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The Lasting Effects of Using Auricular Acupuncture to Treat Combat-related PTSD: A Case Study By Greg Golden, MSOM, DiplOM (NCCAOM), LAc AbstractPost-traumatic stress disorder (PTSD) is a condition of certain psychological symptoms occurring long Greg Golden, MSOM, DiplOM (NCCAOM), LAc was
trained in the NADA protocol at the Lincoln Recovery
term after a traumatic event or series of such events. Center in South Bronx, NY, where the protocol was first The condition is especially prevalent with combat invented and utilized to treat recovering addicts. He veterans. Research suggests that acupuncture can be completed his master's level training at the National a low-cost and highly effective treatment for a variety University of Health Sciences in Lombard, IL, where of psycho-emotional issues, including PTSD. In this he helped to start a free PTSD clinic for veterans and case study, acupuncture treatment was performed over abuse survivors. He travels once a month to Portland, a six-month period on a 60-year-old male Vietnam OR, to continue his education as a doctoral candidate at the Oregon College of Oriental Medicine. His veteran with longstanding symptoms of PTSD. The doctoral research focuses on the emotional roots of auricular treatment protocol, created by and named after the National Acupuncture Detox Association (NADA), was used. The treatments provided relief to a variety of symptoms including chronic fatigue, depression and grief, general anxiety, headaches, insomnia, nightmares, irritability, and panic attacks. Treatments were given over a six-month period, and a follow-up survey was conducted seven months after treatment ceased in order to ascertain if the therapeutic effects from the treatment were retained. The seven-month follow-up survey indicated that some level of relief was retained for a majority of the reported symptoms and that some of the symptoms were completely resolved. Results of this case indicate that auricular acupuncture may be a viable treatment option for veterans suffering from mental "dis-ease." Keywords: auricular acupuncture, PTSD, NADA protocol, veterans
T h e A m e r i c a n A c u p u n c t u r i s t Summer 2012
" Acupuncture affects the same part of the brain that is affected in those who are suffering from PTSD4, 5 and studies indicate that acupuncture may be very effective for treating PTSD.6, 7" suffering from PTSD, 12 different TCM diagnostic patterns were identified.8 In general TCM terminology, PTSD falls under a basic classifica- Post-traumatic stress disorder (PTSD) is a state of long-term stress tion as a disturbance of the shen or spirit. There is also often an resulting from exposure to a traumatic event or series of events.1 impediment to the flow of life-force energy, or qi, which manifests The condition is classified as a combination of three categories of as irritability, frustration, and possibly anger. Diagnoses with symptoms: intrusive memories that may include flashbacks and components of shen disturbance and stagnation of qi were the most recurring dreams, symptoms of avoidance and emotional numb- common in one recent study treating 16 different PTSD patients.9 ing that can include hopelessness, depression and concentration There may be associated meridian and organ system involvement, problems, and symptoms of increased arousal that can include depending on the types of emotions which the patient presents.
irritability, anger, substance abuse and insomnia.1 In total, there are six diagnostic criteria for PTSD, listed A-F,2 that involve a combi- The heart is known as the "house of the shen" in TCM, and nation and recurrence of specific symptoms per the Diagnostic and disturbances of the shen are often treated by use of points associ- Statistical Manual of Mental Disorders. (see Table 1) ated with the heart.10 In TCM there are 12 primary meridians, or channels, that correspond to one of five primary elements as well as an associated emotion.11 For example, both the kidney (KD) and urinary bladder (UB) meridians are said to belong to the element of water. Deficiencies in this area can contribute to fear.11 Anger, often associated with the liver meridian, can be due to a disturbance of the wood element.11 While anger is the primary emotion associated stressor that elicits a response of "fear, helplessness or horror" 2 with the element of wood, many mental and emotional disorders fall under the domain of this element and are diagnosed as a bind- At least one instance of re-experiencing ing depression of the liver qi, more commonly referred to as liver qi stagnation.11 These emotional correspondences provide clinicians intrusive memory such as a nightmare or flashback with tools to fine-tune diagnoses and treatment strategies. This case study reports the treatment outcome of a Vietnam War veteran who had suffered for almost 40 years with the symptoms seven listed avoidance and/or numbing responses associated with PTSD. Not only were his symptoms significantly relieved by the auricular acupuncture protocol, but his relief The experience of at least 2 out of 5 listed continued long after he discontinued his treatments. The disturbance symptoms in Criteria B-D have occurred for a period of at least one Mr. H, a veteran of the Vietnam war, is a biracial, Caucasian and Native American 60-year-old male. He presented to the acupunc- An impairment of some level of functioning ture PTSD clinic on November 11, 2010, referred by his wife. The requirement for treatment at this clinic is an official diagnosis of PTSD, which he received from the Veterans Administration hospital (VA) five years previously. At the time of the initial clinic The National Institute of Mental Health standard of care for visit, the patient was not in psychotherapy or taking any psycho- PTSD includes psychotherapy that may include talk therapy com- tropic medications. The patient reported type 2 diabetes, ringing in bined with another modality such as cognitive behavioral therapy the ears, some hearing loss, occasional nasal congestion, occasional (CBT) and psychotropic medications including, but not limited to, throat itchiness and soreness, shortness of breath and asthma, antipsychotics, benzodiazepines, and antidepressants.3 The Mayo borderline high blood pressure, and palpitations/irregular heartbeat.
Clinic recognizes that acupuncture may be beneficial for PTSD in The patient filled out a PTSD checklist reporting on symptom conjunction with Western biomedical treatments.1 prevalence at his initial visit (see Table 2). The patient reported having previous problems with drugs and alcohol but at the time of intake was clean and sober for 22 years. The patient also reported Acupuncture affects the same part of the brain that is affected symptoms of chronic fatigue/lack of energy, chronic pain, depres- in those who are suffering from PTSD4,5 and studies indicate sion/grief, general anxiety, headaches, insomnia, irritability, quick that acupuncture may be very effective for treating PTSD.6,7 In temper and other anger issues, nightmares, skin rashes and other traditional Chinese medicine (TCM), PTSD and its symptoms can skin problems, occasional panic attacks, and stomach/intestinal be diagnosed as many different patterns, depending on the presen- tation of the various symptoms. In a recent study of 21 patients v 60 T h e A m e r i c a n A c u p u n c t u r i s t The Lasting Effects of Using Auricular Acupuncture to Treat Combat-related PTSD: A Case Study Table 2: PTSD Checklist (Baseline responses at the initial interview) Sympathetic, Kidney, Liver and Lung points on the ear.12 The Shenmen point is one of the primary points to calm the mind.13 The Sympathetic point regulates both sympathetic and parasympathetic nervous systems and treats disorders stemming from disturbances of the autonomic nervous system.14 The Kidney point treats the brain along with a variety of related symptoms, including nervousness, poor Chronic pain (circle) back, neck, pelvis memory, and autonomic nervous system imbalances.14 The Liver point treats the stagnation of liver qi 13 as well as a wide variety of emotional and mental disturbances.11 The Lung point calms panting and treats chest pain, night sweats, spontaneous sweating, and many skin problems.13 The actions of these points therefore make them an appropriate choice to treat PTSD and its associated symptoms. The correspondences of the Kidney, Liver and Lung meridians to the emotions of fear and panic, anger and irritability, and sadness and grief respectively,11 also support these point selections, as these feel- ings are all potential emotional components of patients with PTSD.2 There is often substance abuse in veterans suffering from mental illness.15 Since, as noted, the NADA protocol has been used since the early 1970s to treat a wide variety of chemical addictions,12 this provides additional support for its use to treat combat-related PTSD. One recent study used the NADA protocol to treat refugees from all over the world suffering from PTSD. This treatment was found to be effective, providing "a considerable reduction in symptoms related to PTSD in 14 of the 16 patients."9 The NADA protocol The patient chose not to discuss his nightmares or lack of sleep; has also shown to be effective for other psycho-emotional issues, his response was "Let's not even go there." He described the some of which may pertain to veterans suffering from PTSD, such chronic pain (circled "pelvis" on the checklist in Table 2) as being as attention deficit hyperactivity disorder16 and anxiety related to the in the coccyx area. He also reported diabetic neuropathy in his withdrawal from psychoactive prescription medications.17 extremities. He indicated the "skin rashes and other skin problems" from the questionnaire checklist above to be a rash on the upper Over the course of a six-month period from 11/11/10 to 5/12/11, the chest and back that he attributed to Agent Orange exposure. The patient received a total of 18 treatments. Treatment utilized 5 0.18 x majority of the symptoms have been affecting his quality of life for 15mm, Spring type, DBC brand, Korea, needles inserted bilaterally 38 years since the end of his active duty in Vietnam (1968-1972).
and retained for 30 minutes. Again, points needled comprised the Diagnostic Assessment and Treatment Strategy auricular acupuncture protocol commonly referred to as NADA- the Normally, an individual undergoes a complete intake, including Shenmen, Sympathetic, Liver, Kidney, and Lung points of the ear. a variety of questions designed to assess the entire individual. The The patient lay supine on the treatment table and rested or slept question topics cover diet and bowel function, sleep quality, energy during treatments. The patient was given consecutive weekly treat- level, aches and pains as well as emotions and quality of life. Tongue ments for the first seven treatments. He then received treatment on and pulse diagnosis is also performed by inspecting the color and an as-needed basis every one to four weeks for the remainder of the coating of the tongue and palpating the pulse at three distinct locations on each wrist each at three different depths in order to ascertain both the location and the depth of any given illness; after One week after the first treatment the patient reported still feeling this process, an individual treatment is prescribed accordingly.
somewhat fatigued but had a noticeable increase in overall energy However, the design of this PTSD clinic was not to provide level. He reported no skin itching or irritation and no panic attacks. an individual diagnosis or treatment but to provide symptom He also reported less irritability and anger. During the interview relief for as many PTSD patients as possible utilizing an auricular before the third treatment, the patient reported feeling markedly less acupuncture protocol named after the National Acupuncture Detox stress, less irritability, less anger, and an increased energy level. He Association (NADA), referred to simply as the "NADA protocol." reported 3-4 total irritability/anger incidents over the entire week's The NADA protocol was originally developed to treat drug time-down from the previously reported 3-4 per day. addiction back in the early 1970s.12 The protocol is a set of five During the interview before the fourth treatment, the patient acupuncture points needled bilaterally, consisting of the Shenmen, reported that the past week had "gone well overall," allowing the T h e A m e r i c a n A c u p u n c t u r i s t Summer 2012
The Lasting Effects of Using Auricular Acupuncture to Treat Combat-related PTSD: A Case Study first full night of sleep in a very long time. Over the course of the During this follow-up interview, the patient was now willing to remaining treatments, the patient continued to report improve- elaborate on his sleep troubles previous to treatment and compare ments, saying that his sleep, mood, and fatigue had all improved those un-restful nights to the markedly restful sleep he was now significantly and that his nightmares were "less realistic" and "easier experiencing. He related that before treatment began he could sleep to get away from." He also reported more control over his mood only 15-30 minutes at a time in "cat naps." The most sleep at any and demeanor, stating that incidents that previously would have one time prior to treatment was one hour straight. He reported "set him off" passed more easily.
a tremendous fear of going to sleep prior to therapy and would Four weeks passed between the twelve and thirteenth treatments. try to force himself to stay awake. He continued these "cat naps" Although untreated for nearly a month, the patient reported throughout the night and day, especially when seeing movies with only one extremely angry and irritable moment. Nightmares still his family. He further reported that he could never stay awake reportedly occurred but with less frequency and an increased sense through a movie no matter how interesting he found it. Also, he of "control." Several treatments later, the patient reported his sleep said he would wake in the darkness and not know where he was as "amazing" and stated that he could now sleep through the night, or who was beside him and whether they were friend or enemy. It with nightmares reduced from nightly to once a week. On the last frequently took him a long time to "get out of a dream" and realize day of treatment, the patient reported that all PTSD symptoms he was safe in his house lying next to his wife. He stated that it was from which he had previously reported relief continued to be not uncommon to suddenly awake with a start, wondering where his weapon was and feeling that he was still in the jungle. In summary, over the course of eighteen treatments during a six At the follow-up interview, he reported that his sleep was now month period, the patient progressed from reporting symptoms of greatly improved and that he got 2-3 hours of good sleep before irritability, anger, panic, physical fatigue, sleeplessness, nightmares, Table 3: Comparison of PTSD Checklist Responses (Baseline/Intake, 11/11/10 vs. Follow-up 7 months post treatment, 12/17/11) *NOTE: IMPROVEMENTS AT FOLLOW-UP ARE INDICATED BY AN "I" decreased anger, increased physical energy, nights of up to six hours of teenage son, and a loss of irrational energyfears.
seven months after the patient discontinued care. During the call, 5 out of the 11 reported initial symptoms. There was no change v 60 T h e A m e r i c a n A c u p u n c t u r i s t The Lasting Effects of Using Auricular Acupuncture to Treat Combat-related PTSD: A Case Study waking either to urinate or from nightmares, although he now the interest of all those suffering from combat-related PTSD, further did not have any difficulty in going back to sleep after waking. evaluations are necessary in order to examine and compare treatment Regarding the nightmares that he would have occasionally at the results from a larger patient base and to further research the long-term time of follow-up, he reported, "I'm more prepared to deal with results and effectiveness of this care.
them. They feel real but it then it takes a second and I realize I'm in the real world and not in the dream world." The patient also reported that he felt less stuck in the "dream world" in general and 1. Mayo Clinic. Post traumatic stress disorder (PTSD). http://www.mayoclinic.com/health/ thought less about being in the jungle or under fire. Additionally, since he was more rested on a regular basis, he could watch movies 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000 all the way through and found it enjoyable to watch older movies 3. National Institute of Mental Health. Post-traumatic stress disorder. (informational booklet) US that in the past he could not watch straight through without falling Department of Health and Human Services, National Institutes of Health. http://www.nimh.nih.
asleep. He noted he felt like he was "seeing these old movies for the gov/health/publications/post-traumatic-stress-disorder-ptsd/nimh_ptsd_booklet.pdf first time." After almost 40 years of sleepless nights, Mr. H is now 4. Cannistraro PA, Rauch SL. Neural circuitry of anxiety: Evidence from structural and functional able to get a full night of sleep the majority of the time with only neuroimaging studies. Psychopharmacol Bull. 2003;37:8 -25.
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6. Hollifield M, Sinclair-Lian N, Warner T, and Hammerschlag R. Acupuncture for posttraumatic stress disorder: A randomized controlled pilot trial. The Journal of Nervous and Mental Disease, There is currently an increased need for safe and cost-effective ways to treat PTSD. A recent population-based survey of 30,000 7. Hollifield M. Acupuncture for posttraumatic stress disorder: conceptual, clinical, and biological veterans indicates that the number of Gulf War veterans who suffer CNS Neuroscience & Therapeutics. 2011;17(6):769-79.
from PTSD is more than double that of veterans of wars preceding 8. Sinclair-Lian N, Hollifield M, Menache M, Warner T, Viscaya J, Hammerschlag R. Developing a traditional Chinese medicine diagnostic structure for post-traumatic stress disorder. J Altern the Gulf War.18 A recent assessment of 88,235 troops returning Complement Med. 2006;12:45-57.
from the Iraq War found that over 20% of active soldiers, and over 9. Pease M; Sollom R; Wayne P. Acupuncture for refugees with posttraumatic stress disorder: Initial 42% of reserve component soldiers required some form of mental experiences establishing a community clinic. Explore (NY). 2009;5(1):51-4.
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The NADA protocol may be an effective stand-alone treatment 11. Wiseman N, Ellis A. Fundamentals of Chinese medicine. Brookline, MA: for PTSD patients or as a complement to the care PTSD patients receive from the VA. The current standard of care is palliative and 12. National Acupuncture Detox Association. NADA Protocol. http://acudetox.com/ includes prescribing multiple expensive and habit-forming phar- 13. Huang L. Auricular treatment: Formulae and prescriptions. Hoover, AL: Auricular Medicine maceuticals, which, when treating chronic military service-related International Research and Training Center. (Date not listed) PTSD, may be no more effective than placebos.20 This has become 14. Chen, P. Modern Chinese ear acupuncture. Brookline, MA: Paradigm Publications; 2004. an issue of national interest. The New York Times recently published 15. Petrakis IL, Rosenheck R, Desai R. Substance use comorbidity among veterans with posttrau- matic stress disorder and other psychiatric illness. The American Journal on Addictions / articles about the ineffectiveness of anti-psychotic drugs to treat American Academy of Psychiatrists in Alcoholism and Addictions. 2011;20(3):185-9.
combat-related PTSD21 as well as reports of multiple veteran deaths 16. Lee MS, Choi TY, Kim JI, Kim L, Ernst E. Acupuncture for treating attention deficit hyperactiv- in which coroner reports attributed the causes of death to toxic ity disorder: a systematic review and meta-analysis. Chinese Journal of Integrative Medicine combinations of prescription drugs.22 Acupuncture is safe, non- [Chin J Integr Med] 2011;17(4):257-60.
invasive, and non-addictive. Since the NADA protocol has been 17. Black S, Carey E, Webber A, Neish N, Gilbert R. Determining the efficacy of auricular acupuncture for reducing anxiety in patients withdrawing from psychoactive drugs. shown to be effective for PTSD without a lengthy intake process Journal of Substance Abuse Treatment. 2011; 41(3):279-87.
or diagnosis,9 more veterans can be treated in less time with fewer 18. Kang H, Natelson B, Mahan C, et al. Post-traumatic stress disorder and chronic fatigue resources. This protocol can be given in a group environment, syndrome-like illness among gulf war veterans: A population-based survey of 30,000 veterans. American Journal of Epidemiology (2003);157(2):141-148.
19. Milliken C, Auchterlonie J, Hoge C. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 2007;298(18):2141-2148.
Mr. H reported relief to almost all of his symptoms more than 20. Krystal J, Rosenheck RA, Cramer JA, et al. Adjunctive risperidone treatment for seven months after ceasing treatment. Data collected during the antidepressant-resistant symptoms of chronic military service-related PTSD: initial interview compared to follow-up data indicates an improve- A randomized trial. JAMA. 2011;306(5):493-502.
ment to the PTSD condition and symptoms. The outcome of this 21. Carey B. Drugs found ineffective for veterans' stress. New York Times. August 2, 2011, (A print version of this article appeared on August 3, 2011, p A13 of the New York edition with the case study suggests that the auricular acupuncture NADA protocol headline: "Antipsychotic Use Is Questioned for Combat Stress.") can be an effective long-term therapy for PTSD. The same NADA 22. Dao J, Carey B, Frosch D. For some troops, powerful drug cocktails have deadly results. New protocol discussed in this article is currently provided as a free treat- York Times. February 12, 2011 (A print version of this article appeared on February 13, 2011, p A1 of the New York edition.) ment for veterans, their families, and their caregivers at the Walter 23. Walter Reed National Military Medical Center. Bethesda, MD. Reed Veterans Administration Hospital in Washington, D.C.23 In T h e A m e r i c a n A c u p u n c t u r i s t Summer 2012

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