Case Report: Acupuncture in the Treatment of Symptoms of Anxiety and Stress with Comorbidities of Post-Traumatic Stress Disorder and Dissociative Identity Disorder
Author: Paul New
Bastyr University-Kenmore, WA, United States
Anxiety and stress are common disorders that affect many people in the world today. According to a report published by the World Health Organization, acupuncture has proven effective in treating both of these conditions in controlled clinical trials. This case report documents 1 patient experiencing anxious feelings and stress associated with diagnoses of Post-Traumatic Stress Disorder and Dissociative Identity Disorder. The patient had a primary mental health provider whom she saw for therapy and counseling but was not taking any prescription medication for her conditions. This report documents the use of acupuncture successfully to lessen the frequency and severity of anxious feelings and stress. Further research is needed on the effectiveness in treating the aforementioned disorders in patients with comorbidity of PTSD and DID.
Anxiety disorders, stress, post-traumatic stress disorder (PTSD), Dissociative Identity Disorder (DID), acupuncture
In a 2001 report by the World Health Organization on mental health1, it states that an estimated 450 million people suffer from mental, neurological, or psychosocial problems worldwide, with only a small portion of those people receiving any form of treatment. Globally, many people are victimized for their illness and become the targets of discrimination. Mental disorders represent four of the 10 leading causes of disability worldwide. Furthermore, mental and behavioral disorders are estimated to account for 12% of the global burden of disease, yet the mental health budgets of the majority of countries constitute less than 1% of their total health expenditures1. Psychological distress refers to a state of general emotional discomfort in response to a stressor or demand2 and is typically characterized by symptoms of depression and anxiety3,4,5. These symptoms often coexist6 and co-occur with common somatic complaints7 e.g., insomnia, headaches and fatigue; a wide range of chronic conditions8, as well as with medically unexplained syndromes9 e.g., IBS and fibromyalgia.
Current guidance suggests watchful waiting, pharmacological and non-pharmacological treatment and referral to specialist care as possible strategies for treating psychological distress, depending on the severity of symptoms, level of functional impairment, as well as patient preferences9,10. Watchful waiting accompanied by general advice may be recommended in mild cases, given that many patients experience spontaneous resolution of their symptoms over time11 . Nonetheless, patients often consider this strategy to be unhelpful and prefer active treatment12. Psychotropic medication is recommended for moderate-to-severe cases10,11, although their use even in severe cases is debated13. Up to one-fifth of patients have been found to consider medication unbeneficial12 and many patients prefer not to take such medication14. A wide variety of non-pharmacological interventions, including psychological, behavioral and psychosocial therapies, may be offered in primary care and there is some evidence for their efficacy, particularly cognitive behavioral therapy15.
The use of complementary and alternative medicine (CAM) modalities for treating psychological distress is substantial16 and it has been suggested that people with this condition are more likely to use CAM therapies than conventional medical or mental health treatments17. One of the most widely used CAM therapies is acupuncture18. Acupuncture has been shown to reduce psychological distress in many studies and four systematic reviews, including one from the Cochrane Collaboration, concluded that although results to date have been mixed and despite methodological deficiencies, acupuncture appears to be a promising treatment option for psychological distress19,20,21,22. For example, a moderate-large effect size (.73) between manual acupuncture versus waiting list in reducing depression was reported in a recent Cochrane review22. The mechanisms underlying the effects of acupuncture on psychological distress are not fully understood. Acupuncture may influence neurotransmitter and hormonal pathways underlying emotional states. For example, acupuncture stimulates secretion of serotonin and norepinephrine23, two neurotransmitters presumed to be associated with depression24. Acupuncture may also stimulate sensory nerves, induce the release of endogenous opioids and modulate the autonomic nervous system25 and thereby influence mood and increase the patient’s sense of well-being.
The patient is a 36-year-old female who presented to the Oregon College of Oriental Medicine (OCOM) downtown clinic in October 2015 with a chief complaint of body memories and secondary complaints of anxious feelings and feelings of stress. She has Western diagnoses of post-traumatic stress disorder (PTSD) and dissociative identity disorder (DID), as well as Alopecia Areata. She is an information technologist consultant who has received 141 treatments in the OCOM clinic, of which I performed 40 of those treatments.
She has had episodes of anxious feelings and stress for most of her life; symptoms that accompany her PTSD and DID. This past year they have been more frequent and bothersome, with some manifesting to a more severe level. The patient also experiences physical pain that results from “body memories,” resulting from her childhood sexual abuse/trauma, both physical and mental. She presents with areas of “puffiness/swelling” around her eyes, ears, the occipital region and posterior head, as well as the lateral aspect of her upper torso and lower back. She states that this is not a result of inflammation, rather it is her body’s way that it stores the traumas that she experienced as a child. She states that emotional flashbacks trigger her muscles to tighten and spasm, heart palpitations, shortness of breath, panic attacks, feeling of a lump in her throat preventing her from speaking, headaches, alternating fever and chills, and loss of physical coordination. In severe situations, the pain is a 10/10, she can lose sensory function, bodily function, and black out. She has a mental health provider/psychotherapist whom she sees on a regular basis for those aspects of treatment.
The patient had received acupuncture a few times before coming to OCOM and has been receiving regular acupuncture treatments for over 3 years now. She has been prescribed a few formulas in the past, but didn’t tolerate them well, so I have mainly focused on acupuncture treatments. She does not take any other prescribed or over the counter (OTC) medications except Advil, but that is only on rare occasions. She has seen continued improvement in her symptoms since coming to OCOM, with the most noticeable results/improvements coming over a 4-month period from April to July of 2019. The patient stated that the last 2 months of treatments and results have been the best she has had since first coming to OCOM. She has a family history of breast cancer with her maternal grandmother and stomach cancer with her paternal grandfather. Patient has a history of childhood sexual trauma, physical and emotional abuse, PTSD, DID, alopecia areata, deviated septum in 1999, broken arm twice in 1980’s, partial hospitalizations in 2009 and 2012 for increase in PTSD symptoms, multiple imaging (MRI, X-Ray, etc.) for unexplained menses pain 1999-2000, and tubal ligation surgery in March 2019.
The following Traditional Chinese Medicine (TCM) diagnostic information was collected at her first visit with me in the clinic: Her subjective feeling of temperature is usually cold, especially in her hands and feet. She experiences night sweats often, sometimes saturating her clothes and sheets. She has occasional headaches that occur on the sides of the head, around the ears, and the occipital area which she states are usually caused by her body storing traumatic memories in this area. She has congestion in the sinus/temporal area, but she explains that it is another area in which her body stores traumatic memories rather than phlegm or mucous. She occasionally has heart palpitations and shortness of breath, but the treatments help to mitigate their frequency and severity. Her appetite is “good,” she eats 2-3 meals a day and reports thirst as normal but doesn’t feel that she drinks enough water. She prefers room temperature or warm liquids. She reports that her digestion is fair, with a lot of bloating, gas, and some discomfort at times, with feelings of “stuckness” in her abdomen. Her bowel movements are once or twice daily, usually loose and sticky. Urination feels complete and adequate for the amount of intake. Her menses are irregular, sometimes late or non-existent, with varied length, flow, and color of blood. Her sleep is not good, with trouble falling asleep, staying asleep and vivid nightmares/dreams. She states her mental/emotional well-being as fair, diet is good but craves chocolate as a comfort food, and she does yoga, meditation, and walks for exercise. Patient reports no caffeine, alcohol, tobacco or drug use.
The patient is of average build, weighing 124 pounds at her last appointment and is 5’2”. Her last blood pressure reading was 120/75, pre-treatment, left arm and seated, and her last pulse rate was 70bpm. She is attentive and friendly, smiles and makes good eye contact during the conversation. She has moments of rapid eye movement/flutters that she states as a visible sign of other personalities trying to surface. Her pulse is deep and wiry in all positions. Her tongue is puffy with red sides, toothmarks, and redder at tip, deep center crack, with a split in the center at the tip. The coat is thick, greasy, yellow toward the root, little to no coat at the tip.
The only outcome measurement tool I have used with this patient is to measure symptom free days between each weekly treatment. Prior to the first visit with me, 2 days was the average per week.
Her TCM disease diagnosis is anxious feelings and stress and her working TCM pattern is qi and blood stagnation in the shaoyang channels with underlying HT and KI disharmony, LV/GB Damp-Heat, and LV qi stagnation invading SP and ST. Her working Korean Theory pattern is shaoyang excess. The validating symptoms are the nature and location of her pain, a history of trauma and sexual abuse as a child, her symptoms are worse with stress, body memory pain, insomnia, vivid dreams/nightmares, night sweats, mental restlessness, hypochondriac distension and pain, loose stools, bloating, flatulence, irregular menstruation, deep, wiry pulses, puffy, red tongue with red sides and tip, center crack with split in tongue at tip, no coat at tip and thick, greasy yellow coat at root.
The treatment principles are to move qi and blood in the channels, balance channels, calm shen, and stop pain. Utilizing Korean theory and treatment methods, the results were longer periods of symptom free days; 3-5 on average, with some weeks being symptom free for seven days. I utilized four different Korean theory protocols depending on the symptoms present at the time of treatment: Gate Opening (Tong Gi Chim), Meridian Flow (Ju Haeng Chim), and Four Needle Technique (Sa’ Am Chim). Sterile, disposable acupuncture needles (Balance P-Type 0.20 x 15 mm) were inserted transversely, angled with the channel for tonification, and at away from the channel to reduce at a depth of approximately 1 mm to 2 mm. Needles were retained for a length of 25 minutes per treatment. The initial treatment utilized the Meridian Connecting treatment, an introductory technique of the more complex Meridian Flow Theory (Ju Haeng Chim) protocol which consists of 7 points (ST36, GB41, SP4, PC6/SJ5, LV14, RN12, Yin Tang), needled in that specific order on the right side only (for female) and removed in the opposite order. PC6 or SJ5 is chosen by the practitioner based on whether Yin Wei or Yang Wei channel treatment is more applicable. I chose SJ5 rather than PC6 for the initial treatment, although I do feel that this patient would also benefit from treatment of the Yin Wei channel as well. The patient presented with a more Yang Wei pattern than Yin Wei at the initial treatment. Treatments after that consisted of Gate Opening (Tong Gi Chim) points which alternated weekly between LI4 and LV3 or HT7 and GB40 bilaterally to begin each treatment session, in addition to Four Needle Technique (Sa Am Chim) points LV1, PC9, KD10, PC3, or GB41, SJ3, BL66, SJ2 alternated weekly (See Table 1). For the Gate Opening protocols, LI4 was always inserted first on the right side followed by LV3 on the left side, then LI4 on the left side followed by LV3 on the right side on all even numbered weeks. On odd numbered weeks, HT7 was always inserted first on the right side followed by GB40 on the left side then HT7 on the left side followed by GB40 on the right side. The four needle point protocols were always needled on the right side of the patient with the tonified points needled first followed by the sedated points. As previously stated, I have not prescribed any Chinese herbal formulas for the patient due to sensitivities and allergies to multiple substances.
The treatment protocols were selected specifically for the patient based upon her chief complaint symptoms, her TCM pattern diagnosis, and her Korean Theory pattern. The Meridian Connecting treatment was chosen as the initial treatment because it uses the eight extraordinary channels. The eight extraordinary channels serve as a reservoir for the 12 channels. Activating the confluent, or meeting points, is similar to opening a dam to refill the channels. The rational for the point selection in this protocol is as follows: ST36 is the initial point because it supports post-natal qi and blood and energetically it is linked with SP4 and RN12. GB41 activates the Dai channel and SP4 activates the Chong channel. PC6 activates the Yin Wei channel and SJ5 activates the Yang Wei channel (SJ5 was chosen as the Yang Wei was more applicable). LV14 is the last point in the cycle of qi flow, while RN12 is the first point because that is where the LU channel begins. Qi flow has a higher probability of stagnating at this interchange than any other since it is not only a link between channels, but also the circuit junction. The addition of yintang opens the upper Dan Tian (third eye) and brings mental clarity, assisting the natural progression of harmony and balance in the physical body 24 . The Wei channels are extraordinary channels that are known as the linking channels that link all yin and yang together. They can be used to treat depression, lack of self-worth, ruminating thinking, loss of will 25. Wei Channels are like a silk cloth containing history of one’s life. Deal with both the past and the future. The Yang Wei channel allows for a patient to make changes in their life. Psychological symptoms associated with the Yang Wei channel are not living in the moment, PTSD (or when a patient keeps repeating the past in the present moment), uncertainty, social anxiety, unable to organize or prioritize, unable to transform emotional states, failure to reach full potential, no given direction in life, settling for 2nd best 26. The Gate Opening protocol of LI4 and LV3 was chosen because it is known as the four gates in TCM. Together, these points work to circulate the qi and blood through the body. They help to open all the meridians, increase circulation, and decrease pain anywhere in the body. The 4 Gates can also be used for emotional issues as well such as feelings of being trapped or stuck in a situation. The HT7 and GB40 protocol was chosen because according to H.B Kim, this combination targets the HT and GB for patterns that fit the Chinese herbal formula, Wen Dan Tang pattern. I chose this as an alternative Gate Opening treatment because the patient did not tolerate herbal formulas well, but her symptoms matched the pattern for prescribing this formula. Finally, the Korean four-needle treatment protocol uses the generating cycle to select which points to use. The treatment principle is to tonify the mother point of the affected channel, tonify the mother point of the mother channel, sedate/drain the grandmother point of the affected channel, and sedate/drain the grandmother point of the grandmother channel. I chose the two four-needle protocols based upon her four-needle pattern indication of shaoyang excess. The shaoyang channels are the LV and GB. I chose to tonify the jueyin channels of PC and SJ, which are paired with the shaoyang channels in the four-needle treatment technique. The Nan Jing chapter 69 says “It is like this. In case of depletion, fill the respective conduit’s mother. In case of repletion, drain the respective conduit’s child. One must fill first and drain after-ward.” 27
|
WEEK |
MERIDIAN CONNECTING |
GATE OPENING |
PC |
SJ |
|
1 |
ST36 GB41 SP4 SJ5 LV14 RN12 Yin Tang |
NONE |
NONE |
NONE |
|
2 |
|
LI4 LV3 |
(+) LV1 (+) PC9 (-) KD10 (-) PC3 |
|
|
3 |
|
HT7 GB40
|
|
(+) GB41 (+) SJ3 (-) BL66 (-) SJ2
|
|
4 |
|
LI4 LV3 |
(+) LV1 (+) PC9 (-) KD10 (-) PC3 |
|
|
5 |
|
HT7 GB40 |
|
(+) GB41 (+) SJ3 (-) BL66 (-) SJ2
|
|
6 |
|
LI4 LV3
|
(+) LV1 (+) PC9 (-) KD10 (-) PC3 |
|
|
7 |
|
HT7 GB40 |
|
(+) GB41 (+) SJ3 (-) BL66 (-) SJ2
|
|
8 |
|
LI4 LV3 |
(+) LV1 (+) PC9 (-) KD10 (-) PC3 |
|
|
9 |
|
HT7 GB40 |
|
(+) GB41 (+) SJ3 (-) BL66 (-) SJ2
|
|
10 |
|
LI4 LV3 |
(+) LV1 (+) PC9 (-) KD10 (-) PC3 |
|
|
11 |
|
HT7 GB40 |
|
(+) GB41 (+) SJ3 (-) BL66 (-) SJ2
|
|
12 |
|
LI4 LV3 |
(+) LV1 (+) PC9 (-) KD10 (-) PC3 |
|
|
13 |
|
HT7 GB40 |
|
(+) GB41 (+) SJ3 (-) BL66 (-) SJ2
|
|
14 |
|
LI4 LV3 |
(+) LV1 (+) PC9 (-) KD10 (-) PC3 |
|
|
15 |
|
HT7 GB40 |
|
(+) GB41 (+) SJ3 (-) BL66 (-) SJ2
|
|
16 |
|
LI4 LV3 |
(+) LV1 (+) PC9 (-) KD10 (-) PC3 |
|
She was placed on a treatment plan for one time per week for six weeks. Because she reported progress marked by the lessoning in frequency and intensity of the episodes of anxious feelings and stress, I continued to treat her for another 10 weeks in which I stopped treating her due to graduating from my master’s program and no longer having access to treating the patient. Due to the chronic nature of the symptoms she experiences, the focus is to minimize the frequency of symptoms between treatments, mental, emotional, and physical, with the long-term goal to reduce the frequency of treatments to bi-weekly, then once a month, and eventually release her to an as-needed treatment plan.
It is difficult to draw a definitive conclusion from this case study about the effectiveness of Korean Theory acupuncture and in treating anxious feelings and stress due to the chronicity of the condition in this patient and the other mental health conditions that she has. However, the lessoning of the frequency and severity of the anxious feelings and stress that she experiences with regular treatments, are markers of progress. Further, there is a realization and concern for more in-depth and quality research in the areas of effective mental health treatments as well as how to use integrative approaches for the best possible treatment outcomes and patient care.
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