More than 1.5 million US military personnel have deployed to Iraq or Afghanistan since the start of military operations in 2001.
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Abstract
The purpose of this article is to evaluate the evidence for the efficacy of acupuncture in the treatment of posttraumatic stress disorder (PTSD) through a literature review of the current research. Since studies on the use of acupuncture for the treatment of PTSD are lacking, studies assessing acupuncture’s role in mitigating individual symptoms of PTSD, such as migraines, anxiety, depression, and insomnia, as well as the modulatory effects of acupuncture on the limbic system, were also included in the literature review.
Introduction
More than 1.5 million US military personnel have deployed to Iraq or Afghanistan since the start of military operations in 2001.1 Approximately 300,000 Iraq and Afghanistan war veterans suffer from PTSD or major depression, and about 320,000 may have experienced at least a mild concussion or brain injury in combat, according to the RAND Corporation study titled The Invisible Wounds of War.2 According to the study, the baseline prediction of 2-year post-deployment PTSD treatment costs for a typical service member returning from Iraq or Afghanistan (an E-5 with 5 to 7 years of service) range from $5,635 to $13,935. One-year post-deployment treatment costs range from $27,259 to $32,759 for mild traumatic brain injury (TBI), and 1-year post-deployment treatment costs range from $268,902 to $408,519 for moderate or severe TBI.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) classifies PTSD as an anxiety disorder that includes 3 main symptoms: re-experiencing, avoidance, and hyperarousal.3 Symptoms of re-experiencing include recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions; having recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated); having intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; and having physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the trauma. Symptoms of avoidance include persistent efforts to avoid thoughts, activities, places, people, feelings, or conversations associated with the trauma; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; and feelings of “numbness” on the inside (eg, inability to have loving feelings). Symptoms of hyperarousal include difficulty falling or staying asleep, irritability with outbursts of anger, difficulty concentrating, exaggerated startle responses, and symptoms of hypervigilance.
PTSD is complex to treat due to the similar symptomatology it shares with TBI. Among individuals with PTSD, the most common comorbidities are with depression, substance use, and other anxiety disorders.4 TBI has been associated with increased risk of psychiatric disorders—specifically anxiety, depressive disorders, and substance use.5 Additionally, PTSD was strongly associated with mild TBI in a study published in 2008 in the New England Journal of Medicine by Hoge et al.6 Overall, 43.9% of soldiers who reported loss of consciousness met the criteria for PTSD, as compared with 27.3% of those with altered mental status, 16.2% of those with other injuries, and 9.1% of those with no injuries.
With the complexities in the treatment of PTSD, the Pentagon is seeking new ways to treat troops suffering from combat stress or brain damage by researching such alternative methods as acupuncture, meditation, yoga, and the use of animals as therapy. In 2008, the Pentagon spent $5 million to study these therapies.
Literature Review
Only 1 published study has specifically assessed the effectiveness of acupuncture in the treatment of PTSD. It’s important to note that the research found acupuncture to be effective on civilians with PTSD, and that a majority of the 84 participants in this study (62%) suffered trauma before the age of 12, 21% experienced trauma between the ages of 12 and 17, and 17% of the participants experienced trauma as an adult.7 Participants diagnosed with PTSD were randomized to either acupuncture treatment, an integrated cognitive-behavioral therapy (iCBT) group, or a wait-list control (WLC). Compared to the WLC condition, acupuncture provided large treatment effects for PTSD. PTSD symptoms scores declined significantly from baseline to end treatment of both the acupuncture group and the CBT group. In addition, treatment effects for depression, anxiety, and impairment were similar to effects for PTSD, and both treatment groups improved significantly more than the WLC group. Symptom reductions at end-treatment were maintained at the 3-month follow-up for both interventions (iCBT and acupuncture) as compared to the WLC group.
Although studies on the use of acupuncture for the treatment of PTSD are lacking, studies assessing acupuncture’s role in mitigating individual symptoms of PTSD, such as migraines, anxiety, depression, and insomnia do exist. Results of a recent randomized, controlled trial published in JAMA investigated the effectiveness of acupuncture compared with sham acupuncture and with no acupuncture in patients with migraine.8 The research demonstrated that both the sham acupuncture and acupuncture were more effective than no acupuncture. A total of 302 patients were randomized into 3 groups: sham acupuncture group, acupuncture group, and a WLC group. Acupuncture and sham acupuncture were administered by specialized physicians and consisted of 12 sessions per patient during 8 weeks. Patients completed headache diaries from 4 weeks before to 12 weeks after randomization and from weeks 21 to 24 after randomization. Main outcome measures were the differences in headache days of moderate or severe intensity between the 4 weeks before and weeks 9 to 12 after randomization. The proportion of responders (reduction of headache days with moderate or severe pain by at least 50%) was 51% in the acupuncture group, 53% in the sham acupuncture group, and 15% in the WLC group. Similarly, Spence et al demonstrated that 10 weekly sessions of acupuncture improved anxiety, depression, and insomnia and increased urinary melatonin levels in anxious adults diagnosed with insomnia.9
Clinical and experimental data suggest that at least some acupuncture clinical results are mediated in the central nervous system.
Clinical and experimental data suggest that at least some acupuncture clinical results are mediated in the central nervous system.10,11 Functional MRI (fMRI) and PET studies on acupuncture at specific acupuncture points have demonstrated significant modulatory effects on the limbic system and subcortical structures.12 fMRI neuronal signal reduction in the limbic system is not surprising in view of the therapeutic effects of acupuncture for disorders involving PTSD, anxiety, depression, and substance abuse.13,14,15 Hui et al noted that acupuncture stimulation on a specific acupuncture point (ST36) produced a reduction in neuronal activity, particularly the limbic/paralimbic structures and limbic areas in the cerebrum (ie, amygdala, hippocampus, cingulate, septal area, temporal pole, frontal pole, ventromedial prefrontal cortex). This study could possibly explain the sedating effects of acupuncture on patients with anxiety disorders, which could be an effective treatment plan for PTSD patients with severe hyperarousal (ie, difficulty falling or staying asleep, irritability with outbursts of anger, exaggerated startle responses, hypervigilance).
Conclusion
Even though current research studies on the use of acupuncture for the treatment of PTSD is scarce, current research suggests that acupuncture may be an efficacious treatment option for PTSD. One randomized controlled trial on the use of acupuncture for PTSD on the civilian population demonstrated significant reductions in PTSD symptoms scores from baseline to end-treatment in the acupuncture group. Additionally, treatment effects for depression, anxiety, and impairment in the acupuncture group improved significantly more than the WLC group. Studies assessing acupuncture’s role in mitigating individual symptoms of PTSD, such as migraines, anxiety, depression, and insomnia, demonstrate significant reductions in these symptoms for the studies’ participants. Clinical and experimental data also suggest that at least some acupuncture clinical results are mediated in the central nervous system. fMRI and PET studies on acupuncture at specific acupuncture points have demonstrated significant fMRI neuronal signal reduction in the limbic system. This study could possibly explain the sedating effects of acupuncture on patients with anxiety disorders, which could be an effective treatment plan for PTSD patients with severe hyperarousal.
Author’s Disclaimer
The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. Opinions, interpretations, conclusions, and recommendations herein are those of the author and are not necessarily endorsed by the U.S. Army.
About the Author
References
1 Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med. 2008;358(5):453-463.
2 Tanielian TL, Jaycox LH. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Recovery. Arlington, VA: RAND Corporation; 2008.
3 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. 4th ed. Washington D.C.: American Psychiatric Association; 2000.
4 Tanielian TL, Jaycox LH. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Recovery. Arlington, VA: RAND Corporation; 2008.
5 Ibid.
6 Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med. 2008;358(5):453-463.
7 Hollifield M, Sinclair-Lian N, Warner TD, Hammerschlag R. Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial. J Nerv Ment Dis. 2007;195(6):504-513.
8 Linde K, Streng A, Jurgens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005;293(17):2118-2125.
9 Spence DW, Kayumov L, Chen A, et al. Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report. J Neuropsychiatry Clin Neurosci. 2004;16(1):19-28.
10 Hui K, Liu J, Makris N, et al. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum Brain Mapp. 2000;9(1):13-25.
11 Hui K, Liu J, Marina O, et al. The integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 as evidenced by fMRI. Neuroimage. 2005;27:479-496.
12 Ibid.
13 Hollifield M, Sinclair-Lian N, Warner TD, Hammerschlag R. Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial. J Nerv Ment Dis. 2007;195(6):504-513.
14 Hui K, Liu J, Makris N, et al. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum Brain Mapp. 2000;9(1):13-25.
15 Hui K, Liu J, Marina O, et al. The integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 as evidenced by fMRI. Neuroimage. 2005;27:479-496.