TREATMENT

Recent wars and conflicts have advanced our ability to diagnose and treatment warrior stress. However, past and current treatment options have failed to fully address the problem. In the final analysis, warriors end up carrying a disproportionate amount of stress:

  • Twenty percent of all medical evacuees during WWII consisted of the neuropsychiatric effects of combat;1 and twenty years following the end of the Vietnam War, over 15% of Vietnam Veterans met criteria for PTSD.2

  • A recent study of military personnel returning from Iraq found either a 12% or a 20% prevalence rate of PTSD, depending on the stringency of symptom endorsement used.3
  • An estimated 300,000 veterans have returned from Iraq and Afghanistan with PTSD.4
  • In some veterans, PTSD appears to worsen with time and may be worsened by medical comorbid conditions such as pain and disfigurement, which further increases both the burden and costs associated with combat injury.5-6

TREATMENT GUIDELINES
Current treatments for warrior stress and PTSD include psychotherapy and pharmacotherapy. The World Council of Anxiety, the International Consensus Group on Depression and Anxiety, The American Psychiatric Association, and the Departments of Defense and Veterans Affairs have each published guidelines for the treatment of PTSD. In general, these guidelines recommend the use of psychotherapy for the treatment of mild PTSD and a combination of psycho- and pharmacotherapy for the treatment severe or chronic PTSD. Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are considered the first-line choice for psychotherapy and pharmacotherapy, respectively.7,8

TREATMENT LIMITATIONS
Studies indicate that the recommended modes of treatment have modest success rates with combat-related PTSD. Though there has been some evidence to support the use of CBT and SSRIs for the treatment of combat-related PTSD, the overall literature has yielded mixed results.5,9-19 Suggested reasons for treatment resistance of combat-related PTSD include high symptom severity, gender, nature and severity of the trauma, high rate of chronicity and comorbidity, and possible combat-specific signs and symptoms.20 Mainstream psycho- and pharmacotherapies for the treatment of PTSD also have a number of limitations to their practical use and acceptability for an important subset of patients. These include cost, side-effects, adherence, and stigma. 7,12,18,21,22

The growing number of PTSD has been a challenge for both the VA and military healthcare systems. More effective treatment methods could significantly alleviate the current situation and research for new treatments needs to continue.

ACUPOINT TREATMENTS
Acupuncture has had preliminary success in the treatment of stress and anxiety23-25 as well as pain conditions,26-30 and has potential to be a safe, effective, and acceptable treatment for combat-and non-combat-related PTSD. (See the "How it Works" section for more details.) However, there are several limitations to acupuncture including training, certification, needling, and supplies. It is also something that warriors cannot do by themselves or with one another.

MILITARY RELEVANCE
If acupressure point tapping proves to be an effective way in resolving warrior stress, it can potentially help warriors who are not receiving the current standard of care or complementary treatments, i.e. acupuncture. If proven effective, training warriors and clinical professionals in acupoint tapping techniques could decrease warrior stress and improve the quality of life, relationships, and resiliency for military personnel and their families.

REFERENCES

1. Brill, N. Q. (1966). Hospitalization and disposition. In A. J. Glass & R. J. Bernucci (Eds.), U.S. Army neuropsychiatry in World War II (Vol. 1, pp. 212). Washington, DC: Office of the Surgeon General; Department of the Army.

2. Kulka, R. A., Schlenger, W. E., & Fairbank, J. (1990). Trauma and the Vietnam war generation: Bruner-Mazel.

3. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in iraq and afghanistan, mental health problems, and barriers to care. N Engl J Med, 351(1), 13-22.

4. Tanielian, T., Jaycox, L. H. (Eds). (2008). Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica: Rand Corp. MG-720-CCF.

5. Schnurr, P. P., Friedman, M. J., Foy, D. W., Shea, M. T., Hsieh, F. Y., Lavori, P. W., et al. (2003). Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: Results from a department of veterans affairs cooperative study. Arch Gen Psychiatry, 60(5), 481-489.

6. Wolfe, J., Proctor, S. P., Erickson, D. J., Heeren, T., Friedman, M. J., Huang, M. T., et al. (1999). Relationship of psychiatric status to gulf war veterans' health problems. Psychosom Med, 61(4), 532-540.

7. Stein, DJ, Bandelow, B, Hollander, E, Nutt, DJ, Okasha, A, Pollack, MH, Swinson, RP, &Zohar, J. (2003). WCA recommendations for the long-term treatment of Posttraumatic Stress Disorder, CNS Spectrums, 8 (8), 31-38.

8. Ballenger, JC, Davidson, JR, Lecrubier, Y, Nutt, DJ, Foa, EB, Kessler, RC, McFarlane, AC, & Shalev, AY. (2000). Consensus statement on Posttraumatic Stress Disorder from the International Consensus Group on Depression and Anxiety, Journal of Clinical Psychiatry, 61 (5), 60-66.

9. Van der Kolk, BA, Dreyfuss, D, Michaels, m, Shera, D, Berkowitz, R, Fisler, R, & Saxe, G. (1994). Fluoxetine in Posttraumatic Stress Disorder, Journal of Clinical Psychiatry, 55 (12), 517-522.

10. Creamer, M., Morris, P., Biddle, D., & Elliott, P. (1999). Treatment outcome in Australian veterans with combat-related Posttraumatic Stress Disorder: A cause for cautious optimism? Journal of Traumatic Stress, 12 (4), 545-559.

11. Friedman, M. J. (2002). Future pharmacotherapy for post-traumatic stress disorder: Prevention and treatment. Psychiatr Clin North Am, 25(2), 427-441.

12. Hertzberg, MA, Feldman, ME, Beckham, JC, Kudler, HS, & Davidson, JRT. (2000). Lack of efficacy for Fluoxetine in PTSD: A placebo controlled trial in combat veterans, Annals of Clinical Psychiatry, 12 (2), 101-105.

13. Johnson, DR, & Lubin, H. (1997). Treatment preferences of Vietnam veterans with Posttraumatic Stress Disorder, Journal of Traumatic Stress, 10 (3), 391-405.

14. Ruzek, JI, Riney, SJ, Leskin, G, Drescher, KD, Foy, DW, 7 Gusman, FD. (2001). Do Post-Traumatic Stress Disorder symptoms worsen during trauma focus group treatment?, Military Medicine, 166, 898-902.

15. Monson, CM, Schnurr, PP, Stevens, SP, & Guthrie, KA. (2004). Cognitive-behavioral couple's treatment for Posttraumatic Stress Disorder: Initial findings, Journal of Traumatic Stress, 17 (4), 341-344.

16. Glynn, SM, Eth, S, Randolph, ET, Foy, DW, Urbaitis, M, Boxer, L, Paz, GG, Leong, GB, Firman, G, Salk, JD, Katzman, JW, & Crothers, J. (1999). A test of behavioral family therapy to augment exposure for combat-related Posttraumatic Stress Disorder, Journal of Consulting and Clinical Psychology, 67 (2), 2430251.

17. Escalona, R, Canive, JM, Calais, LA, & Davidson, JR. (2002). Fluvxamine treatment in veterans with combat-related Post-Traumatic Stress Disorder, Depression and Anxiety, 15 (1), 29-33.

18. Davis, LL, Jewell, ME, Ambrose, S, Farley, J, English, B, Bartolucci, A, & Petty, F. (2004). A placebo-controlled study of Nefazodone for the treatment of chronic Posttraumatic Stress Disorder, Journal of Clinical Pharmacology, 24 (3), 291-297.

19. Rothbaum, BO, Hodges, L, Alarcon, R, Ready, D, Shahar, F, Graap, K, Pair, J, Hebert, P, Gotz, D, Wills, B, & Baltzel, D. (1999). Virtual reality exposure therapy for PTSD Vietnam veterans: A case study, Journal of Traumatic Stress, 12 (2), 263-271.

20. Zohar, J, Amital, D, Miodownik, C, Kotler, M, Bleich, A, Lane, RM, & Austin, C. (2002). Double-blind placebo-controlled pilot study of Sertraline in military veterans with Posttraumatic Stress Disorder, Journal of Clinical Psychopharmacology, 22 (2), 190-195.

21. Marshall, RP, Jorm, AF, Grayson, DA, & O'Toole, B. (2000). Medical-care costs associated with Poasttraumatic Stress Disorder in Vietnam veterans, Australian and New Zealand Journal of Psychiatry, 34, 954-962.

22. McDonagh, A, Friedman, M, McHugo, G, Ford, J, Sengupta, A, Mueser, K, Demment, CC, Fournier, D, Schnurr, PP, & Descamps, M. (2005). Randomized trial of cognitive-behavioral therapy for chronic Posttraumatic Stress Disorder in adult female survivors of childhood sexual abuse, Journal of Consulting and Clinical Psychology, 73 (3), 515-524.

23. Chen, A. (1992). An introduction to sequential electric acupuncture (sea) in the treatment of stress related physical and mental disorders. Acupunct Electrother Res, 17(4), 273-283.

24. Kober, A., Scheck, T., Schubert, B., Strasser, H., Gustorff, B., Bertalanffy, P., et al. (2003). Auricular acupressure as a treatment for anxiety in prehospital transport settings. Anesthesiology, 98(6), 1328-1332.

25. Wang, J. D., Kuo, T. B., & Yang, C. C. (2002). An alternative method to enhance vagal activities and suppress sympathetic activities in humans. Auton Neurosci, 100(1-2), 90-95.

26. Alimi, D., Rubino, C., Pichard-Leandri, E., Fermand-Brule, S., Dubreuil-Lemaire, M. L., & Hill, C. (2003). Analgesic effect of auricular acupuncture for cancer pain: A randomized, blinded, controlled trial. J Clin Oncol, 21(22), 4120-4126.

27. Kvorning, N., Holmberg, C., Grennert, L., Aberg, A., & Akeson, J. (2004). Acupuncture relieves pelvic and low-back pain in late pregnancy. Acta Obstet Gynecol Scand, 83(3), 246-250.

28. Nesheim, B. I., Kinge, R., Berg, B., Alfredsson, B., Allgot, E., Hove, G., et al. (2003). Acupuncture during labor can reduce the use of meperidine: A controlled clinical study. Clin J Pain, 19(3), 187-191.

29. Sim J, Adams N. (2002) Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia. Clin J Pain. 18(5):324-36.

30. Sim, C. K., Xu, P. C., Pua, H. L., Zhang, G., & Lee, T. L. (2002). Effects of electroacupuncture on intraoperative and postoperative analgesic requirement. Acupunct Med, 20(2-3), 56-65.