The Diagnosis and Treatment of Post-Traumatic Stress Disorder According to Chinese Medicine

by Sarito Carroll, MS, L.Ac.

Post-Traumatic Stress Disorder (PTSD) is a debilitating stress reaction that occurs in response to experiencing or witnessing a traumatic event. PTSD, as a disease, first came into the public eye when Vietnam war veterans exhibited symptoms of persistent activation of the nervous system manifesting as anxiety, nightmares and a number of somatic sensations. However, writings on PTSD-like symptoms go back to the 1800s and PTSD is by no means limited to those who have lived through combat. In fact, PTSD can develop following any type of traumatic experience, such as rape, child abuse, spousal abuse, a car accident, or even persistent neglect. Contemporary western psychiatry recognizes PTSD as a type of anxiety disorder.

PTSD is characterized by recurrent activation of the fight or flight response long after the threat has been removed. Symptoms include persistent anxiety or terror, a highly sensitive startle response, memory impairment, oscillation between emotional numbness and activation, and increased aggressiveness and irritability. Those with PTSD often relive their trauma via thoughts and memories of their traumatic event during the day, and have nightmares and sleep disturbances by night. PTSD is often complicated by depression, bipolar disorder, other anxiety disorders and substance abuse. In severe cases, PTSD sufferers have trouble with daily functioning, being too anxious to work or socialize. Western diseases associated with PTSD include hyperthyroidism, cardiac arrhythmias, and seizure disorders.

PTSD affects about 5.2 million adult Americans. Studies suggest that between 6% and 30% of trauma survivors develop PTSD, with women being two times more likely to develop the disease than men. One’s susceptibility to developing PTSD is not clearly defined, but some factors such as the magnitude and duration of the trauma, as well as one’s social support system are thought to play a role. In general, PTSD symptoms develop within three months of the triggering event. However, in some cases symptoms may only emerge years after the event. PTSD is only diagnosed if the symptoms persist for more than a month.

PTSD sufferers display a number of distinct neurobiological and physiological changes, including chronically elevated stress hormones (epinephrine, norepinephrine, cortisol, and opioids), decreased volume in the hippocampus, and abnormal activation of the amygdala. Those with PTSD systematically are unable to appropriately differentiate and modulate responses to incoming stimuli, and many seemingly normal stimuli can act as triggers. As the fear center, the amygdala automates an organism’s reaction to fear by initiating the fight or flight response. The increased activation of the amygdala explains the beginning of the feedback loop that leads to increased stress hormones. The hippocampus compares incoming information with stored information and determines how they are related. In those with PTSD, this sorting mechanism is damaged to varying degrees. Van Der Kolk, a researcher at Harvard Medical School, states that “decreased hippocampal functioning causes behavior disregulation by interpreting incoming stimuli as an emergency. “(Van Der Kolk).

Treatment for PTSD includes targeted psychotherapy, as well as drug therapy. In recent years a number of trauma therapy modalities have emerged that aim to work directly with the lymbic brain. These therapies bypass talking, and instead focus on resolving and regulating somatic reactions to stimuli. These therapies include EMDR, Sensiomotor Reprogramming, and Somatic Experiencing (Peter Levine’s work). Traditional western medicine has also found Cognitive Behavioral therapy to be quite effective in the treatment of PTSD.
The primary medications prescribed to PTSD sufferers are Selective Serotonin Reuptake Inhibitors (SSRIs). Benzodiazepines are used short-term for acute conditions, but are not recommended long-term since they are habit forming.

Chinese Diseases

The main Chinese diseases that relate to PTSD are Racing of the Heart, Fright and Fear, Vexation and agitation, and Anxiety.

Racing of the heart is usually due to blood deficiency. However, it also often involves phlegm. According to Zhu Dan Xi, “If there is worry and anxiety and the heart throbs, this is ascribed to vacuity and scant blood. However, in most cases, If the throbbing starts and stops, this is due to phlegm stirred by fire.” (Yang Shou-Zhong, Pg. 262)

Fright and Fear are two of the 7 affects, which when excessive create pathological outcomes. Fright and fear are ascribed to the liver and kidneys respectively. Wiseman states that “Fright, like wind, causes spasm, since the sinews of a person subjected to frightening stimulus will tense” (Wiseman, pg. 229). Fear is ascribed to the kidneys, and kidney deficiency whether due to pre-heaven deficiency or post-heaven detriment, can result in susceptibility to fear.

Vexation and agitation refer to the somaticized expression of anxiety, which manifest as “disquietude in the chest (vexation)” (Wiseman, pg. 654) and fidgeting of the limbs (agitation). Vexation and agitation appear in hot, cold, vacuity and depletion patterns.

Disease Causes and Mechanisms

The disease causes for PTSD include damage by the 7 affects, pre-heaven deficiency, and taxation damage.

PTSD is characterized by repeated damage by the 7 affects, which in turn damages the right qi (zheng qi) in various ways. These influences mostly affect the heart, liver and spleen, three organs that play an integral part in regulating the emotions. The heart houses the shen, and when it’s normal flow of qi and blood is disturbed by heat, blood deficiency, blood stasis or phlegm, the heart is not nourished and the shen is disturbed. Excessive fear can affect the kidneys, leading to kidney deficiency. Kidney yin deficiency can lead to hyperactivity of yang, which rises upwards to harass the liver and/or heart, which in turn disquiets the shen. Similarly if kidney yang is deficient, it will fail to warm the spleen and the spleen will become deficient, leading to impairment of it’s transformation and transportation mechanisms. This then leads to the accumulation of dampness and disturbance of the Yi, manifesting as excessive worrying. The spleen can become deficient from many causes as well, including a propensity to worrying to begin with, or a poor diet, which often accompanies PTSD. Excessive fright leads to liver qi stagnation and consequently the disregulation of the emotions. As liver depression builds, it transform to heat or fire. The liver then may overact on the spleen, causing spleen qi xu. Liver fire may rise upwards and harass the heart, or liver fire may stream dampness into phlegm. Phlegm heat may then rise upward and disturb the heart/shen and block the free flow of qi. Prolonged damage by the 7 affects and the resulting disease mechanisms described above eventually lead to blood deficiency, blood stasis, and phlegm accumulation, all of which are patterns that can produce the anxiety symptoms seen in PTSD. If the blood is deficient or stagnant, the heart/shen will not be nourished. Prolonged damage by the 7 affects wears down the whole body and eventually affects the kidneys, depleting the jing. The liver, spleen, and heart are closely linked via the 5 element generating, controlling, and reverse controlling cycles. As such, disease mechanisms of all three organs are often combined in PTSD.

Treatment Based on Pattern Identification

1. Gallbladder Phlegm-Heat Disturbance

   This pattern arises when liver depressive heat transfers to the gallbladder channel, condensing fluids into phlegm. Phlegm-fire then rises upward and harasses the heart/shen.

   • Symptoms include: Fright, palpitations, restlessness, insomnia, tension, chest fullness, difficulty making decisions, ribside pain, frequent sighing, bitter taste in the mouth, possible vomiting, a red tongue with a yellow greasy coat, and a rapid slippery pulse.
   • Treatment Principles: Clear heat, transform phlegm, course the liver and gallbladder, calm the shen.
   • Points: GB43 and LVR 2 to clear heat and course qi; P6 to open the chest, descend qi and calm the shen; GB 24 to resolve damp heat; PC 5 to transform phlegm that mists the heart.

2. Heart and Spleen Qi Deficiency with Qi Stagnation and Blood Stasis

   This pattern is primarily caused by heart qi xu which in turn leads the blood to move more quickly in an attempt to nourish the body. This increased flow leads to an increased heartbeat, and shortness of breath. When the heart lacks blood, the shen is not nourished and becomes uprooted. Similarly, if the qi of the chest is depleted, qi does not flow freely, which leads to obstruction of the chest and a feeling of chest oppression.

   • Symptoms: Sudden fear, tension, dread, restlessness, shortness of breath, rapid heart beat, chest oppression, insomnia, profuse dreams, a dark pale tongue, and a thin, weak, and perhaps irregular pulse.
   • Treatment principles: Tonify the qi, nourish the heart, quicken the blood and unblock the qi in the vessels.
   • Acupoints: LI 4 and LVR 3 to course qi and remove obstruction; PC 6 to open the chest and calm the shen; ST 36 to tonify the qi; UB 17 to benefit the blood; HT 7 to nourish the heart; GB 20 to descend qi.

3. Heart Qi Stagnation and Blood Stasis

   This pattern arises due to the seven affects disrupting the free flow of qi, which results in qi stagnation and blood stasis. Over time stagnation leads to malnourishment of the heart spirit, resulting in symptoms of anxiety.

   • Symptoms: Chronic worry and anxiety, forgetfulness, vexation, insomnia, agitation, sallowness, severe heart palpitations, fear and dread, belching and hiccups, green circles under the eyes, a dark complexion, a red tongue with stasis macules and/or protruding vessels under the tongue, and a deep wiry or choppy pulse.
   • Treatment principles: Regulate qi and blood, calm the shen
   • Acupoints: LVR 3 and LI 4 to move qi; SP 10 to resolve blood stasis; PC 6 and HT 7 to calm the shen and open the chest. Bleed network vessels if any are visible.

4. Heart Qi and Blood Deficiency with Spleen Qi Deficiency
   • Symptoms: worry and anxiety, fright palpitations, insomnia, fatigue, poor memory, lassitude of spirit, loose stools, poor appetite, cold hands and feet, pale complexion, a swollen scalloped tongue with a thin white coat, and a thin and weak pulse
   • Treatment principles: Tonify the spleen, nourish the heart, supplement the blood, calm the shen
   • Acupoints: UB 15 to nourish the heart and calm the shen; UB 14 to calm the shen; UB 20 to tonify the spleen; UB 17 to supplement the blood; ST 36 to tonify qi; PC 6 to calm the shen.

5. Kidney-Heart Disharmony

   This pattern emerges when kidney yin is deficient and cannot contain yang. Yang then rises upwards and harasses the heart spirit. This classic pattern is characterized by fire above and cold below. The vacuity below accounts for the back pain, knee pain and frequent urination. The deficiency fire above accounts for the fright and agitation as well the classic yin xu heat signs.

   • Symptoms: Fright, agitation, dizziness, insomnia, tinnitus, heart palpitations, tidal fever, night sweats (optional), 5 palm heat, malar flush, frequent nocturnal urination, low back and knee pain, a red tongue with sparse or no coating, a thin and rapid or surging pulse. The pulse may also lack root.
   • Treatment principles: Nourish yin, clear deficiency heat, calm the shen.
   • Acupoints: KD 3 to nourish the kidneys; KD 7 to clear deficiency heat and regulate sweating; PC 5 to de-mist the heart and calm the shen; DU 20 to descend qi and calm the shen; Yin Tang to calm the shen; HT 7 to sedate the heart.

6. Liver and Heart Blood Deficiency
   • Symptoms: Palpitations, fearful throbbing, profuse dreaming, insomnia, amnesia, dizziness, tremors of the hands and feet, irritating sensation of the eyes, pale complexion, a pale tongue, and a weak pulse.
   • Treatment principles: Nourish the blood, calm the shen.
   • Acupoints: UB 17 to nourish the blood; HT 7 and UB 15 to nourish the heart and calm the shen; KD 3 to nourish the kidneys; UB 20 to tonify the spleen and promote blood production.

References

Dan-Xi, Zhu. Dan Xi Zhi Fa Xin Yao (The Heart and Essence of Dan-Xi’s Methods of Treatment). Translated: Shou-Zhong, Yang. Boulder: Blue Poppy Press, 1993.

Flaws, Bob, and James Lake. Chinese Medical Psychiatry. Boulder: Blue Poppy Press: 2001.

National Center for PTSD website: www.ncptsd.com.

National Institute of Mental Health website: www.nimh.nih.gov.

Servan-Schreiber, David, The Instinct to Heal: Curing Depression, Anxiety, and Stress Without Drugs and Without Talk Therapy, USA: Rodale, 2004.

Shin, Lisa, et al, “Regional Cerebral Blood Flow in the Amygdala and Medial Prefrontal Cortex During Traumatic Imagery in Male and Female Vietnam Veterans with PTSD,” Archives of General Psychiatry 61 (2004): 168-176.

Van Der Kolk, “The Body Keeps Score: Memory and the Emerging Psychobiology of Post Traumatic Stress.” Harvard Review of Psychiatry 1 (1994): 253-265.

Wiseman, Nigel, and Feng Ye. A Practical Dictionary of Chinese Medicine, 2nd Edition. Brookline: Paradigm Publications: 1998.

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