Releasing Trauma: Late versus Early-Onset in the Treatment of PTSD
The archetypal image of Post-Traumatic Stress Disorder (PTSD) is that of a war-torn veteran, but in an era of rampant accumulating stressors, horrifying news stories, and tragic imagery from around the globe fed daily into our televisions and social media feed, more and more people are showing the signs of psychological wear-and-tear. Whereas we expect the veteran to have flashbacks with sweats and sleep disturbances, the more mild symptoms of PTSD have a wide range: anxiety (with or without sweats and panic attacks), emotional numbness and numbing behaviors (eating, alcohol, drugs, sex, cleaning, organizing, shopping), forgetfulness and short-term memory difficulties (“I don’t even remember how I drove here; good thing for auto-pilot!”) are some of the most common. These are symptoms we see all the time in our clinical practices; they have become the unfortunate norm in our stressed-out culture.
Fortunately, releasing Trauma is pretty straightforward, and there are two major types: Late and Early-Onset. Late- Onset PTSD is based on events that occurred well after the individual formed a healthy sense of self, with proper boundaries and the development of one’s physical and mental abilities. Early-Onset PTSD is based on events that happened at a young age or at any time before the sense of self was fully realized. The treatment protocols for these two types are quite different; here is a basic Chinese Medicine approach for addressing either type.
Late-Onset Trauma: Impact on the Fluids
The Heart-Emperor controls our conscious awareness and short-term memory. If there is too much emotional or stressful experience to be processed, the Heart becomes overwhelmed and unable to perform its functions properly. As the Organ responsible for the production of Blood, some form of fluid pathology will develop. A mild inability to manage the production of Blood is likely to present as Blood Deficiency, which is a common stress-induced pattern. As Blood is the “Mother of Qi”, Qi Deficiency – especially of the Spleen – will often go hand-in-hand with Blood Deficiency due to psychological Trauma.
The Heart is not just in charge of making the Blood, it is also in charge of circulating it. More severe problems with Heart functioning may manifest as Blood Stasis, as the Heart “churns” the Blood in an attempt to process psychologically distressing input. Here it is important to remember that Body Fluids “thin” the Blood to prevent Stasis; instead of allowing Blood Stasis to form, the system may drain Body Fluids to keep Blood flowing properly, creating Yin Deficiency or Phlegm. As Qi is the “Commander of Blood”, it could also work extra hard to keep Blood flowing and prevent Stasis, developing Qi Deficiency and/or Stagnation as well. Clearly these patterns are more likely to show up as Heart Organ problems (i.e., Heart Blood Deficiency, Heart Blood Stasis, Phlegm obstructing the Heart, etc.), but the problem may show up somewhere else as the Kingdom protects the Emperor. Any other Yin Organ can show Late-Onset Trauma pathology as they all have major interaction with the Heart: the Lungs through the Upper Jiao and Zong Qi, the Liver as Heart’s 5 Element Mother, the Kidneys as Heart’s Yin-Yang polar opposite, and the Spleen as Heart’s 5 Element Child.
When a client comes in for “Heart Overwhelm” (they might say Stress Management), there are basic patterns to consider based on the Heart’s functions and relationships to other Organs, as described above. As each of them deal with either fluid nourishment or movement, herbs are critical to get the system working properly. In conjunction with customized Acupuncture treatments, common patent formulas can be used to offset the effects of Late-Onset Trauma; here are some of the most commonly used formulas from my own practice:
- Blood Deficiency: Si Wu Wan, Suan Zao Ren Wan, Shao Yao Gan Cao Wan
- Blood Deficiency with Qi Deficiency: Nu Ke Ba Zhen Wan, Gui Pi Wan
- Blood Deficiency with Qi Stagnation: Xiao Yao Wan
- Blood Deficiency with Blood Stasis: Tao Hong Si Wu Wan
- Blood Stasis: Xue Fu Zhu Yu Tang Wan, Yan Hu Suo Zhi Tong Wan, Shen Tong Zhu Yu Wan
- Phlegm: Er Chen Wan, Nei Xiao Luo Li Wan, Liu Jun Zi Wan, Chai Hu Long Gu Mu Li Wan
- Yin Deficiency: Tian Wan Bu Xin Wan, Liu Wei Di Huang Wan, Gan Mai Da Zao Wan
When choosing herbs, the Trauma itself may dictate the choice of formula. For example, Blood Stasis due to divorce and Heart-break might require Xue Fu Zhu Yu Tang Wan, whereas Blood Stasis due to rape or birth Trauma could be more appropriately treated with Gui Zhi Fu Ling Wan. The age of the client may also play a part as Stagnation is common in middle-aged and older individuals, so Blood Stasis and/or Phlegm may arise more easily than Deficiency.
But what happens if a Traumatic event impacts the system before emotional maturity is complete?
Early-Onset Trauma: The 5 Element Axial Approach
Whereas Late-Onset Trauma can be addressed with Zang Fu Diagnosis of fluid pathology, Early-Onset Trauma gets laid in more deeply. Due to the on-going growth and development of the individual, Trauma goes straight into the non-matured psychological fabric, shifting one’s perspective on the world and the body’s ability to properly function in it. Although there are Zang Fu Patterns commonly seen in Early-Onset Trauma work, the actual damage to the system lies along the North-South or the East-West Axes of Heart-Kidney (North-South) or Liver-Lung (East-West). In the axial concept of the 5 Elements, Earth sits at the center, reflecting stability in the midst of change; because of this central position the Spleen and/or Stomach Organs are impacted by any form of Early-Onset Trauma.
Which Axis has been damaged, and where that obstruction or “break” has occurred are the most important things to identify when approaching Early- Onset Trauma. Fortunately, our understanding of Pattern diagnosis can help pinpoint areas where Trauma has settled in. The “dis-harmonic” combinations due to Axial damage are actually some of the most common patterns we identify as Chinese Medicine practitioners, including:
East – West Axis
- Wood – Earth Disharmony: Liver-Qi Stagnation & Spleen Qi Deficiency, often with Dampness or Phlegm accumulation in the Middle Jiao. Look for IBS and other bowel disorders affecting the Metal Element; consider Xiao Yao Wan, Xiao Chai Hu Wan, or Mu Xiang Shun Qi Wan.
- Wood – Metal Disharmony: Liver & Lung Qi Stagnation, often with Phlegm in the Upper Jiao. Look for Asthma conditions with minor digestive upsets; consider Ban Xia Hou Po Wan (typically in combination with another formula).
- Metal – Earth: Lung & Spleen Qi Deficiency, often with Phlegm in the Upper Jiao. Look for chronic rhinitis, nasal/ chest congestion, sinusitis; consider Er Chen Wan, Si / Liu Jun Zi Wan, Bu Zhong Yi Qi Wan.
North – South Axis
- Fire – Earth Disharmony: Spleen Qi & Heart Blood Deficiency, often with Dampness. Look for anxiety, insomnia; consider Gui Pi Wan, Nu Ke Ba Zhen Wan, Gan Mai Da Zao Wan.
- Earth – Water Disharmony: Spleen & Kidney Yang Deficiency, often with Dampness or Phlegm accumulation in the Middle or Lower Jiao. Look for chronic diarrhea, weight gain, edema; consider Ba Ji Yin Yang Wan, Zhen Wu Tang Wan.
- Fire – Water Disharmony: Heart & Kidney Yang Deficiency or Heart & Kidney Yin Deficiency with Empty-Heat, often with Dampness or Phlegm in any Jiao. Consider Tian Wan Bu Xin Wan, Zhen Wu Tang Wan, Huan Shao Dan, Golden Flower: Gui Zhi Jia Long Gu Mu Li Wan.
By no means is this a comprehensive listing of all Zang Fu Patterns that can develop from Early-Onset Trauma; it is merely a guide to understanding how patterns develop from an Axial perspective. It is worthy to note that Dampness and Phlegm appear frequently in these combinations as the disruption in Qi movement along the axes will obstruct the San Jiao’s ability to regulate the water passages. The development of Dampness or Phlegm is typically dictated by the degree of obstruction and/or the chronic nature of the condition, though Diet and Lifestyle can play a part. Due to the impact on Kidneys, Lungs, and/or Spleen in combination with the impact on “the body’s ability to properly function in the world,” the circulation and functioning of the Wei Qi may be damaged as well; atopic asthma, eczema, allergies, and various auto-immune conditions are commonly seen.
It is also possible that a client has both Early & Late-Onset Trauma. Pattern diagnosis will naturally lead the treatment principles, but make sure to look for evidence of Axial damage along with Blood and Body Fluid issues.
Treatment Guidelines: The Importance of Etiology
When choosing points, herbs, essential oils, or other treatment tools, it is critical to remember that the Etiological origin of the dis-ease is Trauma, a concern of the Spirit. No matter what physical symptoms are present, it is still a Spirit treatment and must be handled as such. This affects:
- Point selection: Utilize points that treat the Spirit, not just the presenting physical symptoms
- Needle insertion: Consider issues of depth, speed, gentleness
- Length of treatment session: This varies greatly among individuals
- Qi Mechanism: The disruption of Qi will obstruct fluids and the San Jiao; incorporate all three Jiaos in your treatment approach to help re-integrate the system.
- Approach: Set your intention before you start treating; Spirit is the most ephemeral and fast-moving form of Qi in the body so it may take very little for the pulse to harmonize.
- Therapy selection: Traumatized clients commonly cannot handle needle insertion or retention and may respond better with moxa, essential oils, or acupressure.
The importance of Etiology also cannot be overlooked when developing the overall treatment plan. For example, treating Blood Deficiency by recommending nourishing foods and bone-broth soups is important, but inviting the client to recognize how much stress their psychological system is under (which is the true cause for the “depletion” of the Blood) is the real key to a full recovery.
Make sure to inform the client that you are working on releasing Trauma, as they might experience emotional upheaval during the post-treatment 24 – 48 hour Qi cycle. Providing them guidance to allow this release is a critical component to processing the event(s) without putting more fear and resistance into the condition. The good news is that – just like anything in Chinese Medicine – this work is easy and effective. If it is done right, you will see dramatic improvements in your clients and reap the benefits of their bountiful gratitude. The following cases can help illustrate many of the treatment principles described above.
Case #1: Vietnam Veteran, early 60’s male
“Tom” had experienced PTSD with anxiety, rage, insomnia, night sweats, nightmares, and flashbacks since surviving multiple days and night of continuous battle at the front lines during the Easter Offensive in March – April 1972. The symptoms started each year in early March and would dissipate in early – mid April, but managing family relationships (wife of 30 + years, and 2 adult children), work, and the Easter holidays was always difficult. Beside the PTSD, “Tom” presented with an overbuilt upper body from heavy workouts, and tension areas in his shoulders (GB 21 – SJ 15 area) and intra-scapular region (UB 13 – 17, and 42 – 46). The swollen sides and dark-distended sublingual veins of his tongue, and the wiry-tight Liver-Heart-Lung pulse positions confirmed my diagnosis of Qi and Blood Stagnation. He also had deep-hidden Kidney pulses; likely due to the combination of age and the Liver Qi chronically over-drawing on the Kidney energy to help “push through” the stasis. As “Tom’s” traumatic event occurred during his early 20’s, I thought there might be some minor involvement of the axes along with Fluid Stagnation (Blood), so I treated Stagnation of Qi & Blood in the Chest (Lungs & Heart) along with Liver Qi Stagnation (an East-West Axis disruption of Liver – Lung). I used both acupuncture and herbs to address the Patterns and to Calm the Shen & Hun. Weekly treatments began in late February.
- Points were rotated, selected from the following categories: GB 21 & GB 34, GB 41 – SJ 5, Liver 3 & LI 4 – to course Qi; Lung 1 or 2, Ren 17, Stomach 40, Pericardium 6 – to unbind the chest; Du 20 & Yintang, Du 24, Pericardium 6, Heart 5 – to Calm the Spirit; Liver 3 or Spleen 4 & Pericardium 6, UB 17, Spleen 10 – to move Blood; Lung 5 & Kidney 7, Lung 9 & Kidney 3, Lung 7 – Kidney 6 – to support Lungs and tonify Kidneys; Liver 14 – Lung 1 to harmonize Wood-Metal axis.
- Initial herbal formulas: Xue Fu Zhu Yu Tang Wan with Chai Hu Long Gu Mu Li Wan.
- Stationary and “running” cupping on the upper back and shoulders were done after acupuncture for the first 3 sessions to bring stasis to the surface (cupping was stopped after bruising and redness no longer appeared).
- Once bruising from cupping abated, Xue Fu Zhu Yu Wan was replaced with Tao Hong Si Wu Wan.
- Tao Hong Si Wu Wan with Chai Hu Long Gu Mu Li Wan was used until mid-April.
After 8 sessions it was mid-April, the time when the PTSD attacks would typically stop. Over the past 8 weeks, “Tom” had experienced only mild anxiety and insomnia, which he associated more with the fear of getting a PTSD attack, rather than actually having one. We shifted the treatment schedule to every six weeks (seasonal starts and high points), and used a low daily dose of Xiao Yao Wan to keep Qi and Blood flowing. The next March, we did four weekly treatment sessions, and “Tom” made it through the month completely symptom free. At that point we discontinued the regular use of Xiao Yao Wan, but “Tom” was instructed to use it again the next March – April as a preventative measure and schedule an appointment if he felt any anxiety or upset brewing; he used the herbs the next spring, but he did not need to come in for treatment. After 40 years suffering from PTSD, “Tom” has now been symptom-free for over three years.
Case #2: Overworked, late 20’s female
“Jane” had a diagnosis of Irritable Bowel Syndrome (IBS) and gluten intolerance along with menstrual irregularities, chronic intrascapular-shoulder-neck-jaw tension, low back pain, and cold feet. Her work for a local non-profit agency was extremely demanding, and the low pay brought constant financial stress; she was also in psychotherapy and AA for a history of alcohol abuse (sober for almost a decade). Her pale-swollen tongue and wiry-weak pulse confirmed a Liver-Spleen disharmony underlying the IBS, with Liver Qi Stagnation clearly contributing to the tension and menstrual irregularities (delayed timing, cramps, clots, bloating, emotions, fatigue, increased diarrhea). Her Kidney pulses were also incredibly weak, her lower abdomen felt cold, she was born with only one Kidney, and her IBS typically presented as urgent, early morning diarrhea (6 – 7 am), so Spleen & Kidney Yang Deficiency was part of her Pattern diagnosis.
I assumed from initial intake that “Jane” had an Axis disruption likely due to early childhood sexual abuse because of a combination of factors: the involvement of an Axis (East-West/Liver-Spleen-Large Intestine), the symptomatic involvement of all 3 Jiaos, food intolerance (the inability to “accept”), her history of early alcohol abuse, the impact on the Uterus, and her inability to choose better work (and pay) conditions. Early sexual abuse typically injures the Heart-Kidney axis, so if I was correct, it was presenting in an unusual manner. I asked “Jane” about any early childhood trauma or major events; she denied any knowledge so I dropped it. Due to financial concerns, “Jane” could not come in more than twice monthly and often had to cancel an appointment to pay bills.
- Points were rotated, selected from the following categories: Ren 12 & Ren 6 & Stomach 25 or 27 – to support Spleen and rectify the digestive tract; Spleen 4 – Pericardium 6 or GB 41 – SJ 5, Ren 4 to target Lower Jiao and Uterus; SI 3 – UB 62, Lung 7 – Kidney 6, Kidney 3, UB 23, Du 4, Du 20, GB 25 – to support Kidneys & Yang. ST 36, Sp 6, Sp 3, UB 20 & 22 – to support and tonify Spleen; GB 21, 30, 34, 40, Liver 3, 5, 8, 13, 14, UB 18, 19, 48 – to course and rectify Liver Qi; UB 44, 45 – to treat the intra-scapular tension and Calm the Spirit.
- Initial herbal formulas: Xiao Yao Wan for 1 month, then Ba Ji Yin Yang Wan was added. These formulas were continued for over a year (Jiao Wei Xiao Yao Wan was substituted for Xiao Yao Wan and the dosage of Ba Ji Yin Yang Wan was reduced during the hot summer months). A low dose of Yan Hu Suo Zhi Tong Wan was used for menstrual cramping as needed.
- Moxa (needle and pole) and heating pads were used extensively during treatment sessions.
- Each treatment session was followed by 5 – 10 minutes of Tuina to smooth the Primary & Muscle Channels and encourage the Luo Vessels to release any hidden memories to the surface.
Over the course of two years of monthly – biweekly treatment, “Jane” shifted her relationship to her health and body dramatically, putting it much higher on her priority list. She began taking days off before and after major work events, stopped going out with friends when she was too tired, and paid closer attention to avoiding foods that made her feel un-well. She also recommitted to her AA program with more regular sponsor meetings in combination with her on-going therapy and acupuncture. “Jane’s” symptoms were generally resolved, only appearing with high stress or fatigue. “Jane” and her female partner also got engaged and started planning their wedding.
Shortly after the engagement, “Jane’s” tongue and pulse presentation changed: a dip at the rear of the tongue became constant, fine red points appeared on a newly thin tongue tip, and the pulse became fine and slightly rapid on the left. “Jane” reported no unusual symptoms, so I added a Heart-Kidney Trauma release protocol (Kidney 6 & 16 & 26), a combination I use to help “open” the Spirit (Sishencong directed forward, Du 24 & Yintang), and running cupping on her upper back to release Fluid stasis (UB 13 – 17, 42 – 46), which left minor bruising and redness. At the next treatment session “Jane” casually mentioned that her mother had sexually abused her as a child, confirming the initial diagnosis. We scheduled two weekly follow-up appointments to help open her memories; she cried during and after both sessions. When she came in a month later, she let me know she had decided to “un-invite” her mother to the wedding. With no remaining on-going physical symptoms, we scheduled monthly treatments until her wedding to help manage stress, after which “Jane” was encouraged to come in every 6 – 8 weeks for prevention, working toward seasonal treatments only.
“Jane”, like most survivors, will require regular cognitive therapy and prevention-based acupuncture treatment for many years, but with the incorporation of mindful living practices this does not have to be weekly or monthly. “Jane” is now married, has moved to a different state with a new job, and is happily leading a much healthier, balanced life.
Bio: Catherine J. Lumenello has been in private practice since 2005, specializing in the treatment of PTSD and other psychological concerns using a blend of Classical Chinese Medicine, Japanese Acupuncture, Medical Qigong, and Tuina. She has taught in the field for over a decade, and is currently on the faculty at New England School of Acupuncture in Massachusetts. www.CatherineLumenello.com