Case Study

 

Since August 2016 I have been working with Triwest Choice program to provide Chinese Medicine to veterans who have been dealing with Post-traumatic stress disorder (PTSD) and pain conditions. During my doctorate program I was assigned to write a case study report. I chose the topic of PTSD and how I use acupuncture and Chinese Herbal Formulas in my clinic. For non practitioners, the information could be complex yet I hope that you can at least have a better understanding of how Chinese Medicine works in the treatment of PTSD. If you have any questions about the topic, please don’t hesitate to email me.

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Treating Veteran Related PTSD with Kiiko Matsumoto Style Acupuncture and Classical Chinese Herbal Medicine : An Ongoing Case Study

by

 Ozben Felek L.Ac. 

510.717.5149

Email: ozbenfelek@gmail.com

Written permission from the patient discussed in this study was obtained.

Keywords: PTSD, Veterans, Acupuncture, Chinese Herbal Medicine

Abstract: Post-traumatic stress disorder (PTSD)  is a commonly found disorders in combat-war Veterans in the United States. The most commonly seen symptoms of PTSD are insomnia, panic attacks, anxiety, hyper vigilance and fear of being in crowds. This case study report aims to show there can be clinically significant results for treating PTSD with Classical Chinese Herbal Medicine and Kiiko Matsumoto Style Acupuncture. In this study, fifteen acupuncture treatments were conducted based on Kiiko Matsumoto’ s hara diagnosis and the classical herbal formulas based on my understanding of Dr. Huang Huang and Dr. Suzanne Robidoux’s Chinese Herbal Medicine teachings and books.

Introduction:

Post-traumatic stress disorder (PTSD) is a mental health condition that’s triggered by a terrifying event — either experiencing it or witnessing it. Post-traumatic stress disorder symptoms may start within one month of a traumatic event, but sometimes symptoms may not appear until years after the event. These symptoms can cause significant problems in social or work situations and in relationships. They can also interfere with the ability to go about normal daily tasks.1

Among veterans who ranked combat as their most traumatic event, 42% met lifetime criteria for PTSD.2

Since 2001, nearly 1.5 million US service members have been deployed in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF; Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans and their Families, 2010), with many returning home with psychiatric disorders post-deployment 3

Biomedical View

  PTSD symptoms are generally grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Symptoms can vary over time or vary from person to person.1

1. Intrusive thoughts such as repeated, involuntary memories; distressing dreams; or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.

2. Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that bring on distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.

3. Negative thoughts and feelings may include ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; or feeling detached or estranged from others.

4. Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being easily startled; or having problems concentrating or sleeping. 4

The main treatments for people with PTSD are medications, psychotherapy, or both. The most studied medications for treating PTSD include antidepressants, which may help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Antidepressants and other medications may be prescribed along with psychotherapy. Most commonly used psychotherapy  is cognitive therapy. 5

There has been also studies about the effectiveness of acupuncture in the treatment of PTSD.  The study ‘Acupuncture for Post-traumatic Stress Disorder: A Systematic Review of Randomized Controlled Trials and Prospective Clinical Trials’ gives us hope for the future studies about using acupuncture for PTSD. 6

Chinese Medicine Perspective

Chinese medicine has been used to treat psychiatric illnesses since at least 1100 BCE.The treatment of psychiatric illness was mentioned in the Shang Han Lun in the third century. A simple Chinese medicine psychiatric classification system developed about 1600 AD does not include PTSD. The modern systemization of Chinese medicine known as Traditional Chinese Medicine (TCM), however, is well equipped to deal with the array of psychological and physical symptoms likely to manifest in those who experience PTSD.TCM uses a sophisticated diagnostic system in which many patterns or syndromes can be identified in any given disorder, because individual constitutions differ. The complexities of patterns are found across most disorders; thus it can be a challenge to develop a TCM diagnostic schema that will apply to most patients with a particular biomedical disorder. However clinical trials of acupuncture have shown promise for the treatment of psychiatric disorders such as anxiety, depression, and insomnia.

According to the study of ‘Developing a Traditional Chinese Medicine Diagnostic Structure for Post-Traumatic Stress Disorder’. the list of patterns for PTSD are : Liver Qi stagnation; Liver Fire; Heart Fire; Liver overacting on Spleen; Qi and Blood Stasis; Phlegm Heat/Fire; Phlegm Damp; Heart and Spleen deficiency; Heart and Kidney deficiency (including Heart or Kidney patterns separately); Heart and Gallbladder deficiency, Qi Deficiency; and Blood deficiency. 7

Patient Information and History 

In this case a 32 years old African -American male veteran was referred to my clinic from VA service. His main complaints were low back pain and PTSD.

He injured his lower back in 2014 during his military service when he was trying to carry a heavy generator. MRI showed L4,L5 herniation. Since then he has been having pain with standing long time and bending over. He has experienced sudden shooting pain to the upper legs or the gluteus time to time. He had appendectomy when he was a kid and he had history of pneumonia, bronchitis.

After his military service in Kuwait and Iraq he was diagnosed PTSD. His symptoms were anxiety being in crowds, panic attacks, insomnia (onset and frequent waking up), sweaty palms and feet, night sweats and frequent urination. During his military service, he was a truck driver and he had to hold urine for long time when he was on duty and he has been having frequent urination issues at night and during the day when he was anxious.He has been experiencing depression on and off and he reported that last couple years, it has been more manageable.

To be able to fall a sleep, he has been using medical edible marijuana and for pain 5 mg hydrocodone twice a day and 500mg naproxen once a day.

Diagnostic Assessment and Treatment:

Patient had deep, slippery and slightly rapid pulse. His tongue was dusky with a white thick coat. He is taller than average and slightly overweight with bright eyes and slow demeanor.

His hará diagnosis showed oketsu and adrenal exhaustion signs and my initial diagnoses was Blood stagnation with damp causing Shen disturbance. I have treated the patient every 10 to 15 day for 5 months total 15 times. Based on hara diagnoses and palpating the metal- water points, I treated him using adrenal and oketsu protocol. I used left LV 4, left LU5 for oketsu and based on kidney fire point reflex, I needled KD 7, KD 10 and KD 27 or reacting kidney points on the lower leg with KD27 for adrenal signs. After the first 6 acupuncture treatment, based on my understanding of Dr. Huang Huang, I prescribed him Wen Dan Tang. Over the course of following 9 treatments, in order to have a better result, I used Dr. Suzanne Robidoux’s Jing Feng Classical Chinese Medicine system and I prescribed him modified Chai Hu Jia Long Gu Mu Li Tang.

The progression of some of the treatments, point and herbal formula prescriptions can be found on the table below.

Date  Symptoms/ progress Tongue and pulse Hara diagnosis  Acupuncture points that were used Herbal Diagnosis Herbal Formulas that were prescribed 
09/07/2017 Initial tt -Low back pain, occasional radiation to the front of the legs

-PTSD anxiety, panic attacks

-night sweats

-frequent urination

-t: sl dusky, swollen, white coating

-p: deep, slippery, sl rapid

Adrenal B sj8, gb40, kd 27

L kd 3, lu 10 rice grain moxa, ren 12 rice grain moxa and needle

– du2, L5, ub 15, 52

rice grain moxa and needle

none none
10/02/2017 6th tt -low back pain 2/10, slight radiation to the left buttocks

-no panic attacks,still have anxiety

-no need to use edible marijuana to fall asleep

-freq, urination

-t: dusky, thick, white coat

-p: deep ,slippery, L cun is superficial

L Adrenal, oketsu -L kd 7, kd 10, lu 5, lv 4

-R kd 7, sp9, gb 34

-B kd 27

-ub 52, l5

rice grain moxa and needle

Damp blood stag. Shen disturbance Wen Dan Tang

BX 15-25

FL15

CP 15

GC 5

ZK 15

ZR 10

GJ 5

HZ 15

3 bags for 6 days

10/28/2018 8th tt -cold symptoms: cough, yellow mucus,chills

-R lower back is sore

-less frequent urination

-t: red

-p: r cun superficial

Adrenal, immune -R kd6

-L kd 7, kd 10

-B kd 27, lu 5, li11 (rice grain moxa and needle)

-du 14 , un 13 cupping

Lung phlegm-heat 30 gr Ding Chuan Tang 5 gr Ma Huang + 10 gr Shi Gao

3 grams twice a day

12/12/2017

10th tt

-no back pain

-no panic attacks

-wake up during the night a lot

-dry throat, some rib side pain

-night sweating

-t: red, yellowish coating

-p: deep, slippery

Oketsu, cv15, ren3 -R yao tong xue

-B gb40, sj9

-T5, L5, SI9, 10

rice grain moxa and needle

Damp blood stag. Shen disturbance 35 gr Wen Dan Tang 5 gr Huang Lian + 10 gr Shi Chang Pu

6 grams twice a day

01/02/2018

11th tt

-lpb is 1/10, some radiation to  the r leg

-less day time urination

-palm and feet sweating w anxiety

Night sweats are worse

-t: reddish dusky-p: deep ,rapid Oketsu, liver L: lu5, lv4, ling gu, da bai

R: ht 7, kd 6

yintang

3 yang w taiyin excess damp, Ben Tun 55 gr CHJLGMLT+ 10 gr Bai Zhu,+10 gr Bai Shao

+5 gr extra LG, ML

4.5 grams twice a day

01/26/2018 15th tt -low back sore, no pain, no radiation

-night sweats only once

-no panic attacks, anxiety is less

-rib side pain

-wake up a lot

-dry mouth, dry throat

-less daytime urination, 3 times night time urination

-t: dry, red , thick white coating

-p: deep, slippery

-oketsu, liver excess, immune L: lu5, lv 4

R: Zhong bai, Xia Bai, rice grain moxa on lv 8

3 yang w taiyin excess damp, Ben Tun 60 gr CHJLGML + 10 gr Huang Qi + 8 gr Bai Shao 5 gr  additional Fu Ling

4.5 grams twice a day

Results: 

After the first treatment, patient reported having less pain, 2/10 and better quality of sleep. He did not have any panic attacks but still experienced underlying anxiety and frequent urination. Over the course of 15 treatments, he stopped using edible marijuana to be able to fall asleep. After adding the herbal formulas, his night sweats reduced as well as anxiety and also daytime urination . He still goes to bathroom 3 or 4 times at night. His pain is tolerable and most of time not noticeable unless he stands for a long time. The week before the last treatment, he had a situation that would have triggered the panic attacks but he reported feeling very stable and calm and he attributed that to the treatments. He reduced the hydrocodone from two times to once a day. He reported having dry mouth and throat, and desire to drink cold water which I will be addressing these symptoms with future treatments.

Discussion:

Considering that there are many Chinese Medicine patterns that can be addressing the treatment of PTSD, I decided to do Kiiko Matsumoto Style (KMS) acupuncture suing hara diagnosis as well as tongue, pulse diagnosis.

Kiiko Matsumoto Style(KMS) acupuncture utilizes a systematic, easy to learn, palpatory method which is designed to provide instant feedback. When using this system, a KMS practitioner follows a palpation sequence which, both establishes a diagnosis and suggests several treatment options which might be effective for treating a particular patient. 8

One of the palpatory method that has been used in KMS acupuncture is Hara diagnosis.

The reflex zone of Adrenal exhaustion is pressure pain or tightness around the navel around kd 16 area. The adrenal sign is most commonly active on patients who have suffered or suffering from shock, trauma and extreme stress. The basic adrenal treatment is needle KD 7, KD 10, KD 27 if there is pressure pain on KD2, if not KD6 and Kd 27. 9

The reflex zone of Oketsu ( blood stagnation) is found of the lower left quadrant of the abdomen approximately the location that governs ST 26, 27 area. Some of the sign and symptoms of Oketsu are headed, insomnia, palpitation , sciatica, backache, neurosis, anxiety, depression.

The main treatments points to reduce the pressure pain at the Oketsu sign are Liver 4 and Lu5 on the left side. 10

I decided to use Chinese herbal formulas with the acupuncture after the first 6 treatments. First I prescribed Wen Dan Tang. Even though it showed effects of reducing the anxiety, I decided to use Suzanne Robidoux’s approach to get a better results and I prescribed modified CHJLGMLT based on his symptoms as well as his tongue and pulse diagnosis.

Dr. Huang Huang emphasis on two main formulas in the treatments of psycho- emotional issues: Wen Dan Tang (WDT) and Chai Hu Jia Long Gu Mu Li Tang (CHJLGMLT).

Dr. Huang Huang explains that Wen Dan Tang has been used primarily treating those who ‘are easily startled by events, have dream-disturbed sleep, shortness of breath, palpitations and fatigue, or spontaneous sweating.’ Those with the Gallbladder presentation often express with prominent psycho-emotional symptoms that include sleep disorders, insomnia with excessive dreaming, irritability to calm down, panic attacks. 11

First, I prescribed him 3 bags of raw WDT. He took one bag for two days. After the six days of taking the decoction, he reported having less anxiety and no panic attacks. He reported drinking the decoction very difficult due to the taste and wanted to use granules next time, The following week he had a cold so I prescribed him  30 gr Ding Chuang Tang + 5gr Ma Huang and 10gr She Gao. The following week his cold symptoms were gone so I prescribed  35 gr WDT with 5 gr Huang Lian and 10 gr Shi Chang Pu.

Even though with each treatment and herbal formula, his anxiety seemed to reduce and he did not have panic attacks, he was still experiencing night sweats, frequent urination. I decided to change my herbal treatment approach. I started using Suzanne Robidoux approach and prescribed the patient modified CHJLGMLT based on Jing Feng style herbalism.

In Dr. Huang Huang’s  book Ten Key Formula Families, under CHJLGMLT chapter he explains that chronic illness, advanced age, long-term psychological stress, and external injury all can lead to patients with bupleurum constitution losing their psycho-emotional and neurological  equilibrium, which can manifest with serious neuropsychiatric symptoms. Problems are expressed in aspects of the behavior, emotions, speech and thought processes, perceptions, consciousness, memory, focus and sleep.12

After reading this chapter and doing more research about CHJLGMLT, I decided to use

Suzanne Robidoux’s herbal intake to see if it’d be appropriate to use CHJLGMLT in her system too.

In Suzanne Robidoux’s lineage Jing Feng theory the six syndromes are not related to channels,Meridians, organs, diseases,  5 element theory or one singular symptoms but are diagnosis system based on the full compilation of symptoms clearly defining the presented syndrome to target a formula pattern. The external syndromes could be Taiyang or Shaoyin , internal syndromes are Yang Ming or Taiyin and the half exterior, half interior (H+H)  are shao yang or shao yin. 13

According to this system if the disease is in the half exterior, half interior, the treatment principle should be harmonizing by clearing the heat above and warming the middle or lower. 14 

Based on this system patient’s diagnose was three yang, taiyin excess damp and ben tun. The patient had dry throat, rib side pain and on and off symptoms which confirmed the H+H, because he had irritability, sweating symptoms, the H+H was Shaoyang instead of Jue yin. The yang ming symptoms were secondary, he had irritability,  dry mouth and occasional night sweats which would be addressed with Long Gu and Mu Li in CHJLGMLT.

After giving modified CHJLGMLT for 3 weeks, the night sweats were reduced significantly, the anxiety continued to reduce too. After harmonizing the half and half, I except the syndrome to move from H+H to Taiyang syndrome or possibly to Yangming. Based on the clinical findings, I will be changing the formula prescription.

I believe that KMS acupuncture works on the constitutional level as well as treating the current symptoms. Over the course of the 15 treatments, the acupuncture treatments helped him to feel less pain, less anxiety which I think, it is due to using mainly adrenal and oketsu blood stagnation treatments based on the hara diagnosis. With the combination of KMS acupuncture and Jin Feng classical herbal medicine, I expect that the patient’s health will continue to improve.

KMS style acupuncture is the main focus of the Harvard Medical School department of continuing education, 9-month acupuncture training course for physicians. I think over the years, with the collaboration of the physicians who have taken the training, we will see more evidence and more research about how KMS style acupuncture works on PTSD.

I also believe that with the continuing support of Veteran Affairs Service and their recognition of Chinese Medicine’s success for treating PTSD, we will see more and more scientific research about Chinese Medicine’s effects on treating PTSD.

References

1 https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder

/symptoms-causes/syc-20355967?p=1

2 Prigerson, H. G., Maciejewski, P. K., & Rosenheck, R. A. (2001). Combat trauma: Trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. Journal of Nervous & Mental Disease, 189, 99–108.

3 M. Price, D. F. Gros, M. Strachan, J Kenneth, R. Acierno ( 2012). Combat Experiences, Pre-Deployment Training, and Outcome of Exposure Therapy for Post-Traumatic Stress Disorder in Operation Enduring Freedom/Operation Iraqi Freedom Veterans

4 Diagnostic and Statistical Manual of Mental Disorders, (DSM-5) American Psychiatric Publishing, 2013

5 https://medlineplus.gov/posttraumaticstressdisorder.html

6 Y. Kim, I. Heo, B. Shin, C. CrawfordH. Kang,  and J. Lim  (2013) Acupuncture for Post-traumatic Stress Disorder: A Systematic Review of Randomized Controlled Trials and Prospective Clinical Trial

7 The Journal of Alternative and Complementary Medicine, Volume 12, Number 1, 2006, pp. 45–57, Developing a Traditional Chinese Medicine Diagnostic Structure for Post-Traumatic Stress Disorder

8 http://kiikomatsumoto.com/kiiko-style-acupuncture.html

9 K.Matsumoto, D. Euler (2014). Kiiko Matsumoto’s Clinical Strategies Vol 1. pg 40-44

10 K.Matsumoto, D. Euler (2014). Kiiko Matsumoto’s Clinical Strategies Vol 1. pg 40-44

11 Dr. Huang, The Key Formula Families in Chinese Medicine, 2009, pg 253-255

12 Dr. Huang, The Key Formula Families in Chinese Medicine, 2009, pg 95-97

13 Dr. Shi Lun, Dr. S. Robidoux, 2005, Understanding Shang Han Za Bing Lun with Dr. Feng Shi Lun, Case Study Compilation, pg 8,14

14 https://chinesemedicinetraveller.com/wp-content/uploads/2016/09/Classical-

formula.Six-Syndrome.2016.pdf

    

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