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MANAGING POST TRAUMA REACTIONS-
CHANGING THE DIALOGUE AND
PROTOCOLS
By Joanne Patti Munisteri
1
September 2017
This article is written in the hope that practitioners will have an
arsenal of strategies for treating patients who are, or who have been
in: a) conflict zones or b) have experienced and/or witnessed
sudden, violent and/or repetitive trauma, or c) were in areas where
natural disasters struck and then presented with post trauma
symptoms.
I point out the importance of changing the reporting, dialogue,
diagnostic labels and language used by practitioners, patients and
the wider society to be more exact and supportive descriptions of
patients’ conditions.
The therapies presented in this article may be administered in almost
any environment, are cost effective with fewer potential harmful side
effects than pharmaceutical medications.
Included are specific meridian, auricular and scalp acupuncture
points used therapeutically with moxa and electrical currents for
acute and prolonged cases of what have been labeled in DSM- 5 as:
Post Traumatic Stress Disorder, Traumatic Stress Response, General
Anxiety Disorder and Acute Stress Disorder.
BACKGROUND
In the last decade there is an increasing awareness in conflict zone
hospitals, in military hospitals and clinics in a number of countries, that
acupuncture and traditional Chinese medicine treatments are efficacious
and time/cost effective for treating post traumatic stress and what is labeled
as TSR or Trauma Spectrum Response and the recently listed condition of
ASD (Acute Stress Disorder) and GAD (General Anxiety Disorders).
The immediate and subsequent symptoms can include: insomnia, residual
pain, aphasia, appetite changes, numbing, personality changes,
depression, manias, flashbacks, anxiety, muscular skeletal weakness,
digestive disorders, tinnitus, temporary paralysis, myopia, fatigue, impulse
control problems, filters, triggers, sexual dysfunction, aggressive denial,
phobias, cognitive difficulties, ahedonia, hyper arousal, and other ‘qi/chi’
and/or ‘shen’ disturbances which cause suffering in the patients, as well as
impact their family, friends, colleagues, communities and their wider
society.
2
Patients have presented with physical, emotional/mental and even ‘spiritual’
distress from being a victim, witness and/or perpetrator of trauma. These
symptoms and possible treatment protocols, were described by traditional
Chinese Medicine practitioners in their literature since 240 B.C., when the
Inner Cannon of the Yellow Emperor by Huang Di, known as the Nei Jing,
was written. The Song of the Ghost Points by Sun Si Miao, was
transcribed into written text in the 7th century.
“In classical Acupuncture terms-pathologies of ‘Qi’ (are) objective disharmonies that
generate physical and emotional symptoms simultaneously. In the Acupuncture
paradigm, resonant with the term ‘soldier’s heart’; all emotions affect the Heart, the
vessel of Shen, spirit. Thus a Heart Shen disturbance participates in every case of
PTSD and TBI (Traumatic Brain Injury) which manifest commonly as exhaustion of
Heart Fire (concentration and memory problems, anxiety, depression, disturbed sleep).
Stagnant Liver Qi escalating into Liver Fire accounts for some of the most distressing
symptoms (muscle tension, hyper vigilance, irritability and outbursts of rage) and both
Heart and Liver disturbances are coupled with Kidney Yin and Yang depletion (fatigue,
fear and helplessness). [1]
In western medicine these symptoms are clustered together and generally
labeled as PTSD (Post Traumatic Stress Disorder) or less commonly as
TSR (Trauma Spectrum Response)
“In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in
the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
The diagnostic criteria are specified below.
Diagnostic criteria for PTSD include a history of exposure to a traumatic event that
meets specific stipulations and symptoms from each of four symptom clusters: intrusion,
avoidance, negative alterations in cognitions and mood, and alterations in arousal and
reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses
functioning; and, the eighth criterion clarifies symptoms as not attributable to a
substance or co-occurring medical condition.
Two specifications are noted including delayed expression and a dissociative subtype of
PTSD, the latter of which is new to DSM-5. In both specifications, the full diagnostic
criteria for PTSD {Post Traumatic Stress Disorder} must be met for application to be
warranted.
“Co-existing symptoms (for example: chronic pain, depression, anxiety, and fatigue) are
common in military fighters who have experienced physical and/or psychological
trauma. These overlapping conditions cut across the boundaries of mind, brain and
body, resulting in a common symptomatic and functional spectrum of physical,
cognitive, psychological and behavioral effects referred to as the ‘Trauma Spectrum
Response’ (TSR).” [2]
3
In addition there is another diagnostic label possible if a practitioner
is treating patients afflicted with symptoms within a specified time
frame after the trauma happened.
“Acute stress disorder
(ASD) is a new diagnostic category that was introduced in 1994 to differentiate time-
limited reactions to trauma from post-traumatic stress disorder (PTSD).” [3]
DIALOGUES
Dis is a prefix which originates from Roman mythology, Dis Pater (Hades in
Greek myths). Dis was the god of the underworld. Dis means ‘against’, as
a prefix, so the word/term ‘disorder’ can simply be understood as being-
against the order of ‘normal health’.
However the somatic and psychic responses of human beings to violence,
horrific events, abuse, sudden life threatening natural disasters, torture,
murder, rape, prolonged deprivation, imprisonment; are essential features
of our human health signaling systems. They are embedded indicators
which dispatch warnings to our physical, emotional and even spiritual
essence to be uniquely alert to the changes that have arisen due to trauma.
Diagnosing a patient with language which condemns her or him to a
seemingly long term, immutable health disturbance can adversely affect
patients as well as health practitioners in the treatment environment.
Words used therapeutically by psychiatrists, psychologists, nurses, care
takers, healers can make considerable difference between short and long
term recovery.
We know from neuroscience imaging research how important encouraging
words/text/ imagery and stimulation are to growth, repair and resilience in
human beings and in animals.
Therefore promoting a shift in perspective and diagnostic label replacement
from “disorder” (acute stress disorder, post traumatic stress disorder) to a
“response” or “reaction” is the first step for all involved in post trauma
management and care.
It is significant to report that health practitioners in countries where I have
worked, and where English is not the national language (for example
Armenia, Ukraine, Afghanistan, Pakistan, Israel, Russia, Morocco, Italy) do
4
not call, label or diagnose post traumatic responses as post traumatic
stress ‘disorder’. This is also the case for Indigenous populations in
Australia (Aboriginal), New Zealand (Maori) and certain First Nation tribes
in the continent of North America.
Officially, health practitioners may label these collections of symptoms-
‘Post Traumatic Stress’ or Trauma Stress Reactions, but in addition they
have other more poetic descriptions such as: “maemae” (hurts/pains-
Maori) ‘katipo’ (poisonous spider-Maori) ‘talking ghosts’,
(translated from Mandarin texts) ‘wind evils’, Iktomi (Lakota), and so forth.
These psycholinguistic distinctions are crucial to changing the attitude and
to de-stigmatizing these conditions.
TREATMENT PROTOCOLS
The usual prescriptions in western medicine approaches to post trauma
involve the administration of pharmaceutical medicine and perhaps the
addition of CBT Cognitive Behavioral Therapy (CBT) and exercise. There
are few other possibilities offered to someone suffering from Post Traumatic
Stress (PTS) or Post Traumatic Stress Response (PTSR) in conflict zones
or in military hospitals at present.
There are a number of studies presenting the efficacy of using guided
imagery, GMI (Graded Motor Imagery) visualization, EMDR(Eye Movement
Desensitization and Reprocessing),[13] medical qigong and meditation- to
shift the paradigm of suicidal, self harming or aggressive actions to more
life affirming, less agitated behaviors. These methods are also part of
successful pain management tools.
“Neuroscientist Vilayanur S. Ramachandran argued that chronic pain can be reinforced
by a learned reorganization of neural circuits. To prove this, he created a treatment
known as the mirror box. All it consists of is two mirrors in a box which, when viewed
from an angle, give an amputee the illusion of having two functional limbs.
The visualization tricks the brain, ends the maladaptive feedback loop, and relieves the
pain. The mirror box changed the way we look at chronic pain, and mirror therapy is
now one of the main components of a treatment called graded motor imagery.
Patients can assuage symptoms on the neuronal level using GMI, in addition to using
physical therapy to promote functional movement. Lifestyle changes like diet and
exercise can also work to provide relief. ” [8]
These techniques are introduced to the patient by a health practitioner who
will choose when to initiate these modalities. All of these are possible with
limited resources and in confined spaces, but they require consistent
5
guidance from a skilled practitioner and regular practice on the part of the
patient.
Complementary strategies for post trauma management may be done in
conjunction with Acupuncture and Traditional Chinese Medicine (TCM).
ACUPUNCTURE AND TRADITIONAL CHINESE MEDICINE
Acupuncture used for Integrated Stress Management (ISM)and Traditional
Chinese Medicine (TCM) meridian points needled on thousands of patients,
in both civilian and military clinics/hospitals, has proved effectual in a
number of randomized, controlled medical investigations arising from
varying circumstances and happening to diverse population groups. [4, 6,
7]
MILITARY MEDICINE APPLICATIONS
“Acupuncture for the treatment of concussions, insomnia, dizziness, headaches, and
PTSD is used in the US military. Stars and Stripes published an article on this topic by
Dr. Stuessi, a Navy sports medicine physician who works in a special concussion care
center. He notes, “I’ve found phenomenal, off-the-charts results doing acupuncture for
sleep, for dizziness and headaches.” [5]
There are a number of commonly used points such as Zu San Li (Stomach
36) which hearken back to Chinese dynasty military campaigns, when due
to depletion or injury soldiers needed to go “3 miles more” on little sleep or
with little food. They applied moxa (heat with mugwort) to the point(s)
and/or needled bilaterally on the leg meridian points for quick reaction
response to “keep on going” until they were able to re supply and
recuperate. There is an entire body of literature and case studies in TCM
(Traditional Chinese Medicine) concerning application of the “Ghost Points”
for treating symptoms similar to those described in western medicine
diagnosis as PTS or TSR.
American military uses of acupuncture date back to the 1960s. Army, Navy,
Air Force and Marine doctors have utilized meridian points for post trauma,
pain relief and emotional resiliency.
“The US military has documented the usefulness of acupuncture since 1967, when an
Army surgeon wrote an article on the efficaciousness of acupuncture in Military
Medicine magazine. Since that time, doctors at the Walter Reed Army Medical Center in
Washington recommend acupuncture for the treatment of physical pain due to injuries.
6
Col. Richard Niemtzow, an Air Force physician, first offered acupuncture in 1995 at
McGuire Air Force Base (New Jersey). Later, he founded the Air Force acupuncture
clinic at Andrews Air Force Base (Maryland). In addition to clinical care for patients,
there is training for doctors to bring acupuncture therapy to war zones in Iraq and
Afghanistan. The focus is on the treatment of pain and PTSD.
The Navy has an acupuncture training program for doctors at Camp Pendleton (San
Diego, California). Dr. Ronald White, as director of pain services at Landstuhl Regional
Medical Center, commented on acupuncture, “There’s no risk; it gives you benefit. Our
goal — my end result — is function. If you come to me complaining that you can’t play
with your kids, you can’t sleep at night, you can’t work, and six months later, I have you
playing, sleeping and back to work….” [16]
While working on Ascension Island, South Atlantic with the British military, I
treated a number of returning soldiers who were reintegrating after being
wounded on active duty. I used acupuncture and moxa for: phantom pain
after amputations, insomnia, anxiety, muscular skeletal injuries and residual
pain from back, shoulder and neck injuries. The reaction of the doctors
and patients on the island was one of initial disbelief, then surprise and
curiosity since acupuncture (Traditional Chinese Medicine) was so
effective.
“Acupuncture has been widely applied in the treatment of anxiety disorders and
statistically significant effects have been observed.” [8]
On the NATO hospital HKIA base in Kabul, in collaboration with USAF
doctors we treated not only muscular skeletal injuries of the back, neck,
ankle and shoulders but also insomnia using the NADA bi lateral auricular
protocol, plus Yintang (MN-HN-3) and/or Heart 7 (Shen Men on the arm).
If the patients were receptive, I also demonstrated the medical qigong
movements from the Ba Gua / Nei Jia Guan series as a therapeutic means
of calming the nervous system before trying to sleep.
7
Treating patient on base in Kabul, Afghanistan-2017 photo by Shala
Hammond
AURICULAR ACUPUNCTURE
What was originally known as NADA protocol (National Acupuncture Detox
Association) is now known as Auricular Trauma Protocol (ATP) as well as
ISM (Integrated Stress Management) treatment points protocol.
Initially points in the ear were stimulated with electricity however research
at Lincoln Recovery Center in New York City, proved over time that needles
retained for 30-45 minutes provided longer symptomatic relief for patients.
The auricular points for this protocol are: sympathetic nervous system,
shen men, kidney, liver, lung with additional bilateral points such as point
zero and heart.
“Recovery from chemical addiction mirrors the recovery path for individuals suffering
from post-traumatic stress syndrome, which is why the NADA protocol is now being
used to treat the effects of trauma. “[24]
“Translating the Louisiana experience into on base clinics has demonstrated that the
NADA 5 Needle protocol is an effective tool for treating the stresses and wounds of
war.” [15]
8
When these reports mention “5 Needle Protocol” they refer to 5 needles in
each ear. The Korean made sijouk needles, as well as the specially
manufactured NADA protocol needles, can be used on all ages and body
types, are cost effective and easily transportable.
An integral part of treatment in clinics at Lincoln Hospital in the Bronx, New
York, USA, Ballymead clinics in Northern Ireland, and on Maori maraes in
New Zealand- for example- is the involvement of patients in the preparation
of their own treatment. This collaborative process supports personal
empowerment in the therapeutic steps necessary for symptom relief and
ultimately for healing.
The patient fills out their own form each time they return for a session,
rates their own progress or tells a practitioner so their progress can be
recorded. Patients are expected to wash their own hands before being
seated. Patients are instructed on how to swab their own ears before
treatment, seat themselves comfortably and raise their own hand when
they are ready for a practitioner to come over to treat them. Patients are
responsible for disposing of the needles used for their treatment in a
centrally placed sharps container.
The actions the patients complete as part of their own treatment, reinforces
their independence and capability with conditions (such as addiction and
post trauma reactions) which previously or unpredictably may have
overwhelmed them and led to a loss of self-confidence, feeling of
powerlessness, reduced capabilities and dependency.
“The treatment methods include body acupuncture and ear acupuncture, with the
common selected points of Baihui (DU-20), Shenmen (HE-7), Neiguan (P-6), and
Sanyinjiao (SP-6), which is based on traditional Chinese Medicine (TCM) theory of
Zang-Fu organs. Based on the integration of TCM with biomedical knowledge of brain
regions related to anxiety disorders, we designed and located two new stimulation areas
on the scalp with electric stimulation, and this treatment protocol for anxiety disorders
has shown remarkable immediate and long-term effect in our clinical practice.”
SCALP ACUPUNCTURE
Scalp acupuncture is another treatment possibility for practitioners. While
there are not specific points designated just for post trauma (PTS) or GAD;
depending on the symptoms and physical health of the patient, the
following points may be administered: Du 20 (Baihui) “4 Directions points”
(scalp), Du 23,(Shangxing) Du 24 (Shenting) M-HN-9 (Taiyang), GB
8(Tianchong) GB 9 (Shuaigu)
“The unique aspect of our scalp acupuncture treatment protocol is in selecting points on
the Governing Vessel and local points on the head to locate the two scalp stimulation
9
areas with electric stimulation in order to regulate and balance the function of the
corresponding brain regions related to anxiety disorders. The demonstration of
remarkable immediate and long-term effects of this treatment protocol reveals new and
developing prospects of scalp acupuncture for the treatment of anxiety disorders.
•1. Stimulation area one: The line between Yintang (M-HN-3) and Shangxing (DU-
23) and Shenting (DU-24)
•2. Stimulation area two: The line between Taiyang (M-HN-9) and Tianchong (GB-
9) and Shuaigu (GB-8).
•3. Low voltage electric current is passed between the pair of needles to stimulate
the amygdala and hippocampus regions to regulate the neural activity of fear and
anxiety” [19]
Scalp acupuncture may be administered while the patient is seated or lying
prone depending on the situation and facilities available. In combat and
conflict zones, ‘battlefield acupuncture’ has proven to be effective for
immediate symptomatic relief. This may involve a combination of sijouk
and Serian (or other brand TCM needles) of varying length and width
depending on body types, thickness of muscles, skin type, etc.
New Zealand TCM practitioner, Peter Larking at the Om Clinic in
Wellington, uses Tang scalp acupuncture points and he contributes the
following:
In the Tang style acupuncture there is a location called ‘the calm line’ which is used for
anxiety or linking Du 24 and Bl 3 (upper jiao line) back into Du 22 to make a triangle
shape. This is now my go-to technique for chronic insomnia.
Doctors, aid workers, medical practitioners in high stress situations may
also benefit themselves from 30-45 minutes acupuncture treatments on
site.
A number of Ukrainian medical doctors working with US agencies in Kiev
and Ternopil in 2015, were suffering post trauma after the events they
witnessed during the Maidan demonstrations. I administered the 5 point bi
lateral auricular protocol and a few extra points (Baihui-Du 20) the 4 Gates
(Tai Chong-Liver 3, and Hegu-Large Intestine 4) as well as Lung points for
grief.
These proved effective in relieving their symptoms after only two
treatments. They were able to return to their high level functioning and
demanding practice without the need for sleeping or anti depressant
medication.
10
HERBAL REMEDIES
In addition to the above stipulated modalities for treating PTSR, PTS, GAD,
ASD - supplementing ISM with Bach Flower Rescue Remedies in lozenge
or liquid form has been helpful for many patients (between treatments) in
reducing anxiety, stress, triggers, depression and agitation symptoms. The
liquid form is more concentrated but more problematic to transport in
field/combat situations. Pills and lozenges are easy to transport but less
concentrated and patients may need to take more for the same effect as a
few drops on the tongue.
“The result of this independent study is not only welcome news for those of us who
encounter stressful situations every day, but particularly for the 40 million Americans
who suffer from physician-diagnosed anxiety,” said Ronald Stram, MD, who regularly
prescribes Rescue Remedy to his anxious and stressed patients. “Stress compromises
your ability to fight off disease and infection. It can even rewire the brain, making you
more vulnerable to everyday pressures and problems.” [24]
11
Traditional Chinese Medicinal herbs may also be prescribed depending on
the overall health condition of the patient and the availability of the herbs on
site or nearby the clinic, hospital or private practice rooms.
NATURAL DISASTER TRAUMA RESPONSE UTILIZING
ACUPUNCTURE
“In related research, acupuncture is found more effective than paroxetine (Aropax,
Paxil, Sereupin) for relief of PTSD due to earthquake trauma. Researchers from the
Chengdu University of Traditional Chinese Medicine and the Chengdu Military General
Hospital conducted a randomized controlled clinical investigation of 138 patients with
earthquake induced PTSD. Electro acupuncture was applied to the treatment group at
GV20 (Baihui), Sishencong (Ex-HN 1), GV24 (Shenting) and GB20 (Fengchi). The
medication group received oral administration of paroxetine. The medication group
showed improvement. However, the reduction scores of PTSD including specific scores
for anxiety and depression reduction were better in the electro acupuncture group than
the paroxetine group.”[16]
•Unfortunately medications such as paroxetine, SSRIs (anti
depressants) and prescription sleeping medications have side effects
such as long term liver and kidney damage as well as the following short
term symptoms: “drowsiness, nausea, dry mouth, insomnia, diarrhea,
nervousness, agitation or restlessness, dizziness, sexual problems, such as reduced
sexual desire or difficulty reaching orgasm or inability to maintain an erection
(erectile dysfunction), headaches, blurred vision, weight gain and hallucinations”.
{23}.
The Hippocratic Oath all western medical practitioners take -Primum Non
Nocere- ‘to above all do no harm’ -is more easily followed with the use of
the therapies outlined in this article.
Those who come to us, are sent to us or live among us seeking relief
should be able to access comprehensive, non-addictive, effective remedies
which are easily affordable, to cope with the pain and suffering that sudden
and violent trauma inflicts .
“Complementary and IM (Integrative Medicine) modalities include tools that induce
permanent healing in a whole person. Better and more-holistic approaches are needed
for healing the wrTSR. (War related Traumatic Stress Reactions) In addition, there
needs to be greater emphasis on research and implementation of whole-person healing
practices. Finally, it is necessary to recognize the importance of healing as much as
curing.” [25]
All the treatments mentioned may be expanded upon with more research,
observation and implementation. Those who are already trained and
12
skilled TCM practitioners can work together with western medicine trained
practitioners to offer patients a range of healing strategies and treatments.
This is already being done on a limited scale when doctors in clinics,
hospitals and in the field have open minds about different approaches for
physical and psychic pain relief.
This article was written to share information and spur discussion of these
healing modalities.
ACKNOWLEDGEMENTS
Thank you to all the TCM, Western medical doctors and tribal healers who
have trained and worked with me over the last few decades, especially:
Doc Ron Rosen, Dr. Lillian Oh, Dr. Xiao Tian Shen, Chief Archie Fire Lame
Deer, Auntie Jesse Williams of the Gumbayngirr People in New South
Wales, Australia , Canon Wi Te Tau Huata- Ngati Kahungunu, Peter Larking
at the OM Clinic NZ, Dr. Robert Calhoun (USAF) and all those who were
my teachers and colleagues at the New Zealand School of Acupuncture
and Traditional Chinese Medicine between 2003-2006.
Special thanks to Dr. Debra Betts, who was not only an inspiring teacher at
the New Zealand School of Acupuncture and Traditional Chinese Medicine
in Wellington, but an encouraging mentor and rigorous taskmaster who
gave generously of her personal time and expertise.
I am extremely grateful for the many patients I have had over the years in
various places and in often challenging conditions.
13
Heratsi -Yerevan State Medical University, Armenia 2009
REFERENCES /END NOTES
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2. http://www.brainlinemilitary.org/content/2014/06/dsm-v-tr-criteria-for-ptsd.html
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s_says_study
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20044825
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