Advances in Integrative Medicine 2 (2015) 1323

Contents lists available at ScienceDirect

Advances in Integrative Medicine

journal homepage: www.elsevier.com/locate/aimed

The integrative management of PTSD: A review of conventional and

CAM approaches used to prevent and treat PTSD with emphasis on
military personnel
James Lake
International Network of Integrative Mental Health, United States

A R T I C L E I N F O

A B S T R A C T

Article history:
Available online 20 January 2015

Post-traumatic stress disorder (PTSD) may be the most urgent problem the U.S. military is facing today.
Pharmacological and psychological interventions reduce the severity of some PTSD symptoms however
these conventional approaches have limited efcacy. This issue is compounded by the high rate of comorbid traumatic brain injury (TBI) and other medical and psychiatric disorders in veterans diagnosed
with PTSD and unresolved system-level problems within the Veterans Administration and Department
of Defense healthcare services that interfere with adequate and prompt care for veterans and active duty
military personnel. This paper is offered as a framework for interdisciplinary dialogue and collaboration
between experts in biomedicine and CAM addressing three primary areas of need: resiliency training in
high risk military populations, prevention of PTSD following exposure to combat-related trauma, and
treatment of established cases of PTSD.
The evidence for widely used conventional pharmacological and psychological interventions used in
the VA/DOD healthcare systems to treat PTSD is reviewed. Challenges and barriers to adequate
assessment and treatment of PTSD in military personnel are discussed. A narrative review of promising
CAM modalities used to prevent or treat PTSD emphasizes interventions that are not widely used in VA/
DOD clinics and programmes. Interventions reviewed include virtual reality graded exposure therapy
(VRGET), braincomputer interface (BCI), EEG biofeedback, cardiac coherence training, EMDR,
acupuncture, omega-3 fatty acids and other natural products, lucid dreaming training, and energy
therapies. As meditation and mind-body practices are widely offered within VA/DOD programmes and
services addressing PTSD the evidence for these modalities is only briey reviewed. Sources included
mainstream medical databases and journals not currently indexed in the mainstream medical databases.
Although most interventions discussed are applicable to both civilian and military populations the
emphasis is on military personnel. Provisional integrative guidelines are offered with the goal of
providing a exible and open framework when planning interventions aimed at preventing or treating
PTSD based on the best available evidence for both conventional and CAM approaches. The paper
concludes with recommendations on research and policy within the VA and DOD healthcare systems
addressing urgent unmet needs associated with PTSD.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Alternative
Complementary
Integrative
Military
Trauma
PTSD
Post-traumatic stress disorder
Veterans

Introduction
Post-traumatic stress disorder may be the most urgent problem
the U.S. military is facing today. The personal, social and economic
burden of human suffering, treatment costs, disability compensation, and productivity losses related to PTSD are major issues facing

E-mail address: contact@integrativementalhealth.net.

http://dx.doi.org/10.1016/j.aimed.2014.10.002
2212-9588/ 2014 Elsevier Ltd. All rights reserved.

American society and, to a lesser extent, other countries that have

supported the U.S.-led conicts in Iraq and Afghanistan.
After decades of research there is still no consensus on the
causes, nature or treatment of the psychological and psychosomatic consequences of trauma [1,2]. Different understandings of
human trauma have led to different conceptual models and
disparate treatment approaches. Conventional pharmacological
and psychological approaches widely used to treat PTSD are based
on the assumption that traumatic exposure results in chronic
dysregulation in neurophysiology and maladaptive coping with

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J. Lake / Advances in Integrative Medicine 2 (2015) 1323

stressful situations. Many therapies endorsed by mainstream

psychiatry reduce the severity of some PTSD symptoms however
most conventional approaches have limited efcacy. In a review of
55 studies on empirically supported treatments of PTSD high dropout rates or non-response rates (up to 50%) were common [3]. The
limitations of current mainstream approaches invite open-minded
consideration of the range of promising alternative and integrative
approaches aimed at preventing PTSD following exposure to
trauma and treating chronic PTSD.
Challenges and barriers to adequate assessment, prevention
and treatment of PTSD
Adequately assessing and treating the complex symptoms of
PTSD calls for comprehensive screening and multi-modal collaborative treatment. In general, mental health problems among the
military are probably under-reported because of concerns over
condentiality and feelings of shame, anger and guilt [4].
Conversely, some veterans may falsify or exaggerate claims of
mental illnessincluding PTSDwhen seeking disability compensation. These challenges become even greater with respect to
programmes aimed at preventing or treating PTSD in active duty
combatants or veterans because of delays in screening or obtaining
prompt treatment following exposure to trauma, the high
frequency of comorbid psychiatric, substance use and medical
disorders, and the high incidence of severe or refractory PTSD
symptoms in military patients [5]. A signicant and unknown
percent of OIF/OEF veterans diagnosed with PTSD have mild to
moderate traumatic brain injury (TBI) that has not been diagnosed
or treated. TBI is also frequently associated with depressed mood,
mood swings, psychosis, insomnia and chronic pain and increased
risk of substance abuse. Recently revised VA/DOD guidelines
address assessment and treatment of complex cases of PTSD that is
co-morbid with other psychiatric and medical disorders including
TBI (http://www.healthquality.va.gov/guidelines/MH/ptsd/
cpg_PTSD-FULL-201011612.pdf; [6]). Historically the DOD and
VA have emphasised the treatment of established cases of PTSD
however, in order to provide more adequate care for military
personnel, a high priority must also be placed on both predeployment resiliency training and prevention of full-blown PTSD
in active duty combatants at high risk for exposure to trauma, or
recently deployed combat veterans who have been exposed to
trauma but have not yet developed symptoms of PTSD.
Barriers to allocation of resources for adequate and timely
assessment and treatment of PTSD among both active duty
military personnel and combat veterans are related to system-level
issues in a complex multi-tiered federally managed healthcare
system. System-level challenges include inadequate funding,
delays in funding allocations for new programme development
efforts, difculties recruiting qualied mental health professionals,
and slow progress implementing specialised PTSD programme and
clinics. Funding for specialty PTSD programmes in the Veterans
Healthcare Administration has recently been increased however
many veterans are not receiving adequate or prompt care for PTSD
and other serious mental health problems [7]. A recent study
examined treatment intensity dened as the total number of
visits per veteran addressing PTSDamong veterans receiving
mental health services for PTSD at VA outpatient clinics. The
ndings suggest that returning veterans are receiving fewer than
the optimal number of psychotherapy sessions (i.e., a minimum of
915 sessions) needed for PTSD to respond. A June, 2014 report by
the Institute of Medicine concluded that it is impossible to
determine whether veterans or active duty service members
receiving treatment for PTSD are experiencing improvements.
Although both the DOD and the VA are committed to treating PTSD,
neither department uses standard symptom tracking measures to

determine whether the PTSD care it provides is effective,

appropriate or adequate. Further, although 39 VA specialised
PTSD treatment programmes reported outcomes their ndings
showed only modest improvement. (http://www.iom.edu/
Reports/2014/Treatment-for-Posttraumatic-Stress-Disorderin-Military-and-Veteran-populations-nal-assessment.aspx). An
equally important and unknown factor that impacts efforts to
better manage veterans PTSD treatment needs is the absence of
information on the number of veterans who receive private mental
health care after being diagnosed with PTSD within the VHA
system. These problems translate into delays developing and
implementing evidence-based protocols and programmes aimed
at the prevention and treatment of PTSD.
Conventional pharmacological and psychological approaches
used to prevent and treat PTSD: overview and limitations
Prevention of PTSD following trauma
Gartlehner et al. [8] compared the effectiveness and adverse
effects of psychological and pharmacological interventions aimed
at preventing PTSD in adults. Thirteen studies on efcacy included
diverse populations including victims of sexual assault, accidents,
terrorist attacks and others. Signicant ndings included no
evidence for debrieng in preventing PTSD, some evidence for a
collaborative care (CC) model combining pharmacological management and CBT, no evidence for comparative effectiveness of
escitalopram (an SSRI) over cognitive therapy (CT) and prolonged
exposure (PE), no evidence for the comparative effectiveness of
CBT over supportive counselling (SC). There was insufcient
evidence for other interventions in preventing the development of
PTSD following trauma exposure, including CBT, CBT combined
with hypnosis, CT, PE, psycho-education, SC and the medications
escitalopram and hydrocortisone. Based on studies included in the
review there was insufcient evidence to determine the role of
timing, intensity and dosing of specic psychological or pharmacological interventions aimed at preventing PTSD. Findings were
limited by small study sizes, high attrition rates, methodological
problems including absence of randomisation in many studies and
poor statistical methods, and a high risk of bias. A systematic
review of pharmacological treatments aimed at preventing PTSD
following exposure to trauma identied only two studies that met
inclusion criteria: one on escitalopram and one on hydrocortisone.
Both studies were done on civilian populations and ndings were
inconclusive because of small sample size.
Post-deployment Battlemind debrieng is a group preventive
approach developed by the Army with the aim of reducing or
preventing PTSD and other mental health problems in soldiers
returning from combat duty [9]. This approach uses group
facilitators to teach newly returned soldiers coping skills addressing anger management, insomnia and social isolation while
helping them reframe PTSD symptoms including hypervigilance,
insomnia, and emotional withdrawal as maladaptive responses
that need to be modied for successful coping with the stresses of
civilian life. A U.S. study on Battlemind debrieng found that
soldiers with the greatest combat exposure beneted most in
terms of fewer symptoms of PTSD and depressed mood [9].
Another study on Battlemind debrieng found no changes in PTSD
but reduced incidence of binge drinking in returning British
soldiers [87].
Treatment of chronic PTSD
A systematic review and meta-analysis of controlled studies on
psychological and pharmacological approaches used to treat chronic
PTSD found moderately strong evidence for exposure therapy
(especially prolonged exposure therapy) and CBT compared to

J. Lake / Advances in Integrative Medicine 2 (2015) 1323

relaxation training for reducing PTSD symptom severity or achieving

remission and some evidence for cognitive processing therapy (CPT),
cognitive therapy (CT), cognitive restructuring (CR), coping skills
therapy, eye movement desensitisation and reprocessing (EMDR),
and narrative exposure therapy [10]. Among pharmacological
therapies the review found moderately strong evidence for
uoxetine, paroxetine, sertraline, topiramate, and venlafaxine for
reducing symptom severity and achieving remission. Based on
studies included in the review there was insufcient evidence to
determine whether particular treatment approaches were more
effective for victims of specic types of trauma or to determine
comparative risk of adverse effects associated with different
treatments. The strength of evidence for the majority of psychological and pharmacological treatments of PTSD was limited by the fact
that most studies did not report remission from PTSD as a primary
outcome measure.
A systematic review of randomised controlled trials of non-SSRI
drugs including SNRIs, antipsychotics, anticonvulsants, adrenergic-inhibiting agents (e.g. Prazosin), opioid antagonists, benzodiazepines and others in individuals diagnosed with PTSD who either
did not achieve complete remission on SSRIs or discontinued SSRIs
due to adverse effects found weak evidence in support of non-SSRIs
with the exception of risperidone which is sometimes an effective
adjunctive agent in patients who respond partially to SSRIs [80].
Adjunctive use of atypical antipsychotics in combination with
SSRIs may reduce PTSD symptom severity more than SSRIs alone.
In three placebo-controlled trials risperidone taken in combination
with a SSRI signicantly reduced the severity of PTSD symptoms as
well as the frequency of awakenings due to nightmares [80]. In
another study there was a non-signicant difference in response
rates between combat veterans with severe PTSD symptoms
treated with adjunctive risperdone vs placebo [11]. In addition to
limited efcacy many drugs cause signicant adverse effects
resulting in poor adherence or treatment discontinuation including weight gain, sexual dysfunction and disturbed sleep [12].
CAM perceptions and use trends in civilian and military
personnel diagnosed with PTSD
Rates of CAM use among veterans and the civilian population
are comparable and range between 23% and 50% depending on the
type of CAM and the population surveyed [13]. A cohort analysis of
599 individuals who had been diagnosed with PTSD and reported
active symptoms of PTSD within the past year found that 39%
reported using a CAM treatment to address emotional and mental
problems within the same one-year period however only 13% saw
a CAM practitioner for treatment [14]. Types of CAM most widely
used to treat or self-treat PTSD symptoms included relaxation,
meditation, and exercise therapy. Individuals diagnosed with PTSD
were equally likely to use a CAM therapy alone as they were to use
CAM in combination with conventional mental health care. Among
individuals diagnosed with PTSD in general biofeedback and
relaxation are popular CAM therapies [13].
A survey of 170 VA programmes specialising in PTSD treatment
found that 96% of programmes offered at least one CAM modality
[15]. The following CAM modalities were offered in at least one half
of specialised PTSD programmes: mindfulness (88%), stress
management/relaxation training (63%), progressive muscle relaxation (75%), yoga (63%), guided imagery (50%), and spiritual
practices or therapy (50%). CAM therapies were typically offered in
the context of on-going conventional treatment including psychotherapy and medication management. These ndings suggest that
CAM therapies are widely used to treat PTSD in veterans receiving
care at specialised VA PTSD programmes. The signicance of these
ndings is limited by the absence of data on numbers of veterans
treated using specic CAM approaches, frequency of treatment,

15

and outcomes. Acknowledging the widespread use of CAM among

veterans diagnosed with PTSD, the paucity of research evidence for
the majority of CAM therapies, and the limited effectiveness of
existing conventional treatments of PTSD in 2011 a joint leadership
panel representing the VA, Department of Defense and National
Institutes of Health convened to review the evidence for CAM
treatments of PTSD, brainstorm about novel more effective ways to
bring evidence-based CAM modalities into existing PTSD programmes, and develop a CAM research agenda (VA Research
Currents Meeting seeks to expand VAs study of complementary,
alternative therapies for PTSD, MayJune 2011 http://www.
research.va.gov/currents/may-june11/may-june11-01.cfm). A literature review conducted by the VA panel identied acupuncture
and meditation as CAM treatments supported by the highest level
of evidence. The panel commented that mindfulness approaches
already in use in specialised VA PTSD programmes have not been
thoroughly investigated and stressed the need for further research
to evaluate the comparative efcacy of different meditation
techniques in PTSD. The panel also stressed the importance of
identifying CAM therapies that may help improve outcomes when
used in combination with conventional pharmacological or
psychological treatments.
CAM approaches used to prevent or treat PTSD: a review of
select modalities
Meditation and mind-body approaches
Meditation
Research studies have evaluated mindfulness training, mantra
reciting and compassionate meditation (Vipassana) for their
potential benecial effects in PTSD. A review of meditation
practices addressed at preventing PTSD found more evidence
supporting mindfulness meditation than mantra reciting or
compassionate meditation [17]. The majority of studies on
mindfulness have been done on individuals diagnosed with
generalised anxietynot PTSDtherefore outcomes may not
generalise to PTSD. Mindfulness training may reduce symptoms
of PTSD when improved attention permits increased control over
intrusive thoughts or memories. Patients who engage in a
mindfulness practice can be trained to shift attention from
remembered fears to present-focused problem solving permitting
improved coping. The therapeutic benets of mantra meditation
are believed to be related to the effects of repetitive chanting on
reducing the overall level of arousal permitting improved
emotional self-regulation. Compassion meditation (Vipassana) is
believed to reduce symptoms of PTSD (or other anxiety disorders)
by reducing negative emotions and reactivity to stressful
circumstances. Enhanced coping is achieved through improved
resilience and increased social connections achieved in group
meditation practice. Important advantages of meditation as a
treatment of PTSD include ease of training, low cost and practical
implementation in group settings. Emerging ndings suggest that
symptoms of re-experiencing and psychic numbing may be less
responsive to meditation than other symptoms [18]. In addition to
the above meditation practices studies have also examined the
effects of training in transcendental meditation (TM) on PTSD. In a
12-week pilot study (N = 5) OEF veterans diagnosed with PTSD
who trained in transcendental meditation experienced signicant
improvements in overall quality of life and reductions in core PTSD
symptoms [84]. In a 8-week pilot study (N = 16) mainly Vietnam
era veterans diagnosed with PTSD who completed 8 weekly classes
in a form of mindfulness meditation called iRest reported reduced
rage and emotional reactivity and increased feelings of peace,
relaxation and self-efcacy [19]. Future studies on the therapeutic
effects of meditation in PTSD should more clearly dene the

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J. Lake / Advances in Integrative Medicine 2 (2015) 1323

meditation practices being studied, use validated instruments that

reliably measure targeted outcomes, and evaluate the efcacy of
meditation in combination with widely used psychological
approaches including mindfulness-based cognitive therapy
(MBCT), exposure therapy, dialectical behavioural therapy (DBT)
and other therapies.
Mind-body practices. Mind-body practices including yoga and
others are used to treat PTSD in both civilian and military
populations. A literature review of studies on mind-body practices
used to treat PTSD found that many approaches in current use
reduce some PTSD symptoms including intrusive memories,
avoidance and emotional arousal [20,21]. Individuals who engaged
in mind-body practices reported improvements in mental health
problems frequently associated with PTSD including anxiety,
depressed mood and anger, resulting in improved coping with
stress. An internal VA survey conrmed that yoga practices are
widely used in VA specialised PTSD treatment programmes [22].
The authors concluded that variability in both the context in which
yoga practices are offered and methods of instruction may reect
differences in patient-centred care needs in different clinical
settings. Large studies are needed to evaluate the effectiveness of
yoga in alleviating PTSD symptoms. In a small 7 day study (N = 21)
OIF/OEF veterans diagnosed with PTSD randomised to daily 3-h
sessions of a breathing-based style of yoga but not a waitlist
control group showed reductions in PTSD symptom severity,
anxiety symptoms and respiration rate at the end of the study and
at 1-year follow-up [23]. In a 6-week pilot study (N = 16) veterans
diagnosed with PTSD who attended yoga sessions twice weekly
reported signicant improvements in sleep and other symptoms
but non-signicant improvements in overall PTSD severity, anger
or quality of life [24]. Preliminary ndings from case reports
suggest that taichi and qigong may reduce PTSD symptom severity
in torture survivors [25] however no studies using these mindbody approaches have been done on veterans or active duty
combatants diagnosed with PTSD.
Eye movement desensitisation and reprocessing (EMDR). Eye movement desensitisation and reprocessing (EMDR) is a psychological
approach widely used to treat PTSD however research ndings are
mixed. Two reviews [26,27] of published studies on EMDR in the
treatment of PTSD identied few large quality studies but
promising ndings including reductions in the symptom severity
3 months after the end of treatment, comparable efcacy to
exposure therapy, and superiority over relaxation training and
delayed treatment groups.
A systematic review of studies comparing EMDR with cognitive-behavioural therapy (CBT) in individuals diagnosed with PTSD
concluded that these two therapies are equally efcacious [28]. A
literature review of studies on EMDR in PTSD found contradictory
ndings regarding the need for eye movements to achieve clinical
improvements [29]. Some studies suggested that bilateral eye
stimulation may increase access to episodic memories or make
focusing on traumatic memories less unpleasant. As these two
therapies have equivalent efcacy the authors recommended that
the choice of EMDR vs CBT should be based on clinician experience
and patient preference. In a controlled study (N = 46) individuals
diagnosed with PTSD (N = 46) randomised to EMDR or emotional
freedom technique (EFT) experienced equivalent signicant
improvements at study end and 3-month follow-up [30]. More
studies are needed to verify these ndings and help determine
when it is appropriate to refer patients diagnosed with PTSD to
EMDR, EFT or other therapies. In spite of considerable evidence
supporting the use of EMDR as a treatment of established cases of
PTSD, on-going institutional resistance within the VA to fully
researching, training clinicians, and implementing EMDR in PTSD

treatment programmes may be interfering with veterans access to

this modality within VA healthcare system [31].

Exposure therapies based on advanced technologies: virtual reality

graded exposure therapy (VRET), and human-computer interface
(HCI)
Virtual reality graded exposure therapy (VRGET)
Considerable research is on-going to develop virtual reality
tools for assessing, preventing and treating combat-related PTSD
[32]. Virtual reality (VR) technology employs high-end computer
graphics, 3D displays and multi-sensory feedback to create the
illusion of interacting with a computer-generated environment
resulting in intense feelings of immersion and presence.
Sessions are guided by a therapist who regulates the virtual
scenario to achieve the appropriate intensity of arousal for the
patient. Repeated exposure results in habituation to a particular
fear-inducing environment (i.e. reduced autonomic arousal),
extinction of fear response and reduction in severity of PTSD
symptoms.
Findings of a study on combined multisensory exposure and
VRGET reported signicant reductions in severity of PTSD
symptoms in active duty combatants who had failed to respond
to other forms of exposure therapy [33]. Several patients in the
study reported signicant improvement following only ve
VRGET sessions however there was considerable variability in
the number of VRGET sessions needed to reduce symptom
severity to the same level. The ndings suggested that brief VR
exposure therapy may result in rapid extinction when combined
with multisensory exposure and D-cycloserine or other medications. A pilot study in which nine healthy subjects were exposed to
stress induced by a virtual bomb explosion investigated combined
Virtual Reality (VR) and EEG bio-feedback as a potential treatment
of stress-related disorders [81]. Findings of correlations between
general stress levels, serum cortisol levels, heart rate variability
and mid-frontal alpha EEG asymmetry suggest that real-time
neurophysiological data may provide useful inputs for adjusting
VRGET protocols to enhance stress resilience or accelerate
treatment response.
VR applications are being developed to assess the risk of
developing PTSD following trauma, and mental resilience training
aimed at preventing PTSD in active duty soldiers and other high
risk groups [34]. Efforts are ongoing to develop interactive internet
and smart-phone applications for VRGET protocols addressing
PTSD in this population [35]. Sub-threshold PTSD symptoms may
be associated with impaired physical health, mental health, and
increased risk of subsequently developing PTSD. In a pilot study
newly returning veterans who experienced signicant subthreshold symptoms but who did not meet full criteria for PTSD
exhibited elevated heart rates in response to a VR paradigm
(Virtual Iraq) designed to elicit fear [36]. Stress Inoculation Training
(SIT) is a recently developed approach that emphasizes cognitive
restructuring and the acquisition and rehearsal of coping skills
during graded virtual exposure to stressors that simulate the
trauma. Preliminary ndings suggest that pre- or post-deployment
stress inoculation training in groups of soldiers may reduce
symptoms of autonomic arousal [37].
Some individuals using VRET report mild transient symptoms
of disorientation, nausea, dizziness, headache and blurred vision.
Simulator sleepiness has been dened as feelings of generalised
fatigue that sometimes follow exposure to virtual environments.
Virtual environments can triggers migraine headaches, seizures, or
gait abnormalities and individuals diagnosed with these medical
problems should be cautioned about possible adverse effects of
exposure to virtual environments. [32].

J. Lake / Advances in Integrative Medicine 2 (2015) 1323

Humancomputer interface (HCI)

Humancomputer interface (HCI) systems based on cognitivebehavioural therapy and biofeedback are being developed for
resilience training in individuals at risk of developing PTSD following
exposure to trauma. STRIVE (Stress resilience in virtual environments) is a kind of stress resilience training aimed at enhancing
emotional coping strategies prior to active deployment [38,39].
STRIVE employs an immersive VR environment to simulate combat
situations that includes a virtual mentor who guides the soldier
through the virtual experience while coaching him or her in
relaxation and emotion self-regulation skills. The intensity of the
virtual stimulus used is determined by the individuals habituation
based on heart-rate variability (HRV) and other measures of
autonomic arousal. The STRIVE system permits users to be
immersed in stressful combat scenarios and interact with virtual
characters for training in a variety of coping strategies that may
enhance resilience in the face of extreme stress. Physiological
biomarkers of stress response are measured before and after VRGET
sessions. The STRIVE protocol may provide a useful tool for
predicting the risk of developing PTSD or other psychiatric disorders
in new recruits prior to actual combat exposure [40]. Recruits who
display high resilience and thus presumably at relatively lower risk
of developing PTSD might be more suitable for direct combat roles
while individuals who display low resilience might preferentially be
assigned to non-combat roles.
Research ndings suggest that combining VR environments
with real-time feedback based on neurophysiological responses to
stress may permit each unique patient to optimise the level and
type of VR exposure to enhance resiliency training and speed the
rate of recovery from PTSD [41]. Larger studies on patient
populations diagnosed with PTSD using head-mounted displays
and other technologies that create more immersive virtual
environments are needed to determine whether combining VRET
and EEG biofeedback is practical in clinical settings and yields
superior outcomes compared to either approach alone.
Biofeedback: cardiac coherence training and neurofeedback training
Biofeedback is widely used to treat stress-related disorders
however there is limited evidence for biofeedback as a treatment of
chronic PTSD [13]. However promising ndings have been
reported in two specialised areas of biofeedback based on heartrate variability (HRV) monitoring and brain wave recordings (i.e.
electroencephalography), respectively.
Cardiac coherence training. Cardiac coherence is an indicator of
heart rate variability (HRV). Abnormal low HRV is associated with
decits in attention and short-term memory in combat veterans
diagnosed with PTSD. In a small pilot study all participants who
received visual feedback in HRV patterns while undergoing
relaxation training [42] had improved cardiac coherence (i.e.
increased HRV) as well as improvements in attention and shortterm memory. The researchers inferred that increased cardiac
coherence may lessen the severity of cognitive symptoms that often
accompany PTSD. The ndings of a pilot study suggest that veterans
diagnosed with combat-related PTSD who receive HRV biofeedback
experience signicant increases in HRV and reduced PTSD symptom
severity compared to veterans receiving treatment as usual [43]. In a
small 3-week open exploratory study a group of active duty service
members diagnosed with PTSD or depressed mood who received
heart-rate variability biofeedback plus treatment as usual did not
report greater reductions in symptom severity compared to a group
receiving treatment as usual only [44].
Neurofeedback. Neurofeedback can be conceptualised as a specialised kind of operant conditioning in which pre-selected EEG
frequencies or other EEG features are provided to the trainee in the

17

form of a game that employs visual, auditory, and tactile feedback.

The individual is rewarded by progressing in the game only when
specic EEG frequencies corresponding to a calmer or more
regulated mental or emotional state exceed threshold. Repetitive
training in select frequencies reinforces the individuals ability to
achieve a target state of baseline EEG activity corresponding to
enhanced cognitive functioning or improved emotional selfregulation. The technique is currently widely used to treat
Attention Decit Disorder and a range of anxiety disorders in
both children and adults.
Recent research ndings suggest that neurofeedback involving
very low frequencies, between 0.02 and 0.2 Hz, results in rapid
signicant reductions in the severity of PTSD symptoms [45] and
improvements in overall cognitive functioning [46]. Such infralow frequencies may induce benecial shifts in the functional
connectivity of the brains resting state networks resulting in
reduced over-all arousal, enhanced cognitive functioning and
emotional stability.
As early as the late 1980s studies showed that neurofeedback
could be used successfully in the remediation of PTSD and
associated alcohol abuse in Vietnam era veterans [86]. These
ndings were replicated in a large controlled study with multiyear follow-up [83]. In a pilot study seven Vietnam era war
veterans with chronic treatment-refractory PTSD who trained with
the infra-low frequency neurofeedback protocol reported signicant reductions in symptom severity after 20 sessions [82]. Waitlisted controls subsequently reported similar improvements. More
recently, neurofeedback training using infra-low frequencies has
been extensively eld-tested at six U.S. military bases. At one large
military base more than 500 active duty combatants who had been
diagnosed with PTSD were trained in infra-low frequency (ILF)
neurofeedback. Training was done 13 times per week and was
administered by licensed psychotherapists certied in neurofeedback therapy. Symptom severity was evaluated weekly using the
PCL-5the military version of the PTSD Checklist (PCL)and other
standardised symptom rating scales. Findings from a cohort
analysis of 300 of the 500 active duty Marines in the original group
suggest that 75% of individuals with moderate to severe symptoms
experienced signicant clinical improvement based on a review of
symptoms frequently associated with PTSD including psychological, cognitive, psychophysiological and physiological symptoms
that were tracked using a custom computerised symptom tracking
programme. 25% of subjects in the cohort reported that all
symptoms had resolved completely with fewer than 20 neurofeedback sessions; another 50% experienced signicant reductions in
symptom severity after forty sessions [48]. The remaining subjects
took much longer to respond to treatment, continued to report
clinically signicant symptoms, discontinued training prematurely, or were non-responsive to the neurofeedback training protocol.
The above ndings have led to formal evaluation of infra-low
frequency training in connection with the Navys OASIS programme for the most severely symptomatic and most treatmentresistant cases of PTSD. At the time of writing this study has been
completed but ndings have not yet been published.
Traditional Chinese medicine
Chinese medicine and contemporary biomedicine are highly
integrated systems approaches that use similar conceptual
schemata to characterise the phenomenology and biological
mechanisms of PTSD [49]. Among the various Chinese medical
therapeutic modalities acupuncture has been most studied as a
treatment of PTSD. On a practical vein acupuncture is inexpensive,
safe and easy to provide in military eld conditions.
A review of prospective trials on acupuncture as a treatment of
PTSD identied four quality sham-controlled studies and two
quality uncontrolled trials that met inclusion criteria [20,21]. One

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J. Lake / Advances in Integrative Medicine 2 (2015) 1323

high-quality trial [50] included in the review showed statistically signicant differences between the acupuncture and waitlist group but non-signicant differences between the acupuncture and CBT groups. Patients receiving acupuncture or CBT
continued to report clinical improvements in PTSD symptoms 3
months after study endpoint. A meta-analysis of pooled ndings
showed superiority of a combined regimen of acupuncture and
moxibustion over SSRIs and superiority of acupoint stimulation
plus CBT over CBT alone in reducing PTSD symptoms. Two other
studies included in the review (but not the meta-analysis)
reported greater but non-signicant improvement in PTSD
patients receiving acupuncture vs SSRIs, more favourable
responses to combined acupuncture plus CBT compared to
CBT alone, and greater improvement with acupuncture plus
moxibustion compared to SSRIs on three outcome measures.
These ndings are limited by the small number of trials that met
inclusion criteria (only one study reviewed was included in the
analysis), the absence of sham-controlled studies, the use of
different study designs across trials examined, and poor
methodological quality of many studies. Findings from two
randomised controlled trials and six outcome studies support
that tapping on certain acupressure points in parallel with
imaginal exposure therapy may result in rapid reduction in
maladaptive fear responses to traumatic memories in individuals diagnosed with PTSD [51].
A review of studies on acupuncture for the treatment of
symptoms that are frequently comorbid with PTSD in active duty
military returning from combat, reported promising results for
acupuncture in reducing the severity of headaches, anxiety,
fatigue, sleep disturbances, depression and chronic pain [52].
Acupuncture may be a practical and effective treatment of PTSD
in emergency room settings [53]. Acupuncture is being
investigated for its potential applications in military eld
conditions for both medical and psychological conditions with
reductions in sick leave and limited duty status resulting in
improved unit performance [54]. In contrast to conventional
pharmacological treatment, acupuncture has infrequent mild
adverse effects such as bleeding, bruising and pain on needling
[55].
Natural products
Omega-3s. Symptoms of PTSD may develop when consolidation of
intense fear memories takes place in the absence of neural
mechanisms that permit extinction. Increasing hippocampal
neurogenesis soon after trauma may result in more rapid
clearance of fear memories (i.e. extinction) and interfere with
consolidation of immediate post-trauma memories into longterm memories reducing the risk of developing PTSD [56]. Animal
studies conrm that Omega-3 fatty acids increase hippocampal
neurogenesis [5759]. Studies in Japan following the 2011
tsunami are investigating the effectiveness of pre-treatment with
omega-3s in preventing the development of PTSD following
exposure to trauma in rst medical responders mobilised in
national emergencies Two pilot studies found that daily supplementation with omega-3s signicantly reduces the severity of
PTSD symptoms in individuals who experienced trauma related to
accidental injury [6062].
DHEA. Dehydroepiandrosterone (DHEA) is a prohormone that
may protect against cortisol-induced hippocampal atrophy [63].
Increased severity of PTSD is correlated with reduced DHEA
blood levels [64]. In a small open-label study (N = 5) women with
treatment-refractory PTSD related to early childhood abuse and
who had not responded to conventional pharmacological
therapy, experienced decreases in numbing, re-experiencing,

hyperarousal and other core symptoms, improved sleep and

improved libido with DHEA at doses between 25 and 100 mg/day
[65]. DHEA should be avoided in men at risk of prostate cancer
and women who have a history of oestrogen receptor-positive
breast cancer.
Proprietary multi-nutrient supplementation. Findings suggest that
taking a multi-nutrient supplement containing vitamins, minerals,
amino acids and anti-oxidants before exposure to trauma may
increase emotional resilience and reduce the severity of PTSD
symptoms following exposure. Adults enrolled in a study on a
proprietary micronutrient formula for ADHD at the time of a major
New Zealand earthquake reported feeling signicantly less anxious
and stressed compared to matched adults who were not taking the
supplement [66]. A subsequent study following a severe aftershock several months after the earthquake compared measures of
anxiety, mood and post-traumatic symptoms (e.g. intrusive
thoughts, avoidance and hyper-arousal) in individuals in the
general population taking two doses (four capsules vs eight
capsules) of an identical formula. At the end of 4 weeks individuals
taking the formula reported signicant decreases in stress, anxiety,
avoidance and arousal. There were non-signicant differences
between the high-dose and low-dose groups for all outcome
measures and all individuals in the treatment group reported
clinically signicant reductions in symptoms compared to the
control group. The researchers remarked that measured outcomes
using micronutrient formulas were comparable to those observed
with conventional medications [67], behavioural therapy using an
earthquake simulator [68], and eye movement desensitisation and
reprocessing [69,70], but with fewer side effects and better
retention rates. The signicance of ndings is limited by small
study size and the absence of a placebo group, blinding and
randomised protocols.
Lucid dreaming training
Training in lucid dreaming may reduce the severity and
frequency of nightmares in individuals diagnosed with PTSD
however core symptoms of PTSD may remain unchanged. Lucid
dreaming is a unique state of consciousness in which an individual
is self-aware while dreaming, and able to change or control dream
content [85]. Training in lucid dreaming methods involves 46
weeks of daily dream journaling and weekly sessions for training in
lucid dream-induction techniques focusing on insights related to
themes of recurrent nightmares. Lucid dreaming techniques
including dialoging with or physically embracing dream
characters reduce feelings of helplessness and terror as the patient
learns that he or she can control frightening images or experiences
associated with past trauma.
Trauma survivors frequently have recurring vivid nightmares
that may represent a dream-anxiety syndrome. Findings from
case reports and small clinical studies suggest that lucid dream
induction techniques may reduce the frequency and intensity of
nightmares related to memories of trauma in combat veterans
resulting in clinical improvement in the severity of PTSD [71,72]. A
12-week pilot study on individuals who reported frequent
nightmares (N = 23; some individuals had been diagnosed with
PTSD) found that individualised and group training in lucid
dreaming techniques resulted in equivalent reductions in the
frequency of nightmares however sleep quality and PTSD
symptom severity remained unchanged, however no correlation
was found between lucidity and reduction in nightmare
frequency [73].
Energetic and spiritual approaches to PTSD
Spiritual or so-called energy healing methods used to treat
PTSD include energy psychology, including healing touch (HT),

J. Lake / Advances in Integrative Medicine 2 (2015) 1323

thought-eld therapy (TFT) and emotional freedom technique

(EFT), somato-emotional release, craniosacral therapy, qigong,
Reiki, specic spiritual methods in Ayurvedic and Tibetan
medicine, and shamanic ritual healing. Psychological, biological
and possibly also subtle energetic processes have been postulated
to explain therapeutic effects of energy healing. Quantum
mechanics may help explain subtle effects of energy healing or
directed intention on health and illness [74]. In a 3-week
randomised controlled trial active duty military diagnosed with
PTSD following exposure to combat (n = 123) randomised to six
sessions of Healing Touch plus Guided Imagery vs treatment as
usual experienced signicant reductions in PTSD symptoms and
depression and signicant improvements in overall mental quality
of life [75].
Somatoemotional release is an energy healing approach that
purportedly results in release of pathological energetic states
resulting from physical injury. The technique involves gently
touching the patients body with the goal of stimulating somatic
memories of past trauma. Clinical improvement is believed to take
place when pathological energy is released through gentle
stimulation. In a two-week study 22 Vietnam veterans diagnosed
with PTSD who underwent both Craniosacral Therapy and
somatoemotional release experienced signicant improvements
in symptoms of physical distress, depressed mood, anxiety,
guardedness and behavioural isolation [76]. These ndings are
limited by small study size, the absence of a sham treatment arm
and follow-up, and use of non-standardised outcome measures.
Energy psychology is a rapidly growing eld based on both
conventional psychological theory and Chinese medical theory
based on the assumption that energetic imbalances in the
meridians manifest as emotional or mental symptoms [88].
Thought eld therapy (TFT) and emotional freedom technique
(EFT) are specic approaches used in energy psychology to treat a
range of mental health problems. In TFT the patient is asked to
invoke a thought eld associated with a traumatic memory after
which the TFT practitioner re-attunes energetic imbalances
manifesting as persisting memories of trauma by gently tapping
on specic acupuncture points resulting in symptom reduction.
Emotional Freedom Technique (EFT) is a simplied version of TFT
that uses only one routine for stimulating acupuncture points.
Emotional freedom technique (EFT) has been evaluated in the
treatment of phobias, generalised anxiety, and PTSD that may be
poorly responsive to exposure therapy. EFT has been manualized
and can be easily self-administered following brief training
session. An advantage of EFT over conventional exposure therapies
is avoidance of the risk of re-traumatization through in vivo
exposure. Few controlled studies have evaluated EFT as a
treatment of PTSD and ndings are limited by the absence of
sham arms in most studies, small study size, methodological aws,
and inconsistent outcomes [77]. During several six-week retreats
veterans and their spouses (N = 218), many of whom had been
diagnosed with PTSD, participated in a multi-modal intervention
involving Emotional Freedom Technique (EFT) and other energy
psychology approaches together with a range of complementary
and alternative approaches for stress reduction [78]. Both veterans
and spouses experienced signicant reductions in PTSD symptom
severity as measured by the PTSD checklist (PCL), and these gains
were maintained by veteransbut not spouseson follow-up.
Towards an integrative model for preventing and treating PTSD
Numerous conventional and CAM therapies addressing PTSD
are currently used or are at various stages of investigation. Exh 1
summarises evidence for conventional and CAM therapies aimed
at preventing or treating PTSD including comments on limitations
of ndings and safety.

19

Exhibit 2 is provided as a concise guide to interventions

addressing the three target populations of interest:
 Groups who are at high risk of exposure to trauma because of the
nature of their work including active duty military, re ghters,
police ofcers, medical relief workers
 Individuals who have recently been exposed to trauma but have
not yet developed symptoms
 Individuals who have chronic symptoms of PTSD

Recommendations on policy and research

Challenges interfering with access to care and quality of care
within the VA and DOD healthcare systems include inadequate
funding, delays in funding allocation to new programme development efforts, difculties recruiting qualied mental health
professionals, and slow progress around implementation of
specialised PTSD programme and clinics. Such system-level
problems directly impact on the timely implementation of
adequate, appropriate, cost-effective evidence-based services
and resources addressing PTSD and call for a radical re-visioning
of existing VA and DOD policies and programmes. The above
system-level problems result in treatment delays, inadequate
treatment and poor outcomes, and are compelling reasons for reevaluating existing programmes and services aimed at preventing
and treating PTSD.
New services and programmes should be put in place within the
VA and DOD healthcare systems based on the best available
evidence for conventional and CAM approaches addressing
resiliency training, prevention and treatment. Identifying interventions that enhance resilience in active duty military who are at
high risk of exposure to combat-related trauma, and that reduce
the risk of developing PTSD following trauma in active duty
combatants, will result in enormous reductions in psychiatric
morbidity, improved quality of life and commensurate gains in
productivity. The RAND Corporation has estimated that improvements in interventions aimed at preventing PTSD may translate
into reductions in productivity losses on the order of billions of
dollars annually [79].
A joint VA-DOD task force on PTSD should be created with the
goal of identifying critical stafng needs including both conventionally trained mental health professionals and CAM practitioners, and establishing expert resources on PTSD. The joint task
force should review and revise existing VA-DOD policies and
procedures addressing care delivery to personnel diagnosed with
PTSD and do all possible to rapidly implement proactive reforms in
current scheduling practices and stafng policies to ensure timely
referrals to qualied specialists within established VA/DOD
programmes and services as well as qualied therapists in the
private sector when patient care needs cannot be met internally.
The highest priority should be placed on improving access to
screening for at-risk military personnel soon before deployment
and soon after returning from combat, and identifying effective
interventions aimed at reducing the risk of developing PTSD in
these highly vulnerable populations.
Large VA/DOD sponsored outcome studies on promising
interventions aimed at both prevention and treatment are urgently
needed to conrm efcacy and effectiveness, determine optimal
treatment strategies for PTSD targeting disparate symptoms and
levels of severity, address treatment safety issues, develop
practical cost-effective evidence-based treatment protocols, and
characterise treatment choices appropriate for individuals who
have failed multiple trials on conventional or CAM therapies, or
who refuse widely used treatments because of concerns over
adverse effects or cost. Federal research funding should prioritise

J. Lake / Advances in Integrative Medicine 2 (2015) 1323

20

Exhibit 1
Conventional and CAM approaches used to prevent or treat PTSD, treatment evidence limitations of ndings safety issues.
Psychotherapy

Conventional drugs
Prevention

Treatment

Meditation

EMDR

Technology-based therapies
Virtual reality graded
exposure therapy (VRGET)

BCI and HCI

HRV and EEG biofeedback

training

Chinese medicine
Natural products

Limited evidence supports debrieng, CBT

(alone or in combination with hypnosis),
cognitive therapy, debrieng, prolonged
exposure therapy, psychoeducation, and
supportive counselling for preventing PTSD
following trauma
Battlemind debrieng may reduce risk of
developing PTSD in newly returning
combat soldiers

Findings limited by small study sizes, high

attrition rates, methodological problems
including absence of randomisation in many
studies and poor statistical methods and high
risk of bias. Many studies on civilian
populations only
Only 2 studies inconsistent ndings

Few studies ndings largely inconclusive

Only 2 quality prevention studies (escitalopram

and hydrocortisone)

Fluoxetine, paroxetine, sertraline,

topiramate, and venlafaxine often reduce
symptom severity and may increase
remission rate
Adding atypical antipsychotics to SSRIs
may improve response
Mindfulness meditation may be more
effective in prevention than other forms

Unknown comparative risk of adverse effects

associated with different treatments. Findings
limited by failure to report remission rates in
most studies
Few studies done, inconsistent ndings
Findings may not generalise: most studies done
in individuals diagnosed with GAD (not PTSD)

Re-experiencing and psychic numbing may

be less responsive to meditation than other
PTSD symptoms
TM may reduce overall PTSD symptom
severity
Efcacy may be comparable to exposure
therapy, and superior to relaxation training
Efcacy may be comparable to emotional
freedom technique (EFT)

Limited ndings single pilot study

Signicant reductions in PTSD sex severity

(after 5 sessions) in active duty combatants
non-responsive to other forms of exposure
therapy
Brief VRET combined with multisensory
exposure and D-cycloserine or medications
may result in rapid extinction
Pre- or post-deployment stress inoculation
training in groups of soldiers may reduce
symptoms of autonomic arousal thus
reduce risk of developing PTSD following
trauma exposure
Combining VR environments with realtime feedback of neurophysiological or
autonomic activity may help optimise level
and type of VR exposure to enhance
resiliency training and speed recovery
HRV biofeedback may be more effective at
reducing PTSD symptom severity more
than conventional treatment
Iraq war veterans with treatmentrefractory PTSD reported signicant
improvement with regular Neurofeedback
Neurofeedback using very slow frequencies
(0.020.2 Hz) may be associated with rapid
dramatic reductions in PTSD symptom
severity
Acupuncture plus CBT superior to CBT alone

High variability in number of VRET sessions

needed to reduce symptom severity to same
level

Omega-3 supplementation may prevent

the development of PTSD following
exposure to trauma
DHEA (25100 mg/D) may improve
treatment-refractory PTSD including
decreased numbing, re-experiencing,
hyperarousal and other PTSD core
symptoms
A proprietary multi-nutrient formula taken
soon after exposure to trauma may result in
signicant decreases in stress, anxiety,
avoidance and arousal

Few large quality studies

None

None

Adverse effects of long-term SSRI or

SNRI use include weight gain, sexual
dysfunction and disturbed sleep

Rare reports of dissociation

depending on skill of instructor and
stability of meditator

Rare cases of dissociation

Findings based on one small controlled study

(EFT poorly substantiated)

Reports of cyber sickness including

dizziness, headaches and
disorientation

Few small studies

Few small studies

No ndings to report: rst studies on-going at

time of writing

Same as for VRGET

Few small open trials on HRV biofeedback,

ndings inconsistent

None

Small uncontrolled study

None

Findings based on analysis of case reports in

active duty military reporting varying degrees
of symptom severity

None

Various protocols used; large sham controlled

trials lacking
Small open trial

Infrequent mild adverse effects can

include bleeding, bruising and pain
Case reports of nausea, increased
bleeding time

Small open trial

Avoid in men at risk of prostate

cancer and women with history of
oestrogen-receptor positive breast
cancer

Small open trial in general (non-clinical)

population

Case reports of toxic interactions

when combined with mood
stabilisers

J. Lake / Advances in Integrative Medicine 2 (2015) 1323

21

Exhibit 1 (Continued )
Lucid dreaming training

Energy medicine and

energy psychology

Training in lucid dreaming may help reduce

the severity and frequency of nightmares in
individuals diagnosed with PTSD however
core symptoms of PTSD may remain
unchanged
Healing Touch (HT), EFT and other energy
healing or energy psychology approaches
May signicantly reduce PTSD symptom
severity

Preliminary ndings based on few small trials

None

Few small studies, methodological problems

None

Exhibit 2
Interventions used to increase resilience prior to trauma exposure, prevent or reduce the severity of PTSD following trauma, and treat chronic PTSD.
Intervention type

Target population

1st Tier interventions

2nd Tier interventions

Resiliency training prior to trauma

High-risk groups including active duty

military, re ghters, police ofcers,
medical relief workers
Individuals who have recently
experienced trauma but have not
developed symptoms
Individuals who have chronic
symptoms of PTSD

VRGET (including stress

inoculation and STRIVE)

Proprietary multi-nutrient
supplement

Battleeld debrieng
Mindfulness training

Omega-3s

Exposure therapy
Medications
VRGET plus multi-sensory
exposure
Acupuncture

EMDR
HRV and EEG biofeedback
Healing touch and guided imagery

Approaches used soon after trauma

to prevent or mitigate PTSD
Treatment of chronic PTSD symptoms

EFT and other energy psychology

techniques

Note: 1st Tier interventions are supported by moderate to strong evidence; 2nd tier interventions are supported by weak or inconsistent evidence.

development of those modalities that show the greatest promise

including, for example, specic VRGET and BCI protocols,
acupuncture, and select natural products reviewed in this paper.
Finally, regular in-service trainings of all VA/DOD mental health
providers should be widely implemented to ensure that clinicians
knowledge and skills remain up to date and reect the best
available evidence for interventions aimed at preventing and
treating PTSD.
Conicts of interest
The author has no nancial conicts of interest to declare.

[11]

[12]

[13]

[14]

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