Acupuncture, Sleep Disorders, and Prolonged Exposure ...



Acupuncture, Sleep Disorders, and Prolonged Exposure Therapy in PTSD PatientsKim MeltzUniversity of Wisconsin – Green BaySubmitted to:Eng Comp 105-0002Dr. Paul M.L. Belanger5/6/2020Available at:AbstractPost-traumatic stress disorder (PTSD) can happen at any age and it is a normal response to traumatic events. PTSD symptoms cannot be cured but they can be managed in several ways, including medications, psychotherapy (prolonged exposure), and self-meditation to reset the neuroactivities of the brain. The brain works as an alarm system. However, PTSD symptoms make this alarm system overwork and become extra sensitive. In time, the parts of the brain that responsible for thinking and memory stop working properly. As a result, this alarm system has a difficult time identifying normal events and traumatic events. For instance, the first part of the brain is the amygdala which acts as one of the alarm systems of the brain. It sends a fear signal to the brain whenever there is a disturbance event occurs. In PTSD patients whose have sensitive response alarm system tend to turn something normal like a car backfiring to a panic stimulation. The second part of the brain is the hippocampus responsible for the formation, storage of memories, and linking the sensation to the memories. The third part of the brain is the prefrontal cortex contributes to focusing, managing emotional reactions, planning for the future, and coordinating and adjusting complex behaviors. Can you imagine an overactive amygdala plus an underactive prefrontal cortex combined with improper functioning hippocampus? It would be a perfect recipe for a disaster. Like food and water are essential elements for the body to stay alive, sleep can form and maintain the pathway for the brain to learn and create new memories. Without sleep, it is hard to concentrate, control emotions, and increase the risk of being anxious and depressed. Besides, dreams help process emotions that invade the thoughts during sleep cause frightening dreams in patients suffering from anxiety and depression. This interdisciplinary research will help you realize that PTSD symptoms have a negative impact on brain function and structures. Understanding how that brain works can help PTSD symptoms more manageable with prolonged exposure therapy (PET). Despite sleep disturbances and frightening dreaming sometimes decrease the effectiveness of PET but acupuncture can help patients overcome sleeping disorders, reduce anxiety and depression, and gaining quality sleep thereby enhance the efficacy of PET. Keywords: sleep cycle, sleep disorders, acupuncture, prolonged exposure therapy, post-traumatic stress disorder Acupuncture, Sleep Disorders, and Prolonged Exposure Therapy in PTSD PatientsSleep disorders (SD) and post-traumatic stress disorders (PTSD) are two common issues among mental health patients. It is important to understand the complicated relationship between science and sleep, SD and PTSD, and how SD influence PTSD symptoms. By understanding these concepts, we can figure out the way to use acupuncture to treat SD before applying prolonged exposure therapy (PET) to PTSD patients. The combination of treatments between acupuncture and prolonged exposure therapy will enhance the efficacy of PET in time. PET is a form of cognitive-behavior therapy, a gold standard treatment for PTSD. However, when treating PTSD, SD is a major complaint in PTSD patients. Thus far, many psychiatrists and therapists have struggled to find a good solution to treat patients with both symptoms. The first thing many therapists usually do is prescribing sleep medications for patients with SD. Sleep medications may help to provide adequate sleep in the short term. Conversely, long term use of sleep medicines will cause harmful side effects such as headache, drowsiness, overdose, and withdrawals. On top of that, health insurance becomes more expensive that not everyone can afford to seek help from psychiatrists. So far after finding an effective treatment for PTSD, SD is still a concern in patients with both symptoms from the beginning. Originally, PET is developed by Edna Foa, Director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania. The goal of this therapy is to help patients with PTSD face memories and thoughts related to trauma without raising anxiety and stress levels. In 2001, PET has received an Exemplary Substance Abuse Prevention Program Award from the U.S. Department of Health and Human Services Substance Abuse and Mental health Services Administration (SAMHSA). PET is selected by SAMHSA and the Center of Substance Abuse Prevention as a Model Program for national dissemination. Some researchers have pointed out an issue with PET, that is SD elevates the level of violence, suicidal ideation, and depression. For example, a poignant story about Davis Morris, a former infantry marine officer who has experienced reverse side effects from PET. During PET treatment for PTSD symptoms, Morris experienced elevated anxiety and depression, which eventually disturbed his sleep cycle and pushed him to drop out of PET treatments. Along with Morris’s story, there are several studies that show SD is a predictor of PET effectiveness in patients with PTSD. If that is the case, it is important to understand the sleep and sleep cycle, and how SD affects PTSD symptoms. Additionally, this research paper will point out how an alternative treatment such as acupuncture might be hope for PET to gain its effectiveness in treating PTSD symptoms.Just like our body needs food and water to survive, our brain needs sleep to function properly. It is hard to know how much sleep is enough and what would happen to the body if we do not get enough sleep. According to Minesh, in general, adults need around 7 to 9 hours to sleep, and it depends on the needs, some of them may just need just 6 hours to fulfill their sleep cycle (Minesh, 2019). Sleep can affect daily productivity and emotional balance. Sleep maintains the connections in the brain that help with learning and creating new memories. Without getting quality sleep, it is hard to concentrate and have quick responsive actions. According to The National Institute of Health, sleep is important to every tissue and system in the brain, heart, and lungs. Sleep loss and not getting enough quality sleep can increase the chance of getting high blood pressure, cardiovascular disease, diabetes, depression, and obesity (Bethesda, 2019). When patients with PTSD put too much effort in to meet the high demand work schedule, they find that it is just fine to get less sleep during the week and get extra sleep over the weekend. They simply think that this analogy will balance the sleep cycle. However, the sleep cycle is not that simple. Sleep is a complex process; most health issues begin when the body does not get enough sleep. Sleep is important for most nerve cells to communicate with each other in the brain. Sleep also removes toxins that were built up in the brain during the awake cycle. Several brain structures rely on and benefit from adequate sleep – the time the body is in resting mode.In order to understand how sleep affects PTSD patients, we need to understand how the sleep cycle works first. One of the most important control centers of the body is the hypothalamus, which contains the suprachiasmatic nucleus. The suprachiasmatic is responsible for behavioral rhythm. Damage to the suprachiasmatic would cause patients to sleep during the day because there is an impaired activity between the day and night cycle. This impaired activity will eventually cause disruption in the sleep cycle, which leads to SD. Sleep disorders are a sign of medical and neurological issues such as stress, anxiety, depression, and heart diseases. Stress, anxiety, and depression can be as simple as persistence concerns or can be serious as a mental illness that needed attention and treatment. In “Which Came First, Sleep Problems or Anxiety?” Minesh suggests that sleep disorders can affect stress, anxiety and depression or it can go both ways. Meaning that patients can have a hard time to fall asleep if they are worrying and feeling stress before bedtime. Thereby, not be able to fall asleep leads to not getting enough sleep and can cause more stress, anxiety, and depression. Not getting enough sleep while under pressure from depression and anxiety are something that patients with PTSD symptoms most complained about.Additionally, the thalamus can send sensory information to the cerebral cortex. The thalamus mostly inactive during sleep stages. According to Felson in “What Are REM and non-REM sleep?” the body tries to repair and regrow tissues, build bones, muscles, and the immune system is strengthened in sleep stages. Felson also mentioned that 20% of adults spend their sleep in the REM stage (Felson, 2018). The heart rates and breathing rhythmic start getting faster. Most of the dream occurs during REM sleep because the brain is more active at this stage. Dreams are filled with images, sounds, and other sensations that were sent from the thalamus to the cortex. Dreams are a way the body processes thoughts during sleeping. Dreams can be entertained, romanced – good dreams. Dreams can be as disturbing, and frightening –nightmares, which caused by fear, stress, trauma, and emotional issues. Especially in military members, nightmares are common after witnessing traumatic events such as witnessing death and exposure to violence. Combat veterans with PTSD symptoms are more likely to experience flashbacks and nightmares. For combat vets who cannot get a good sleep in a long time to have a normal life sounds like a major issue. This simple because combat vets have posttraumatic nightmares with a real traumatic event and violent scenes that they have seen in the past. In fact, according to Peters, 5% of all people have nightmares and 88% of combat veterans have nightmares once a week (Peters, 2019). Sleep disorders such as insomnia and sleep apnea are the main triggers for nightmares in PTSD patients. In order words, SD can affect PTSD symptoms and it can go either way, where each symptom can make the other get worse. PTSD increases the duration of light sleep, interferes with REM sleep, and the stages of sleep that involved in dreaming and nightmares. Insomnia can interfere with memory processing, increase the vulnerability to traumatic events. As a result, PTSD can affect the brain, the sleep cycle, and keep the body from falling asleep, which makes it hard for the brain to process the trauma memory. Thus, the brain will have a difficult time identifying between safe and unsafe environments. If this cycle maintains, it will be very vulnerable to patients with SD and PTSD. Moving on, Traditional Chinese Medicine (TCM) such as acupuncture has been known as treating methods for sleeping disorders, including insomnia and sleep apnea. Acupuncture is one of the oldest forms of healing in Chinese over thousands of years. Acupuncture involves penetrating thin needles through the skin at certain points on the body. The needles can be inserted into various depths. The theory of acupuncture is based on energy -qi- called chi. This energy flow through a pathway called meridians. When energy was blocked, illness occurs, acupuncture is used to unblock that energy and help the energy flow back into balance. Acupuncture is considered the primary source of treatment in Asia. Outside of Asia, acupuncture remained unknown until the 1970s. In 1971, James Reston, a columnist, who worked for the New York Times, visited China and had to go under an emergency appendectomy. After the surgery, Reston had some experiences with discomforting pain, nausea, and vomiting. Reston elected to get acupuncture instead of pain medicine. The symptom was relieved instantly. Reston was impressed with acupuncture (Reston, 1971). After returning to the U.S., he wrote an article about acupuncture. People believe this article triggers intense interest in acupuncture in the U.S. Acupuncture has rapidly become an alternative treatment in America. According to Doctor Frey in “Acupuncture” by 1993, 12 million Americans visited acupuncturists per year and spent $500 million on treatment in acupuncture. Frey also mentioned that by 1995, around 10,000 certified acupuncturists practicing in America and about a third of medical doctors have credentialed acupuncturists in the United States in 2002 (Frey, 2020). In fact, in 2007, a survey was conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics stated that 40% of adults use acupuncture as an alternative treatment therapy (Lin & Tung, 2017).While the TCM method works on the flow of energy to maintain a balanced health state, Western medicine works on an approach between health and disease. TCM believes that the insertion of needles stimulates neurohormonal pathways which release endorphin hormones that makeup of happy and euphoric feeling in the body. Western medicine believes that opioid receptors in the brain are what control pain, reward, and addictive behavior. There are many disagreements on how this process works. Until now, it still remains unanswered. Both approaches have been helping patients in many ways. Most of the research in acupuncture was done in small trials, with no standardization, and is only written in the Chinese language creates confusion, lack of understanding, and a mixed outcome of results for acupuncture effectiveness. However, in recent researches, there has been some growth in randomized and controlled trials, giving some validity to acupuncture in the scientific field. Acupuncture can increase the level of serotonin hormone in the body. Serotonin is responsible for the happy feeling, decreases anxiety level which can help patients fall asleep faster. A study is conducted by a group of researchers in rats to investigate the effectiveness of acupuncture. Researchers plant a micro dialysis guide cannula into the nucleus accumbens, which is responsible for the reward system in the brain. Acupuncture treatment is applied at the bladder urinary channel 23 acupoints. This acupoint channel is located at both sides of the spinal on the lower back of rats. The study finds that acupuncture treatment can increase and prolong the level of serotonin in the reward system pathway of the rat’s brain. This finding suggests that acupuncture may have a positive effect on treating emotional disorders (Yoshimoto, et al., 2006). Granted this is only suggesting that it may have positive effects and cannot be conclusive until human trials are conducted.Besides conventional, needle-based, acupuncture, auricular acupuncture is another technique used to treat sleeping disorders. A study in 15 elderly who complain of insomnia was treated with auricular acupuncture report that good sleep quality increased during the treatment process and good sleeping patterns even continue 6 months after treatment has stopped (Lake, 2019). According to TCM, the ears have acupoints that connect to the rest of the body. The needle is inserted into these acupoints on the ears and other acupoints on the body to increase the full affection during acupuncture treatments. Another large study involved 500 patients with schizophrenia reports that acupuncture has helped them improved their sleep cycle after acupuncture treatments (Lake, 2019)Along with acupuncture used in TCM, acupressure has been applied in massage techniques to alleviate muscle soreness and relaxation. Few pressure points might help with the sleep cycle. One of them is the Shen Men point or HT7 is just above the wrist. A study is enrolled in a randomized controlled trial involved 50 residents in long-term care facilities with insomnia. The goal of the study is to evaluate the effect of acupressure on HT7 points. One group receives acupressure on HT7 on both wrists for five weeks and the other group receives light touch on the same point. Turn out the group that receives acupressure on HT7 has better sleep even up to two weeks afterward (Sun, Sung, Huang, Cheng, & Lin, 2010). Along with HT7, point SP6, is above the inner side of the ankle, also helps with insomnia, menstrual cramps, urinary issues, and other pelvic conditions. An investigation on the efficacy acupressure on point SP6 on fatigue and sleep quality in breast cancer patients. During the relaxing acupressure routine, the SP6 points are applied to patients both legs for three minutes. These pressure stimuli the relaxation feeling which increases the sleep quality in patients. Although, the researcher suggests that pregnant patients should avoid point SP6 during pregnancy because it could induce the labor process (Zick, Sen, & Wyatt, 2016). In conclusion, there is no argument that SD interferes with the efficacy of PET in treating PTSD patients. However, research has shown that an alternative treatment such as acupuncture can address the SD. Acupuncture also can help patients regain an adequate sleep cycle. There is a hope that PET can regain its efficacy by applying acupuncture before PET treatment. Correspondingly, acupuncture can be used as an alternative treatment to relieve anxiety before PET treatment is taken place. By combining both treatments, there is a chance that PSTD symptoms can be more manageable. References BIBLIOGRAPHY Bethesda. (2019, August 13). National Institutes of Health. Retrieved from Brain Basic: Understanding Sleep: , S. (2018, October 26). WebMD. Retrieved from What Are REM and Non-REM Sleep?: , R. (2020, March 1). Encyclopedia. Retrieved from Acupuncture: , J. (2019, May 10). Psychology Today. Retrieved from Acupuncture for Insomnia: A Concise Review: , K., & Tung, C. (2017, June 1). The Regulation of the Practice of Acupuncture by Physicians in the United States. NCBI, 121-127. Retrieved from The Regulation of the Practice of Acupuncture by Physicians in the United States: , K. (2019, November 5). How Much Sleep Do You Need? Retrieved from WebMD. , B. (2019, November 24). verywellhealth. Retrieved from Causes and Treatment of PTSD Nightmares: , J. (1971, July 26). The New York Time. Retrieved from Now, About My Operation in Peking: , J., Sung, M., Huang, M., Cheng, G., & Lin, C. (2010, January 6). Effectiveness of Acupressure for Residents of Long-term Care Facilities with Insomnia: A Randomized Controlled Trial. Retrieved from PubMed, 798-805: , J. (2017, May 12). Live Science. Retrieved from Which Came First, Sleep Problems or Anxiety?: , K., Fukuda, F., Hori, M., Kato, B., Kato, H., Hattori, H., . . . Yasuhara, M. (2006). Acupuncture stimulates the release of serotonin, but not dopamine, in the rat nucleus accumbens. PubMed-National Institutes of Health, 321-6. Retrieved from : , S., Sen, A., & Wyatt, G. (2016). Investigation of 2 Types of Self-administered Acupressure for Persistent Cancer-Related Fatigue in Breast Cancer Survivors. Retrieved from JAMA Network, 1470-1476. ................
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