Anxiety Disorders

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Understanding the diagnosis in anxiety disorders

There are six major types of anxiety disorders, each with their own distinct symptom profile: generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, post-traumatic stress disorder, and social anxiety disorder. The underlying mechanisms, or pathophysiology, are very similar in these types of anxiety disorder, but the array of treatment options in the holistic protocol are different. Sometimes, behavioral and cognitive changes are needed, and these too need to be understood. Changing behavior and mental habits of cognition are not something that is done to you, but something that you do yourself.

There is considerable comorbidity, or concurrent occurrence, between anxiety mood disorders and depressive mood disorders, with studies noting that approximately 60 percent of patients diagnosed with one of these also can be diagnosed with the other. Depression is diagnosed in a great majority of patients with panic disorder, obsessive compulsive disorder and post-traumatic stress disorder, while a relatively small percentage of patients with a social anxiety or generalized anxiety disorder will also suffer a depressive mood disorder. Generally, depressive mood disorders tended to occur within a year of onset of a diagnosed anxiety mood disorder, and all of the anxiety mood disorders showed increased risk for developing depression. Early treatment is thus important for anxiety mood disorders, and resolving the underlying causes of these anxiety mood disorders is obviously important, not just controlling the disorder with medication. There is considerable comorbidity between the various types of anxiety mood disorders as well, and while this typing is valuable for both the patients and the physicians in designing individualized treatment protocols, we must also look to a more expansive treatment strategy to address these issues. A separate article on this website, entitled Depression, Melancholia and Bipolar Disorders, will help you to understand these pathologies as well. Greater understanding and a proactive approach is very important in effectively treating and curing these mood disorders.

Aging, hormonal imbalance, and vulnerability to stress

It has long been observed that with aging comes an increased vulnerability to stress. Researchers in Japan have been trying to better define this phenomenon physiologically and come up with an effective treatment strategy. At the National Institute for Longevity Sciences in Aichi, Japan, researchers found that aging is associated with dysregulation of emotional and endocrine responses in stressful environments, and that repeated stress creates a different set of responses than acute stress. The field of Neuroimmunopsychology has long collected data that proves that cell receptors in the brain often respond not only to neurotransmitters, but to hormones and even immunomodulating cytokines. Aging brings about a slow decline in the efficiency of hormone production and regulation, as well as increased stress on the immune system as aging tissues require more immune response to maintain and repair aging and hardened tissues. Each individual may have a different profile in this regard, and those persons with increased hormonal dysregulation, or chronic inflammatory states, may have a more difficult time with handling common daily stressors. Not only patients with emotional and psychological disorders are vulnerable in this regard. The treatment and health maintenance protocols must reflect this broad holistic aspect of stress-related pathology, especially concerning anxiety disorders.

These researchers in Japan measured cortisone responses and c-Fos immunoreactivity in the brain in response to restraint stress in both young and old laboratory animals. C-Fos is a protein released by a basic gene of the Fos family in our cells that triggers a cascade of responses to stress. The Fos gene family have been identified as integral in regulation of cell proliferation, differentition and transformation, and various Fos genes produce regulatory proteins implicated in a wide variety of brain responses, such as anxiety, addiction, excess appetite, depression, and other stress-related behavioral and cognitive expressions. C-Fos and other Fos gene proteins have been widely studied in relation to cellular dysregulation in cancer, effects of chronic viral illnesses (e.g. some retroviruses express analogues to the human c-Fos protein), and may provide us with a better understanding of the physiological mechanics of these diverse pathologies.

A very complex array of chemicals interact in our cells to properly regulate cell function, proliferation, and normal programmed cell death (apoptosis). When this complex system is disrupted or overstressed, a variety of cellular dysfunctions may occur. In the brain, lack of control of neural firing may result in sudden mood changes or unwanted psychological and emotional reactions to normally benign stressors. Immune cytokines, growth factors, chemicals that act both as immune modulators and neurotransmitters (e.g. serotonin), and protective chemicals such as tumor necrosis factor (TNF), all interact with c-Fos expression. Cortisone, or corticosterone, is a key hormone produced by the adrenal gland of the kidneys that is first responder to stress, as well as immune-related inflammatory needs. We now know that cortisone is not only an immune and inflammatory modulator, but the constant level of corticosterone in circulation, or diurnal cortisone response, is integral to proper control of emotional states, hormonal regulation, sleep quality, and a variety of other key functions that we take for granted. Cortisone is easily converted according to our body's needs into other hormones, and a bioavailability of cortisone must be maintained. For example, pregnenelone is a precursor hormone to cortisone, and cortisone may convert to aldosterone, an adrenal hormone that controls sodium and potassium levels in our body, as well as blood pressure via the renin-angiotensin system. By decreasing stress, providing pregnenelone, maintaining mineral balance, improving hypothalamic function, and improving the function of the adrenals and kidneys, as well as steroid hormone balance, we may improve the cortisone metabolism to restore health with Complementary Medicine.

In this research concerning aging and stress, it was found that animals that are older and experience repeated stress react to acute stress with higher cortisone concentrations in the blood circulation, and decreased c-Fos expression in key areas of the brain, such as the amygdala, pre-frontal cortex, hippocampus, and hypothalamus. This condition made the aging patient with repeated daily stress much more vulnerable to acute stress and produced a wide variety of autonomic nervous reactions, such as racing heart and temperature changes, as well as hormonal problems. The effects on cortisone regulation could impact blood pressure, sleep quality, and even metabolic controls, explaining changes in blood sugar metabolism, weight gain, etc. The effects on diurnal cortisone regulation could also have immediate impact and inflammatory mediation, explaining increases in inflammatory pain in relation to acute stress. These neurohormonal changes require attention, and treatment with holistic medicine provides an array of treatments that may significantly improve a number of physiological systems and reduce the effects of acute stress in a patient with age-related and repeat stress-related susceptibility of acute stress, which results in a more severe generalized anxiety disorder.

Researchers at Cambridge, the most prestigious of college in England, in 2004, proved that in women with estrogen deficiencies induced by menopause or hysterectomy, that reductions in available estradiol increased physiological reactions to acute stress, especially with the effects of aging and repeat stress history. Supplementation with 17beta-estradiol significantly improved the physiological adverse reactions to acute stress. Now, it is well documented that treatment with synthetic estrogen, or estradiol variants, comes with considerable risks and side effects, and these hormonal contraceptives and menopausal drugs result in psychological side effects for a high percentage of patients. A safer approach is to supplement with a bioidentical estriol in low dosage and topical form, to stimulate a greater estrogen bioavailability. Estriol is the most abundant form of estrogen in the body and converts to estrone and estradiol as needed. Stimulation of estriol metabolism with this herbal treatment will have significant effect upon the 17beta-estradiol bioavailability in the patient. This type of treatment, though, needs to be professionally monitored, and a balance of estrogen and progesterone maintained. Such therapeutic protocols have to be individually tailored to each patient as well, as estrogen is not a panacea for all types of anxiety disorder. The Licensed Acupuncturist and herbalist is a Complementary Medicine physician that may inexpensively monitor active hormone metabolites via saliva testing, and prescribe estriol and progesterone stimulating topical creams, within a comprehensive protocol of treatment, utilizing herbal and nutrient medicine, and acupuncture, as well as deep tissue massage, or TuiNa, to effectively restore neurohormonal balance in these states, and achieve a dramatic improvement in reaction to acute stress. All treatment in Traditional Chinese Medicine should be complete, holistic and restorative of a number of systems in the body, not focused on just one part of the whole dysfunction.

Generalized Anxiety Disorder or GAD

Generalized anxiety disorder (GAD) is characterized as a constant state of worry and stress, often with restless sleep, insomnia, fatique and upset stomach. This disorder often prompts one to exagerrate problems emotionally and jump to negative conclusions. The high level of stress anxiety may lead you to react excessively to what others do or say, negatively impacting home and work functions. Often, the excessive worry and anxious state leads to worsening problems with muscle tension and chronic pain as well. Sometimes, simple changes in habits will help this disorder, such as reducing consumption of caffeinated drinks, such as coffee, tea and soft drinks, taking time to relax before eating, and addressing work one task at a time, not letting your mind get too far ahead of what you are doing. Stress reduction techniques often will help greatly as well. These range from simple habits of stopping and taking a deep breath, to reserving time for yoga, deep breathing techniques, aerobic excercise, qi gong, tai chi, or some other form of enjoyable therapeutic activity. The first step is, of course, not to get anxious about reserving time for these activities. Cognitive retraining involves taking small steps before attempting a marathon, and stopping your mind from coming up with anxious reasons why you can't. By training yourself to just do the right thing, and not overthink, you will find yourself in a more relaxed place. Time spent with the physician in Complementary Medicine will not only provide you with therapy, but may also reinforce these positive habits and ways of coping. The Licensed Acupuncturist often takes the time to engender habits and reinforce positive therapeutic behavior and cognition.

Underlying health problems may be a significant factor in GAD. Adrenal fatique, or deficiency dysfunction, is commonly seen today, and is often related to subclinical hypothyroid states, hypothalamic dysfunction, and even hyperparathyroid imbalance. Neuroendocrine stress may be a significant factor in generalized anxiety disorder in a number of patients. The whole system and health history should be examined to determine whether the GAD is secondary to other problems. Therapeutic approaches in these cases should first address the primary causes, and then proceed to direct therapy to control anxiety. If the therapeutic approaches described above seem ineffective, you may need to restore healthy function to the neuroendocrine system first.

Social Anxiety Disorder

Social Anxiety Disorder is characterized by distress and impaired function resulting from a persistent chronic fear of being adversely judged and embarassed by others. While this disorder may stem from some psychological trauma early in life, the inability to cope and adjust implies a likely problem with mechanisms of trust and identity, sometimes related to deficiencies of neurohormonal modulators in the brain. Symptoms of excessive blushing, sweating, trembling, palpitations, nausea or stammering may occur. Many scientists speculate that problems with serotonin and dopamine metabolism are related, and increased serotonin and dopamine transporter binding has been found to be consistent in patients. Low dopamine receptor type 2 binding has also been noted. Excess norepinephrine (adrenalin) and deficient GABA have also been implicated. The result of these findings again suggests that a restoration of neurohormonal health is important, and that specific allopathic treatments may not be completely effective. Like other anxiety disorders, underlying problems with the hypothalamic and adrenal functions, metabolic concerns and nutrient chemical deficiencies, and cognitive and behavioral problems could all be contributing.

Social Anxiety Disorder is addressed extensively in classic Traditional Chinese Medicine (TCM), with a variety of diagnostic and treatment differentiations, and treatment protocols with acupuncture. For example, the eight extraordinary meridians, or patterns of point prescription in TCM, are a set of systems that describe coordination of various unique systems that function holistically in the body, and provide systemic effects and balance in homeostasis. The Dai Mai, or girdling meridian, one of the eight extraordinary meridians, describes a neurohormonal system that may be integral to emotional disorders causing physical manifestations resulting from a lack of emotional support, or girdling, in life. Emotional trauma and a feeling that a parent, sibling, friend or supervising adult did not provide the expected support and protection needed during a tramatic time, may create a chronic sense of abandonment, and leave one with emotional constraints and chronic anxiety in social situations where emotional memories trigger responses. In ancient China, this was addressed with use of the prescription of points along the Dai Mai meridian, along with counseling, and use of herbal formula. These points are documented as affecting the central nervous system, the amygdala, and hypothalamic control of neurohormonal physiology today with fMRI studies.

Current research in social anxiety disorder has revealed that a relative deficiency of 5-hydroxy tryptophan (5-HT), and subsequent lack of regulation of the enzyme glycogen synthase kinase 3-beta (GSK3-beta) in the forebrain, leads to poor resilience to social defeat and increased social anxiety. GSK3-beta deficiency or inhibition was found to have both negative effects on anxiety and sociability in the forebrain, and affect the mood control and memory association in the hippocampus and striatum (Latapy C et al, Laval Univ. Quebec; Philos Trans R Soc Lond B Biol Sci. 2012 Sep 5;367(1601):2460-74). By supplementing the 5-HT bioavailability with 5HTP (griffonia seed extract), or utilizing a balanced array of low dose 5HTP, P5P, melatonin, and St. John's Wort, combined with the stimulation of the hippocampus/amygdala subcortical areas with acupuncture and electroacupuncture, and a conscious cognitive and behavioral improvement, a significant improvement in control of social anxiety may be realized. GSK3-beta is an important enzyme in the brain, and thus subject to tight regulation. This enzyme chiefly regulates the addition of phosphate (phosphorylation) onto key amino acids in protein regulators (e.g. tyrosine), and GSK3 activity is far greater in the cell mitochondria and nucleus than in the cytosol of neurons. GSK3 is implicated in a variety of diseases, including Alzheimer's, diabetes type 2 (Metabolic Syndrome), bipolar disorder, and some cancers and inflammatory disorders. Including 5HTP, L-tyrosine, P5P, and a magnesium-phosphate compound in therapy may help to restore this important homeostatic metabolism over time, and may have other beneficial effects to improve or prevent these other diseases.

Current reviews of the widespread use of Complementary Medicine in the treatment of Anxiety Disorders has revealed that in areas of more widespread use and acceptance, such as Germany and California, much success is reported, and significantly less dependence on chronic drug use. Studies in Europe have shown that German physicians widely utilize herbal medicine to treat anxiety, with much lower rates of dependency on problematic benzodiazepines than the rest of Europe. Studies at UCLA reveal that nearly half of the patients in a broad survey utilized Complementary Medicine to treat generalized anxiety disorder, with a significant percentage of patients achieving more than a 50 percent reduction in anxiety and ability to discontinue the therapy. In Complementary Medicine chronic dependence on medicines or treatment is not the goal.

Panic disorder

Panic is a biological response that generates hightened fear, which overrides other mental and physical responses. A panic attack is a sudden period of intense anxiety that creates alarming symptomatic responses, such as feelings of sudden faintness, nausea, heavy or rapid breathing, rapid heart rate, trembling, shortness of breath, heart palpitations, chest pain, hot or cold sensation, sweating, dizziness, light-headedness, tingling sensations, and choking sensation. These are heightened responses in the autonomic nervous system, a balanced physiological response between the sympathetic and parasympathetic systems. These sympathetic nervous system responses to fear and alarm are usually moderated by the parasympathetic nervous system responses, but in Panic Disorders this balanced set of responses fails. The patient usually describes a feeling of imminent danger or going crazy, and often goes to the emergency room. There is often no specific trigger found in Panic Disorder, but episodes of panic can be triggered by medications (e.g. Ritalin, antidepressant SSRIs, or even certain antibiotics), withdrawal syndromes (e.g. benzodiazepines, alcohol), stimulants, significant emotional trauma, phobias, or even certain chronic cardiac pathologies.

Panic Disorder is a syndrome with recurrent panic attacks. Many patients with panic disorder acquire anticipatory anxiety that cause another panic attack when mild symptoms occur. Studies also show that as many as 36 percent of patients with panic disorder also acquire a separate problem called agoraphobia because of the anticipation of, or fear of, panic attacks, avoiding many public or social situations where a panic attack would be embarrassing, such as travel on an airline. Agoraphobia might also be linked to chronic use of benzodiazepines taken to decrease anxiety, and has been linked to PTSD in many cases. Standard medicine has failed to explain the Panic Syndrome sufficiently, instead searching for treatment with a variety of past medications, with little success. For this reason, many patients and doctors have turned to Cognitive and Behavioral Therapy, and Complementary Medicine, to provide a more individualized, safer, and less problematic treatment than pharmaceuticals afford. Agoraphobia may involve a heightened fear of spaces that are enclosed or are difficult to escape from, such as a tunnel, bridge, airplane, or locked room, and may involve a fear of spending time alone, being dependent on someone else, losing control in public, or feeling helpless. It may also result in someone not wanting to leave the house or getting involved in relationships, and hence, there is an array of presentations to this type of panic disorder. Often, in clinical study, agoraphobia occurs after a panic attack, or after onset of an anxiety depressive mood disorder, and like a panic attack, agoraphobia may involve episodes of chest or stomach discomfort, shortness of breath, distress, trembling or sweating. Agoraphobia should be considered an offshoot of Panic Disorder, and treated holistically in much the same individualized way as Panic Disorder. While standard treatment involves SSRI or SNRI medication, benzodiazepines, or other antidepressants, and hopefully a short course of cognitive behavioral therapy, Complementary Medicine can be integrated to achieve greater success and hopefully avoid chronic dependence on these types of drugs.

Patient understanding of Panic Disorders and anxiety depressive mood disorders is very important to finding the most effective and efficient individualized protocol to correct these mood imbalances. Misunderstanding of Panic Disorder has been perpetuated by false assumptions and little scientific research, though, and a one-size-fits-all therapeutic approach has been adopted. For years, hyperventilation in anxiety was thought to trigger a panic episode, but this was proven false in studies. Similarly, hypocapnia, or a reduced amount of carbon dioxide in the blood, that may be caused by responses to acidity or excess of oxygen intake, was assumed for decades to be a trigger. Scientific study has revealed that hypercapnia (excess carbon dioxide in the blood), not hypocapnia is involved, which may be caused by hypoventilation, constriction of the alveolae of the lung, or changes in the pulmonary blood pressure. Since regulatory centers in the brain read PCO2 (blood plasma carbon dioxide) levels to exert changes in respiration, affecting acidity levels as well as the balance between oxygen and carbon dioxide, a response to high levels of carbon dioxide in the brain is rapid breathing, which reduces carbon dioxide. Unfortunately, studies have shown that repeated habits of hyperventilation often triggers more hyperventilation (Repich 2002), and conscious controls may need to be initiated. Reflex hyperventilation may also lower carbon dioxide (PCO2) excessively, triggering gasping, choking and trembling, and the feeling of being smothered, or in other words, a panic attack. A relative increase in oxygen may occur with an increase in blood pressure, or a catecholamine release (adrenaline and dopamine), which may be a parasympathetic response to increased plasma carbon dioxide, and trigger alarm as well.

There is no simplistic trick to control breathing in panic and anxiety, though, as the normal breathing reflexes exert necessary controls, but a more nuanced and complex understanding of breathing will allow the patient to objectively exert controls that actually work in response to these reflexes and symptoms, and keep the patient from developing bad breathing habits and responses that perpetuate the anxiety and panic. Breathing techniques in yoga and Qi Gong may help the patient to learn and understand these nuanced techniques and apply them in an individualized fashion. Adopting healthier daily normal breathing techniques may also help dramatically in anxiety and panic, and studies do show that many patients gradually learn poor breathing habits, underutilizing the diaphragm, often related to chronic pain, and often decreasing the normal pattern of a deep breath about every 7 breaths. Adopting better breathing habits, having myofascial release of the diaphragm performed, and perhaps utilizing conscious techniques of clearing excess carbon dioxide may be helpful in the long term. Simplistic advice in breathing to relieve anxiety and panic may be problematic.

Cholecystokinin (CCK), a protein hormone secreted in the small intestine to stimulate gallbladder contraction and secretion of pancreatic enzymes, has proven to be a trigger of panic attack in the laboratory, and panic following a meal is not unusual in these disorders. Researchers have found an abundance of CCK receptors in the brain, as well as direct affects on the vagus nerve, and excess CCK may induce stomach cramps, taurine depletion affecting the heart rate, and an association between CCK and sleep disorders has been found. Gastric hypofunction, bile sludge, deficient pancreatic enzymes, or pancreatic inflammation may induce excess CCK production. CCK in excess may induce gastric hypofunction, increase gastric distention and the feeling of pressure on the cardiac sphincter of the stomach, and inhibit appetite both by affecting the vagal nerve and via central mechanisms in the brain, together with leptin and gastrin. Increased CCK has been associated with anorexia and polycystic ovary syndrome with obesity. The array of factors that may be involved in the mechanism of panic attacks is complex, and may require a complex approach in treatment to restore homeostasis.

An integrated theory of cause of Panic Disorder, called the false suffocation theory of Klein, is based on the theory that increased plasma carbon dioxide in the brain, along with increased lactate, signals potential asphyxiation, and may trigger a panic response. Since a large majority of patients reporting Panic attacks are women, a hormonal origin or contributor has been researched, and both a lack of hypothalamic-pituitary response, and the sensitivity to neural receptors by progesterone have been linked to the Panic response. Klein's integrative theory states that panic, separation anxiety, and premenstrual dysphoria, are all linked physiologically with a disturbance of the endogenous opioid systems that create adaptation to excess plasma carbon dioxide and lactate, with a functional endogenous opioid (endorphins and dynorphins) deficit most likely involved. Separation anxiety and CO2 sensitivity are both under opioidergic control in the brain, and are focal hallmarks of Panic Disorders. Since acupuncture stimulation is well known to increase the opioid neurotransmitters endorphin and dynorphin, this would explain the modest success demonstrated with acupuncture stimulation in this disorder. In addition, more recent research has revealed that electroacupuncture to the points ST36 and Ren12 also significantly stimulated removal of lactate from circulation. To achieve greater success, researched acupuncture stimulation may need to be combined with herbal and nutrient medicine, and cognitive and behavioral therapies, though.

There is still a poor understanding of the physiological mechanisms of panic disorder. Most experts believe that the manifestations of panic originate in the amygdala and dysfunction of the GABA neurotransmitter system of mood control, but studies have revealed that a much heightened adrenal response occurs, with an accumulation of adrenaline (norepinephrine) in tissues, especially the heart tissues, afterward. This would create a situation where the next triggering of panic is more likely, as excess adrenalin is slowly released from the heart tissue, and the heart rate and force is affected. A number of researchers are also exploring epigenetic changes that occur with anxiety and panic disorders, both in the brain and heart, making the patient more susceptible to future panic attacks. Epigenetic modifications are reversible chemical changes of the molecules that surround the genes, altered by our environment, but affecting genetic expression of regulating proteins. The focus is on epigenetic modifications of the regulation of amines (norepinephrine, serotonin, dopamine, histamine), glucocorticoids (cortisol) and the serotonin metabolism. Healthy changes in diet, environmental toxin exposure, the biota, etc. may reverse epigenetic modifications. Both immediate symptom relief and long-term improvements in health may be needed to properly treat Panic Disorder.

Both the mind and body must be considered in Panic Disorder. Research has revealed that glucocorticoids such as cortisol act on the amygdala, hippocampus and frontal lobes of the brain, in synergism with adrenaline (norepinephrine) to enhance the formation of what are called flashbulb memories, or emotionally charged memories of events. Often these flashbulb memories are of negative events that are sublimated, or suppressed. High cortisol levels, from increased stress or adrenal dysfunction, may enhance memory of these sublimated emotionally arousing events, and have a negative effect on short-term memory function overall. This creates a situation where emotionally charged memories are not effectively organized and controlled. Dominique de Quervain is a Swiss neuroscientist that has pioneered the effects of cortisol imbalance on memory retrieval mechanisms, at the University of Basel, Division of Cognitive Neuroscience, in Switzerland, as well as the epigenetic modifications that may explain why some patients develop a panic disorder that persists. Imbalances of amine neurotransmitters, the serotonin system, and glucocorticoids like cortisol may affect brain function and ability to assess memory, react to stress, and our cognitive ability. The hypothalamic-adrenal axis is the focus of this research in seeking an answer to reduction of triggering of panic. We see that a more holistic approach to restoration of health may be in order once the panic disorder occurs, and that persistence in this regard may be needed even when the panic attacks stop.

The points of focus in the holistic treatment of Panic Disorder thus involves gastric hypofunction, digestive function and pancreatic enzymes, CCK production and excess, deficient taurine and heart regulation, the carbon dioxide metabolism, balance of the autonomic nervous system, diurnal imbalance of the cortisol system, the adrenal-hypothalamic axis, hypothalamic function, bioavailability of amine neurotransmitters such as norepinephrine (adrenaline), dopamine and serotonin, epigenetic changes affecting expression of proteins modulating amine neurotransmitters, cortisol, and serotonin, progesterone and estrogen balance, and the bioavailability of opioid neurotransmitters. This is a long list of concerns that research has revealed, and an individualized, thorough, thoughtful, and holistic step-by-step course of therapy in Complementary and Integrative Medicine (CIM) may be the key protocol in finally resolving this panic disorder pathology. This long list of factors potentially contributing to Panic Disorder points to the fact that we should not expect an allopathic drug to cure the disorder.

Post-traumatic stress disorder or PTSD

Post-traumatic stress disorders are now recognized as occurring with alarming frequency in the population. Not only near-death trauma, such as experiencing nearly fatal wounds in war or a car crash, but now experts are also recognizing PTSD occurring after less severe musculoskeletal injury. An article published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) revealed that studies confirm that 20-51 percent of patients with an orthopaedic injury experiences some type of PTSD (see the article citation link below). Dr. Daniel Aaron, MD, a clinical instructor in the department of orthopaedics at Brown University in Providence, Rhode Island, stated: "Basically, any type of musculoskeletal injury that results from significant trauma may be associated with PTSD. PTSD occurs with a significant frequency in civilian patients who have suffered an orthopaedic trauma, and it can hinder emotional, physical and functional recovery following orthopaedic treatment. Generally, higher energy mechanisms are most commonly associated with PTSD, but no specific type of fracture or injury has been identified. Without effective treatment, PTSD can hinder activities of daily living, such as bathing, eating, paying bills, shopping, laundry and other household chores. Patients with PTSD also may be delayed in returning to work." Dr. Aaron found that risk factors precluding PTSD included a low socioeconomic status, young age, female gender, less education, and use of drugs or alcohol. Anyone can experience PTSD, though, the studies showed, and no single prevention protocol has been found. Identifying PTSD early in the course of the disorder is very important to gaining a resolution, and patients that are not diagnosed at an early stage after traumatic injury often develop a chronic disorder that is difficult to fully resolve.

PTSD often results after experiencing physical or mental abuse, rape, a devastating loss that appears to be caused by an abuse in the patient"s life, even a natural disaster. PTSD has also been observed after alarming episodes such as an acute asthmatic attack requiring ER intervention. The stress disorders are not the same for these different types of patients and causes, but modern allopathic medicine feels a need to define each disorder in a uniform way to justify a single type of therapy or medication to treat it. Experts in the field of psychotherapy often disagree with this approach, though, and find that an individualized therapeutic protocol is required. Patients with a chronic stress disorder associated with childhood abuse, sexual trauma, enslavement, or other prolonged trauma have been given the diagnosis of PTSD, yet clearly suffer a disorder that is clinically different from that experienced by a single physical injury. Integration of various treatment protocols in an individualized step-by-step course of therapy addressing the unique needs of the patient is often needed, and should be largely directed by the patient themselves, with trusted advice from therapists, as often only the patient can truly understand their disorder. TCM, acupuncture and herbal nutrient medicine, could play an important role as adjunct therapy to improve the outcomes with various psychotherapeutic methods.

One difficulty in the treatment of post-traumatic stress disorder is the lack of clarity in defining this set of psychological disorders, and the lack of understanding has become a large problem for patients suffering from this disease mechanism. Often, the patient with PTSD becomes alienated from family, friends and business associates due to the lack of understanding of what PTSD actually involves. The common assumptions in PTSD are that the patient experiences a severe fear during trauma, which triggers flashbacks, fear of the trauma repeating, and a debilitating state of anxiety. In reality, many victims of PTSD return to the exact circumstances surrounding their trauma. The movie The Hurt Locker was based upon a reporter's true experiences imbedded with soldiers who returned to Afghanistan and Iraq after experiencing PTSD and resumed a very dangerous job of disarming improvised explosive devices. So far, research has been designed with apriori assumptions of what PTSD actually involves, but with more objective research into brain functions and neurochemical responses, a different picture is emerging of what the actual functional problems really are.

Differentiation in PTSD is now the subject of much serious research, The NIH division, National Institutes of Health Clinical Center, is now studying objective differences in stress disorders with magnetic resonance imaging (MRI) of the brain combined with neuropsychological testing. Functional (fMRI) measures of blood flow, concentrations of certain chemicals in the brain, and functional activity in various centers of command, will be analyzed and compared to cognitive performance to gain a better guideline for therapy in the future. Another concurrent study at the NIH is exploring the mapping of effects of acupuncture stimulation on brain centers and the neurochemical responses (Clinical trial NCT00397111). The United States military has been studying the effectiveness of acupuncture in the treatment of PTSD for a number of years now, mainly in Bethesda, Maryland, and has found a significant role in this for integrative and complementary therapy.

Three types of therapeutic approaches in standard medicine are being explored as well by the NIH, interpersonal psychotherapy, prolonged exposure, and relaxation therapies. Prolonged Exposure Therapy is a type of cognitive behavioral treatment that recreates the memories and emotions of the triggering event, and has proven very successful. Dr. Edna B. Foa designed this therapy at the Center for the Treatment and Study of Anxiety at the Perelman School of Medicine at the University of Pennsylvania. Much adaptation and individualized refinement has occurred with this type of cognitive and behavioral therapy in the last decade, with amazing success in instilling daily function, confidence and the ability to cope. Such cognitive and behavioral therapies have been greatly diminished in the United States in favor of strict drug protocols, though. This is entirely due to the manipulation of medical fees by the insurance companies, in collusion. Experts in the field of psychotherapy recognize that a true cure for these problems is not achieved with a chemical treatment and dependency, only a masking of symptoms and management of symptomatic behavior. There is great profit in the industry, though, with the prescription of psych drugs, and this motivation is now what determines care in the United States. Hopefully, we are now on a new path to a more effective integrated treatment protocol that actually gives the patient hope of resolving chronic stress disorders, especially those that have occurred after devastating traumatic events in life. Cognitive behavioral therapy combined with relaxation therapies, including acupuncture, may be the key to success.

So far, a number of promising studies have objectively defined areas of dysfunction in both command centers of the brain and in biochemical responses. Studies of post-9/11 victims found a subdued hippocampal function. The hippocampus is believed to be a counterweight to the amygdala, an area of the brain that is found to deal with memory and emotion. The hippocampus is believed to function to control excess brain activity related to responses associated with frightening or strong emotional memories. Elizabeth Phelps, a professor of psychology at New York University, states that: "We know that there are differences in the hippocampus in people that go on to develop PTSD and those that do not". Studies by the Netherlands Department of Military Psychiatry have also found that there are differences between soldiers who experienced the same traumatic events, with those that experienced PTSD showing less activity in the amygdala. These studies also noted a higher objective pain tolerance in the subjects diagnosed with PTSD. Studies of PTSD by the U.S. military note that soldiers diagnosed with PTSD in follow-up show a worse physical health, more doctor's visits, and more missed workdays later in life. Resolution of PTSD, rather than managing symptoms with pharmaceuticals that themselves present chronic side effects and ill health, seems a sensible approach for the individual with PTSD and for society as a whole. With health care being the number one problem with government spending, interventions that resolve PTSD may result in significant savings in the long run. Complementary and Integrative Medicine will play a significant role in this regard.

Study of traumatic PTSD in the military has also revealed that a significant number of soldiers suffered blast trauma to the head that resulted in a condition called chronic traumatic encephalopathy (CTE), a neurodegenerative disease that has been clarified by autopsy studies. Similar CTE has previously been noted in studies of pro football players damaged from a succession of concussions. Ultimately, CTE is likely to lead to cognitive disability and dementia, and ultimately may be a cause of death. So far, CTE is only definitively diagnosed with autopsy, which reveals abnormal tau protein tangles, as in Alzheimer's disease. A number of other tests are now being researched, such as unique protein biomarkers indicative of brain damage that should be administered within a few days of traumatic brain injury, and a follow-up later with an MRI technique called macromolecular proton fraction (MPF) mapping, which examines the health of myelin sheaths on nerves. MPF mapping is being used extensively now with patients with chronic cognitive dysfunction and multiple sclerosis. We see a pattern in this form of the PTSD, similar to a number of types of neurodegenerative disease, that demands restoration of a healthy homeostasis in the brain with multiple goals that require a more holistic treatment protocol.

In 2008, a large randomized controlled study of women with chronic PTSD was conducted by National Institute of Nursing Research, overseen by Johns Hopkins University Medical School, and found that women with PTSD consistently showed measures of low cortisol and high DHEA in circulation, stimulating higher levels of pro-inflammatory cytokines TNF-alpha and Il-6. Normally, cortisol and DHEA are balanced in the body, but with this type of chronic stress syndrome we see an imbalance that affects the neurohormonal immunological system. DHEA (dehydroepiandosterol) is an adrenal precursor to androgens, and the feedback homeostatic balance of the hypothalamus-adrenal axis is disrupted in PTSD, affecting women differently than men. This neurohormonal imbalance creates an immunological dysfunction that leads to a Th1/Th2 imbalance (T helper cell types), which is a hallmark for chronic inflammatory diseases and autoimmune disorders. In this study, a flattened diurnal cortisol pattern level was also observed, implying an Adrenal Stress Syndrome was occurring. Such study helps design individualized integrated treatment protocols, and implies that a broad multi-system array of complement therapies should be included, both to relieve PTSD symptoms and prevent comorbid conditions. To see this study, click here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829297/

By 2013, experts in the field of PTSD noted that many patients suffered from a long-term neurodegenerative condition, and chronic health problems that were not described in typical descriptions of PTSD, long thought to be a temporary disorder. Dr. Judith Herman of Harvard University suggested that we diagnose these chronic sufferers with Complex PTSD (C-PTSD), and others in the field suggested Disorder of Extreme Stress (DESNOS), Developmental Trauma Disorder, and other diagnostic terms. Dr. Herman noted that most of the patients she has seen with Complex PTSD had experienced prolonged states of trauma involving a state of either emotional or physical captivity, or control and abuse by another individual. Dr Herman suggested that Complex PTSD/DESNOS was characterized by explosive anger, persistent sadness, suicidal thoughts, dissociative states (feeling detached from one's body or mind), helplessness, shame, guilt, stigma, and negative self-perception, distorted perceptions of others, preoccupation with revenge, distrust, isolation, hopelessness, and repetitive searching for a rescuer, rather than exerting a pro-active effort to regain control, function and stability. These symptoms are not unlike the psychopathic personality disorder, in that distrust of the therapist, a strong feeling of isolation, and hopelessness makes the success in therapy very difficult. The key to healing from such disorders is the self-realization that the individual should depend on themselves in managing their treatment, develop trust in various physicians, and promote a reconnection with others. Engaging in this development of self-control, and connection with others, is essential to success, and continuing to look for a savior, without trusting those who are offering treatment, is perhaps the biggest impediment to regaining a functional and healthy state of mind. Both restoration of neurohormonal health and cognitive and behavioral health is very important in such as difficult pathology. A more holistic and proactive approach is needed, not just medication.

Research into the pathophysiology of C-PTSD reveals that like other forms of PTSD a change in the functions of the amygdala and hippocampus occur, the centers that link fear and memory. Other areas of the brain that are related to associative pathways are also damaged with neurodegneration in this disorder, as revealed by various studies with brain scans such as specialized fMRI and PET. While cognitive resolution is essential to relearning and restoration of these interacting centers in the brain, much scientific study shows that specific acupuncture and electroacupuncture stimulations exert significant modulating and restorative effects on these areas of the brain, improving the crosstalk and coordination, especially between centers in the limbic system, such as the amygdala and hippocampus. These studies also reveal that stronger stimulation, traditionally called obtaining qi, or de qi, and specific electrical stimulations on the needles, exert different modulating effects. Neuroprotective and neuromodulating strategies with herbal and nutrient extracts are also well studied and found to be effective, although this science is complex and should be directed by a physician who has studied these effects and brain function. As always, an individualized course of therapy conducted in a goal oriented step-by-step manner is needed, not just the purchase of some well advertised miracle cure off the internet. Such therapeutic protocols, as well as bioavailability of neurohormonal modulators, and neurohormonal balancing, could be the key to more rapid success with standard protocols in psychotherapy. The difficulties in diagnosis and treatment of C-PTSD often add to the hopelessness of the patient, and Complementary and Integrative Medicine offers a chance for the patient to take a more proactive approach and improve the success of their therapies, working intelligently on both the biochemical and psychological aspects in a more holistic manner. A more proactive patient approach, social support initiated by the patient, more individualized cognitive and behavioral therapy, and complementary approaches to add to stress control and neurohormonal restoration and balance provide this holistic protocol that is needed.

While researchers at Stanford University in California are studying stimulation of various brain centers with Transcranial Magnetic Stimulation (TMS) in the treatment of PTSD, researchers at Harvard Medical University are finding that acupuncture stimulation may be a safer and less expensive way to achieve such stimulation and modulation of brain activity. Their research has demonstrated how significantly different acupuncture stimulations affect the amygdala, hippocampus, hypothalamus and related centers in the brain in a modulatory manner that seems to restore a homeostatic balance. One can access the links to studies in Additional Information on this article, as well as the article entitled Brain Health and Function, to see such amazing research. Current therapy for PTSD includes cognitive reliving of the experience (prolonged exposure), combined with interpersonal pyschotherapy, and relaxation therapies, augmented with medications to calm anxiety, control excitable mood swings, and aid sleep. The affects of targeted acupuncture stimulation during this therapeutic protocol may greatly benefit the restructuring of an ordered response to traumatic memory, restoration of brain homeostasis, increased relaxation, and improved sleep. Herbal and nutrient medicine also has shown great efficacy in restoration of the GABA mechanisms and neurobalancing. A number of herbs have been proven to contain anxiolytic chemicals and chemicals with a benzodiazepine effect, without the side effects or drug dependency. Nutrient medicines continue to improve in the researched combination of chemicals and dosage that restore neurochemical homeostasis and provide a bioavailability of chemicals to allow the brain to do what it is genetically programmed to do.

Scientific studies, a few of which are cited below with links, demonstrate the sound research findings that prove that specific acupuncture stimulations will treat stress disorders by modulating important chemicals found to be deficient in the amygdala, hippocampus and other limbic areas associated with stress, anxiety and memory. To learn more of these studies, read the article entitled Brain Function on this website, where over a decade of study has found evidence that leads many scientists to believe that the chief mode of action in acupuncture is the stimulation and modulation of the midbrain, hypothalamus, amygdala, and related nuclei. As more specific research continues, we will find that acupuncture stimulation provides us with a simple, safe and inexpensive form of treatment to integrate with individualized psychotherapies to achieve a better cure of PTSD.