Integrative Medical Practices for Combat-Related Posttraumatic … · 2018-12-05 · of...

PSYCHIATRIC ANNALS 43:4 | APRIL 2013 Healio.com/Psychiatry | 181

Integrative Medical Practices for Combat-Related Posttraumatic Stress Disorder

The discrepancy between mili-tary and civilian prevalence rates of posttraumatic stress disorder

(PTSD) indicates that military service, in particular combat duty, carries with it an in-creased risk for the development of PTSD, thereby representing one of the key chal-lenges to military mental health care. The US Department of Defense (DoD) has ex-perimented with incorporating integrative

medicine practices into a variety of PTSD treatment centers. Much of the pioneering work started with the Warrior Resilience Center in Fort Bliss, TX, during the early years of the war in Iraq. Though it is an outpatient program, the Warrior Resilience Center should be acknowledged as a model for the two intensive residential programs recently designed to support active duty service members diagnosed with PTSD.

The Overcoming Adversity and Stress Injury Support (OASIS) and National In-trepid Center of Excellence (NICoE) have embraced the truly dynamic challenge of treating PTSD in active duty service mem-bers by augmenting traditional evidence-based exposure therapies for PTSD with a variety of integrative approaches. This strategy is due in no small part to demands from patients who seek alternatives to

Paul D. Sargent, MD, is Founding Program Di-

rector, OASIS Residential PTSD Program, Naval

Medical Center San Diego. Justin S. Campbell,

PhD, is Research Psychologist, Space and Naval

Warfare Systems Command, San Diego. Ken-

neth E. Richter, DO, is Current Program Director,

OASIS Residential PTSD Program, Naval Medi-

cal Center San Diego. Robert N. McLay, MD,

PhD, is Research Director for Mental Health,

Navy Medical Center San Diego. Robert L. Koff-

man, MD, MPH, is Department Chief for Clinical

Operations at the National Intrepid Center of

Excellence, Bethesda, MD.

Address correspondence to: Paul D. Sar-

gent, MD, 34800 Bob Wilson Drive, San Di-

ego CA 92134; email: Paul.Sargent@navsoc.

socom.mil.

Disclosure: The authors have no relevant

financial relationships to disclose.

doi: 10.3928/00485713-20130403-10

Paul D. Sargent, MD; Justin S. Campbell, PhD; Kenneth E. Richter, DO; Robert N. McLay, MD, PhD; and Robert L. Koffman, MD, MPH

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“Central Park” at NICoE. Part of a series of meditative walks offered to encourage mindfulness.

182 | Healio.com/Psychiatry PSYCHIATRIC ANNALS 43:4 | APRIL 2013

standard treatments that in some cases are perceived to be ineffective or incomplete. What follows is a discussion of these prac-tices and how they might be practically configured to support evidence-based mainstream therapies.

ROLE OF INTEGRATIVE MEDICINE IN PTSD TREATMENT

In 2008, the National Center for Com-plementary and Alternative Medicine (NCCAM) issued guidelines grouping in-tegrative practices (also known as CAM) into four categories: 1) natural products; 2) mind and body medicine; 3) manipulative

and body-based practices; and 4) “other”, including movement therapies, traditional healers, energy field manipulation, and whole medical systems. Full definitions of these NCCAM definitions of these catego-ries are found in Table 1.

In what appears to be the most thor-ough quantitative review of integrative treatments in PTSD, the US Veteran’s Administration (VA) conducted an ex-haustive literature review, identifying nine peer-reviewed published studies on the ef-fect of CAM modalities on PTSD.1 One study performed by Hollifield et al,2 which compared acupuncture and cognitive-

behavioral therapy (CBT) each against a wait-list control group, was found to be both the best designed and most support-ive of CAM’s efficacy in reducing PTSD symptoms. The other studies showed modest reductions in symptoms, but also tended to be plagued by study designs that either failed to apply experimental blinds or could not isolate CAM as the sole thera-peutic modality applied to the participant.

Although the evidence-base for CAM interventions as stand-alone therapies is not robust, some evidence-based therapies rely heavily on CAM-type interventions as a part of the process. In particular, stress inoculation training (SIT) relies heav-ily upon mind-body tools such as deep breathing exercises, thought regulation, and progressive muscle relaxation.3 SIT, along with trauma-focused psychotherapy, which includes components of exposure and/or cognitive restructuring, were found to be the two best evidenced-based ap-proaches for the treatment of PTSD in the review conducted to support the current DoD/VA Clinical Practice Guideline for PTSD, issued in 2010.4

At the VA, psychotherapy treatment ad-herence has improved in its PTSD patient population over the past 20 years with the addition of residential care. For the DoD, residential treatment is a new endeavor to provide care consistent with the VA/DoD clinical practice guidelines, and also ex-pand service to include novel treatments with an emerging evidence base.

Within the residential programs dis-cussed in this article, patients are provided treatments that have been shown to have a positive impact on depression, substance use disorders, stress management, and re-silience. Some are currently considered in-tegrative, as the theoretical underpinnings are not consistent with Western concepts of illness, or they fall more appropriately under the heading “mind-body medicine” because, although they are not typically prescribed by doctors, they are based in a western model of health and illness.

Some of the services provided, such as

TABLE 1.

NCCAM Categories and Practices Applied at OASIS and NICoE

NCCAM Categories and Definitions* OASIS NICoE

Natural Products: “… a variety of herbal medicines (also known as botanicals), vitamins, minerals, and other ‘natural’ products. Many are sold over the counter as dietary supplements.”

Nutritional supplementation Nutritional

Education

Mind and Body Medicine: “… focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical function-ing and promote health.”

Acupuncture

Meditation

Yoga

Spirituality

Deep Breathing

Biofeedback (EEG-based)

Acupuncture

Meditation

Yoga

Spirituality

Deep Breathing

Tai Chi

Biofeedback (heart

rate variability-

based)

Manipulative and Body-Based Prac-tices: “ ... focus primarily on the struc-tures and systems of the body, including the bones and joints, soft tissues, and circulatory and lymphatic systems.”

Physical Exercise Mindful Movement

Other Recreational Art

Recreational Music

Art Therapy

Healing Touch

Energy

Pet (canine)

Therapy

Creative Writing

Music Therapy

* Definitions provided by the National Institutes for Health’s National Center for Complimentary and Alternative Medicine (NCCAM) 2007 fact sheet.


acupuncture, require only passive coop-eration, whereas others, such as medita-tion, require the patient’s full engagement if the benefits of the intervention are to be realized.

INTEGRATIVE PRACTICES AT OASIS The Therapeutic Milieu

OASIS is located at the Naval Base Point Loma, CA, and service members re-side in multiple occupancy rooms during the 10 weeks of their treatment. Patients are encouraged to support each other through the therapeutic process, which is based in cognitive processing therapy (CPT) but also includes prolonged expo-sure therapy (PET) combined with a vari-ety of integrative modalities.

Cohorts of 10 patients are admitted every 5 weeks, which allows mentorship of junior patients by senior patients. “Unit cohesion” is emphasized during the course of care.

Natural Products/SupplementationAt OASIS patients are routinely offered

omega-3 fatty acids (fish oil supplement) at a dose of 2,000 mg daily. This supple-ment contains 18% eicosapentaenoic acid (EPA) and 12% docosahexaenoic acid (DHA). The rationale for this is multifold. Recent investigation into the effects of nutrition on mental health has highlight-ed the role of inflammation. The use of omega-3 fatty acids to reduce anxiety and depression may result from or contribute to changes in immunomodulation,5 which impacts inflammation levels in the body.

In addition, vagus nerve tone is thought to be important in promoting relaxation and stress mediation in the body.6 Indeed, both depression and psychological stress have well-documented negative effects on vagal activation: omega-3 fatty acid intake can boost mood and vagal tone, dampen nuclear factor-kappa B activation and re-sponses to endotoxin, and modulate the magnitude of inflammatory responses to stressors.7 For PTSD patients who are thought to have excessive sympathetic

tone, it is hoped that the omega-3s will augment vagal (parasympathetic) tone.

Furthermore, when patients get to the program, many of them are on a variety of medications, such as SSRIs, SNRIs, antihistamines, sleep aids, and even some atypical antipsychotics. One goal of treat-ment is to obtain maximal symptom im-provement with reduced-risk of adverse reactions due to polypharmacy. If patients are able to improve symptom parameters by augmenting their diet with omega-3s, then they might be able to reduce their medication loads.

The final motivation for using these supplements is that many of our patients experience chronic physical pain as a re-sult of inflammation. Omega-3s have shown some benefit in that area as well. Although Vitamin D supplementation has been suggested by some as a helpful agent in treating depression,8 OASIS is not us-ing vitamin D supplements at this time as the data remain unclear as to the benefit, and vitamin D toxicity has been reported in cases of overdose.9

AcupunctureAt OASIS, acupuncture is used to ad-

dress acute anxiety and irritability and pain that otherwise can derail the therapeutic process. In the combat trauma population, it is not uncommon to have chronic mus-culoskeletal pain as an area of clinical con-cern. Using acupuncture to treat that pain reduces the potential for polypharmacy re-sulting from comorbid mental health and pain conditions. Patients are given the op-tion of treatment with acupuncture, which may include scalp, ear, body, or electro-acupuncture (see Figure 1).

The strongest evidence for the use of acupuncture as an integrative treatment comes from research investigating mus-culoskeletal pain interventions, for which acupuncture has demonstrated efficacy when used in conjunction with conven-tional pain treatments.10 As noted previ-ously, one small randomly controlled trial has documented the effectiveness of

acupuncture as a stand-alone treatment for PTSD, although it is not used as a sole treatment at OASIS.2

MeditationMeditation was selected as an inter-

vention at OASIS because there is some evidence that meditation activates para-sympathetic pathways and inhibitory brain regions to counteract hyperarousal symp-toms.11 Other data have suggested that, even if meditation does not reduce PTSD symptoms, it may reduce substance use in populations with high comorbidity.12 The expert consensus guidelines of the Interna-tional Society for Traumatic Stress Stud-ies also support the use of meditation as a second-line intervention for PTSD to tar-get emotional, attentional, and behavioral (aggressive) disturbances.13

At OASIS, an hour-long class on medi-tation is conducted each week to educate patients on its expected benefits, as well as to guide them through a meditation ses-sion that lasts approximately 15 minutes. Staff encourage patients to engage in a daily meditation practice and to use it as a coping skill to alleviate stress and promote a sense of being “grounded” in the mo-ment. The response to this has been favor-able, leading the program to adopt a brief daily meditation practice that is structured and supervised by staff to maximize the benefits of this intervention.

Figure 1. Example of auricular acupuncture.

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YogaSimilar to meditation, the effects of

yoga are believed to stem from the ac-tivation of parasympathetic circuits and improved modulation of the hypothalam-ic-pituitary-adrenal (HPA) axis.14 One neuroimaging study also documented a 27% increase in brain gamma-aminobu-tyric acid GABA levels after an hour-long yoga session, when compared with a con-trol group (0% change in GABA level) who spent that time reading.15 At OASIS, patients are required to attend a weekly, hour-long yoga class taught by a trained, volunteer instructor. The poses and prac-tices are consistent with standard Hatha yoga (see Figure 2). The yoga session immediately follows one of the weekly CPT sessions, since anecdotal evidence at OASIS has shown that time spent focused on breathing and body movement helps patients stay functional, even after expe-riencing the sometimes intense emotions triggered by CPT sessions.

SpiritualityMuch has been written in the nonsci-

entific literature about the impact of com-bat trauma on the spirit.16,17 A more recent report based on data from 28,000 ran-domly selected service members focused on spiritual beliefs as predictive factors for depression, PTSD, and suicidality.18

Their study showed high spirituality had a protective effect on depression symptoms, whereas medium and low spirituality lev-els predicted depression symptoms among those with moderate combat exposure. Medium spirituality levels also predicted PTSD symptoms among those with mod-erate levels of combat exposure; it also predicted self-reported suicidal ideation/attempt among those never deployed. Clearly, these results point to a complex relationship between spirituality and men-tal health.

At OASIS, patients spend 1 hour per week in a group dedicated to discussions about spirituality. Since its inception, the group has been run by several active and

retired military chaplains. The goal is to allow a space for patients to discuss any is-sues related to faith or existential questions that arose as a result of their trauma. It is an ecumenical group and does not pro-mote one faith over another. The group at OASIS is not manualized at this time, but this may be re-evaluated in the future since manualized groups are available through the VA.19

Physical ExerciseThe literature examining the direct im-

pact of physical exercise in the treatment of PTSD is somewhat limited in quality and quantity. Some studies have shown a benefit to PTSD symptoms,20 whereas others show unchanged symptoms but im-proved quality of life.21 Physical exercise has repeatedly been shown to benefit pa-tients with state and trait anxiety.22

At OASIS, patients have access to a

fully equipped gym and fitness instructors. They are scheduled for physical training (PT) for 1 hour every day, and expected to participate in some form of aerobic or anaerobic exercise, which may be self-directed but is supervised by the staff to ensure that some activity is actually taking place. In addition, patients may engage in team sports as a part of recreation therapy, and at least one fitness period per week is allotted to structured group exercise (eg, spin class).

Patients are given education on fit-ness effects for depression and anxiety, asked to self-pace fitness activities, and asked not to push through physical pain. One additional important aspect of using physical exercise in this population is the fact that it is consistent with their military ethos. Maintaining physical fitness is at the core of military professionalism and military proficiency. Active-duty patients

Figure 2. Marine practicing Hatha yoga exercises.

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with combat-related PTSD will often find this a very acceptable modality. If it im-proves their PTSD symptoms, improves their readiness to return to duty, and pos-sibly mitigates the weight gain caused by psychotropic medications, OASIS staff have concluded it makes sense to incorpo-rate the use of this modality in multimodal treatment planning.

Art Therapy/Music Therapy/Recreation Therapy

Many patients with PTSD have lost the ability to find enjoyment in things they previously enjoyed. Their daily routine becomes one of managing potential symp-tom triggers and often, avoiding encoun-ters with other people. There is very little time spent in play or recreation. This hurts their relationships as those around them may begin to see them as dour or severe. The reintroduction of playful and creative outlets provides a healthy outlet for stress, facilitates communication with others, and widens their options for socialization with-out the use of alcohol. The use of sports, games, art, and music helps to rebuild a lost sense of self-efficacy and promotes the belief that they can return their lives to a state of normalcy and wellness.

Although a recent Cochrane database review of the efficacy of sports and games for PTSD yielded no studies that met in-clusion criteria,23 and despite an incon-sistent evidence-base for art, music, and recreation therapy, anecdotal evidence at OASIS has shown that these modalities are very effective for patients.

We believe that further research will demonstrate these practices to be helpful as adjunctive measures to support the de-livery of evidence-based psychotherapy. Patients are involved in at least 1.5 hours of structured artistic expression per week. They have created a variety of projects, such as murals symbolizing their recov-ery, as well as “trauma masks” that help them visualize and communicate the ef-fects of the trauma on their psyche. They also create collages at three points in their

treatment, reflecting where they were at the beginning, middle, and end of their treatment. These are used as a part of the graduation ceremony at the completion of treatment.

In addition, patients are given up to 7 hours per week of recreation therapy ac-tivities that include sports, games, and rec-reational and community service outings. Music therapy is provided at OASIS for at least 1 hour per week. This includes song writing, lyric analysis, and basic instruc-tion in the use of musical instruments for relaxation or expression. In the literature, one study on music therapy demonstrated increased well-being and relaxation dur-ing listening to music and during musical improvisation.24 An increase in immuno-globulin A and decreased cortisol were also noted.

INTEGRATIVE MEDICINE AT THE NICoE Therapeutic Milieu

Built through the generosity and sup-port of the Intrepid Fallen Heroes Fund, the National Intrepid Center of Excellence (NICoE) is located in a state-of-the-art building on the campus of the new Walter Reed National Military Medical Center in Bethesda, MD. The facility was built ex-pressly to address the “invisible wounds of war” (traumatic brain injury and PTSD), which are particularly associated with the conflicts in Iraq and Afghanistan. The building itself incorporates many specific features designed to minimize photosen-sitivity, promote relaxation, and support mindfulness-based interventions.

Case Conceptualization NICoE features an interdisciplinary

staff and holistic clinical care model in-tegrating an array of diagnostic and treat-ment equipment that supports the tripar-tite NICoE mission: patient and family focused evaluation, individualized treat-ment planning, and clinical research. The NICoE residential model lasts up to 4 weeks and culminates in a discharge that

hands-off directly to the patient’s primary care providers for sustainment and follow-up care.

The NICoE clinical evaluation is bio-psycho-social-spiritual in content and in-cludes an explicit CAM and wellness eval-uation. Key contributors to this evaluation are an art therapist, nutritionist, recreation-al therapist, and chaplain who are super-vised by a lead psychiatrist. Patient choice and control is emphasized in selecting mo-dalities to address pain control, autonomic regulation, and relaxation response. It is believed that empowerment of the patient in this way improves compliance, and fosters a collaborative spirit with the treat-ment team. Additionally, the self-advocacy developed though selecting effective treat-ment options becomes an important skill for patients to utilize in the future.

At the conclusion of care, the inter-disciplinary team develops an individual-ized treatment plan that is communicated back to the patient’s referring primary care manager. Depending upon the patient’s personal preference, desired outcomes, and perceived results, the final treatment plan may or may not include integrative practices. However, discharge surveys have revealed that CAM modalities make up a significant proportion NICoE treat-ments that patients most look forward to continuing at discharge.

Mind and Body Practices As displayed in Table 1 (see page 182),

NICoE offers a variety of traditional CAM modalities under the rubric of integrative medicine. Patients are encouraged, but not compelled, to try as many of them as possi-ble during their stay at NICoE. The NICoE model is heavily invested in integrative medicine, and offers treatments such as Gua Sha,25 a Chinese fascial release mo-dality, and micro-current therapy,26 which utilizes tiny pulses of energy to heal inju-ries at the cellular level, both of which have been shown to be beneficial for musculo-skeletal pain.

Acupuncture at NICoE is provided


by a psychiatrist and a physical medicine and rehabilitation physician, trained and licensed to perform regimented medi-cal acupuncture as taught in the Medical Acupuncture for Physicians course.27 This practice applies a rigorous understanding of both western and eastern perspectives of anatomy and physiology, and a firm knowledge of acupuncture points and channels. Medical acupuncture such as that utilized at NICoE is highly regulated compared with nonmedical versions of acupuncture.

Although acupuncture is primarily indicated as a treatment for musculoskel-etal pain, NICoE physicians have found it beneficial for helping to stimulate a bond between patient and provider, so much so that the phrase “come for the needles, stay for the therapy” has often been re-peated. There has been some speculation that the close, physical hands-on contact required to administer acupuncture helps patients lower defensive postures associ-ated with the high sympathetic nervous system dominance consistent with PTSD hyperarousal. Such interpersonal proxim-ity, combined with extended periods of low external stimulation during treatment, may foster greater parasympathetic regu-lation of the nervous system, a situation that others have hypothesized will pro-mote social engagement between patient and provider.28

Art Therapy Art therapy at NICoE has proven to be

a very salient treatment, The emotionally compelling artwork seems to arouse a vis-ceral sense of the patients’ struggle with their experiences of combat. It is also be-lieved that many patients with PTSD have impaired declarative memory,29 and facili-tating expression of their trauma through artwork is helpful in supplementing tradi-tional psychotherapy.

When indicated by the initial clini-cal intake evaluation, the art therapist at NICoE engages in a multistage program that starts with individualized sessions that

include and initiation of a personally tai-lored art project.

The week one project, described as “warrior identities,” encompasses the use of preformed, content-void, white androg-ynous masks that serve as the blank canvas upon which the service member can proj-ect his or her inner- and outer-self through artistic expression.

Art sessions may begin with guided imagery to help reduce tension and cope with potential hyperarousal symptoms. Patients move from masks to montages in the third week of the program, and con-clude the final week with the possibility of having patients present their art work to the treatment team and discussing it within the context of their overall treatment ex-perience.

Canine/Pet Therapy Visitors, patients, and staff frequently

come into contact with the two or more trained canines that routinely patrol the halls of NICoE. These dogs are raised by trainers who have specifically taught the dogs to be nurturing and patient with their masters/patients. The dogs are perceived as protective and reassur-ing. They not only have the capacity to help service members differentiate real from imagined danger, and thus hyper-vigilance, but also help patients learn or relearn trust and emotional bonding, which are counter to PTSD symptoms of avoidance and numbing.30 Another ben-efit of the dog program at NICoE is that the patients are able to engage in several sessions of training a dog who will later

be given as a therapy animal to a veteran. They feel in this way that they are “pay-ing it forward” by continuing to provide service to others.

NICoE’s use of CAM modalities is in-tegrative and focuses as much on relieving pain and establishing the therapeutic al-liance between patient and provider as it does on relieving symptoms of PTSD and working through trauma-related memories and cognitions. Despite the limited body of evidence supporting CAM modalities as stand-alone treatments for PTSD, their subjective popularity, both with patients and providers at NICoE, suggests that as integrative or adjunctive interventions, CAM modalities are a critical buttress to standard, first-line, trauma-focused thera-pies for PTSD and traumatic brain injury.

CONCLUSIONSThere are a variety of reasons why in-

tegrative medicine should be included in comprehensive programs for PTSD treat-ment. Clearly the evidence base has not developed to the extent that is has for ex-posure-based therapies or pharmacother-apy for PTSD, but absence of evidence is not evidence of absence. There are numer-ous recent examples of therapies that were first thought to be so outside the norm as to be inappropriate for rational, evidence-based care, but gained acceptance after further empirical study. For example, in the late 1990s eye movement desensiti-zation and reprocessing was thought by many to be akin to mesmerism.31 It is now recommended as an effective treatment by the American Psychiatric Association, the VA, the National Institute for Clinical Excellence (UK), and others, and is in the DoD Clinical Practice Guidelines for PTSD.

One critical factor in using CAM to augment evidence-based treatment is that patients tend to comply with them. Many treatments for PTSD are known to have a high drop-out rate,32 but CAM modalities may encourage patients to remain engaged if the services are packaged together.

Their subjective popularity suggests CAM modalities are

a critical buttress to standard, first-line, trauma-focused

therapies for PTSD.


There are no current data that show that patients remain in CAM treatment longer than other treatments, but there is one study that demonstrated that patients with a higher internal locus of control were more likely to select CAM types of treatment. Incorporating CAM can give a patient a greater sense of autonomy and empower them to approach their recovery assertively. This may be important for tri-age of PTSD patients into psychotherapy, as it requires a high degree of commitment on the part of the patient.33

Good access to care for the population of returning service members with PTSD will require a great number of providers. Determining which modalities of care offer benefit is crucially important to ex-panding the size of the provider base who can effectively treat this disorder. Multi-modal programs offer an opportunity to study the effectiveness of CAM modali-ties and increase the knowledge base of how to effectively treat syndromes of traumatic stress.

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