With the goal of helping readers to navigate the growing literature on CAM, below we briefly review the current evidence for the most well-established mind-body therapies for PTSD: acupuncture, relaxation training, and meditation.
Based on that evidence, we make recommendations as to the next appropriate steps in pursuing the development of these interventions.
Acupuncture, a modality of Chinese medicine, encompasses a group of therapies in which needles are inserted into subcutaneous tissue in order to restore balance within body systems. For those interested, Hollifield (2011) provides an accessible summary of the conceptual rationale and proposed biological mechanisms in support of the potential efficacy of acupuncture for PTSD.
One good-quality study identified in the Strauss et al. (2011) review found that improvement in PTSD following 12 weeks of biweekly, 60-minute acupuncture sessions was comparable to a group CBT and greater than waitlist control in a predominantly male, non-Veteran sample (Hollifield, Sinclair-Lian, Warner, & Hammerschlag, 2007). Treatment gains following acupuncture were retained at the 24-month follow-up.
Although the study was methodologically rigorous, strong conclusions cannot be drawn from a single RCT. This study also highlights the challenge of selecting an adequate comparison condition for these novel interventions. The control that was used, a group intervention that included psychoeducation, CBT skills (e.g., behavioral activation, activity planning, cognitive restructuring), and exposure exercises, may have been selected to provide a comparison to treatment as usual or minimal good treatment.
Nonetheless, it does not control for critical features of the technique, such as the application of needles. To understand whether or not study results could be driven by different expectations about the treatments, a control such as placing needles in sham sites would be necessary. Thus, we believe that proof-of-concept has been established for acupuncture, but recommend withholding judgment about its effectiveness for PTSD until additional controlled trials have been conducted.
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Strauss et al. (2011) identified three relatively small RCTs of relaxation techniques; they did not demonstrate significant clinical improvement relative to active comparators (Echeburúa, de Corral, Sarasua, & Zubizarreta, 1996; Vaughan et al., 1994; Watson, Tuorila, Vickers, Gearhart, & Mendez, 1997). In each case, interpretation of study findings was hampered by significant methodological flaws, including ambiguous reporting of randomization and treatment of missing data, nonblinded group assignment and/or assessments, and inadequate statistical power. In some cases, lack of clarity about differences between components of the intervention and active comparator further complicate the picture. Additionally, the Echeburúa et al. (1996) study compared a CBT intervention that included instruction in progressive muscle relaxation (PMR) to PMR alone, but the differences in “dosing” and the introduction of PMR within these protocols was not specified. Of note, the Strauss et al. (2011) review of relaxation studies was limited to those in which the intervention was conceptualized as an active treatment and described in sufficient detail to understand the key components.
Five additional studies, in which relaxation showed modest effects and performed less well than active comparators, were excluded
from that review based on these criteria. Relaxation likely has a role to play in helping to manage the arousal associated with PTSD, but relaxation alone is unlikely to be sufficient to reduce other types of symptomatology for many people with PTSD.
The first studies of meditation techniques for PTSD involved mantra meditation (including transcendental meditation and mantra my repetition), a type of meditation that involves intensely focusing attention on an object or word. Studies of these techniques have shown some positive effects but are limited by small sample sizes, enrollment of exclusively male Veterans, and lack of follow-up (Bormann, Thorp, Wetherell, & Golshan, 2008; Brooks & Scarano, 1985). Thus, these studies primarily demonstrate the feasibility of enrolling and retaining Veterans in mediation group interventions.
More recently, Bormann et al. (2012) compared the addition of mantra my repetition to usual care (i.e., medication and case management) to usual care alone, and found modest improvements in symptoms of depression and PTSD. Without a control for nonspecific aspects of the group meetings, however, it is difficult to definitively attribute these gains to use the man tram approach. Work is ongoing to more definitely answer this question. Kearney and colleagues (2012) conducted an uncontrolled study of mindfulness-based stress reduction (MBSR) as an adjunct to usual care for Veterans with PTSD.
MBSR is a group intervention that incorporates mindfulness practices, including meditation and yoga. The authors reported a medium effect size in the change in PTSD, depression, and functioning in those who took part in the group. Although mechanisms of change could not be determined by this uncontrolled study design, it is notable that changes were mediated by changes in mindfulness. Because MBSR is a well-established intervention with some demonstrated effectiveness for treatment of anxiety more generally, additional empirical evaluation of MBSR is indicated.
A struggle for those who undertake such studies will be the selection of appropriate controls. For example, it may be appropriate to compare mindfulness to relaxation, to establish that observed changes are attributable to something more than a quiet pause in one’s day. Alternately, it may be important to compare a mindfulness-based approach to other commonly used coping skills, such as cognitive-behavioral anxiety management techniques.
Lang et al. (2012) recently reviewed the theoretical basis for three types of meditation as an intervention for PTSD. Based on the extant literature in this area, it appears that there could potentially be different mechanisms underlying different types of meditative practice. The literature on cognitive changes related to mindfulness suggests that through the practice of shifting attention and assuming a nonjudgmental stance, patients may learn to be less reactive to intrusive or ruminative thoughts. Mantra meditation has more commonly been linked to decreasing physiological arousal.
For patients with PTSD, this may be a good coping strategy for times when memories are intentionally (as in exposure-based therapy) or unintentionally triggered. Compassion meditation, which involves directing feelings of warmth and compassion towards others, has been linked to increases in positive emotion and social connectedness. Given the deficits in positive emotion and feelings of connection with others that are characteristic of PTSD, compassion meditation is a promising strategy but is without empirical application to PTSD. It is also possible that there are nonspecific factors common to all of these types of meditation. Future research should evaluate these approaches and attempt to understand the mechanisms by which they create change.
In summary, CAM is widely requested and used by consumers for a variety of complaints and conditions, and the relevant research base is rapidly evolving. The umbrella of CAM modalities includes a broad range of approaches, not all of which may hold the same level of promise for the treatment of PTSD.
Preliminary findings, albeit mixed, suggest that CAM treatments merit consideration. At this point, there is very limited empirical evidence of their effectiveness, so they may be best applied as an adjunct to other PTSD treatments or as a gateway to additional services for patients who initially refuse other approaches.
Overall, the current evidence base does not support the use of CAM interventions as an alternative to current empirically-established approaches for PTSD, or as first-line interventions recommended within evidence-based clinical guidelines.
This article was originally published by National Center for PTSD
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