Homeopathic treatment in Post Traumatic
Disorder
[Yasmeen Lankesar]
This research involved the holistic, individualized treatment of
patients with post traumatic stress disorder (PTSD), employing homoeopathic
medicine. Post traumatic stress disorder can lead to
a variety of complications which may diminish or destroy interpersonal
relationships, may handicap the patient occupationally or recreationally, or
may lead to substance abuse. Research has
indicated that patients with PTSD are more likely to have a personality
disorder; a previous history of depression, abuse or substance abuse or a
family history of psychopathology. Given this,
it is presumed that PTSD can occur in anyone who has experienced trauma
and sufficient stress. In order to reduce post traumatic stress severity,
treatment should emphasise and acknowledge
that mental, emotional, behavioural and social factors contribute to
trauma.
This study involved ten patients (plus two additional) who participated
in five homoeopathic consultations, over a period of four months. The
appropriate homoeopathic remedy, or similimum,
was determined using each patient’s distinguishing mental,
emotional and physical symptoms.
Each participant completed the Researcher’s Questionnaire at each
consultation and recorded their stress episodes on a calendar to be handed in
at each follow-up appointment. These results,
together with holistic progress as noted by the researcher at every
consultation, were used to determine the efficacy of homoeopathy on post
traumatic stress disorder.
The intent of the research was to prove that treatment should be
specific and individualistic, irrespective of the diagnosis. This study aimed
to provide a holistic therapy for PTSD and the results indicated that the similimum treatment in sufferers of post traumatic stress
disorder was effective in reducing post traumatic stress frequency, severity,
and intensity. Moreover, improvement in mental and emotional wellbeing, sleep
patterns, appetite, and energy levels were noted in all the patients.
The study aimed to establish the efficacy of the homoeopathic similimum in the treatment of post traumatic stress
disorder.
IMPORTANCE OF THE PROBLEM
Persons with chronic PTSD have unusually high rates of associated
psychiatric conditions throughout life, including substance abuse and
dependence (23%); major depression (20%); alcoholic dependence (75%) and
personality disorder (20%) (Brady, Pearlstein, Asnis,
2000: 1837-1844). Marais, de Villiers, Moller, Stein
(1999: 638) report that patients with PTSD were more likely
to attempt suicide and had more unexplained physical symptoms and more
visits to medical practitioners.
Co-morbidity surveys identified increased odds of school and college
failure, teenage pregnancy, marital instability and unemployment associated
with a diagnosis of PTSD (Mezey and Robbins, 2001:
561). The subject of PTSD was raised on numerous occasions in the Truth and
Reconciliation (TRC) hearings in South Africa. At hearings on conscription by
the apartheid military, for
example, a white psychologist in the former South African Defence Force
described his personal experiences and the symptoms of PTSD. This emphasised
the long-term negative impact that exposure to violence may have (Swartz, cited
in Stein, 1998: 456).
High crime and violence rates in South Africa are associated with the
progressive disintegration of families and communities that occurred under
apartheid.
The potential for research into violence prevention and treatment of
victims of violence in South Africa is enormous. This is particularly in a
context in which past state policies have seriously undermined social
relationships and trust, and in which the legacies of apartheid are still
apparent in post-apartheid South Africa (Emmett, 2001: 4, 15).
A central feature of the destructive impact of apartheid on the social
fabric was the severe toll it exacted on children, and the implications this
had for succeeding generations. With the disruption
of families and communities during the Group Areas Act, relationships,
networks and rights were destroyed and with this, the sense of security and
social control. Children were thus the main victims, as they had to cope with
the absence of parents, neglect, domestic violence and abuse (Emmett, 2001: 6,
7).
In light of the above, researchers observe that the most tragic
reflection of violence in which South Africa finds itself, is that it faces the
years to come with children who have been socialized to
find violence completely acceptable and human life cheap (Chikane, 1986: 344).
Physical trauma is second only to cardiovascular disease as the largest
cause of overall deaths in South Africa and the psychological impact that
follows is substantial.
Approximately 1/3 of patients seen in South African emergency units
present with injuries – interpersonal violence, and the combination of
motor vehicles and alcohol, are the main contributors.
In a typical American emergency unit, trauma patients make up about 12%
of the patient population, while in the UK the figure is about 8%. South Africa
is the trauma capital of the world, and
some overseas doctors spend time in South African hospitals to gain
experience in the management of traumatic conditions (Stein, Seedat, Emsley, 2002: 790).
Post Traumatic Stress Disorder (PTSD) is a significant clinical problem
in the mental health field (Elhai, 2000: 449). It is
generally accepted that PTSD arises as a consequence of an interaction between
the stressor and the amount of exposure to it, personality, such as, particular
styles; pre-existing belief systems and attributional
style and the recovery environment, such as availability
of social support (Parry-Jones, 1997: 230-237).
PTSD may affect some 2-3% of the general population at any one time and
thus accounts for considerable morbidity within the population and deserves
greater research scrutiny (Green, 2003: 200).
Stress occurs when individuals have more demands made on them than they
are able to cope with. It is really neither the emotional nor the physical
sphere which is the cause of these symptoms, but a disturbance in the whole
body, expressed in particular ways by particular people (Handley, 1995: 19).
Because of the longevity, the depth and the complexities of the trauma
process, superficial healing will often not suffice (Chappell, 1994: 31).
Anxiety disorders is a normal accompaniment of growth, of change, of
experiencing something new and untried, of finding one’s own identity and
meaning of life.
Pathological anxiety by contrast, is an inappropriate response to a
given stimulus by virtue of either its intensity or its duration (Kaplan et al,
1994: 573). It is evident that there are various stressors that could give rise
to the symptoms of anxiety and these can produce seemingly illogical - often
restrictive - patterns of behaviour (Sue, Sue and Sue, 1994: 161,194). Anxiety
disorders are characterised either by manifest anxiety or by behaviour patterns
aimed at warding off anxiety. Whatever its form, anxiety involves a subjective
sense of tension, fear an d apprehension, behavioural responses such as
avoidance of a feared situation, and psychological reactions which include
sweating, palpitations and increased respiration (Bootzin,
Acocella and Alloy, 1993: 180).
Research shows that the anxiety itself may be the major disturbance (as
in panic disorder and generalized anxiety disorder). It could arise when the
individual confronts a feared object or situation
(as in phobias), may result from an attempt to master the anxiety-based
symptoms (as in obsessive-compulsive disorder), or may manifest during
intrusive memories of a traumatic event (as in PTSD) (Sue et al., 1994:164).
Anxiety is an alerting signal that warns of external or internal threat
to one’s unity or wholeness. An individual not functioning properly, in
an adaptive balance, will manifest an anxiety disorder (Kaplan et al., 1994:
574-575).
Anxiety disorders afflict up to 93% of the general population who report
exposure to traumatic events (Lee and Young, 2001: 156). Only one in four
persons with an anxiety disorder is correctly diagnosed and treated, many never
seek help. Often individuals blame their distress on work, financial problems,
or medical symptoms. Many hate to admit that they may be suffering from an
anxiety disorder because they see it as a sign of weakness. Early
treatment can prevent a great deal of suffering and help people to feel and
functions like themselves again.
Most who obtain help, even those with severe and disabling problems,
improve dramatically (Hales and Hales, 1995: 118).
PTSD differs from acute stress disorder in that the minimum duration of
the symptoms of PTSD is one month (Kaplan et al., 1996: 606). Lifetime
prevalence estimates vary from 1 to 14% and the sequence may be lifelong and
serious, particularly in those whose trauma is prolonged or inflicted by other
human beings, such as survivors of concentration camps, torture or rape. The
effects may extend to the children of these survivors (Smith, Sell and Sudbury,
1996: 331, 332).
Definition of Post Traumatic Stress Disorder The Merck Manual (Beers and
Berkow, 1997: 1587) defines PTSD as “a neurotic
disorder produced by exposure to an overwhelming external stress
and characterised by recurrent episodes of re-experiencing the traumatic
event, numbing of emotional responsiveness and dysphoric
general hyper-arousal”. The Diagnostic and Statistical Manual for Mental
Disorders (DSM-IV), (APA, 1994: 427-429) criteria state that the A-criterion
for PTSD (traumatic exposure) involves experiencing, witnessing or being
confronted with an event that is life-threatening or involves serious threat or
injury to oneself or others. The B-criterion (re-experiencing) involves
persistent intrusive memories, and sudden reminders or flashbacks associated
with the trauma.
The C-criterion (avoidance) includes symptoms of persistent avoidance of
stimuli associated with the trauma.
Avoiding thoughts, feelings or memories of the trauma, an inability to recall
important aspects of the trauma, numbing symptoms, as well as outright refusal
to acknowledged or discuss the experience are common.
The D-criterion (hyper-arousal) may manifest as sleep disturbance,
irritability, anger outbursts and concentration problems. Symptoms must cause
significant distress or impairment and endure for more than 1 month (DSM-IV,
APA, 1994: 427-429).
Prevalence and Aetiology
Studies estimates that 5-6% of men and 10-12% of women in the general
population have experienced PTSD at some point in their life (Resick, Stein, Seedat, Emsley, 2001: 97). Further studies report that a much
higher percentage of females suffer from this disorder than do males (Flannery
and Quin-Leering, 2000: 839 and Seedat,
Nood, Vythilingum, Stein, Kaminer, 2000: 38).
Research upholds that people who have PTSD are at an increased risk of
developing other psychiatric disorders and are at significant increased risk of
committing suicide. The effect of this disorder on employment and work
productivity is similar to that associated with depression and translates into
an annual loss of productivity above 3 billion dollars in the U:S. (Kessler,
2000: 5-10).
Thus the socio-economic consequences, as well as the personal distress
associated with diagnosis, are substantial.
Studies propose that there is considerable evidence that students’
exposure to violence is associated with both anti-social behaviour and
psychological trauma, for example, depression; anxiety;
anger; PTSD. A significant relationship was found between exposure to
violence and their feelings of hopefulness, sense of purpose in life, and
symptoms of depression (Flannery and Quin-Leering,
2000: 839).
Levels of anger and aggression were positively related to their
experiences of physical as well as verbal abuse (Flannery and Quin-Leering, 2000: 839). Research found that both PTSD and
major depression were significantly more common in patients with a history of
domestic violence (Marais, de Villiers, Moller,
Stein, 1999: 638).
The stressor is the prime causative fact or in the development of PTSD,
although individual pre-existing biological factors, pre-existing psychosocial
factors and events that happen after the trauma must be considered (Kaplan et
al., 1994: 607).
The qualifying level for the stressor is difficult to determine, but the
stress must be of a nature or degree which almost anyone would find extremely
disturbing. Rather illogically, DSM-IV advises that people with symptoms of
PTSD in response to a lesser stress be diagnosed as having adjustment disorder.
This would seem to ignore the probability that onset of symptoms must be
determined by a subjective threshold level of stress.
This would be determined by interaction of the environment with the
individual vulnerabilities, and many studies of at-risk groups have shown that
the development of symptoms is related to pre-morbid personality and
psychopathology (Smith et al., 1996: 331).
The principle features of PTSD are: the repeated, intrusive, painful
recollections of the experience; as flashbacks, images, thoughts or nightmares;
a pattern of avoidance of objects or situations reminiscent of the experience,
or amnesia for aspects of it; emotional numbing of responsiveness; fairly
constant hyper-arousal and hypervigilance (Smith,
Sell and Sudbury, 1996: 332).
Patients may also describe dissociative states and panic attacks.
Illusions and hallucinations may be present and impairments of memory and
attention may be revealed. Associated symptoms include aggression, violence,
poor impulse control, depression and substance-related disorders (Kaplan et
al., 1994: 608-609).
The DSM-IV diagnostic criteria for PTSD allow the clinician to assess
patients suspected of suffering from PTSD. This criteria also allows
specification as to whether the disorder is acute (symptoms lasted less than 3
months), chronic (symptoms lasted 3 months or more), or with delayed onset
(symptom onset was 6 months or more after event) (APA, 1994: 429).
A careful neurological examshould be part of
the evaluation of every patient with suspected PTSD in order to rule out the
presence of brain lesions underlying the changes in memory and the difficulty
in concentration (Beers et al., 1997: 1587).
With regard to this study however, this was not necessary since all
participants were pre-diagnosed.
DD.: PTSD can be distinguished from other mental disorders by
interviewing the patient regarding previous traumatic experiences and by the
nature of the current symptoms.
Borderline personality disorder can be difficult to distinguish from PTSD.
The two disorders may coexist or may be casually related. Patients with
dissociative disorders do not usually have the degree of avoidance behaviour,
the autonomic hyper-arousal, or the conscious memory of the trauma that
patients suffering from PTSD usually report (Kaplan et al, 1994: 609).
Symptoms of avoidance, numbing, and increased arousal that are present
before exposure to the stressor do not meet criteria for the diagnosis of
post-traumatic stress disorder and require consideration of other diagnoses
(e.g. a mood disorder or another anxiety disorder). Moreover, if the symptom
response pattern to the extreme stressor meets criteria for another mental
disorder
(e.g. major depressive disorder), these diagnoses should be given
instead of, or in addition to, post traumatic stress disorder (Kaplan et al,
1994: 609).
In obsessive-compulsive disorder, there are recurrent intrusive
thoughts, but these are experienced as inappropriate and are not consciously
related to an experienced traumatic event. Flashbacks
in PTSD must be distinguished from illusions, hallucinations, and other
perpetual disturbances that may occur in schizophrenia and psychotic disorders.
Malingering should be ruled out in these situations in which financial
remuneration, benefit eligibility, and forensic determinations play a role
(APA, 1994: 427).
Acute stress disorder is a reaction to events that involve actual or
threatened death or serious injury or that threaten the physical integrity of
the individual or others. Overwhelmed by fear or helplessness, people may
develop dissociative symptoms, such as numbing or detachment, as a
psychological defense (Hales and Hales, 1995: 270).
Symptoms last for a minimum of 2 days and
a maximum of 4 weeks and occur within 4 weeks of a trauma.
The disturbance causes significant distress or impairment in social,
occupational or other important areas of functioning or prevents the individual
from performing necessary tasks (DSM-IV, APA, 1994: 429-431).
Although little is known about this recently recognized disorder, mental
health professionals believe that with early intervention, most individuals can
recover and will not suffer long term problems (Hales et al., 1995: 274).
Short term prescription of sedatives and hypnotics are justified to normalize
sleep and reduce anxiety (Smith et al., 1996: 330).
Risks and Complications
Individuals who have recently been through trauma are at higher risks of
accidents because they cannot concentrate, their attention wanders, and they
may overreact to sudden sound or movement. They should avoid driving, operating
heavy machinery, and any tasks that demand alertness for safety. PTSD can lead
to phobias about certain situations or activities that resemble or symbolize
the original trauma.
Frequent mood swings, depression, and guilt may lead to substance abuse,
self-defeating behaviour, or suicidal actions. Other complications can include
aggression and violence, as well as their consequences (Hales et al., 1995:
280).
Treatment
The primary aim of specialised PTSD therapy is to allow the individual
to quell the distress and arousal associated with the recurrent and involuntary
reminders of the trauma and minimizes the accompanying behavioural and
effective constriction. This can be accomplished using any variety of
modalities that have the goal of helping the patient move away from the
persecution and ongoing suffering (McFarlane and Yehuda,
2000: 942).
Behavioural desensitization and relaxation techniques are particularly
helpful, and where disso ciative mechanisms underlie
symptom formation, psychotherapy, producing catharsis; abreaction and insight
may be useful.
Anti-anxiety and anti-depressant medications may be used adjunctively
when necessary, but it should be remembered that this group of patients is particularly
prone to develop drug dependency,
so that prolonged pharmacotherapy is generally contraindicated (Beers
and Berkow, 1997: 1588).
Pharmacological Treatment
Several drugs are listed for the treatment of PTSD (dopaminergic
agents/serotonergic agents/tri-cyclic
antidepressants/benzodiazepines/anticonvulsants/anti-manics/opioid antagonists)
(Donnelly and Amaya-Jackson, 2002: 167).
The selective serotonin re-uptake inhibitors (SSRIs)
are considered broad spectrum agents in the treatment of PTSD. Serotonergic agents may be important in psychiatric
symptoms commonly associated with PTSD such as aggression, obsessive/intrusive
thoughts, panic attacks and suicidal behaviour. Although controlled trials
suggests that most adult drug responders will show general improvement within 2
weeks of SSRI treatment and that SSRIs will
ameliorate all symptom clusters of PTSD, optimal results may entail high doses
at relatively long duration (8-12 weeks), and side effects such as nausea,
vomiting, diarrhea and constipation pose clinical
problems (Brent, 1995: 209-15).
Although Benzodiazepines (BDZ) are effective in the treatment of adult
anxiety disorders and have been widely utilized in the treatment of PTSD in
adults, studies indicate that they have little effect on core PTSD symptoms of
re-experiencing, avoidance or numbing and pose the risk for rebound effects
such as anxiety, sleep disturbance and prominent rage reactions. Clinicians
should
be aware of the troublesome and sometimes serious adverse effects of dis-inhibition, sedation, irritability as well as
withdrawal syndrome in patients given BDZs even for
short periods (Donelly
and Amaya-Jackson, 2002: 167).
High dose opiate antagonist, naltrexone,
therapy has been utilized with mixed results in treating PTSD. Naltrexone blunts the tendency to self-mutilate and reduces
rates of relapse in alcoholic patients who have achieved sobriety.
Unfortunately, high dosages of naltrexone carries
risk of hepatotoxicity, thus is not recommended for
clinical use (Donelly et al, 2000: 168).
Tri-cyclic anti-depressants (TCA’s)
appear to reduce symptoms of re-experiencing and depression related to PTSD,
but their diverse affect profile (dry mouth, blurred vision, urinary retention,
tachycardia and postural hypotension) is considerable.
Dopaminergic agents are reserved for patients
with refractory PTSD who exhibit paranoid behaviour, para-hallucinatory
phenomena, self-destructive behaviour, explosive or overwhelming anger
or psychotic symptoms.
Their risks of adverse effects such as extra-pyramidal symptoms and tardive dyskinesia reserve them
for only the most debilitating cases when other agents have failed or when
symptoms of psychosis, severe mutilation or aggressiveness are limiting
recovery (Donelly and Amaya-Jackson,
2002: 164).
Psychotherapy
Psychodynamic reprocessing, behavioural therapy, cognitive
psychotherapy, hypnotherapy and rapid eye-movement desensitization are some of
the specialized therapeutic approaches to the treatment of PTSD.
Essentially these treatments differ primarily in the techniques that are
used by the therapist to provide safe environments that are conducive to
re-collecting the trauma and managing reactions to
the remembering and working through of the memories (McFarlane and Yehuda, 2000: 1994).
Psychodynamic reprocessing emphasizes that symptoms are a result of the
individual’s inability to integrate the complexity of the cognitions and
affects caused by trauma. The aim of treatment is
to modify the defensive and copying strategies (that is, symptoms) used
to modulate the maladaptive representations of the trauma and to facilitate the
processing of the meaning of the traumatic memories and their accompanying
emotional distress by gently confronting the patient’s feelings of
happiness, shame and vulnerability (Marmar, 1991; 21:
405-414).
Behavioural therapy stresses that symptoms result from classical and
operant-conditioned responses to the trauma. The aim of treatment is to reduce
the anxiety and the physical and emotional conditioned responses by altering
the fear reactions to reminders of the trauma. This can be accomplished through
the use of guided exposure to triggers (that is, exposure to symbols or places,
or guiding the patient’s rehearsal of the traumatic story).
These techniques are based on the application of learning theory
principals such as habituation and extinction (Keane, Fairbank, Caddell and Zimering 1989; 20:
245-260).
Cognitive psychotherapy stresses that symptoms result not only from the
conditional response, but also from maladaptive assumptions of patients, such
as that catastrophic outcome could have been predicted or avoided.
Treatments use cognitive restructuring strategies (e.g. exploration and
re-examination of individual responsibility, vulnerability and helplessness), in
addition to a behavioural component which relies on stimulating the fear
invoked during the trauma, to effect a change in the representation of the
memory. In some variants of this treatment stress inoculation training is
provided to help modulate unbearable affects (Foa, Dancu, Hembree, 1999; 67:
194-200).
Rapid eye-movement is a novel and controversial treatment for PTSD, in
which the therapist instructs the patient to focus on the therapist’s
finger which is moved laterally backwards and forwards across the
patient’s gaze, while the patient maintains an image of the original
traumatic experience. The patient then describes the traumatic event and the
associated feelings, and then thinks about
a reassuring or safe image. Although the mechanism through which
therapeutic outcome is achieved is unknown, it is believed that symptom relief
is acquired by allowing the patient to work through the traumatic event in a
state of deep relaxation (McCann, 1992; 23: 319-323).
The goal of psychological intervention is to help the patient move away
from the persecution and ongoing suffering, but the actual efficacy of
treatment may depend on a range of factors which include age of the patient,
severity of the stressor, past medical treatment, education of the patient and
the quality of the therapeutic relationship. Regardless of which modality is
chosen, there is usually some type of dialectic that occurs in trauma work.
While treatments which have a primary focus on confronting the fear
memory of the trauma have been demonstrated to be particularly useful, this is
an approach which a significant proportion of patients will not consent to
engage in (McFarlane et al., 2000; 34: 943).
2.5 HOMOEOPATHY AND POST TRAUMATIC STRESS DISORDER
All our dysfunctions ultimately stem from being traumatized and not
being able to process it at the time or later. This kind of cause and effect
are the ‘rule’ in understanding health. Traumas usually have an
associated set of emotions, including fear, anger and grief/loss. It has stages
of occurrence and recovery. Lack of love seems to be the basis of most
traumatic feelings, especially isolation, rejection, lack of confidence, and
poor self-esteem, although fear is also a contributing factor (Chappell, 1994:
9, 10, 13).
The prolonged exposure to trauma and its mismanagement can have
potentially devastating effects because trauma invades the mental, emotional,
physical and spiritual spheres of an individual’s
life (Foaet al., 1999: 195). Homoeopathy is a
medicine for the individual (Shepherd 2, 1995: 10). It treats holistically and
cures rapidly, yet gently and permanently (Hahnemann, 1998: 112). In this
light, it is anticipated that homoeopathy could appropriately heal
maladjustments in patients with PTSD.
Experience has gradually proved that a person fitting a trauma picture
and given the appropriate remedy will get better irrespective of what is wrong
physically, although in reality mind and body symptoms go together.
All physical symptoms mirror the mind state and vice versa. When accurately
perceived, mind states, thoughts and feelings reflect the deepest current
trauma or inner state that it is necessary to treat.
The inner intelligence of our immune system always presents what is
wrong at the forefront of our being, so as to ‘request’ curative
help. Frequently the presentation is based on very early experiences. Beyond
this, homoeopathy has integrated much from the field of modern psychology, both
humanistic and traditional (Chappell, 1994: 91).
We get into trouble and illness not only because, but also in order to,
be moved to reach new levels of awareness and differentiation. When we are
beset with difficulties or illnesses it may be well,
to ask not only “How may I have caused this?”, but also
“What is it trying to teach me?” Our need to learn and develop and
grow while we are alive on this Earth is not a matter of fault. It may be
a matter of being offered a learning experience through having to find
the appropriate similimum out there and the meaning
within (Whitmont, 1991: 74).
Used and succesful remedies in 12 cases:
Hep. Sulph.
Carc.
Nat-m. 3x
Bry.
Sulph.
Lach.
Plat.
Staph. Thuj.
Sep. Ph-ac.
Lac-c. Lyc.
Tarant. Anac.
Stram. Gels. Arg-n.