presented by: caroline meyer, nd at the oand annual convention on 18 november 2014

Presented by: Caroline Meyer, ND At the OAND Annual Convention On 18 November 2014

The Impact of Trauma When you're born a light is switched on, a light which shines up through your life. As you get older the light still reaches you, sparkling as it comes up through your memories. And if you're lucky as you travel forward through time, you'll bring the whole of yourself along with you, gathering your skirts and leaving nothing behind, nothing to obscure the light. But if a Bad Thing happens part of you is seared into place, and trapped for ever at that time. The rest of you moves onward, dealing with all the todays and tomorrows, but something, some part of you, is left behind. That part blocks the light, colours the rest of your life, but worse than that, it's alive. Trapped for ever at that moment, and alone in the dark, that part of you is still alive. Michael Marshall Smith, Only ForwardMichael Marshall Smith, Only Forward

Learning Objectives: Understand the prevalence of trauma in the general female population Learn how to recognize the features of trauma in women in the clinical setting Review recent research on the impact of trauma to the CNS and hormonal system Review conventional medical treatment of trauma Explore naturopathic approaches in the treatment of trauma, including dietary, nutraceutical, lifestyle, counselling,botanical and homeopathic prescriptions

First, Some Definitions Trauma: any experience that interferes with normal physiological, mental-emotional, social functioning PTSD, according to new DSM V criteria (1), includes: 1) Experience of a stressor (acute, chronic, witnessing, and/or indirect) 2) Intrusive symptoms (1) 3) Avoidance symptoms (1) 4) Negative changes in mood & cognition (2) 5) Changes in reactivity & arousal (2) 6) Duration of sx last more than 1 month Patient also can have dissociative sx and may have delayed onset of sx

Prevalence of Trauma According to Stats Can, it is estimated that 50% of Canadian women and 1/3 of men have survived at least one incidence of sexual or physical abuse (2) Even though boys and girls are equally likely to be exposed to family violence, 4 out of 5 victims of family-related sexual violence are girls (2) Similar findings in US studies

Health Impacts of Trauma From the ACE (Adverse Childhood Events) study involving 17 000 respondents (3): Having 4 or more indices of childhood trauma significantly increases risk of: Depression Suicide attempt COPD Addiction, including risk of becoming a smoker and/or alcohol dependent Liver disease, Early death and more medical conditions

More Health Impacts People with PTSD have increased self-reported experience of pain and increased impairment in daily activities to pain (4)

Trauma Changes The Brain Lang, a leader in neurobiology of trauma, proposed that emotionally-charged memories are held in associative networks that impact many different structures and functions in the brain (5) Trauma appears to negatively impact the functioning of the brains cortex as well as brain stem In people with PTSD, the prefrontal cortex & particularly the anterior cingulate (which governs rationality/reason) is smaller along with shrinking of hippocampus (6) Emotionally based memories are stored, too, in the amygdala and trauma can increase the sensitivity of the amygdala to non-threatening stimuli (6)

Trauma Destabilizes the Autonomic Nervous System PTSD associated with impaired parasympathetic control (as measured by low respiratory sinus arrhythmia) along with increased sympathetic sensitivity (7 ) Clinically, this presents as overstimulation- based symptoms (eg. anxiety) along with under-arousal symptoms (eg. depressed mood)

Trauma and Neurotransmitters Trauma has been associated with lowered GABA levels especially in the anterior cingulate and this corresponds with increased insomnia severity (measured by ISI scores) (8) Again, Lang has shown that trauma often induces dysregulation of serotonin and dopamine pathways in the CNS (5)

Hormonal Effects of Chronic Stress vs. PTSD in Adults (6,9,10) Chronic Stress PTSD Increased cortisol Increased CRF (ie. Abnormal negative feedback loop) Tendency for insensitivity of glucocorticoid receptors Lowered or normal cortisol Increased CRF (ie. normal negative feedback loop) Tendency for heightened sensitivity of glucocorticoid receptors

Hormonal Impact of PTSD in Children PTSD appears to affect children differently: Initially (shortly after traumatizing event), high evening cortisol and elevated IL-6 are predictive of developing PTSD within six months of event (11) Six months after trauma event, cortisol levels return to normal but catecholamines levels higher (11)

Generational Impact of PTSD Adults with PTSD may confer alterations of stress hormone responses in their children Children of Holocaust survivors with PTSD as well as mothers pregnant during 9/11 who reported symptoms of PTSD had: Lower urinary excretion of cortisol and lower salivary cortisol levels (compared to children of parents who experienced these traumatic events but didnt have PTSD) (12,13)

Conventional Treatment of Trauma: Therapy Usually involves combination of trauma-specific therapy and psychoactive medications (14) Main therapeutic approaches include: EMDR (Eye Movement Desensitization & Reprocessing) CBT, has been shown to be effective in both adults and particularly with children and adolescents (15) Exposure therapy (a form of behaviour therapy)

Therapeutic Approach: Judith Herman Judith Herman published Trauma and Recovery (16), a classic book on the healing of trauma Her approach includes the following steps: Developing A Healing Relationship Creating Therapeutic Safety Remembrance and Mourning Reconnection Commonality

Therapeutic Approach: Peter Levine Another classic approach developed by Peter Levin takes its inspiration from observations in the animal world; that is, observing how animals in the wild respond to acute trauma(17) Levines key elements of trauma therapy include: Establishing sense of relative safety Encouraging patients self-awareness of body sensations Decoupling & discharging body sensations from the memories of trauma

Conventional Treatment of Trauma: Medication First-line medications include SSRIs and SNRIs (eg. Venlafaxine/Effexor) (14) Second-line medications include tricyclic antidepressants, mirtazapine/Remeron, anticonvulsants, and MAO inhibitors Adjunct treatment can involve antipsychotic meds, benzopdiazapines, and Prasozin/Alpha-adrenergic blocker (15)

Novel Conventional Treatment of Trauma: Cortisol Low dose oral cortisol tx for 4 weeks significantly reduced the recall of traumatic memories for people with PTSD (18) without major adverse effects

Novel Conventional Treatment of Trauma: MDMA & Cannabinoids These psychoactive components appear to positively impact the process of fear conditioning and reduce anxiety (15, 19) This research is in its first stages, and the long-term effects of MDMA and cannabinoids are unclear Nevertheless, these findings may explain in part why people with PTSD often use psychoactive drugs to self-medicate

Recognizing Trauma in Clinical Practice: Red Flags Beyond the typical clinical symptoms of PTSD, look for: Never Well Since . Unexplained physical symptoms that do not fit neatly into diagnostic categories, including recurrent abdominal pain, idiopathic infertility I have found that people with certain medical conditions are more likely to have a traumatic past, including endometriosis, fibromyalgia, and BPD (borderline personality disorder)

Naturopathic Treatment of Trauma: Initial Steps (20) 1) Ensure that patient is safe and not at immediate risk of harming self or others 2) Where PTSD and/or trauma is significantly impacting your patient and you determine it is beyond your scope of practice, refer patient for care with psychologist, psychiatrist, psychotherapist, or another practitioner with experience in trauma 3) Even if referral is made, naturopathic medicine has much to offer patients in supporting them in healing from trauma and co-managed care is often optimal

Naturopathic Treatment of Trauma: Ongoing Steps 4) As you continue to work with a patient undergoing treatment for trauma, it is important to ensure patient has a crisis management plan. The healing path is circuitous especially with trauma, and acute distress can occur. 5) May be obvious but ongoing self-care for you as the practitioner is essential because treating patients with trauma histories can be emotionally intense and draining

Naturopathic Treatment of Trauma: Creating Safety in the Clinical Setting When a patient has disclosed a history of trauma, I always take care to: Clarify what feels safe in terms of physical touch for physical exams, acupuncture, etc. Set very clear professional boundaries Remain mindful that it is not always necessary (or therapeutic) for the patient to divulge details of her trauma history Ensure that the patient feels grounded at the end of the visit, and leaving adequate time for closure

Naturopathic Treatment: Adrenal Support Regular Daily Routine Most effective adrenal support is the cultivation of daily habits done at regular times of the day (ie. Meal times, sleeping & waking times, time for physical exercise, etc) The mind-body responds positively to the regularity of routine Use Adrenal Tonics over adrenal stimulants in most cases (21)

Naturopathic Treatment: Neurotransmitter Support Given that trauma appears to disrupt neurotransmitter function in CNS, replenishing neurotransmitters can be effective therapeutic approach (22) Also consider use of precursors to neurotransmitters, including 5-HTP, Tryptophan, P5P, magnesium, phenylalanine, tyrosine

Naturopathic Treatment: Mind-Body Approaches Loving Kindness/Metta Meditation Pilot study published in 2013 on loving- kindness/metta meditation sessions lasting over 12 weeks showed significant improvement in PTSD symptoms immediately at the end of the program and at the 3-month follow-up (23, 24)

Naturopathic Treatment: Mind-Body Approaches Yoga Again, small studies involving yoga has shown moderate positive effect on PTSD symptoms (25,26) A pilot study involving women found that women with PTSD in the yoga group had lowered suppression of emotional expression and increased psychological flexibility by the end of the program compared to the control group, resulting in reduction of intensity of PTSD symptoms (25)

Naturopathic Treatment: Body-Focused Therapy Emotional Freedom Technique (EFT)/ Tapping Tapping, or Emotional Freedom Technique/EFT, has shown promising results for treating trauma in several small pilot studies (27,28) One study done in Rwanda with 50 orphaned adolescent genocide survivors showed a dramatic reduction in self-reported and caretaker ratings of trauma-induced symptoms, including flashbacks, depression, enuresis, nightmares, and impaired concentration (27)

Naturopathic Treatment: Meditation A small pilot study (only involving 9 participants) found that after an 8-week mindfulness-based stress reduction (MBSR) program, people with PTSD experienced a significant reduction in PTSD & depression symptoms, as well as shame-based trauma appraisals (29) Also, acceptance of the emotional impact of trauma was increased over the course of the program

Naturopathic Treatment: Acupuncture Again, some promising results for constitutional acupuncture in reducing the intensity of PTSD symptoms (30) Range of different protocols have been shown to be effective, including constitutional acupuncture with or without electrostim; with or without moxa Auricular acupuncture also effective

Naturopathic Treatment: Acupuncture Clinically, I have seen positive impact of NADA auricular protocol for managing symptoms of PTSD NADA protocol includes: Shen Men, Autonomic point, C. Kidney, Lungs, Liver I often add in Point Zero, Brain & Limbic System Trauma can clearly damage Kidneys, grief can drain Lung qi and suppression of emotions and/or anger can stagnate Liver qi

Naturopathic Treatment: Flower Essences Clinically, I have found that flower essences can powerfully facilitate the healing of trauma Bach Flower Essences Star of Bethlehem releases shock, useful for acute trauma Aspen removes fears that are not clearly defined White Chestnut heals recurrent upsetting & intrusive thoughts Elm transforms sense of overwhelm Rock Rose helps to resolve fears that keep patient frozen, unable to react Sweet Chestnut restores faith/hope that all will be okay

Naturopathic Treatment: Constitutional Homeopathy One of my favorite and most effective ways to fortify and balance the vis, thus helpful in healing trauma Case #1: 35 year old woman presenting with social anxiety and dysmenorrhea Started in early 20s while in undergrad More problematic now that she is in relationship and has a young daughter; wants to be present and supportive in her family relationships Feels better when doing intense physical exercise; has recently discovered Crossfit

Naturopathic Treatment: Constitutional Homeopathy Desires to feel strong, powerful and in control, but knows that this also results in her feeling emotionally shut down and isolated from others During treatment, patient develops an acute hamstring injury (from overtraining at Crossfit ) I prescribe acutely Arnica 1M once per day for three days (31) Patient returns with revelation of sexual abuse as child and sexual assault in undergrad; feels free and more emotionally open in sharing her experience with her partner and close friends

Naturopathic Treatment: Constitutional Homeopathy Patient continues to respond well to Arnica but I eventually prescribe a single dose of 10M After the 10M dose, the patients dysmenorrhea significantly reduces 18 months after first taking Arnica 1M (and with follow-up remedy of Lac-maternum 200C(32), patient has a child of her own; something she never thought possible physically or emotionally

Naturopathic Treatment: Constitutional Homeopathy Case # 2: 56 year old patient presents with HTN, obesity, hypothyroidism and FM of 10+ years duration When I asked for a medical timeline, patient returns with a chronological history of severe physical and sexual abuse from ages 3 to 45 She has several other medical supports including weekly psychiatrist appointments, reiki practitioner, and First Nations elder Patient also experiences dissociative symptoms in which she can lose several hours of a day; happens a few times per month Has intense dreams of flying quickly, being at height

Naturopathic Treatment: Constitutional Homeopathy Patient describes FM pain as heavy, constricted around muscles and when BP is high, she feels constricted feeling in chest with palpitations Patients weight has fluctuated greatly in past 10 years, gaining and losing and then gaining 100lbs. She has had several drug experiences earlier in life but has been sober for over 10 years Has intense dreams of flying quickly, being at height Often has headaches with dissociative episodes characterized by crushing, constrictive pain that is worse with closing eyes

Naturopathic Treatment: Constitutional Homeopathy I prescribe patient Anhalonium LM4 once per day for 7 days in a row (LM because I was concerned about possible aggravation) Commonly known as Peyote, member of Cactaceae family (31) Keynote sensations: Constrictive, oppressive, heavy Some keynote rubrics for Anhalonium: Generalities; pain; crushing, as if Mind; delusions; enlarged

Naturopathic Treatment: Constitutional Homeopathy In first & second follow-ups (4 & 8 weeks later), she reports having intense dreams on the first 3 nights of taking the remedy; all involve her totem animal showing her book of wisdom and various crystals Feels grounded and no dissociative symptoms since taking the remedy FM pain has improved and she is able to exercise daily Reduced appetite and has lost 10 pounds since taking remedy

Prevention: Building Trauma Resilience Key components of preventing traumatic experience from developing into PTSD/chronic trauma symptoms (16): Access to social support networks Placing traumatic event in broader context, giving the experience a deeper meaning Healing by helping others

Prevention: Building Trauma Resilience Interesting genetic research on neuropeptide Y whose presence seems to confer a protective benefit for prevention of chronic trauma(33) Mixed results in the research for traditional talk therapy and debriefing sessions after traumatic event as effective means for primary prevention of PTSD(34)

Spiritual Journey of Trauma Intense life experiences, whether positive or negative, have the potential to transform our lives The suppression of traumatic memories and emotions consumes an enormous amount of energy; as trauma heals, that well of energy is available for patient to use Levine has observed that when trauma is healed, patients often have intense spiritual experiences not unlike the generation of Kundalini energy or Satori within meditative practices (17)

The Promise of Healing Trauma The wound is the place where the Light enters you. RumiRumi

References 1. American Psychiatric Association. DSM-V. Arlington, VA; American Psychiatric Assoc; 2013. 2. Johnson H & Sacco VF. Researching violence against women: Stats Cans national survey. 1995. Cdn J Criminiology. 3. Anda R, Felitti VJ. 2014. The adverse childhood experiences study: Center for Disease Control & Prevention website.http://www.cdc.gov/ace/findings.htm. Accessed on 25 July 2014.http://www.cdc.gov/ace/findings.htm 4. Powers A et al. Childhood abuse and the experience of pain in adulthood. 2013. Psychosomatics. Oct 23. Epub ahead of print. 5. Lang PJ, McTeague LM, Bradley MM. Pathological anxiety and function/dysfunction in the brains fear/defense circuitry. 2014. Restor Neurol Neurosci; 32(1):63-77.

References 6. Yehuda R. Biology of posttraumatic stress disorder. 2001. J Clin Psychiatry. 62 Suppl 17:41-6. 7. Blechert J, Michael T et al. Autonomic and respiratory characteristics of posttraumatic stress disorder and panic disorder. 2007. Psychosom Med. Dec;69(9):935-43. 8. Meyerhoff DJ et al. Cortical gamma-aminobutyric acid and glutamate in posttraumatic stress disorder and their relationships to self-reported sleep quality. 2014. Sleep. May 1; 37(5)_893-900. 9. Jones T, Moller MD. Implications of hypothalamic-pituitary-adrenal axis functioning in posttraumatic stress disorder. 2011. J Am Psychiatr Nurses Assoc. Nov-Dec; 17(6): 393-403. 10. Wahbeh H, Oken BS. Salivary cortisol lower in posttraumatic stress disorder. 2013. J Trauma Stress. Apr; 26(2):241-8.

References 11. Pervanidou P. Biology of post-traumatic stress disorder in childhood and adolescence. 2008. J Neuroendocrinol. May; 20(5):632-8. 12. Yehuda R, Bierer LM. Transgenerational transmission of cortisol and PTSD risk. 2008. Prog Brain Res. 167: 121-35. 13. Lehrner A Bierer LM et al. Maternal PTSD associates with greater glucocorticoid sensitivity in offspring of Holocaust survivors. 2014. Psychoneuroendocrinology. Feb; 40:213-20. 14. Jeffreys M, Capehart B, Friedman MJ. Pharmacoptherapy for posttraumatic stress disorder: review with clinical applications. 2012. J Rehabil Res Dev. 49(5): 703-15. 15. Kerbage H, Richa S. Non-antidepressant long-term treatment in post-traumatic stress disorder. 2013. Curr Clin Pharmacol. Feb 4 [Epub ahead of print].

References 16. Herman J. Trauma and recovery (rev). New York: Basic Books; 1997. 17. Levine PA. In an unspoken voice: how the body releases trauma and restores goodness. Berkley CA; North Atlantic Books: 2010. 18. deQuervain DJ, Margraf J. Glucocorticoids for the treatment of post-traumatic stress disorder and phobias: a novel therapeutic approach. 2008. Eur J Pharmacol. Apr 7; 583(2-3):365-71. 19. Passie T, et al. Mitigtion of post-traumatic stress symptoms by Cannabis resin: a review of the clinical and neurobiological evidence. 2012. Drug Test Anal. Jul-Aug;4(7-8):649-59.

References 20. Talbot C et al. Coalescing on women and substance use: violence, trauma and substance use. Trauma-Informed Online Tool. BC Centre of Excellence for Womens Health. www.coalescing- vc.org. Accessed on 25 July 2014.www.coalescing- vc.org 21. Bone K & Mills S. Principles and practice of phytotherapy (2 nd ed). London UK; Churchill Livingstone: 2012. 22. Braverman ER. The edge effect: achieve total health and longetivity with the balanced brain advantage. New York NY; Sterling: 2005. 23. Wahbeh H et al. Complementary and alternative medicine for posttraumatic stress disorder symptoms: a systematic review. 2014. J Evid Based Complementary Altern Med. Mar 27; 19(3):161-75.

References 24. Kearney DJ, Malte CA et al. Loving-kindness meditation for posttraumatic stress disorder: a pilot study. 2013. J Trauma Stress. Aug;26(4):426-34. 25. Dick AM et al. Examining mechanisms of change in a yoga intervention for women: the influence of mindfulness, psychological flexibility, and emotional regulation on PTSD symptoms. 2014. J Clin Psychol. May 28 [Epub ahead of print]. 26. Mitchell KS et al. A pilot study of a randomized control trial of yoga as an intervention for PTSD in women. 2014. J Trauma Stress. 19(6): 19-28.

References 27. Sakai CE, Connolly SM, Oas P. Treatment of PTSD in Rwandan child genocide survivors using thought field therapy. 2010. Int J Emerg Ment Health. Winter;12(1):41-9. 28.Ortner N. The tapping solution: a revolutionary system for stress- free living. Carlsbad CA; Hay House: 2013 29. Goldsmith RE et al. Mindfulness-based stress reduction for posttraumatic stress symptoms: building acceptance and decreasing shame. 2014. J Evid Based Complementary Altern Med. [Epub ahead of print]. 30. Kim YD, Heo I et al. Acupuncture for posttraumatic stress disorder: a systematic review of randomized controlled trials and prospective clinical trials. 2013. Evid Based Complement Alternat Med. 2013:615857.

References 31. Sankaran R. An insight into plants: vol 1. Mumbai: Homeopathic Medical Publishers; 2002. 32. Assilem M. Matridonal remedies of the humanun family: gifts of the mother. Tunbridge Wells Kent UK; Helios Pharmacy: 2009. 33. Sah R, Ekhator NN et al. Cerebrospinal fluid neuropeptide Y in combat veterans with and without PTSD. 2014.Psychoneurendocrinology. Feb; 40: 277-83. 34. Skeffington PM et al. The primary prevention of PTSD: a review. 2013. J Trauma Dissociation. 14(4): 404-22.

presented by: caroline meyer, nd at the oand annual convention on 18 november 2014

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