTSD,
neither department uses standard symptom tracking measures to
determine whether the PTSD care it provides is ‘effective,
appropriate or adequate.’ Further, although 39 VA specialised
PTSD treatment programmes reported outcomes their findings
showed only modest improvement. (
in-Military-and-Veteran-populations-final-assessment.aspx). An
equally important and unknown factor that impacts efforts to
better manage veterans’ PTSD treatment needs is the absence of
information on the number of veterans who receive private mental
health care after being diagnosed with PTSD within the VHA
system. These problems translate into delays developing and
implementing evidence-based protocols and programmes aimed
at the prevention and treatment of PTSD.
Conventional pharmacological and psychological approaches
used to prevent and treat PTSD: overview and limitations
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 man-
agement and CBT, no evidence for comparative effectiveness of
escitalopram (an SSRI) over cognitive therapy (CT) and prolonged
exposure (PE), no evidence for the comparative effectiveness of
CBT over supportive counselling (SC). There was insufficient
evidence for other interventions in preventing the development of
PTSD following trauma exposure, including CBT, CBT combined
with hypnosis, CT, PE, psycho-education, SC and the medications
escitalopram and hydrocortisone. Based on studies included in the
review there was insufficient evidence to determine the role of
timing, intensity and dosing of specific psychological or pharma-
cological interventions aimed at preventing PTSD. Findings were
limited by small study sizes, high attrition rates, methodological
problems including absence of randomisation in many studies and
poor statistical methods, and a high risk of bias. A systematic
review of pharmacological treatments aimed at preventing PTSD
following exposure to trauma identified only two studies that met
inclusion criteria: one on escitalopram and one on hydrocortisone.
Both studies were done on civilian populations and findings were
inconclusive because of small sample size.
Post-deployment ‘‘Battlemind debriefing’’ is a group preventive
approach developed by the Army with the aim of reducing or
preventing PTSD and other mental health problems in soldiers
returning from combat duty [9]. This approach uses group
facilitators to teach newly returned soldiers coping skills addres-
sing anger management, insomnia and social isolation while
helping them reframe PTSD symptoms including hypervigilance,
insomnia, and emotional withdrawal as maladaptive responses
that need to be modified for successful coping with the stresses of
civilian life. A U.S. study on Battlemind debriefing found that
soldiers with the greatest combat exposure benefited most in
terms of fewer symptoms of PTSD and depressed mood [9].
Another study on Battlemind debriefing found no changes in PTSD
but reduced incidence of binge drinking in returning British
soldiers [87].
Treatment of chronic PTSD
A systematic review and meta-analysis of controlled studies on
psychologicaland pharmacological approachesused to treat chronic
PTSD found moderately strong evidence for exposure therapy
(especially prolonged exposure therapy) and CBT compared to
J. Lake/ Advances in Integrative Medicine 2 (2015) 13–23
relaxationtraining for reducing PTSD symptomseverity or achieving
remissionand some evidence for cognitiveprocessing therapy (CPT),
cognitive therapy (CT), cognitive restructuring (CR), coping skills
therapy, eye movement desensitisation and reprocessing (EMDR),
and narrative exposure therapy [10]. Among pharmacological
therapies the review found moderately strong evidence for
fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine for
reducing symptom severity and achieving remission. Based on
studies included in the review there was insufficient evidence to
determine whether particular treatment approaches were more
effective for victims of specific types of trauma or to determine
comparative risk of adverse effects associated with different
treatments. The strength of evidence for the majority of psychologi-
cal and pharmacological treatments ofPTSD was limited by the fact
that most studies did not report remission from PTSD as a primary
outcome measure.
A systematic review of randomised controlled trials of non-SSRI
drugs including SNRIs, antipsychotics, anticonvulsants, adrener-
gic-inhibiting agents (e.g. Prazosin), opioid antagonists, benzodia-
zepines and others in individuals diagnosed with PTSD who either
did not achieve complete remission on SSRIs or discontinued SSRIs
due to adverse effects found weak evidence in support of non-SSRIs
with the exception of risperidone which is sometimes an effective
adjunctive agent in patients who respond partially to SSRIs [80].
Adjunctive use of atypical antipsychotics in combination with
SSRIs may reduce PTSD symptom severity more than SSRIs alone.
In three placebo-controlled trials risperidone taken in combination
with a SSRI significantly reduced the severity of PTSD symptoms as
well as the frequency of awakenings due to nightmares [80].In
another study there was a non-significant difference in response
rates between combat veterans with severe PTSD symptoms
treated with adjunctive risperdone vs placebo [11]. In addition to
limited efficacy many drugs cause significant adverse effects
resulting in poor adherence or treatment discontinuation includ-
ing weight gain, sexual dysfunction and disturbed sleep [12].
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
used to treat or self-treat PTSD symptoms included relaxation,
meditation, and exercise therapy. Individuals diagnosed with PTSD
were equally likely to use a CAM therapy alone as they were to use
CAM in combination with conventional mental health care. Among
individuals diagnosed with PTSD in general biofeedback and
relaxation are popular CAM therapies [13].
A survey of 170 VA programmes specialising in PTSD treatment
found that 96% of programmes offered at least one CAM modality
[15]. The following CAM modalities were offered in at least one half
of specialised PTSD programmes: mindfulness (88%), stress
management/relaxation training (63%), progressive muscle relax-
ation (75%), yoga (63%), guided imagery (50%), and spiritual
practices or therapy (50%). CAM therapies were typically offered in
the context of on-going conventional treatment including psycho-
therapy and medication management. These findings suggest that
CAM therapies are widely used to treat PTSD in veterans receiving
care at specialised VA PTSD programmes. The significance of these
findings is limited by the absence of data on numbers of veterans
treated using specific CAM approaches, frequency of treatment,
and outcomes. Acknowledging the widespread use of CAM among
veterans diagnosed with PTSD, the paucity of research evidence for
the majority of CAM therapies, and the limited effectiveness of
existing conventional treatments of PTSD in 2011 a joint leadership
panel representing the VA, Department of Defense and National
Institutes of Health convened to review the evidence for CAM
treatments of PTSD, brainstorm about novel more effective ways to
bring evidence-based CAM modalities into existing PTSD pro-
grammes, and develop a CAM research agenda (VA Research
Currents ‘‘Meeting seeks to expand VA’s study of complementary,
alternative therapies for PTSD,’’ May–June 2011 http://www. A lit-
erature review conducted by the VA panel identified acupuncture
and meditation as CAM treatments supported by the highest level
of evidence. The panel commented that mindfulness approaches
already in use in specialised VA PTSD programmes have not been
thoroughly investigated and stressed the need for further research
to evaluate the comparative efficacy of different meditation
techniques in PTSD. The panel also stressed the importance of
identifying CAM therapies that may help improve outcomes when
used in combination with conventional pharmacological or
psychological treatments.
CAM approaches used to prevent or treat PTSD: a review of
select modalities
Meditation and mind-body approaches
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. Mindfulness training may reduce symptoms
of PTSD when improved attention permits increased control over
intrusive thoughts or memories. Patients who engage in a
mindfulness practice can be trained to shift attention from
remembered fears to present-focused problem solving permitting
improved coping. The therapeutic benefits of mantra meditation
are believed to be related to the effects of repetitive chanting on
reducing the overall level of arousal permitting improved
emotional self-regulation. Compassion meditation (Vipassana) is
believed to reduce symptoms of PTSD (or other anxiety disorders)
by reducing negative emotions and reactivity to stressful
circumstances. Enhanced coping is achieved through improved
resilience and increased social connections achieved in group
meditation practice. Important advantages of meditation as a
treatment of PTSD include ease of training, low cost and practical
implementation in group settings. Emerging findings suggest that
symptoms of re-experiencing and psychic numbing may be less
responsive to meditation than other symptoms [18]. In addition to
the above meditation practices studies have also examined the
effects of training in transcendental meditation (TM) on PTSD. In a
12-week pilot study (N= 5) OEF veterans diagnosed with PTSD
who trained in transcendental meditation experienced significant
improvements in overall quality of life and reductions in core PTSD
symptoms [84]. In a 8-week pilot study (N= 16) mainly Vietnam
era veterans diagnosed with PTSD who completed 8 weekly classes
in a form of mindfulness meditation called ‘iRest’ reported reduced
rage and emotional reactivity and increased feelings of peace,
relaxation and self-efficacy [19]. Future studies on the therapeutic
effects of meditation in PTSD should more clearly define the
J. Lake/ Advances in Integrative Medicine 2 (2015) 13–23
meditation practices being studied, use validated instruments that
reliably measure targeted outcomes, and evaluate the efficacy of
meditation in combination with widely used psychological
approaches including mindfulness-based cognitive therapy
(MBCT), exposure therapy, dialectical behavioural therapy (DBT)
and other therapies.
Mind-body practices. Mind-body practices including yoga and
others are used to treat PTSD in both civilian and military
populations. A literature review of studies on mind-body practices
used to treat PTSD found that many approaches in current use
reduce some PTSD symptoms including intrusive memories,
avoidance and emotional arousal [20,21]. Individuals who engaged
in mind-body practices reported improvements in mental health
problems frequently associated with PTSD including anxiety,
depressed mood and anger, resulting in improved coping with
stress. An internal VA survey confirmed that yoga practices are
widely used in VA specialised PTSD treatment programmes [22].
The authors concluded that variability in both the context in which
yoga practices are offered and methods of instruction may reflect
differences in patient-centred care needs in different clinical
settings. Large studies are needed to evaluate the effectiveness of
yoga in alleviating PTSD symptoms. In a small 7 day study (N= 21)
OIF/OEF veterans diagnosed with PTSD randomised to daily 3-h
sessions of a breathing-based style of yoga but not a waitlist
control group showed reductions in PTSD symptom severity,
anxiety symptoms and respiration rate at the end of the study and
at 1-year follow-up [23]. In a 6-week pilot study (N= 16) veterans
diagnosed with PTSD who attended yoga sessions twice weekly
reported significant improvements in sleep and other symptoms
but non-significant improvements in overall PTSD severity, anger
or quality of life [24]. Preliminary findings from case reports
suggest that taichi and qigong may reduce PTSD symptom severity
in torture survivors [25] however no studies using these mind-
body approaches have been done on veterans or active duty
combatants diagnosed with PTSD.
Eye movement desensitisation and reprocessing (EMDR). Eye move-
ment desensitisation and reprocessing (EMDR) is a psychological
approach widely used to treat PTSD however research findings are
mixed. Two reviews [26,27] of published studies on EMDR in the
treatment of PTSD identified few large quality studies but
promising findings including reductions in the symptom severity
3 months after the end of treatment, comparable efficacy to
exposure therapy, and superiority over relaxation training and
delayed treatment groups.
A systematic review of studies comparing EMDR with cogni-
tive-behavioural therapy (CBT) in individuals diagnosed with PTSD
concluded that these two therapies are equally efficacious [28].A
literature review of studies on EMDR in PTSD found contradictory
findings regarding the need for eye movements to achieve clinical
improvements [29]. Some studies suggested that bilateral eye
stimulation may increase access to episodic memories or make
focusing on traumatic memories less unpleasant. As these two
therapies have equivalent efficacy the authors recommended that
the choice of EMDR vs CBT should be based on clinician experience
and patient preference. In a controlled study (N= 46) individuals
diagnosed with PTSD (N= 46) randomised to EMDR or emotional
freedom technique (EFT) experienced equivalent significant
improvements at study end and 3-month follow-up [30]. More
studies are needed to verify these findings and help determine
when it is appropriate to refer patients diagnosed with PTSD to
EMDR, EFT or other therapies. In spite of considerable evidence
supporting the use of EMDR as a treatment of established cases of
PTSD, on-going institutional resistance within the VA to fully
researching, training clinicians, and implementing EMDR in PTSD
treatment programmes may be interfering with veterans’ access to
this modality within VA healthcare system [31].
Exposure therapies based on advanced technologies: virtual reality
graded exposure therapy (VRET), and human-computer interface
Virtual reality graded exposure therapy (VRGET)
Considerable research is on-going to develop virtual reality
tools for assessing, preventing and treating combat-related PTSD
[32]. Virtual reality (VR) technology employs high-end computer
graphics, 3D displays and multi-sensory feedback to create the
illusion of interacting with a computer-generated environment
resulting in intense feelings of ‘immersion’ and ‘presence.’
Sessions are guided by a therapist who regulates the virtual
scenario to achieve the appropriate intensity of arousal for the
patient. Repeated exposure results in habituation to a particular
fear-inducing environment (i.e. reduced autonomic arousal),
extinction of fear response and reduction in severity of PTSD
Findings of a study on combined multisensory exposure and
VRGET reported significant reductions in severity of PTSD
symptoms in active duty combatants who had failed to respond
to other forms of exposure therapy [33]. Several patients in the
study reported significant improvement following only five
VRGET sessions however there was considerable variability in
the number of VRGET sessions needed to reduce symptom
severity to the same level. The findings suggested that brief VR
exposure therapy may result in rapid extinction when combined
with multisensory exposure and
-cycloserine or other medica-
tions. A pilot study in which nine healthy subjects were exposed to
stress ind uced by a virtual bomb ex plosion investiga ted combined
Virtual Reality (VR) and EEG bio-feedback as a potential treatment
of stress-related disorders [81].Findingsofcorrelationsbetween
general stress levels, serum cortisol levels, heart rate variability
and mid-frontal alpha EEG asymmetry suggest that real-time
neurophysiological data may provide useful inputs for adjusting
VRGET protocols to enhance stress resilience or accelerate
treatment response.
VR applications are being developed to assess the risk of
developing PTSD following trauma, and mental resilience training
aimed at preventing PTSD in active duty soldiers and other high
risk groups [34]. Efforts are ongoing to develop interactive internet
and smart-phone applications for VRGET protocols addressing
PTSD in this population [35]. Sub-threshold PTSD symptoms may
be associated with impaired physical health, mental health, and
increased risk of subsequently developing PTSD. In a pilot study
newly returning veterans who experienced significant sub-
threshold symptoms but who did not meet full criteria for PTSD
exhibited elevated heart rates in response to a VR paradigm
(Virtual Iraq) designed to elicit fear [36].Stress Inoculation Training
(SIT) is a recently developed approach that emphasizes cognitive
restructuring and the acquisition and rehearsal of coping skills
during graded virtual exposure to stressors that simulate the
trauma. Preliminary findings suggest that pre- or post-deployment
stress inoculation training in groups of soldiers may reduce
symptoms of autonomic arousal [37].
Some individuals using VRET report mild transient symptoms
of disorientation, nausea, dizziness, headache and blurred vision.
‘‘Simulator sleepiness’’ has been defined as feelings of generalised
fatigue that sometimes follow exposure to virtual environments.
Virtual environments can triggers migraine headaches, seizures, or
gait abnormalities and individuals diagnosed with these medical
problems should be cautioned about possible adverse effects of
exposure to virtual environments. [32].
J. Lake/ Advances in Integrative Medicine 2 (2015) 13–23
Human–computer interface (HCI)
Human–computer interface (HCI) systems based on cognitive-
behavioural therapy and biofeedback are being developed for
resiliencetraining in individuals at riskof developing PTSD following
exposure to trauma. STRIVE (Stress resilience in virtual environ-
ments) is a kind of ‘stress resilience training’ aimed at enhancing
emotional coping strategies prior to active deployment [38,39].
STRIVE employs an immersive VR environment to simulate combat
situations that includes a ‘virtual mentor’ who guides the soldier
through the virtual experience while coaching him or her in
relaxation and emotion self-regulation skills. The intensity of the
virtual stimulus used is determined by the individual’s habituation
based on heart-rate variability (HRV) and other measures of
autonomic arousal. The STRIVE system permits users to be
immersed in stressful combat scenarios and interact with virtual
characters for training in a variety of coping strategies that may
enhance resilience in the face of extreme stress. Physiological
biomarkers of stress response are measured before and after VRGET
sessions. The STRIVE protocol may provide a useful tool for
predicting the risk of developing PTSD or other psychiatric disorders
in new recruits prior to actual combat exposure [40].Recruitswho
display high resilience and thus presumably at relatively lower risk
of developing PTSD might be more suitable for direct combat roles
while individualswho display low resilience might preferentially be
assigned to non-combat roles.
Research findings suggest that combining VR environments
with real-time feedback based on neurophysiological responses to
stress may permit each unique patient to optimise the level and
type of VR exposure to enhance resiliency training and speed the
rate of recovery from PTSD [41]. Larger studies on patient
populations diagnosed with PTSD using head-mounted displays
and other technologies that create more immersive virtual
environments are needed to determine whether combining VRET
and EEG biofeedback is practical in clinical settings and yields
superior outcomes compared to either approach alone.
Biofeedback: cardiac coherence training and neurofeedback training
Biofeedback is widely used to treat stress-related disorders
however there is limited evidence for biofeedback as a treatment of
chronic PTSD [13]. However promising findings have been
reported in two specialised areas of biofeedback based on heart-
rate variability (HRV) monitoring and brain wave recordings (i.e.
electroencephalography), respectively.
Cardiac coherence training. Cardiac coherence is an indicator of
heart rate variability (HRV). Abnormal low HRV is associated with
deficits in attention and short-term memory in combat veterans
diagnosed with PTSD. In a small pilot study all participants who
received visual feedback in HRV patterns while undergoing
relaxation training [42] had improved cardiac coherence (i.e.
increased HRV) as well as improvements in attention and short-
term memory. The researchers inferred that increased cardiac
coherence may lessen the severity of cognitive symptoms that often
accompany PTSD. The findings of a pilot study suggest that veterans
diagnosed with combat-related PTSD who receive HRV biofeedback
experience significant increases in HRV and reduced PTSDsymptom
severity comparedto veterans receiving treatment as usual[43].Ina
small 3-week open exploratory study a group of active duty service
members diagnosed with PTSD or depressed mood who received
heart-rate variability biofeedback plus treatment as usual did not
report greater reductions in symptom severity compared to a group
receiving treatment as usual only [44].
Neurofeedback. Neurofeedback can be conceptualised as a special-
ised kind of operant conditioning in which pre-selected EEG
frequencies or other EEG features are provided to the trainee in the
form of a game that employs visual, auditory, and tactile feedback.
The individual is ‘rewarded’ by progressing in the game only when
specific EEG frequencies corresponding to a calmer or more
regulated mental or emotional state exceed threshold. Repetitive
‘training’ in select frequencies reinforces the individual’s ability to
achieve a target state of baseline EEG activity corresponding to
enhanced cognitive functioning or improved emotional self-
regulation. The technique is currently widely used to treat
Attention Deficit Disorder and a range of anxiety disorders in
both children and adults.
Recent research findings suggest that neurofeedback involving
very low frequencies, between 0.02 and 0.2 Hz, results in rapid
significant reductions in the severity of PTSD symptoms [45] and
improvements in overall cognitive functioning [46]. Such ‘infra-
low frequencies’ may induce beneficial shifts in the functional
connectivity of the brain’s resting state networks resulting in
reduced over-all arousal, enhanced cognitive functioning and
emotional stability.
As early as the late 1980’s studies showed that neurofeedback
could be used successfully in the remediation of PTSD and
associated alcohol abuse in Vietnam era veterans [86]. These
findings were replicated in a large controlled study with multi-
year follow-up [83]. In a pilot study seven Vietnam era war
veterans with chronic treatment-refractory PTSD who trained with
the infra-low frequency neurofeedback protocol reported signifi-
cant reductions in symptom severity after 20 sessions [82]. Wait-
listed controls subsequently reported similar improvements. More
recently, neurofeedback training using infra-low frequencies has
been extensively field-tested at six U.S. military bases. At one large
military base more than 500 active duty combatants who had been
diagnosed with PTSD were trained in infra-low frequency (ILF)
neurofeedback. Training was done 1–3 times per week and was
administered by licensed psychotherapists certified in neurofeed-
back therapy. Symptom severity was evaluated weekly using the
PCL-5—the military version of the PTSD Checklist (PCL)—and other
standardised symptom rating scales. Findings from a cohort
analysis of 300 of the 500 active duty Marines in the original group
suggest that 75% of individuals with moderate to severe symptoms
experienced significant clinical improvement based on a review of
symptoms frequently associated with PTSD including psychologi-
cal, cognitive, psychophysiological and physiological symptoms
that were tracked using a custom computerised symptom tracking
programme. 25% of subjects in the cohort reported that all
symptoms had resolved completely with fewer than 20 neurofeed-
back sessions; another 50% experienced significant reductions in
symptom severity after forty sessions [48]. The remaining subjects
took much longer to respond to treatment, continued to report
clinically significant symptoms, discontinued training premature-
ly, or were non-responsive to the neurofeedback training protocol.
The above findings have led to formal evaluation of infra-low
frequency training in connection with the Navy’s OASIS pro-
gramme for the most severely symptomatic and most treatment-
resistant cases of PTSD. At the time of writing this study has been
completed but findings have not yet been published.
Traditional Chinese medicine
Chinese medicine and contemporary biomedicine are highly
integrated systems approaches that use similar conceptual
schemata to characterise the phenomenology and biological
mechanisms of PTSD [49]. Among the various Chinese medical
therapeutic modalities acupuncture has been most studied as a
treatment of PTSD. On a practical vein acupuncture is inexpensive,
safe and easy to provide in military field conditions.
A review of prospective trials on acupuncture as a treatment of
PTSD identified four quality sham-controlled studies and two
quality uncontrolled trials that met inclusion criteria [20,21]. One
J. Lake/ Advances in Integrative Medicine 2 (2015) 13–23
high-quality trial [50] included in the review showed statisti-
cally significant differences between the acupuncture and wait-
list group but non-significant differences between the acupunc-
ture and CBT groups. Patients receiving acupuncture or CBT
continued to report clinical improvements in PTSD symptoms 3
months after study endpoint. A meta-analysis of pooled findings
showed superiority of a combined regimen of acupuncture and
moxibustion over SSRIs and superiority of acupoint stimulation
plus CBT over CBT alone in reducing PTSD symptoms. Two other
studies included in the review (but not the meta-analysis)
reported greater but non-significant improvement in PTSD
patients receiving acupuncture vs SSRIs, more favourable
responses to combined acupuncture plus CBT compared to
CBT alone, and greater improvement with acupuncture plus
moxibustion compared to SSRIs on three outcome measures.
These findings are limited by the small number of trials that met
inclusion criteria (only one study reviewed was included in the
analysis), the absence of sham-controlled studies, the use of
different study designs across trials examined, and poor
methodological quality of many studies. Findings from two
randomised controlled trials and six outcome studies support
that tapping on certain acupressure points in parallel with
imaginal exposure therapy may result in rapid reduction in
maladaptive fear responses to traumatic memories in individu-
als diagnosed with PTSD [51].
A review of studies on acupuncture for the treatment of
symptoms that are frequently comorbid with PTSD in active duty
military returning from combat, reported promising results for
acupuncture in reducing the severity of headaches, anxiety,
fatigue, sleep disturbances, depression and chronic pain [52].
Acupuncture may be a practical and effective treatment of PTSD
in emergency room settings [53]. Acupuncture is being
investigated for its potential applications in military field
conditions for both medical and psychological conditions with
reductions in sick leave and limited duty status resulting in
improved unit performance [54]. In contrast to conventional
pharmacological treatment, acupuncture has infrequent mild
adverse effects such as bleeding, bruising and pain on needling
Natural products
Omega-3s. Symptoms of PTSD may develop when consolidation of
intense fear memories takes place in the absence of neural
mechanisms that permit extinction. Increasing hippocampal
neurogenesis soon after trauma may result in more rapid
clearance of fear memories (i.e. extinction) and interfere with
consolidation of immediate post-trauma memories into long-
term memories reducing the risk of developing PTSD [56].Animal
studies confirm that Omega-3 fatty acids increase hippocampal
neurogenesis [57–59]. Studies in Japan following the 2011
tsunami are investigating the effectiveness of pre-treatment with
omega-3s in preventing the development of PTSD following
exposure to trauma in first medical responders mobilised in
national emergencies Two pilot studies found that daily supple-
mentation with omega-3s significantly reduces the severity of
PTSD symptoms in individuals who experienced trauma related to
accidental injury [60–62].
DHEA. Dehydroepiandrosterone (DHEA) is a prohormone that
may protect against cortisol-induced hippocampal atrophy [63].
Increased severity of PTSD is correlated with reduced DHEA
blood levels [64]. In a small open-label study (N=5)womenwith
treatment-refractory PTSD related to early childhood abuse and
who had not responded to conventional pharmacological
therapy, experienced decreases in numbing, re-experiencing,
hyperarousal and other core symptoms, improved sleep and
improved libido with DHEA at doses between 25 and 100 mg/day
[65]. DHEA should be avoided in men at risk of prostate cancer
and women who have a history of oestrogen receptor-positive
breast cancer.
Proprietary multi-nutrient supplementation. Findings suggest that
taking a multi-nutrient supplement containing vitamins, minerals,
amino acids and anti-oxidants before exposure to trauma may
increase emotional resilience and reduce the severity of PTSD
symptoms following exposure. Adults enrolled in a study on a
proprietary micronutrient formula for ADHD at the time of a major
New Zealand earthquake reported feeling significantly less anxious
and stressed compared to matched adults who were not taking the
supplement [66]. A subsequent study following a severe after-
shock several months after the earthquake compared measures of
anxiety, mood and post-traumatic symptoms (e.g. intrusive
thoughts, avoidance and hyper-arousal) in individuals in the
general population taking two doses (four capsules vs eight
capsules) of an identical formula. At the end of 4 weeks individuals
taking the formula reported significant decreases in stress, anxiety,
avoidance and arousal. There were non-significant differences
between the high-dose and low-dose groups for all outcome
measures and all individuals in the treatment group reported
clinically significant reductions in symptoms compared to the
control group. The researchers remarked that measured outcomes
using micronutrient formulas were comparable to those observed
with conventional medications [67], behavioural therapy using an
earthquake simulator [68], and eye movement desensitisation and
reprocessing [69,70], but with fewer side effects and better
retention rates. The significance of findings is limited by small
study size and the absence of a placebo group, blinding and
randomised protocols.
Lucid dreaming training
Training in lucid dreaming may reduce the severity and
frequency of nightmares in individuals diagnosed with PTSD
however core symptoms of PTSD may remain unchanged. Lucid
dreaming is a unique state of consciousness in which an individual
is self-aware while dreaming, and able to change or control dream
content [85]. Training in lucid dreaming methods involves 4–6
weeks of daily dream journaling and weekly sessions for training in
lucid dream-induction techniques focusing on insights related to
themes of recurrent nightmares. Lucid dreaming techniques
including ‘‘dialoging’’ with or ‘‘physically embracing’’ dream
characters reduce feelings of helplessness and terror as the patient
learns that he or she can control frightening images or experiences
associated with past trauma.
Trauma survivors frequently have recurring vivid nightmares
that may represent a dream-anxiety syndrome. Findings from
case reports and small clinical studies suggest that lucid dream
induction techniques may reduce the frequency and intensity of
nightmares related to memories of trauma in combat veterans
resulting in clinical improvement in the severity of PTSD [71,72].A
12-week pilot study on individuals who reported frequent
nightmares (N= 23; some individuals had been diagnosed with
PTSD) found that individualised and group training in lucid
dreaming techniques resulted in equivalent reductions in the
frequency of nightmares however sleep quality and PTSD
symptom severity remained unchanged, however no correlation
was found between lucidity and reduction in nightmare
frequency [73].
‘‘Energetic’’ and spiritual approaches to PTSD
Spiritual or so-called ‘energy healing’ methods used to treat
PTSD include energy psychology, including healing touch (HT),
J. Lake/ Advances in Integrative Medicine 2 (2015) 13–23
thought-field therapy (TFT) and emotional freedom technique
(EFT), somato-emotional release, craniosacral therapy, qigong,
Reiki, specific spiritual methods in Ayurvedic and Tibetan
medicine, and shamanic ritual healing. Psychological, biological
and possibly also subtle energetic processes have been postulated
to explain therapeutic effects of energy healing. Quantum
mechanics may help explain subtle effects of ‘energy’ healing or
directed intention on health and illness [74]. In a 3-week
randomised controlled trial active duty military diagnosed with
PTSD following exposure to combat (n= 123) randomised to six
sessions of Healing Touch plus Guided Imagery vs treatment as
usual experienced significant reductions in PTSD symptoms and
depression and significant improvements in overall mental quality
of life [75].
Somatoemotional release is an energy healing approach that
purportedly results in ‘‘release’’ of pathological energetic states
resulting from physical injury. The technique involves gently
touching the patient’s body with the goal of stimulating somatic
memories of past trauma. Clinical improvement is believed to take
place when ‘‘pathological energy’’ is ‘‘released’’ through gentle
stimulation. In a two-week study 22 Vietnam veterans diagnosed
with PTSD who underwent both Craniosacral Therapy and
somatoemotional release experienced significant improvements
in symptoms of physical distress, depressed mood, anxiety,
guardedness and behavioural isolation [76]. These findings are
limited by small study size, the absence of a sham treatment arm
and follow-up, and use of non-standardised outcome measures.
Energy psychology is a rapidly growing field based on both
conventional psychological theory and Chinese medical theory
based on the assumption that energetic imbalances in the
meridians manifest as emotional or mental symptoms [88].
Thought field therapy (TFT) and emotional freedom technique
(EFT) are specific approaches used in energy psychology to treat a
range of mental health problems. In TFT the patient is asked to
invoke a ‘‘thought field’’ associated with a traumatic memory after
which the TFT practitioner re-attunes energetic imbalances
manifesting as persisting memories of trauma by gently tapping
on specific acupuncture points resulting in symptom reduction.
Emotional Freedom Technique (EFT) is a simplified version of TFT
that uses only one routine for stimulating acupuncture points.
Emotional freedom technique (EFT) has been evaluated in the
treatment of phobias, generalised anxiety, and PTSD that may be
poorly responsive to exposure therapy. EFT has been manualized
and can be easily self-administered following brief training
session. An advantage of EFT over conventional exposure therapies
is avoidance of the risk of re-traumatization through in vivo
exposure. Few controlled studies have evaluated EFT as a
treatment of PTSD and findings are limited by the absence of
sham arms in most studies, small study size, methodological flaws,
and inconsistent outcomes [77]. During several six-week retreats
veterans and their spouses (N= 218), many of whom had been
diagnosed with PTSD, participated in a multi-modal intervention
involving Emotional Freedom Technique (EFT) and other ‘energy’
psychology approaches together with a range of complementary
and alternative approaches for stress reduction [78]. Both veterans
and spouses experienced significant reductions in PTSD symptom
severity as measured by the PTSD checklist (PCL), and these gains
were maintained by veterans—but not spouses—on follow-up.
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 military, fire fighters,
police officers, medical relief workers
Individuals who have recently been exposed to trauma but have
not yet developed symptoms
Individuals who have chronic symptoms of PTSD
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 develop-
ment 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 addressing PTSD and call for a radical re-visioning
of existing VA and DOD policies and programmes. The above
system-level problems result in treatment delays, inadequate
treatment and poor outcomes, and are compelling reasons for re-
evaluating existing programmes and services aimed at preventing
and treating PTSD.
New services and programmes should be put in place within the
VA and DOD healthcare systems based on the best available
evidence for conventional and CAM approaches addressing
resiliency training, prevention and treatment. Identifying inter-
ventions that enhance resilience in active duty military who are at
high risk of exposure to combat-related trauma, and that reduce
the risk of developing PTSD following trauma in active duty
combatants, will result in enormous reductions in psychiatric
morbidity, improved quality of life and commensurate gains in
productivity. The RAND Corporation has estimated that improve-
ments in interventions aimed at preventing PTSD may translate
into reductions in productivity losses on the order of billions of
dollars annually [79].
A joint VA-DOD task force on PTSD should be created with the
goal of identifying critical staffing needs including both conven-
tionally trained mental health professionals and CAM practi-
tioners, and establishing expert resources on PTSD. The joint task
force should review and revise existing VA-DOD policies and
procedures addressing care delivery to personnel diagnosed with
PTSD and do all possible to rapidly implement proactive reforms in
current scheduling practices and staffing policies to ensure timely
referrals to qualified specialists within established VA/DOD
programmes and services as well as qualified therapists in the
private sector when patient care needs cannot be met internally.
The highest priority should be placed on improving access to
screening for at-risk military personnel soon before deployment
and soon after returning from combat, and identifying effective
interventions aimed at reducing the risk of developing PTSD in
these highly vulnerable populations.
Large VA/DOD sponsored outcome studies on promising
interventions aimed at both prevention and treatment are urgently
needed to confirm efficacy and effectiveness, determine optimal
treatment strategies for PTSD targeting disparate symptoms and
levels of severity, address treatment safety issues, develop
practical cost-effective evidence-based treatment protocols, and
characterise treatment choices appropriate for individuals who
have failed multiple trials on conventional or CAM therapies, or
who refuse widely used treatments because of concerns over
adverse effects or cost. Federal research funding should prioritise
J. Lake/ Advances in Integrative Medicine 2 (2015) 13–23
Exhibit 1
Conventional and CAM approaches used to prevent or treat PTSD, treatment evidence limitations of findings safety issues.
Psychotherapy Limited evidence supports debriefing, CBT
(alone or in combination with hypnosis),
cognitive therapy, debriefing, prolonged
exposure therapy, psychoeducation, and
supportive counselling for preventing PTSD
following trauma
Findings limited by small study sizes, high
attrition rates, methodological problems
including absence of randomisation in many
studies and poor statistical methods and high
risk of bias. Many studies on civilian
populations only
‘Battlemind debriefing’ may reduce risk of
developing PTSD in newly returning
combat soldiers
Only 2 studies inconsistent findings None
Conventional drugs
Prevention Few studies findings largely inconclusive Only 2 quality prevention studies (escitalopram
and hydrocortisone)
Adverse effects of long-term SSRI or
SNRI use include weight gain, sexual
dysfunction and disturbed sleep
Treatment Fluoxetine, paroxetine, sertraline,
topiramate, and venlafaxine often reduce
symptom severity and may increase
remission rate
Unknown comparative risk of adverse effects
associated with different treatments. Findings
limited by failure to report remission rates in
most studies
Adding atypical antipsychotics to SSRIs
may improve response
Few studies done, inconsistent findings
Meditation Mindfulness meditation may be more
effective in prevention than other forms
Findings may not generalise: most studies done
in individuals diagnosed with GAD (not PTSD)
Rare reports of dissociation
depending on skill of instructor and
‘stability’ of meditator
Re-experiencing and psychic numbing may
be less responsive to meditation than other
PTSD symptoms
Limited findings single pilot study
TM may reduce overall PTSD symptom
EMDR Efficacy may be comparable to exposure
therapy, and superior to relaxation training
Few large quality studies Rare cases of dissociation
Efficacy may be comparable to emotional
freedom technique (EFT)
Findings based on one small controlled study
(EFT poorly substantiated)
Technology-based therapies
Virtual reality graded
exposure therapy (VRGET)
Significant reductions in PTSD sex severity
(after 5 sessions) in active duty combatants
non-responsive to other forms of exposure
High variability in number of VRET sessions
needed to reduce symptom severity to same
Reports of cyber sickness including
dizziness, headaches and
Brief VRET combined with multisensory
exposure and D-cycloserine or medications
may result in rapid extinction
Few small studies
Pre- or post-deployment stress inoculation
training in groups of soldiers may reduce
symptoms of autonomic arousal thus
reduce risk of developing PTSD following
trauma exposure
Few small studies
BCI and HCI Combining VR environments with real-
time feedback of neurophysiological or
autonomic activity may help optimise level
and type of VR exposure to enhance
resiliency training and speed recovery
No findings to report: first studies on-going at
time of writing
Same as for VRGET
HRV and EEG biofeedback
HRV biofeedback may be more effective at
reducing PTSD symptom severity more
than conventional treatment
Few small open trials on HRV biofeedback,
findings inconsistent
Iraq war veterans with treatment-
refractory PTSD reported significant
improvement with regular Neurofeedback
Small uncontrolled study None
Neurofeedback using very slow frequencies
(0.02–0.2 Hz) may be associated with rapid
dramatic reductions in PTSD symptom
Findings based on analysis of case reports in
active duty military reporting varying degrees
of symptom severity
Chinese medicine Acupuncture plus CBT superior to CBT alone Various protocols used; large sham controlled
trials lacking
Infrequent mild adverse effects can
include bleeding, bruising and pain
Natural products Omega-3 supplementation may prevent
the development of PTSD following
exposure to trauma
Small open trial Case reports of nausea, increased
bleeding time
DHEA (25–100mg/D) may improve
treatment-refractory PTSD including
decreased numbing, re-experiencing,
hyperarousal and other PTSD core
Small open trial Avoid in men at risk of prostate
cancer and women with history of
oestrogen-receptor positive breast
A proprietary multi-nutrient formula taken
soon after exposure to trauma may result in
significant decreases in stress, anxiety,
avoidance and arousal
Small open trial in general (non-clinical)
Case reports of toxic interactions
when combined with mood
J. Lake/ Advances in Integrative Medicine 2 (2015) 13–23
development of those modalities that show the greatest promise
including, for example, specific VRGET and BCI protocols,
acupuncture, and select natural products reviewed in this paper.
Finally, regular in-service trainings of all VA/DOD mental health
providers should be widely implemented to ensure that clinicians’
knowledge and skills remain up to date and reflect the best
available evidence for interventions aimed at preventing and
treating PTSD.
Conflicts of interest
The author has no financial conflicts of interest to declare.
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Exhibit 1 (Continued )
Lucid dreaming training Training in lucid dreaming may help reduce
the severity and frequency of nightmares in
individuals diagnosed with PTSD however
core symptoms of PTSD may remain
Preliminary findings based on few small trials None
Energy medicine and
energy psychology
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May significantly reduce PTSD symptom
Exhibit 2
Interventions used to increase resilience prior to trauma exposure, prevent or reduce the severity of PTSD following trauma, and treat chronic PTSD.
Intervention type Target population 1st Tier interventions 2nd Tier interventions
Resiliency training prior to trauma High-risk groups including active duty
military, fire fighters, police officers,
medical relief workers
VRGET (including stress
inoculation and STRIVE)
Proprietary multi-nutrient
Approaches used soon after trauma
to prevent or mitigate PTSD
Individuals who have recently
experienced trauma but have not
developed symptoms
Battlefield debriefing Omega-3s
Mindfulness training
Treatment of chronic PTSD symptoms Individuals who have chronic
symptoms of PTSD
Exposure therapy EMDR
Medications HRV and EEG biofeedback
VRGET plus multi-sensory
Healing touch and guided imagery
Acupuncture EFT and other energy psychology
Note: 1st Tier interventions are supported by moderate to strong evidence; 2nd tier interventions are supported by weak or inconsistent evidence.
J. Lake/ Advances in Integrative Medicine 2 (2015) 13–23
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... This places a great burden on the person, with high costs to the person's well being and everyday functioning. This state of chronic threat awareness and readiness to respond (fight/flight/freeze) typically defies standard therapeutic attempts to achieve its extinction (Othmer and Othmer, 2009;Lake, 2015). These are whole-body memories centered in the limbic structures and the autonomic nervous system, making them inaccessible for processing and resolution via the analytical mind for rational examination. ...
... Some eight U.S. military bases adopted the use of Neurofeedback protocols for active-duty service members in the 2009 time frame and after, and the training was also offered in Afghanistan and Iraq (Lake, 2015). At Camp Pendleton, CA, symptom tracking for 65 categories of interest was conducted on the first 300 active-duty combat Marines to experience the training in the 2009-2010-time frame. ...
... -Alpha-Theta Neurofeedback training has proven to be an effective method for opening a window into traumatic memories without emotional abreaction. This allows those unresolved memories to be released and processed with less risk of client re-traumatization that is common in talk or exposure therapy (Lake, 2015). -Neurofeedback has proven to be superior to so-called "evidence-based" PTSD treatment in terms of effectiveness, temporal efficiency, and cost (Fragedakis and Toriello, 2014;van der Kolk, 2014). ...
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This paper reviews how and why ILF Neurofeedback has proven to be a parsimonious and efficient way to remediate the neuro-physiological effects of trauma. Reference is made to several large- and small-scale institutional proof of concept experimental studies each addressing a specific kind of trauma. It ends with a case report by the author (Kirk) working with an American combat veteran. It makes the argument that given its success that ILF Neurofeedback and Alpha-Theta training become accepted as part of an integrative and holistic approach for treating survivors of trauma.
... The additional psychosomatic treatment includes psychoeducation, neurofeedback, mindfulness training, imaginative therapy, and general support throughout the process and with optimization of the conditions of living (Lake, 2015). ...
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The practical use of a combination of trauma psychotherapy and neurofeedback [infra-low-frequency (ILF) neurofeedback and alpha-theta training] is described for the treatment of patients diagnosed with complex post-traumatic stress disorder (C-PTSD). The indication for this combined treatment is the persistence of symptoms of a hyper-aroused state, anxiety, and sleep disorders even with adequate trauma-focused psychotherapy and supportive medication, according to the Guidelines of the German Society of Psycho-Traumatology (DeGPT). Another indication for a supplementary treatment with neurofeedback is the persistence of dissociative symptoms. Last but not least, the neurofeedback treatment after a trauma-focused psychotherapy session helps to calm the trauma-related reactions and to process the memories. The process of the combined therapy is described and illustrated using two representative case reports. Overall, a rather satisfying result of this outpatient treatment program can be seen in the qualitative appraisal of 7 years of practical application.
... Regarding rehabilitation, there is strong evidence supporting the use of VR therapy [5][6][7] in the treatment of pain, phobias, post-traumatic stress disorder (PTSD) [5], eating disorders [8], mental disorders, such as anxiety, schizophrenia and autism [9], and chemical abuse [10]. Moreover, VR has proven to be an important tool for exposure therapy [11]. Interestingly, a recent review on the medical literature has revealed that no reports of photosensitive epilepsy evoked by the use of VR headset [12]. ...
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The present article reports the results of a systematic review on the potential benefits of the combined use of virtual reality (VR) and non-invasive brain stimulation (NIBS) as a novel approach for rehabilitation. VR and NIBS are two rehabilitation techniques that have been consistently explored by health professionals, and in recent years there is strong evidence of the therapeutic benefits of their combined use. In this work, we reviewed research articles that report the combined use of VR and two common NIBS techniques, namely transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). Relevant queries to six major bibliographic databases were performed to retrieve original research articles that reported the use of the combination VR-NIBS for rehabilitation applications. A total of 16 articles were identified and reviewed. The reviewed studies have significant differences in the goals, materials , methods, and outcomes. These differences are likely caused by the lack of guidelines and best practices on how to combine VR and NIBS techniques. Five therapeutic applications were identified: stroke, neuropathic pain, cerebral palsy, phobia and post-traumatic stress disorder, and multiple sclerosis rehabilitation. The majority of the reviewed studies reported positive effects of the use of VR-NIBS. However, further research is still needed to validate existing results on larger sample sizes and across different clinical conditions. For these reasons, in this review recommendations for future studies exploring the combined use of VR and NIBS are presented to facilitate the comparison among works.
... For example, intense physical training, frequent exposure to mental stress, and periodic conditions of sleep, water, and caloric restriction create unique circumstances that alter resting-state HRV among soldiers [19][20][21]. Moreover, HRV has been used to predict the occurrence of post-traumatic stress disorder following combat deployment [22], as well as to monitor the effects of therapeutic interventions on ANS activity [23]. Thus, HRV tracking has a variety of applications among this population, warranting further investigation into expedient recording procedures that facilitate frequent assessment. ...
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We aimed to (a) evaluate the agreement between ultra-short-term and criterion resting heart rate variability (HRV) measures in military trainees, and (b) compare associations between HRV recording lengths and body composition. HRV recordings were performed for 10 min in 27 military male students. Mean RR interval, the root-mean square of successive differences (RMSSD), RMSSD:RR interval ratio, standard deviation of normal-to-normal RR intervals (SDNN), and SDNN:RR interval ratio were determined from the last 5 min of the 10-min recording and considered the criterion. Parameters were also recorded in successive 1-min epochs from the 5-min stabilization period. No differences were observed between criterion values and any of the 1-min epochs (p > 0.05). Effect sizes ranged from −0.36-0.35. Intra-class correlations ranged from 0.83-0.99. Limits of agreement ranged from 38.3-78.4 ms for RR interval, 18.8-30.0 ms for RMSSD, 1.9-3.1 for RMSSD:RR, 24.1-31.4 ms for SDNN, and 2.5-3.0 for SDNN:RR. Body fat% was associated (p < 0.05) with all HRV parameters at varying time segments. A 1-min HRV recording preceded by a 1-min stabilization period seems to be a suitable alternative to criterion measures. Ultra-short procedures may facilitate routine HRV tracking in tactical populations for status-monitoring purposes.
... AuthorBiofeedback Health Review title-reference Year Title Abstract keywords Major Minor condition The integrative management of PTSD: A review of conventional and CAM approaches used to prevent and treat PTSD with emphasis on military personnel-[38] ...
This chapter consists of five main sections. It begins by discussing the scope of utilizing biofeedback technology in healthcare systems. Then, it presents a brief history of biofeedback technology and previous reviews. The second section highlights the sensory technology in biofeedback systems by presenting the different types of sensors and their features. The third section explores recent research of biofeedback-based healthcare systems by presenting a range of applications in different fields combined with the utilized sensors. The fourth section discusses the challenges and issues that affect the deployment of biofeedback in healthcare systems. The last section concludes this review.
... Such alarming findings prompted biofeedback scientists and practitioners to begin using heart rate variability coherence training among traumatized veterans to help them learn balancing of sympathetic and parasympathetic activity (Lake, 2015;Lande, Williams, Francis, Gragnani, & Morin, 2010;Tan, Dao, Farmer, Sutherland, & Gervitz, 2011;Tan, Wang, & Ginsberg, 2013;Wahbeh & Oken, 2013;White et al., 2017). Breathing retraining techniques were incorporated as a treatment adjunct to aid in the reduction of PTSD symptoms (Polak, Witteveen, Denys, & Olff, 2015). ...
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The posttraumatic stress disorder (PTSD) condition is a systemic neuroinflammatory state that emanates from a failure to recover from traumatic occurrence(s). Major complications associated with PTSD include problems with impulse control and issues related to verbal and physical outbursts of anger and rage. The Veteran's Administration (VA) projects a post-9/11 veteran population of around 3.5 million by 2019. Emotional problems are prevalent among combat service members and veterans with about half of the group suffering from various symptoms of PTSD. Three in four among them report they are reliving traumas in the form of flashbacks and nightmares. Current mental health treatments have not fully remediated the negative impact that results from PTSD. We present a case study of a novel and transformative treatment approach called Reconsolidation Enhancement by Stimulation of Emotional Triggers (RESET) Therapy. The intervention uses binaural sound to unlock the memory reconsolidation process, thereby releasing the emotional component of experienced trauma. RESET Therapy offers a compelling therapeutic adjunct to the practicing biofeedback/neurofeedback clinician, who is under constant pressure to deliver interventions that are rapid, tolerable, and cost-effective. Additionally, the treatment spares the therapist from repeated exposures to the raw limbic activity of traumatized patients, thereby minimizing the potential for vicarious traumatization.
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The progressive escalation in military suicides, along with a substantial increase in post-traumatic stress diagnosis among active military personnel and veterans, has become a significant humanitarian, societal, and cultural concern. Such a defining moment illuminates the need for timely and innovative treatment approaches for combat-related post-traumatic stress. This research explored depth psychological practices within short-term, group-based treatment programs. Using a phenomenological research method, interviews were conducted with six former combat veteran alumni of these programs to gather new insights and understanding into their lived experience. Informants described meaningful reductions in post-traumatic stress, moral injury, and treatment-resistance, while treatment completion rates increased significantly. Research findings suggest depth psychological practices do exhibit compelling potential as valuable, or formidable treatment approaches, alongside current evidence-based treatments. Based on the findings of this preliminary exploration future research is warranted on depth psychological treatments and group-based programs for combat-related post-traumatic stress.
Purpose. To increase the level of medical care for depression patients with autoaggressive manifestations (AM) in victims during a radiation disaster and fighting by developing new diagnostic and treatment programs. Material and methods. The object and methods of the study were 70 liquidators of the accident consequences at the Chernobyl nuclear power plant aged from 54 to 65 years old and 45 combatants of the Anti-terroristic operation (Joint forces operation) aged from 25 to 59 years old – comparison group, depression patients with AM, psychosomatic pathology were examined. For the main group and the comparisons group were used clinical and paraclinical methods, division into groups, according to diagnostic and treatment programs, therapy and follow-up from 2 months to 2 years. Results. The main group observed increasing depressive frequency disorders with AM in liquidators of the accident consequences at the Chernobyl nuclear power plant. The examination revealed asthenic – in 34 (48.6 %) patients, anxiety – in 13 (18.6 %), apathetic – in 8 (11.4 %), hypochondriac – in 7 (10 %), dysphoric – in 5 (7.1 %), obsessive-phobic – in 3 (4.3 %) variants of depression with AM. These particular disorders are characterized asthenic, anxiety and apathetic symptoms, progressive course, personality changes with organic and psychosomatic traits, cognitive deficit (р <0,05). In the comparison group, asthenic was found in 13 (28.3 %) patients, anxious in 11 (23.9 %), hypochondriac in 10 (21.7 %), dysphoric in 6 (13 %), and obsessive-phobic – in 3 (6.5 %) and apathetic variants – in 2 (4.4 %) depression with AM. After the participation in the Anti-terroristic operation (Joint forces operation) fighters exhibit depression with AM in combination with psychosomatic and personality traits, changes in the bioelectrical activity of the brain. These particular disorders are characterized asthenic, anxiety, hypochondriac symptoms, personality and psychosomatic traits (р <0,05). Conclusions. The proposed comprehensive treatment and diagnostic program will increase the level of medical care of the liquidators of the accident consequences at the Chernobyl nuclear power plant, combatants of the Anti-terroristic operation (Joint forces operation) and prevent the occurrence of suicide. Key words: depression, autoaggressive manifestations, diagnostics, treatment, prevention, combatants of the Anti-terroristic operation (Joint forces operation), liquidators of the consequences of the Chernobyl accident.
This chapter explores the most relevant aspects in relation to the outcomes and performance of the different components of a healthcare system with a particular focus on mobile healthcare applications. In detail, we discuss the six quality principles to be satisfied by a generic healthcare system and the main international and European projects, which have supported the dissemination of these systems. This diffusion has been encouraged by the application of wireless and mobile technologies, through the so-called m-Health systems. One of the main fields of application of an m-Health system is telemedicine, for which reason we will address an important challenge encountered during the realization of an m-Health application: the analysis of the functionalities that an m-Health app has to provide. To achieve this latter aim, we will present an overview of a generic m-Health application with its main functionalities and components. Among these, the use of a standardized method for the treatment of a massive amount of patient data is necessary in order to integrate all the collected information resulting from the development of a great number of new m-Health devices and applications. Electronic Health Records (EHR), and international standards, like Health Level 7 (HL7) and Fast Healthcare Interoperability Resources (FHIR), aims at addressing this important issue, in addition to guaranteeing the privacy and security of these health data. Moreover, the insights that can be discerned from an examination of this vast repository of data can open up unparalleled opportunities for public and private sector organizations. Indeed, the development of new tools for the analysis of data, which on occasions may be unstructured, noisy, and unreliable, is now considered a vital requirement for all specialists who are involved in the handling and using of information. These new tools may be based on rule, machine or deep learning, or include question answering, with cognitive computing certainly having a key role to play in the development of future m-Health applications.
Electroencephalography (EEG) motor imagery signals have recently gained significant attention due to its ability to encode a person’s intent to perform an action. Researchers have used motor imagery signals to help disabled persons control devices, such as wheelchairs and even autonomous vehicles. Hence, the accurate decoding of these signals is important to brain–computer interface (BCI) systems. Such motor imagery-based BCI systems can become an integral part of cognitive modules that are increasingly being used in smart city frameworks. However, the classification and recognition of EEG have consistently been a challenge due to its dynamic time series data and low signal-to-noise ratio. Deep learning methods, such as the convolution neural network (CNN), have achieved remarkable success in computer vision tasks. Considering the limited applications of deep learning for motor imagery EEG classification, this work focuses on developing CNN-based deep learning methods for such purpose. We propose a multiple-CNN feature fusion architecture to extract and fuse features by using subject-specific frequency bands. CNN has been designed with variable filter sizes and split convolutions for the extraction of spatial and temporal information from raw EEG data. A feature fusion technique based on autoencoders is applied. Cross-encoding technique has been proposed and is successfully used to train autoencoders for a novel cross-subject information transfer and augmenting EEG data. This proposed method outperforms the state-of-the-art four-class motor imagery classification methods for subject-specific and cross-subject data. Autoencoder cross-encoding helps to learn subject invariant and generic features for EEG data and achieves more than 10% increase on cross-subject classification results. The fusion approaches show the potential of applying multiple CNN feature fusion techniques for the advancement of EEG-related research.
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Abstract This monograph recounts the development history of the Othmer Method of neurofeedback over more than 30 years. With beginnings in the standard EEG-band protocols developed by neurofeedback pioneers Sterman and Lubar, the method migrated in successive stages from fixed protocols, implemented in an operant conditioning design, to a systematic, sequential, but non-prescriptive approach that is organized according to the developmental hierarchy. This method places initial reliance on training on the tonic slow cortical potential, in the infra-low frequency regime, as the developmental hierarchy maps directly into a frequency hierarchy. The training has to be done in a frequency-specific manner, at frequencies referred to as optimal response frequencies that are unique to each individual. Thus, while the training approach is nomothetic in design, it is idiopathic in execution. The absence of any reinforcers in the training places the brain in charge of the particulars of its journey to functional recovery. The reliance on endogenous neuromodulation to target critical frequencies yields an efficient process with a comprehensive scope. The Infra-Low Frequency (ILF) neurofeedback is complemented by more conventional EEG-band protocols for specific objectives.
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Given the limited success of conventional treatments for veterans with posttraumatic stress disorder (PTSD), investigations of alternative approaches are warranted. We examined the effects of a breathing-based meditation intervention, Sudarshan Kriya yoga, on PTSD outcome variables in U. S. male veterans of the Iraq or Afghanistan war. We randomly assigned 21 veterans to an active (n = 11) or waitlist control (n = 10) group. Laboratory measures of eye-blink startle and respiration rate were obtained before and after the intervention, as were self-report symptom measures; the latter were also obtained 1 month and 1 year later. The active group showed reductions in PTSD scores, d = 1.16, 95% CI [0.20, 2.04], anxiety symptoms, and respiration rate, but the control group did not. Reductions in startle correlated with reductions in hyperarousal symptoms immediately postintervention (r = .93, p < .001) and at 1-year follow-up (r = .77, p = .025). This longitudinal intervention study suggests there may be clinical utility for Sudarshan Kriya yoga for PTSD.
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Posttraumatic stress disorder (PTSD) is a significant health concern for U.S. military service members (SMs) returning from Afghanistan and Iraq. Early intervention to prevent chronic disability requires greater understanding of subthreshold PTSD symptoms, which are associated with impaired physical health, mental health, and risk for delayed onset PTSD. We report a comparison of physiologic responses for recently deployed SMs with high and low subthreshold PTSD symptoms, respectively, to a fear conditioning task and novel virtual reality paradigm (Virtual Iraq). The high symptom group demonstrated elevated heart rate (HR) response during fear conditioning. Virtual reality sequences evoked significant HR responses which predicted variance of the PTSD Checklist-Military Version self-report. Our results support the value of physiologic assessment during fear conditioning and combat-related virtual reality exposure as complementary tools in detecting subthreshold PTSD symptoms in Veterans.
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We propose to combine Virtual Reality (VR) and bio-neuro feedback to help treat stress-related disorders. As a first step in that direction, we here attempted to induce stress through VR and identify (neuro)physiological correlates. Nine participants performed a surveillance task in two different cities within VR while EEG, ECG and cortisol level were recorded over time. We aimed to induce stress by simulating a bomb explosion and providing negative feedback about the participant's performance. As-sociative stress was elicited by having participants return to the city where the bomb explosion occurred and they supposedly performed badly. (Associative) stress was reflected in EEG mid-frontal alpha asymmetry, heart variability and cortisol level. General stress levels as expressed by cortisol and mid-frontal alpha asymmetry correlated between participants. These results are promising for a successful implementation of a VR bio-neuro feedback system.
Background. Although increasing numbers of war veterans are seeking treatment for posttraumatic stress disorder (PTSD) at the U.S. Department of Veterans Affairs (VA), information on the role of psychotropic pharmacotherapy in their treatment has not been available. Method: Records of psychotropic prescriptions for all VA patients diagnosed with ICD-9 PTSD (N = 274,297) in fiscal year 2004 (October 1, 2003, to September 30, 2004) were examined. Descriptive statistics and multivariable logistic regression were used to identify veteran characteristics and measures of service use that were associated with receipt of any psychotropic medication and, among users of such medications, with use of each of 3 medication classes: antidepressants, anxiolytics/sedative-hypnotics, and antipsychotics. Results: Most veterans diagnosed with PTSD received psychotropic medication (80%), and among these, 89% were prescribed antidepressants, 61% anxiolytics/sedative-hypnotics, and 34% antipsychotics. Greater likelihood of medication use was associated with greater mental health service use and comorbid psychiatric disorders. Among comorbidities, medication-appropriate comorbid diagnoses were the most robust predictors of use of each of the 3 medication subclasses, i.e., depressive disorders were associated with antidepressant use, anxiety disorders with anxiolytic/sedative-hypnotic use, and psychotic disorders with antipsychotic use. Use of anxiolytics/sedative-hypnotics and antipsychotics in the absence of a clearly indicated diagnosis was substantial. Conclusion: Diverse psychotropic medication classes are extensively used in the treatment of PTSD in the VA. While disease-specific use for both PTSD and comorbid disorders is common, substantial use seems to be unrelated to diagnosis and thus is likely to be targeted at specific symptoms (e.g., insomnia, anxiety, nightmares, and flashbacks) rather than diagnosed illnesses. A new type of efficacy research may be needed to determine symptom responses to psychotropic medications as well as disorder responses, perhaps across diagnoses.
Predeployment stress inoculation training (PRESIT) is designed to help personnel cope with combatrelated stressors and trauma exposure. PRESIT comprises education on combat and operational stress control, attentional retraining and relaxation training, and practice and assessment via a multimedia stressor environment (MSE). Heart rate variability (HRV) and a reaction time task assessed learned skills and inoculation to MSE arousal. Participants with deployment experience and who were in the experimental group demonstrated improvement, measured as greater relaxation demonstrated during the MSE of a follow-up session relative to that of a baseline session. There was also a training effect for this group, such that those participants who showed greater relaxation from a baseline HRV state during the training (i.e., on relaxation breathing and focusing) showed more improvement between sessions. In contrast, there were no significant predictive variables for the participants in training who had never deployed. Participants with more Posttraumatic Stress Disorder (PTSD) symptoms at baseline showed more capability for improvement, as was true for participants who were more anxious about their next deployment.
Male veterans and their spouses (N = 218) attending 1 of 6 week-long retreats were assessed for posttraumatic stress disorder (PTSD) symptoms pre- and postintervention. Participants were evaluated using the PTSD Checklist (PCL), on which a score of >49 indicates clinical symptom levels. The mean pretest score was 61.1 (SD ± 12.5) for veterans and 42.6 (SD±16.5) for spouses; 83% of veterans and 29% of spouses met clinical criteria. The multimodal intervention used Emotional Freedom Techniques and other energy psychology (EP) methods to address PTSD symptoms and a variety of Complementary and Alternative Medicine (CAM) modalities for stress reduction and resource building. Interventions were delivered in group format as well as individual counseling sessions. Data were analyzed for each retreat, as well as for the 6 retreats as a whole. Mean posttest PCL scores decreased to 41.8 (SE ± 1.2; p <.001) for veterans, with 28% still clinical. Spouses demonstrated substantial symptom reductions (M = 28.7, SE ± 1.0; p <.001), with 4% still clinical. A follow-up assessment (n = 63) found PTSD symptom levels dropping even further for spouses (p <.003), whereas gains were maintained for veterans. The significant reduction in PTSD symptoms is consistent with other published reports of EP treatment, though counter to the usual long-term course of the condition. The results indicate that a multimodal CAM intervention incorporating EP may offer benefits to family members as well as veterans suffering from PTSD symptoms. Recommendations are made for further research to answer the questions posed by this study.
The purpose of this pilot study was to evaluate the feasibility and effectiveness of a yoga program as an adjunctive therapy for improving post-traumatic stress disorder (PTSD) symptoms in Veterans with military-related PTSD. Veterans (n = 12) participated in a 6 week yoga intervention held twice a week. There was significant improvement in PTSD hyperarousal symptoms and overall sleep quality as well as daytime dysfunction related to sleep. There were no significant improvements in the total PTSD, anger, or quality of life outcome scores. These results suggest that this yoga program may be an effective adjunctive therapy for improving hyperarousal symptoms of PTSD including sleep quality. This study demonstrates that the yoga program is acceptable, feasible, and that there is good adherence in a Veteran population.