Whole Health is built around the Circle of Health, which emphasizes the importance of personalized, values-based care that draws in mindful awareness and eight areas of self-care: Surroundings; Personal Development; Food & Drink; Recharge; Family, Friends, & Co-Workers; Spirit & Soul; Power of the Mind; and Moving the Body. Conventional therapies, prevention, complementary and integrative health (CIH) approaches, and community also have important roles. The narratives below describe how the Whole Health approach could have an impact on three different Veterans with PTSD.
Depending on individual needs, a Whole Health approach to PTSD can incorporate a number of different self-care, conventional care, and complementary health approaches. PTSD is especially responsive to mental health interventions. Focusing on relationships, spirituality, and sleep quality—in a way that is tailored to individual needs—can be particularly important. Many professional care approaches can prove useful, starting with trauma-focused psychotherapies, and also including medications, other types of psychotherapies, and an array of CIH approaches. The CIH approaches serve best as adjuncts to more conventional care. Keep reading to learn more about the evidence for the efficacy and safety of these different approaches and how you might incorporate them into a Personal Health Plan (PHP).
Meet the Veteran - Todd, Erica, and Melissa
Todd is a 28-year-old Veteran of Operation Iraqi Freedom (OIF). He “saw a lot go down” during his time in Iraq, but he felt like he was doing fairly well when he completed his tour and returned to the United States in 2009. Six months after his return, however, he developed a number of troubling symptoms:
- He began to have flashbacks, focused on when his teammate, Hal, lost his leg in an explosion.
- He finds himself wanting to avoid crowded areas or places where there is a lot of noise. He tells you, “I can’t set foot in a mall, a theater, or some other crowded place like that.”
- He finds it is impossible to trust anyone now, and he hasn’t felt relaxed or happy in years. He gets into fights easily. He always positions himself in a room so he can see the doors and windows.
- He is haunted by the thought that he should have been the one to lose a leg, not Hal.
- He finds it difficult to maintain romantic relationships or friendships. His concentration is poor, and he is frustrated that he has not done well in college courses he has tried taking. He says, “Every time I try to do something new, it’s like I sabotage myself. Or I get all wired and reactive and it makes everything go wrong.”
To cope, Todd drinks, sometimes as much as a case of beer daily, but on good days, he does not drink at all. He does not own a gun or have plans for harming himself, but it has occurred to him that, as he puts it, “my life has been so hard that I am not so sure I want it anymore.” He was initially diagnosed with anxiety, until he sought out the advice of a psychiatrist who made the diagnosis of PTSD. He takes his medications as prescribed by his psychiatrist, and wants to do “anything and everything” he can to improve his quality of life.
Erica is a 34-year-old Veteran of Operation Enduring Freedom (OEF). During her deployment, she was sexually assaulted. She did not press charges due to various circumstances, including being threatened by a superior officer when she went to him for help. Since her return to the United States, Erica has had difficulty in finding work, primarily because she wants to minimize direct interactions with men. She tells you, “I just can’t stand to be around other people, especially men, because it all takes me back to when I was raped.” For a year, she worked out of her home. However, she developed worsening depression and attempted suicide via an overdose of one of her sleep medications in 2012. In the wake of the suicide attempt, her worsening concentration, sleep problems, and periodic anxiety attacks, she lost her home-based job. She was evicted and has been homeless for several years. She currently lives in a women’s shelter.
Melissa is a 48-year-old Veteran of both the Gulf War (Operation Desert Storm) and OIF. In her role as a medic, she was often one of the first to respond when explosions or other events generated casualties. While she states she “made it out without a scratch,” she also tells you, “I still feel like something is broken inside me.” Melissa currently works as an EMT. She has some good days and some bad days, but it is increasingly difficult for her to go to work due to the fear that she will be a first responder at a serious trauma and end up “losing it to the point where I can’t do my job well.”
Todd, Erica, and Melissa all receive their care at the same VA facility, where they all registered for “Self-Care for PTSD” resources. Each of them, when given the option, agreed to work with a Whole Health Partner. Their Whole Health Partner, Richard, who was diagnosed with PTSD himself after serving in Vietnam, met with each of them several times to outline their Mission, Aspiration, Purpose (MAP) and to begin some personal health planning.
These are men whose minds the Dead have ravished.
Memory fingers in their hair of murders
Multitudinous murders they once witnessed.
Wading sloughs of flesh these helpless wander,
Treading blood from lungs that had loved laughter.
—Wilfred Owen, English poet and WWI soldier, 1893-1918
PTSD affects 7%-8% of all Americans at some point during their lifetimes, with women being affected twice as often as men (10% versus 5%). The National Vietnam Veterans Readjustment Study estimated the lifetime prevalence of PTSD for male and female Vietnam Veterans as 31% and 27% respectively. Prevalence for Gulf War Veterans is about 12%, and for OEF/OIF Veterans, it is around 14%. The risk of developing PTSD seems to increase for many Veterans over time after they experience trauma, especially in the first three to six months after return from combat.
The etiology of PTSD is complex and arises out of a complex interaction of biological, psychosocial, and cognitive factors. Genetic studies indicate that people with combat-related PTSD may be genetically predisposed to have more inflammatory dysregulation, and this is likely linked to why people with PTSD have a higher risk of inflammatory disorders.
According to a 2015 review of 116 studies, the following can be said about risk factors for PTSD in Veterans:
- It is not clear if overall risk is higher for male or female Veterans.
- Risk is higher for younger people; it is higher for males who are under 40 years of age and females under 30.
- Lower level of education correlates with greater risk.
- Black/African American Marines have been noted to have lower risk.
- Not being in a relationship increases risk.
- Being in the Army or the Marines versus other military branches increases chances of developing PTSD.
- Risk is higher for enlisted personnel compared to officers.
- Risk also goes up based on what one does during deployment; it is higher for health care, service and supply, and combat personnel.
Historically, it was argued by some that PTSD is not an actual diagnosis; however, research indicates that there are a variety of neurological and psychobiological reactions to trauma that occur, many of which are linked to the development of PTSD.
After it is established that a person has experienced trauma, there are four main criteria for a PTSD diagnosis outlined in the Diagnostic and Statistics Manual of Mental Disorders, 5th edition. The four general classes of PTSD symptoms include the following:
- Intrusion symptoms. These can include recurrent, involuntary, or intrusive memories or dreams. Distress may be triggered by events that have something in common with the traumatic experience(s). Flashbacks may occur.
- People with PTSD typically attempt to avoid memories, thoughts, feelings, or external reminders related to traumatic experiences.
- Cognitive and/or mood disturbances tied to the traumatic event(s). A person may experience impaired memory, exaggerated negative beliefs, inappropriate blame, persistent negative emotions, and other similar symptoms.
- Hyperarousal and reactivity. This can manifest as irritable behavior, recklessness, hypervigilance, exaggerated startle responses, and sleep problems, among other symptoms.
Symptoms within each category must be present for more than a month for PTSD to be diagnosed. Otherwise, the diagnosis of Acute Stress Disorder is made instead. For more information about diagnosis (useful to both patients and clinicians), refer to the National Center for PTSD (NCPTSD) website.
An estimated 60% of men and 51% of women in the U.S. experience trauma at some point in their lives; however, only 8% of men and 20% of women develop PTSD. Why do some people develop PTSD and others do not? Genetics, the environment,  and adverse childhood experiences all can have a profound impact, as can many other factors. The goal is to stack the odds so as to prevent PTSD from ever even developing, and to focus on healing at all levels if PTSD already has occurred.
Fight or flight, perhaps the most familiar stress response, is linked to activation of the sympathetic nervous system. Polyvagal theory may explain some aspects of the development of PTSD by focusing on the vagus nerve, which is linked with the parasympathetic nervous system. This theory, proposed by Stephen Porges, holds that behavior can be affected differently depending on which part of the vagus nerve is activated. When the ventral vagus is activated, a person feels safe and tends to build connections with others. Conversely, when a person (or other animal) feels that their survival is threatened, the dorsal vagus can be activated. Dorsal vagal activation is associated with withdrawing, even shutting down altogether. This is linked to the avoidance and withdrawal symptoms so commonly observed in PTSD.
Recent research indicates that people with PTSD have significant increases in levels of inflammatory markers, such as interleukins 1β and 6, tumor necrosis factor-α, and C-reactive protein. It is thought that inflammation is not only an effect of having PTSD, but also a causative factor. Neuroinflammation, anxiety, and chronic stress may all contribute to PTSD development.
PTSD is associated with poorer functioning, lower quality of life, and earlier onset of a number of physical and mental health problems.. It is vital to account for these during personal health planning, since they strongly influence overall patient outcomes. PTSD never exists in a vacuum. Just as the Whole Health approach and the Circle of Health can help account for each individual’s unique array of PTSD symptoms, it also can help organize the plan with respect to a person’s multiple comorbid conditions.
Veterans with PTSD have more somatic symptoms, health care visits, and work absenteeism. Of particular concern, as noted in a 2013 systematic review of 16 studies, Veterans with PTSD are much more likely to be suicidal. In fact, the United States National Comorbidity Study found people with PTSD are six times more likely to attempt suicide than their peers. The reasons for this are complex, as noted in a recent factsheet published by the National Center for PTSD. Risk increases if someone has more distressing trauma memories, poorer impulse control, or a tendency toward a higher level of anger than average. A 2017 study suggested that targeting depression and internal hostility might be particularly beneficial for PTSD patients. There is a link between suicide and combat guilt, and the risk is greater in combat trauma survivors who were wounded more than once or hospitalized as a result of their injuries.
Suicide risk is significantly higher in people with PTSD for many reasons. Clinicians should ensure the following numbers are easily accessed by all Veterans and their family/friends:
- National Suicide Prevention Lifeline: 1-800-273-8255
- Veterans Crisis Line: 1-800-273-8255, then press “1”
Fortunately, a landmark 2013 review by Gradus and colleagues indicated that the reverse is also true; successful treatment of PTSD significantly lowers suicide risk. Researchers are actively exploring which suicide prevention measures are most effective for people with PTSD.
Specific comorbidities related to PTSD include the following:
- Sleep disorders. Sleep problems, including insomnia and nightmares, are reported by 70%-87% of people with PTSD and have a significant impact on quality of life and overall outcome.
- Anxiety. What first may seem to be anxiety could actually be part of the hyperarousal symptom cluster that defines PTSD.
- Depression is four to seven times more likely in people with PTSD, particularly in women.
- Personality disorders. Examples include borderline, bipolar, and narcissistic personality.
- Substance use disorders. Alcohol and other substance use disorders are problematic for many people with PTSD.
- Pain disorders. These include chronic pain, fibromyalgia, chronic musculoskeletal disorders, and osteoarthritis.
- Metabolic syndrome. People with PTSD have higher rates of obesity, hypertension, dyslipidemia, diabetes, and vascular disease. This is thought to be in part due to higher cortisol levels that predispose to inflammation. PTSD may be considered an independent heart disease risk factor (pooled hazard ratio was 1.55 with 95% CI of 1.34-1.79).
- Impaired immunity. This is associated with increased infections, gastric ulcers (H. pylori infection), and risk of HIV positivity.
- Autoimmune disorders. These include thyroid disease and rheumatoid arthritis, among others.
- Grief. Grief and traumatic stress are closely connected. Veterans with PTSD who have unresolved loss from trauma may be limited in their ability to grieve more recent losses, and this can result in challenging emotions or behaviors. They may experience depression, low self-esteem, isolation, and an increase in nightmares. A study of 114 Vietnam-era combat Veterans admitted to a PTSD inpatient rehabilitation unit identified that 70% scored higher (i.e., worse) on standardized measures of grief symptoms related to friends lost in combat 30 years previous than did spouses who were bereaved in the past six months. The investigators ultimately concluded that treating the symptoms of unresolved grief may be as important as treating fear-related symptoms of PTSD.
- Traumatic brain injury (TBI). PTSD and TBI share a number of characteristics, including sleep disruption and cognitive impairment.
Fortunately, many problems that co-occur with PTSD often resolve or show improvement when PTSD is successfully treated. For additional information on PTSD and comorbidities, along with a helpful list of resources related to various comorbid conditions, refer to the National Center for PTSD website.
The symptoms of PTSD seldom exist in isolation. Always keep comorbidities in mind when working with people with PTSD. Pain, substance use disorders, affective disorders, autoimmune issues, and sleep problems are among the many comorbidities that may be present. Each of these, when present, can make the risk of suicide even greater.
The three “Meet the Veterans” narratives at the beginning of this overview offer a snapshot of the varied ways PTSD can present.  A traumatic event can involve an actual or perceived threat to life, personal safety and security, or physical integrity. It can be directly experienced, witnessed in person, or heard about (in cases of family members or close friends). As in the case of Melissa, PTSD can arise after witnessing the details of traumatic events being experienced by others.
Combat trauma, as experienced by Todd, is perhaps the most familiar traumatic precursor to PTSD for most clinicians, but PTSD has different causes— and effects—for each person who suffers with it. Unfortunately, Erica’s situation of PTSD secondary to military sexual trauma (MST) is not uncommon. One in six civilian women experience sexual assault, and for military women the frequency climbs to an estimated one in three. Forty percent of homeless women Veterans report a history of sexual trauma in the military. MST is the main causal factor of PTSD in women, in contrast to combat experience being the strongest predictor in men. Male Veterans (1.1%, versus 21% of women) also experience military sexual trauma. Risk of suicide markedly increases (hazard ratios of 1.7 and 2.3 for men and women respectively) with a history of MST.
The VHA currently mandates routine screening for PTSD in ambulatory settings and supports access to treatment through comprehensive mental health services, including PTSD specialty teams, primary care-mental health integration programs, and behavioral health interdisciplinary program teams located in many general mental health clinics. VA policy set forth in the Uniform Mental Health Services Handbook requires that every Veteran diagnosed with PTSD be offered one of two evidence-based psychotherapies—Prolonged Exposure or Cognitive Processing therapies—when clinically appropriate. These therapies are discussed in greater detail below.
The Veterans Administration/Department of Defense Practice Guideline for the Management of PTSD and Acute Stress Disorder previously emphasized patient education as part of the treatment for all patients with PTSD and their family members, but the latest version has scaled back with this given a paucity of research support. Nevertheless, clinicians can consider offering the following (and these steps are very much in keeping with patient centered and patient-driven care):
- Describe to anyone with PTSD the range of available and effective therapeutic options, emphasizing that PTSD is a highly treatable disorder.
- Inform the patient about evidence-based psychotherapy and/or evidence-based pharmacotherapy as first-line treatments, allowing patient and clinician preferences to drive the selection of therapies. Psychotherapies should be offered by practitioners with adequate training in the preferred treatment methods. These are described more in the conventional approaches section
- Support them with self-care. There are a number of excellent educational products developed by the National Center for PTSD for Veterans and their family members. These include “Understand PTSD” and “Understanding PTSD Treatment,” as well as a broad range of smartphone apps and online products. Clinicians can recommend smartphone apps and online tools that allow Veterans to self-monitor symptoms. These include the following:
Collaborative treatment planning
A collaborative care approach to therapy administration, including care management, may be considered; however, supportive evidence for this specifically for PTSD is currently lacking. Given that the average dropout rate in trials of exposure-based and cognitive interventions for PTSD is 20%-25%, and given that it is often difficult to convince those with PTSD to seek any form of treatment, it is vital that clinicians carefully match individual Veterans with the therapies and practitioners most appropriate for them. This can be accomplished through a collaborative process between Veterans with PTSD and their health care teams that includes the following steps:
- Identify realistic, stepwise functional goals including a list of key activities/domains.
- Choose specific treatment goals and patient centered indicators of progress that include self-care strategies across the Personal Health Inventory (PHI) domains. Treatment preferences and self-care strategies should be specific, promote recovery, and be strength-based.
- Problem-solve around barriers to getting care, such as transportation and availability to attend daytime appointments.
As part of ongoing care, it is important for clinicians and patients to:
- Monitor patient centered progress indicators.
- Adjust the treatment plan accordingly over time based on monitoring.
- Re-evaluate and renegotiate treatment focus and components.
- Provide support surrounding barriers and challenges.
A 2019 article noted a number of new directions being taken for PTSD care, including non–trauma-focused interventions, new medications, personalized medicine, family-based therapies, and enhanced focus on physical health (again, in support of working with PTSD comorbidities).
Self-Care and PTSD
A 2018 review of 1,349 studies (29 met eligibility criteria) concluded that individuals with PTSD are 5% less likely to have healthy diets, 9% less likely to be physically active, 31% more likely to be obese, and 22% more likely to smoke. Self-care strategies can complement treatments specifically aimed at PTSD symptoms. For example the National Center for PTSD recommends that people with PTSD do the following, all of which tie into various self-care circles within the Circle of Health:
- Have more contact with other trauma survivors
- Start exercising
- Change neighborhoods if living in a high-crime area
- Avoid alcohol and drugs
- Invest more in personal relationships
Many of the psychotherapeutic approaches that are beneficial in treating PTSD draw in proactive strategies, such as goal setting, increasing problem-solving or coping skills, clarifying values, and broadening social support. These tie in nicely with the Whole Health approach.
Considerations specifically related to PTSD for each of the eight components of proactive self-care are listed below. These are framed as specific steps a care team member can follow when advising self-care practices for someone with PTSD. Of course, which steps are taken will vary according to each individual’s needs.
A 2018 scoping review concluded that mindfulness-based approaches have medium to large effect sizes and low attrition rates. The review included a number of studies focused on different formal approaches for enhancing mindful awareness, including Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT) and metta Loving-Kindness approaches. The same study noted that neuroimaging research indicates that mindful awareness training targets over- and under-modulation of emotions, which are critical features of PTSD. A 2018 review noted that fear extinction, in particular, may be tied to the benefits of mindful awareness for PTSD. Another meta-analysis from 2017, which included 18 studies of mindfulness training, concluded that longer training periods had stronger effects. These effects were not affected by gender, age, or Veteran status. Another 2017 review of 10 meditation trials (n=643) found that meditation approaches appear to be effective for PTSD symptoms (and noted that more research is needed). Yet another 2017 review emphasized that mindfulness approaches should not be used as first-line treatments but nevertheless do have potential benefit.
Developed in 2014, Trauma Interventions Using Mindfulness-Based Extinction and Reconsolidation (TIMBER) is based on Mindfulness-Based Cognitive Therapy (MBCT), and it combines principles of Mindfulness-Based Exposure Therapy trauma memories work. TIMBER is an example of how various mind-body approaches are being adapted to the care of PTSD.
To cultivate mindful awareness, there are now many ways to weave in new technology. For example, clinicians can recommend smartphone apps that allow Veterans to self-monitor symptoms. Some of these are listed in the “Education” section above. Refer to the resource section at the end of this overview as well.
One review suggested that the mechanisms of action for mindfulness as it relates to PTSD might include the following:
- Mindfulness increases ability to shift attention, so that those with PTSD can reframe how they focus on trauma-related stimuli.
- It allows one to modify maladaptive cognitive styles, allowing one to move away from worry and rumination.
- It enables one to adopt a nonjudgmental stance, changing the way that interpretations and negative attributions are habitually done. This can help to counteract avoidance.
Additional research is needed to confirm these theories.
Power of the Mind
Traumatic events, by definition, overwhelm our ability to cope. When the mind becomes flooded with emotion, a circuit breaker is thrown that allows us to survive the experience fairly intact, that is, without becoming psychotic or frying out one of the brain centers. The cost of this blown circuit is emotion frozen within the body. In other words, we often unconsciously stop feeling our trauma partway into it, like a movie that is still going after the sound has been turned off. We cannot heal until we move fully through that trauma, including all the feelings of the event.
―Susan Pease Banitt,
The Trauma Tool Kit: Healing PTSD from the Inside Out
A 2018 review found that, for 15 studies that met inclusion criteria, meditation, mantra repetition, breathing exercises, and yoga combined with breathwork all led to “significant improvements” in symptoms of PTSD. These studies included some post-9/11 Veterans, but 85% were in other conflicts. A 2013 systematic review of the literature found 16 of 92 articles that met review criteria. Studies were usually small, but there was an association between an array of mind-body practices and PTSD symptoms.
When talking about Power of the Mind with Veterans, the following points are worth considering… Explore how the mind-body relationship manifests in daily life, noting what triggers lead to increased tension and hypervigilance.. PTSD is characterized by an altered parasympathetic response to stressors, whereas mind-body approaches typically enhance this response. Teach relaxation techniques to combat hypervigilance and tension. Although evidence is still preliminary, mindfulness-based and other related approaches, such as Acceptance and Commitment Therapy (ACT)and Dialectical Behavioral Therapy (DBT), show promise for helping patients with PTSD. Many mind-body therapies are used frequently enough in the VA that they are most appropriately considered conventional therapies. All of these therapies and the state of the evidence regarding their use are described in the conventional therapies section below.
A 2019 review did not find conclusive evidence that mediation was beneficial for PTSD, but concluded that “…available empirical evidence demonstrates that meditation is associated with overall reduction in PTSD symptoms, and it improves mental and somatic quality of life in PTSD patients.” A 2018 systematic review of 15 studies found benefit for seated or gentle yoga that was accompanied by breathwork and various other types of meditation. A 2017 review of 18 studies indicated a potential benefit of mindfulness training, noting that benefits based on the length of time a person was trained.
Mantram meditation, the repetitive use of a sacred word or phrase throughout the day, was found to be feasible, associated with moderate to high satisfaction, and had a promising effect size in a small cadre of 15 Veterans. A 2012 study by the same lead authors found, in a group of 146 Veterans (66 in the intervention group), that 24% of the intervention group versus 12% of controls showed improvements in PTSD symptom severity. This mind-body approach shows increasing promise as research continues.
This approach has promise for PTSD care, but more research is needed.
A study of 52 people with PTSD had significant symptom improvement with neurofeedback (biofeedback using EEG measurements), and a 2018 systematic review found it showed promise in general for a variety of outcomes measures. In a 2018 study, a group of 20 Veterans were trained using fMRI to up-regulate blood oxygen supply to their amygdalae (a structure in the lower front part of the brain), which markedly improved symptoms in 80% (versus 38% of controls using sham fMRI feedback). Heart rate variability (HRV) biofeedback combined with Cognitive Behavioral Therapy (CBT) was helpful for a small group of people with noncombat-related PTSD. Pre-deployment resilience training that involved HRV biofeedback resulted in lower post-deployment PTSD symptom scores in a group of 342 Army National Guard soldiers.
Research at this point for Guided Imagery is quite limited. Guided Imagery should be used with caution and only by an experienced professional if a person is prone to having flashbacks.
In a 2013 meta-analysis of six studies Writing Therapy was found to have significant benefit for PTSD.
Creative Arts Therapies
A 2018 review noted that evidence for Music, Art, and Drama therapies is not conclusive of clear benefit, and more research is needed.
Mind-body approaches for regulating the autonomic nervous system
In 2011, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury published a review of 13 different mind-body techniques. These were classed into the following five categories:
- Body-based tension modulation practices, including yoga
- Mental focused practices, such as mindfulness, meditation, Guided Imagery, and iRest® Yoga Nidra.
- Mind-body programs that offered multiple techniques in the form of taught skills courses
The report concluded that
“…integrative practices designed to regulate the autonomic nervous system and improve mood stress regulation and arousal are promising. However, in order for these and other related practices to achieve greater recognition and be used in the mainstream military health community, there is a need to compare the relative effectiveness of techniques…to each other, as well as to other more mainstream stress and energy management practices, such as exercise, counseling, and psychopharmacology.”
These are featured in the “Conventional Care” section, below.
Spirit & Soul
Spirituality may be defined, generally, as what brings meaning, purpose, and connection to a person’s life. Each of us has a unique definition of what matters most. Traumatic experiences affect people deeply; there is a reason people refer to them as “soul wounds.” Spirit and soul are important to explore with people with PTSD. A 2018 review of eight studies of spiritual and religious interventions for PTSD found that seven of them showed significant benefit. Another review noted that being religious either reduced or contributed to PTSD depending on a person’s race and the presence of anxiety or depression. A review of PTSD and spirituality for combat Veterans concluded that their results suggested that “…understanding the possible spiritual context of Veterans’ trauma-related concerns might add prognostic value and equip clinicians to alleviate PTSD symptomatology among those Veterans who possess spiritual resources or are somehow struggling in this domain.”
Of course, care team members should never impose their spiritual and religious perspectives on others; as with all aspects of self-care, Whole Health is tailored to the individual. As you develop a PHP related to Spirit and Soul, keep the following in mind:
Consider Moral Injury
Moral injury is defined as pain and suffering that arise because individuals have been damaged at the level of their moral foundation—the level of their core values. A morally injurious event is one that cannot be justified based on someone’s moral or personal beliefs. People feel compelled, often by an authority figure, to do something that in other circumstances, they never would have done. As one research study puts it,
Moral injury is an emerging construct to more fully capture the many possible psychological, ethical, and spiritual/existential challenges among persons who served in modern wars and other trauma-exposed professional groups.
Moral injury and PTSD have been described as overlapping in terms of many of the symptoms they cause, such as anger, affective disorders, substance misuse, and insomnia. However, they are different in some respects. Moral injury is more commonly associated with feelings of alienation, shame, and regret; PTSD, in contrast, is more likely to be linked to fear, flashbacks, and memory loss. While research related to working with moral injury is in its early stages, it is clear that healing often relies on lessening the pain of these injuries, just as one would ease any other cause of suffering.
Work with Chaplains
If a person has concerns, would like to set a goal related to Spirit and Soul, or is struggling with moral injury (described above), asking for the support of a chaplain or other experienced professional is essential. A 2018 article made a case for contextualizing care, noting that chaplains are especially skilled at providing “nonjudgmental, person-centered, culturally relevant care rooted in communities….” A 2019 review noted that spirituality and religion are closely linked to moral injury and that “…help from chaplains may support healing, self-regulation, and mending of relationships, moral emotions, and social connection.” Chapter 11 of the Passport to Whole Health features more information about chaplains.
Explore How Faith Affects One’s Understanding of Traumatic Experiences
Edward Tick, who among other things has trained over 2,000 Army Chaplains, holds that PTSD is, at its core, a “soul wound” that must be addressed as such. Drawing in chaplains, clergy, and others who can offer spiritual support, based on a patient’s personal beliefs, is appropriate. A 2005 (nonsystematic) review of 11 studies found that typically, religion and spirituality are beneficial to people in the aftermath of trauma and that traumatic experiences often lead to a deepening of religion or spirituality. Spirituality is closely linked to posttraumatic growth, which is described in the “Personal Development” section below.
Focus on Meaning
A 2019 evaluation of data from the National Health and Resilience in Veterans Study concluded that a higher level of “global meaning” reported by Veterans was linked to a significantly lower likelihood of suicide in Veterans who experienced morally injurious experiences related to deployment. Exploring a Veteran’s MAP is fundamental to Whole Health for PTSD.
Find more information in the “Spirit & Soul” overview and the MyHealtheVet information on spirituality.
Family, Friends, & Co-Workers
PTSD has a negative impact on Veterans’ relationship functioning. Conversely, good peer relationships during deployment reduce risk of PTSD. Positive family interactions are linked to a lower risk of PTSD over the following 12 months. A 2019 study, asking why only 6%-10% of people with trauma end up being diagnosed with PTSD, noted that a significant proportion of the risk may be explained by differences in social cognition. People with PTSD are more likely to have deficits in understanding social cues, and particularly cues related to perceiving threats.
Consider the following when collaborating with someone with PTSD who wants to focus on relationships:
A sense of community and community support are extremely important to many Veterans. Often, Veterans with PTSD have a sense that they are best understood by other Veterans. Support groups may be helpful. For more information about PTSD and community, refer to the National Center for PTSD website.
Ascertain How PTSD Symptoms Affect Close Relationships
There is some data supporting family-focused therapies, and the VA is placing more emphasis on therapeutic approaches that include family members. While mores studies are needed, it seems there is benefit to incorporating emotion regulation skills into couple- and family-based treatments for PTSD. Be sure to discuss the extent to which family and friends are knowledgeable of one’s diagnosis and whether or not further disclosure would be beneficial.
Animal-Assisted Therapies May Help
Placement of a PTSD service dog was found to improve physiological and psychosocial indicators of well-being for Veterans with PTSD (the study noted that clinical significance still needs to be explored). A study of 141 post-9/11 military members and Veterans concluded that trained service dogs “may confer clinically meaningful improvements” in PTSD symptoms. Yet another 2018 study found that therapeutic horseback riding decreased PTSD scores on different measurement scales. Refer to the “Animal-Assisted Therapy” tool for more information.
Moving the Body
Take care to explore whether exercise is beneficial for a person’s PTSD symptoms and if so, how. Enhance physical activity as appropriate; refer to the “Moving the Body” overview and Chapter 5 of the Passport to Whole Health. Study findings specific to PTSD and the benefits of physical activity include the following:
- A 2016 review concluded that regular exercise is inversely linked to PTSD and its symptoms. Hyperarousal symptoms, in particular, may improve with physical activity.
- Physical activity may offer benefit in people who are resistant to standard medical treatment.
- In a small group of adults, PTSD symptoms were reduced after 12 exercise sessions of 40 minutes each. Improvements were maintained at one-month follow up.
- An eight-week program that included three 40-minute aerobic exercise sessions each week led to reduced PTSD, anxiety, and depression symptoms in adolescent females with PTSD.
- Ninety percent of adolescents who regularly exercised three times weekly for 60-90 minutes had significant reductions in PTSD symptoms.
- In contrast, Cochrane Review did not find any research that met inclusion criteria addressing whether or not sports and games decreased PTSD symptoms.
- Military-tailored yoga for a small group of 18 Veterans with PTSD was found potentially effective as an adjunctive or stand-alone therapy. However, a 2018 meta-analysis found only “…a weak recommendation for yoga as an adjunctive intervention.” A 2017 review of seven studies found that yoga “contributed to a significant overall reduction in PTSD symptoms.” Another 2017 review concluded that yoga in combination with meditation has promise as complements to conventional PTSD treatment. A 2014 trial involving yoga for 64 women with PTSD did find marked improvement in PTSD symptoms in the yoga group. In fact, 16 of the 31 participants in the yoga group no longer met criteria for PTSD at the end of the study.
- There is limited data supporting the use of tai chi or qi gong for PTSD.
Given that exercise can have overall benefits for anxiety disorders, and given that exercise tends to offer many other health benefits as well, it is reasonable to add it as an adjunct to first-line therapies. There is a growing recognition that running or walking groups can be a helpful component to PTSD specialty clinics’ treatment programs.
Some surroundings-related recommendations specific to PTSD:
- Discuss how surroundings are easing or exacerbating symptoms of avoidance, arousal, or re-experiencing trauma. Surroundings on the VA website might be a helpful tool to use.
- Long-term exposures to green spaces are linked to less anxiety; it is reasonable to assume more time in nature may also benefit certain Veterans with PTSD.
Sleep is often severely compromised in PTSD, with people reporting trauma-related nightmares, insomnia, and other problems. Fear of sleep, decreased parasympathetic activity, abnormal rapid eye movement (REM) sleep, and other factors seem to be involved. Explore the relationship between sleep and PTSD symptoms for each individual. Offer suggestions for improving sleep quality, falling asleep, or enhancing sleep hygiene, as appropriate. The “Recharge” chapter of the Passport to Whole Health discusses these further.
Cognitive Behavioral Therapy for Insomnia (CBT-I), along with new CBT-I smartphone applications can be helpful in improving sleep symptoms in patients with PTSD. CBT-I can often prove more effective than medications. Refer to the “Recharge” overview for more information on CBT-I and other psychotherapeutic approaches for improving sleep. Keep medications, such as prazosin, in mind as options, if appropriate.
Food & Drink
Most of the research related to nutrition and PTSD is focused on comorbidities. Consider the following:
- A review that included nearly 590,000 subjects concluded that the odds ratio for obesity among those with PTSD is 1.55. As noted previously, metabolic syndrome is highly prevalent in people with PTSD (39%), to the point where some are questioning whether PTSD should be considered a cardiovascular disease risk factor itself. Abnormal eating behaviors are linked to PTSD. Working with healthy eating patterns is essential to reduce the elevated risk of vascular disease that plagues people with PTSD.
- Address alcohol use. Excessive alcohol use often is done to try to blunt PTSD symptoms but ultimately worsens symptoms and interferes with treatment.
- Explore whether dietary patterns influence symptoms. Some people are more likely to be emotionally labile if they are hungry.
Personal Development also has a role:
- Discuss whether any activities, hobbies, and/or creative pursuits ease PTSD symptoms and whether or not Veterans have insights about this.
- Explore posttraumatic growth, which is
…the development of positive changes and outlook following trauma, including increased personal strength, identification of new possibilities, increased appreciation of life, improved relationships with others, and positive spiritual changes.
A survey of 272 primarily “older” Veterans of Operation Enduring Freedom and Operation Iraqi Freedom found that:
- 72% endorsed a significant degree of posttraumatic growth.
- 52% reported having changed priorities about what is important in life.
- 51% reported a greater appreciation for each day.
- 49% reported being better able to handle difficulties.
Of note, those with higher PTSD scores often score higher for these measures as well; it would seem that posttraumatic stress and posttraumatic growth are not opposite ends of a spectrum, but actually can coexist. Over 50% of people report moderate-to-high posttraumatic growth after a traumatic experience. A 2018 systematic review of 21 studies confirmed that moderate posttraumatic growth, not just PTSD alone, can arise for military service personnel who have experienced trauma. Explore what Veterans need to foster posttraumatic growth as part of their Whole Health care.
In terms of prevention and treatment of PTSD, it is important that evidence-based PTSD therapies be offered to all Veterans. Most research has focused on psychotherapies and pharmaceuticals. The following highlights are based on summary recommendations from the VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder, which was recently updated.
General Clinical Management. Engage patients in shared decision-making and focus on collaborative care using evidence-based treatments.
Diagnosis and Assessment. Screen periodically with measures like the Primary Care PTSD Screen or the PTSD Checklist. In people with suspected PTSD, offer an appropriate diagnostic evaluation. In people diagnosed with PTSD, use self-report measures to monitor treatment progress.
Prevention. Evidence is limited for psychotherapy or medications in the time immediately after trauma. If someone is diagnosed with acute stress disorder, use Trauma-Focused Psychotherapy that includes exposure and/or cognitive restructuring. (These are described in the next section.) Evidence for medications is insufficient.
Start with individual, manualized, trauma-focused psychotherapy (preferred over drug therapy). Drug therapy or non–trauma-focused psychotherapy can be used if trauma-focused psychotherapy is not available or not preferred by a patient. Certain medications (e.g., serotonin specific reuptake inhibitors, or SSRIs) are preferred, and other drug classes are suggested if those are ineffective.
There is not enough evidence to recommend for or against “…repetitive transcranial magnetic stimulation, electroconvulsive therapy, hyperbaric oxygen therapy, stellate ganglion block, or vagal nerve stimulation.”
Acupuncture and other CIH practices are not recommended as primary treatments.
Psychotherapies, sometimes classed under “Power of the Mind” as well, are being used with increasing frequency in the VA, depending on the availability of clinicians trained to offer them. A 2016 review found large effect sizes for an array of therapies, noting that the number needed to treat was <4. More research comparing the different therapies to one another is still needed.
The 2017 VA/DOD guidelines most strongly recommend the following trauma-focused therapies.
Prolonged Exposure Therapy (PET) is built around the idea that repeated exposure to thoughts, situations, and feelings can reduce their power to cause a person distress. It has four main parts, which include education, breathing retraining, practice in real-world situations, and talking through one’s trauma. A 2013 study of 1931 Veterans found that PET significantly decreased PTSD-related symptoms, as well as depression.
Cognitive Processing Therapy (CPT). The primary goal of CPT is to improve mood and behavior by making efforts to change thoughts, beliefs, and expectations that are irrational or dysfunctional. Its four main parts include learning about symptoms, enhancing awareness about thoughts and feelings, learning skills to help challenge these thoughts and feelings, and understanding how trauma changes beliefs. Through these steps a person is able to deal with trauma in new ways.
Eye Movement Desensitization and Reprocessing (EMDR). This involves an eight-phase approach for addressing experiences that contribute to PTSD. After taking an elaborate history and helping patients identify a target for the therapy, clinicians have them focus on a particular image, thought or sensation while their eyes follow the clinician’s finger through a series of prescribed movements. Other stimuli might also be used. A 2018 review found trauma-focused EMDR and Cognitive-Behavioral Therapy to be equally efficacious (if not slightly better) at reducing PTSD symptoms.An August 2014 meta-analysis concluded that EMDR Therapy significantly reduces PTSD symptoms, anxiety, depression, and overall distress in people with PTSD.
Other recommended therapies include Cognitive Behavioral Therapies (CBT) tailored specifically to PTSD, Brief Eclectic Psychotherapy (BEP), Narrative Exposure Therapy (NET), and Written Narrative Exposure (WET).
Some non–trauma-focused therapies are also recommended:
Stress Inoculation Training (SIT) takes people through three stages. In the first, stressors and responses are identified, as are patterns of self-defeating dialog. The second stage, skill acquisition and rehearsal, allows a person to practice new, more rational thought patterns. In the third stage, they practice applying what they have learned in real-life situations. Present-Centered Therapy (PCT) and Interpersonal Psychotherapy (IPT) are also mentioned. Not mentioned in the guidelines but also used for aspects of PTSD care are Imagery Rehearsal Therapy (IRT) involves reducing nightmares by changing the end of remembered nightmares while awake.
Psychodynamic Therapy (PT) is defined differently in various studies. Also known as insight-oriented therapy, it focuses on gaining insight into unconscious processes and how they manifest in the way a person behaves. It has been used primarily in clinical practice for the treatment of depressive disorders. For more information, refer to GoodTherapy website.
Evidence is insufficient to recommend other psychotherapies for PTSD, including Dialectical Behavior Therapy (DBT), Skills Training in Affect and Interpersonal Regulation (STAIR), Acceptance and Commitment Therapy (ACT), Seeking Safety, and supportive counseling.
For more information about each individual therapy, refer to individual PTSD 101 courses on the National Center for PTSD website. Mental health services have supported the rollout training and dissemination of evidence-based PTSD treatments (CPT and PET) to large numbers of VA clinicians. Additional rollout trainings in the past year in cognitive-behavioral treatments for insomnia and pain, as well as problem-solving skills therapy, assist PTSD patients with recovery. These efforts are supported by didactic lectures in both psychotherapy and pharmacotherapy of PTSD, organized by the National Center for PTSD, as well as a broad array of educational courses and materials available on its website.
The 2017 VA/DOD guideline suggests that sertraline, paroxetine, fluoxetine, or venlafaxine be used as monotherapies for those who choose against or cannot access the preferred psychotherapies. Prazosin, an inexpensive alpha-1 antagonist, is recommended for PTSD-related nightmares.. See the full VA/DOD Clinical Practice Guideline the Management of PTSD and Acute Stress Disorder for more specifics. Low-dose ketamine has also been used with increased frequency. More research is needed, but infusing it in a subanesthetic dose seems to be safe and potentially beneficial in Integrative Health approaches. In 2010, 39% of Americans with PTSD reported using complementary approaches (then referred to as complementary and alternative medicine, or CAM) in the past year, with mind-body therapies, relaxation/meditation, exercise, herbal remedies, massage, and chiropractic listed among the most popular. A 2012 survey of 125 Veterans Hospitals revealed that 96% used at least one of a list of 32 CAM therapies in their PTSD treatment programs. The majority of systematic reviews and meta-analyses conclude that “more research is needed” regarding treating PTSD with various complementary medicine modalities. Considerable research to investigate various CIH treatments for PTSD is now underway in the VA.
For a detailed summary of CIH research in PTSD, refer to the National Center for PTSD website. The information below summarizes many of the key research findings of this and other reviews of the literature.
There is currently no research supporting the use of dietary supplements for PTSD, though there is interest in the use of omega-3 supplements. Many who recommend supplements will try supplements similar to those used for anxiety. For more information, go to the “Anxiety” overview.
Limited research is available to support the use of spinal manipulative therapies for PTSD. A small cross-sectional analysis conducted in 2009 with a group of 130 Veterans with neck or low back pain found that the 21 people with PTSD were much less likely to benefit from chiropractic than those without PTSD. Few studies are available on massage and PTSD.
Energy Medicine (Biofield Therapies)
One small randomized controlled trial (RCT) of Healing Touch that included 123 returning active duty military personnel found statistically significant improvements (p<0.0005) in PTSD and depression symptoms.
Acupuncture has shown increasing promise for PTSD in recent years. A 2018 systematic review and meta-analysis of seven trials with 709 participants found evidence was low-quality evidence but suggested significant benefit. A 2012 systematic review of CIH therapies for PTSD found acupuncture superior to no treatment (being waitlisted) and comparable to group-based Cognitive-Behavioral Therapy (CBT). In that study, which did not focus specifically on Veterans, it was the only therapy found to have a moderate effect size; other approaches seemed to have less of an effect. A frequently cited 2007 study of acupuncture for PTSD found improvement in a cohort of non-Veteran males who received a series of 24 acupuncture sessions (one hour each) over 12 weeks. A separate article on acupuncture’s mechanism of action offers detailed explanations of how acupuncture might affect PTSD at the biochemical level.
Emotional Freedom Technique (EFT) has been classed by some as a form of “energy psychology,” and involves a combination of making specific statements and tapping on various acupuncture points. A 2017 meta-analysis of seven trials, found EFT significantly beneficial for PTSD. In addition, an uncontrolled 2014 trial that included 218 couples (Veterans and their spouses) found significant benefit based on PTSD checklist scores. A very small study suggested that EFT may also help prevent progression from subclinical to clinical PTSD.
Overall, research does not support using complementary approaches as replacements for first-line interventions for PTSD. However, there is room, especially regarding acupuncture and mindfulness-based meditation, to use these approaches adjunctively.
Neuromodulatory therapies are techniques for altering nervous system circuitry using different types of electrical modulation. Examples include deep brain stimulation, transcranial magnetic stimulation (TMS), vagal nerve stimulation, and stellate ganglion block. A 2019 study concluded that, overall, research is insufficient to determine efficacy for these interventions, except perhaps for some benefits seen in small studies for repetitive TMS.
Back to the Veterans
Each of the three patients with PTSD—Todd, Erica, and Melissa—completed a Personal Health Inventory (PHI). In every case, their care team members were careful to assess their suicide risk as a first priority and then to assess for current life stressors. Todd reviewed his PHI with his health psychologist, who coordinated the plan with the Patient-Aligned Care Team (PACT) that had previously been assigned to him. Erica went over hers with her primary care practitioner, who specializes in women’s health. An important member of her was a social worker who could help her with her living situation. Melissa reviewed her PHI with a nurse practitioner she often sees, then followed up on her Personalized Health Plan (PHP) with both her psychologist and her Whole Health Coach. Todd decided that his MAP, his reason for wanting his health, was so that he could go back to school to study to be a counselor because “I want to help people like me, and it will help if they have someone who really knows what all this is like.” He also intends to get into a steady relationship. In the meantime, he plans to train as a Peer Support Specialist at his local VA.
Todd’s health plan outlined the following priorities:
- Continue with his medications, as per his psychiatrist.
- Work with a mental health expert who is skilled at offering trauma-based psychotherapies, which he has not yet tried.
- Begin an MBSR course that is offered at his local VA Hospital.
- Try acupuncture, not only for his PTSD, but also for his chronic low back pain.
- Ramp up his exercise to 150 minutes weekly and develop a plan to ensure it happens. Of course, the physical activity will help him in many other ways, as well. Like many people with PTSD, he is at increased cardiac risk and is working on eating healthy, too.
- Reduce alcohol consumption and explore other healthier ways to ease his stress levels. He was given some Veteran handouts on relaxation approaches he can try even before his MBSR class starts.
Erica received help navigating the system from a clinical social worker recommended by her primary care clinician. Once her basic needs of safety and shelter were more reliably met, she and her health coach worked together on the following:
- Erica was evaluated by a psychiatrist skilled in the management of PTSD (she had not been established in the health care system previously).
- The social worker on her care team ensured she was able to get her medications, including prazosin for her nightmares.
- She began to receive regular psychotherapy. PET was difficult for her but ultimately quite helpful. She also received CBT-I, and her sleep gradually improved.
- Erica found a support group for women victims of sexual trauma and cultivated a support network. She ultimately chose to attend church services with some of her new-found friends/supporters. Spirit and Soul became a high priority for her.
- Erica “isn’t quite ready” to focus on diet and exercise, but says her health mission is “to love my body again and really be in it.” She says she will just take it “day by day” and has plans for follow up with a Whole Health Coach after counseling has been ongoing for a few weeks.
Melissa appreciated the psychotherapy she received for her PTSD, and with time, she was able to return to work. EMDR was especially helpful to her. One thing that completing the PHI brought to her attention was that, as someone who works in health care, she wanted to do much more as far as “practicing what I preach.” For her health mission, she noted, “I want to enhance my ability to be a healer, understanding that it starts with me.”
Her PHP includes several steps:
- She will begin by cutting down to, at most, a 50-hour work week (she was working 60 hours) and go back to school to do pre-med coursework.
- She realized that she wants to be more “reassuring and present” with the people she rides with in the back of the ambulance as an EMT. She understands that starting a mindfulness-based practice (she prefers tai chi or something that allows her to stay active while she focuses her attention) can help with this and may (though more research is needed at this point) also help some of her PTSD symptoms.
- Melissa is actively exercising and paying attention to daily calorie intake as part of her plan to model healthy living.