PTSD is a complex problem affecting a person’s mind, body, and vitality, and treatment options need to be interdisciplinary, multimodal, and integrative in order to promote holistic wellness.
One way to achieve this is by promoting diverse therapeutic options through the continual mainstreaming of complementary and alternative therapies into conventional medical treatment options.
To get involved in the theme of “Exploring the Options” for PTSD treatment, this blog explores what massage therapy may do to help individuals with PTSD.
As a patient-centered model of care with its unique elements of human touch, massage therapy stands to empower clients with PTSD by cultivating the importance of self: self-care, self-responsibility, and self-awareness.
Understanding PTSD: The DSM-5 Clinical
It is important that massage therapists understand the clinical manifestation of PTSD so they can properly accommodate clients, including those who may be unaware of their condition.
PTSD affects over 17 million Americans annually, emerging in the wake of traumatic events—most frequently, (5,2):
- Physical or sexual assault
- Natural disaster
- Accident or fire
- Threat or injury to family member/close friend
- Violent death of family member/close friend
- Witnessing physical or sexual assault
PTSD is highly prevalent among veterans, and women are over twice as likely as men to develop PTSD (2).
The American Psychiatric Association (APA) has recognized PTSD in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of psychotherapy since 1980—partially due to the clinical documentation of symptoms and experiences of Vietnam War survivors (4,7). With the recent release of the DSM-5 in May 2013, PTSD has moved from a class of anxiety disorders into a new class of “trauma- and stressor-related disorders” (4,1,3).
The central diagnostic criterion for PTSD in the DSM-5 is identifying the traumatic event(s), which exposed the person to actual or threatened death, serious injury and/or sexual violation (3). Exposure to events triggering distressing symptoms must have taken place in at least one of the following ways:
- The individual directly experienced or witnessed the traumatic event;
- The individual learned that the traumatic event occurred to a close friend or family member (with actual or threatened death being violent or accidental and not by natural causes); or
- The individual directly experienced repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or film unless work-related) (3).
While most of us experience aversive events, our responses differ. A recent, nationally representative survey finds 88 percent of respondents reported exposure to a potentially traumatic event in their lives (2).
It is unclear why some individuals present symptoms after experiencing aversive events while others do not, though sometimes individuals experience delayed onset of PTSD years or even decades after an event (11,12).
The traumatic event, regardless of its trigger, causes the development of characteristic symptoms, which together create a clinically significant level of distress or impairment in the individual’s social interaction, work ability, or functioning (3).
The DSM-5 now recognizes 20 characteristic symptoms, clustered into four categories: intrusion/re-experiencing; altered arousal/reactivity; avoidance; and negative changes in cognitions/mood (1,3).
- Intrusion/re-experiencing is spontaneous flashbacks or recurrent dreams of the traumatic event, or other prolonged or intense psychological distress. Intrusive re-experiencing reflects the lingering imprint of trauma on the mind and body. Traumatic memories are compartmentalized from other memories—not stored in verbal and contextual form but rather as “vivid sensations and images sometimes reenacted unconsciously in behaviors” (10, p. 52).
- Altered arousal/reactivity reflects the hypervigilant expectation of danger, as well as reckless or self-destructive behavior and sleep disturbances.
- Avoidance is the tendency to avoid triggers, cues or memories of the events.
- Negative cognitions and moods is a newly added cluster of symptoms in the DSM-5 including a persistent, distorted sense of blame of self or others, estrangement, markedly reduced interest in activities, and the inability to remember key aspects of the traumatic event(s).
PTSD frequently leads to emotional numbing, substance abuse, and recurrent nightmares (10). PTSD may suppress and weaken the immune system and contribute to comorid physical conditions (10). Research shows that those with PTSD have a smaller hippocampus (up to 12 percent smaller in one study), with sufferers scoring 40 percent lower on verbal memory tests (7,10).
The psychological component of PTSD entails a somatic experience of stress—that is, a neurobiological experience occurring throughout the whole body with the activation of the flight-or-fight response.
This stress response, which is triggered by perceptions of threat within a person’s environment, produces chemical changes within individuals who have PTSD to lead them to become “stuck” in the fight-or-flight, remaining hyper-vigilant or hyper-alert in their expectations of danger (13). This stress cycle may also produce cortisol and norepinephrine burnout, which may cause numbness, lethargy, and symptoms of depression (13).
PTSD is an elusive disease—in part—because it creates a breakdown between the Self and others and thus instantiates ‘invisible scars’. Prof. Joshua S. Goldstein writes, “At the heart of PTSD is isolation—a feeling of disconnection from family and friends,” (10, p. 52).
PTSD affects how individuals connect with their social environments, which affects their physical states. Therefore, PTSD is not only a psychosocial condition but also a sociosomatic one.
Individuals with PTSD commonly feel unable to relate to others who have not experienced the event and, worse, are left with the psychic vulnerability of feeling a startled mistrust of the world, which is triggered as a physical stress response to be perceived as hostile and dangerous (10). A ‘fragmented Self’ may also experience amnesia, as well as dissociation or derealization—that is, a surreal or out-of-body experience of reality.
Exploring Options through Massage Therapy
The potential benefits of massage therapy for individuals with PTSD may include alternative or adjunctive treatment for the many comorbid symptoms that are commonly experienced in conjunction with PTSD, including acute stress, cardiovascular conditions, anxiety and chronic pain.
And, as a holistic form of treatment, massage therapy may provide opportunities for developing patient-centered relationships and coping strategies to enable clients to more actively manage the sociosomatic symptoms of PTSD; to enhance mindful body awareness; and, perhaps most importantly, “to help the client to become safely ’embodied within the self'” (13).
The integrative and professional nature of massage therapy may aid some clients with PTSD to reestablish confidence and relaxation in social and physical interactions, and massage therapists can additionally impart safe and effective methods of self-soothing and awareness, self-care, and stress management (13).
Together, massage therapy may help some individuals with PTSD effectively address the underlying fear and mistrust that has been encoded into their bodies by providing ‘boundaried intimacy’ with another human (13). As an adjunct or complementary therapy, massage therapy may help clients feel safe and calm within their social environments, their physical bodies, and their frames of mind to provide benefit for elements of PTSD—including ineffable aspects—that are not address through talk therapy or prescriptions (13).
There is no specific massage modality or technique that is used to treat clients with PTSD, and massage therapists may have specific concerns when working with clients with PTSD.
For people with PTSD, flashbacks of a traumatic event may occur unpredictably by cues in their social environments, triggering heightened activity in the amygdala—activity which is left unchecked by the hippocampus or the prefrontal cortex, causing the person to re-experience aspects of the original trauma as if it were happening in the present (13) [for a better explanation involving tigers, read here].
For example, for an individual traumatized by sexual abuse, the intimacy of the massage treatment room may trigger a stress response (13). Therefore, establishing trust is essential when working with clients with PTSD, and effective treatment will require that the massage therapist creates a safe place in which the client can regain confidence (13).
Self-care is also essential for therapists working with clients with PTSD (13). Without a good self-care routine for the therapist, burnout and compassion fatigue may develop and affect relationships with clients over time. Clients may notice fatigue and burnout in their therapists and create a false sense of comfort by hiding details of their pain or confusion to protect their massage therapists (13).
The Research: Quantitative and Qualitative
While research on PTSD and massage therapy is limited, existing clinical research suggests that massage therapy may provide direct and indirect benefit to clients with symptoms of PTSD (14,15,16,18,19). Although more quantitative research must be done to demonstrate the clinical efficacy of massage therapy as a treatment, massage therapy may be a safe and effective adjunct or alternative therapy to help improve well-being (18,19).
Some of the most promising research on current trends of use of massage therapy for the symptoms of PTSD has been conducted on veterans. In a 2011 randomized-controlled trial of the use of CAM therapies among 401 veterans, massage therapy was the most preferred option (96% preferred it) for the management of chronic pain, which is very highly prevalent among PTSD sufferers, and the majority of respondents had tried a CAM therapy in the past.
Further, qualitative evidence is similarly suggests successful treatment outcomes to be further explored. Professor Nicholas A. Rattray has conducted pilot research on a program here in Tucson at the University of Arizona on the Energy Therapy, Healing Touch. Rattray describes, “Some student veterans have suggested that PTSD is ‘rampant’, among their peers and that many of them are unaware that they are suffering from its effects” (17).
With the aim of providing student veterans access to alternative options for PTSD treatment, the staff implemented a pilot project using Healing Touch. This included both touch and non-touch (above the body) energy balancing techniques that energize, clear, and balance the physical, mental, emotional, and spiritual aspects of the self, emphasizing “self-healing”—and with some initial success (17).
Students reported (17):
- “It completely changed my life”
- “Learning to control anxiety and stress levels, and relax”
- “Before healing touch I was in a constant state of panic with no hope of relief: medicine, EMDR, and counseling were not proving very effective and sometimes made things worse. Healing touch impacted my health and wellness by changing my attitude towards hoping for an end to my anxiety”
- “Overall well-being is restored. I can sense how much growth these sessions taught me [and I] feel ‘spiritually vibrant and physically well’”
- “Just try it, if nothing else you will get one of the best naps you’ve ever had!”
- “Made me more self aware of how my physical body responds to me [sic] mental stressors.”
Other students reported being better able to refocus and self-soothe, as well as improved sleep, decreased pain, and spiritual wellness from their Healing Touch sessions.
Massage therapy holds much promise for helping individuals with PTSD manage their diverse symptoms. Taking seriously the potential benefits that massage therapy and other CAM therapies may have opens avenues for people with PTSD for developing patient-centered health care plans to restore and promote wellness in their lives.
References(1) US Departartment of Veterans Affairs, 2013. DSM-5 Disgnostic Criteria for PTSD Released.
(2) Miller, M. W., Wolf, E. J., Kilpatrick, D., Resnick, H., Marx, B. P., Holowka, D. W., Keane, T. M., Rosen, R. C., & Friedman, M. J. 2012. “The Prevalence and Latent Structure of Proposed DSM-5 Posttraumatic Stress Disorder Symptoms in U.S. National and Veteran Samples.” Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0029730
(3) American Psychiatric Publishing. 2013. Posttraumatic Stress Disorder.
(4) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed.). Washington, DC: Author.
(5) Field, T., Seligman, S., Scafidi, F., & Schanberg, S. (1996). Alleviating posttraumatic stress in children following Hurricane Andrew. Journal of Applied Developmental Psychology, 17, 37–50.
(6) Silverman, W. K., Orit, C., Viswesvaran, C. D., Burns, B. J., Kolko, D. J., Putnam, F. W., & Amaya-Jackson, L. 2008. Evidence-Based Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events. J. Clin. Child & Adolescent Psych 37(1): 156-83.
(7) Bremner, J.D. & Vermetten, E. 2011. “The Hippocampus and Post-Traumatic Disorders.” In The Clinicial Neurobiology of the Hippocampus: An Integrative View, Ed. Thorsten Bartsch, 267-68. Oxford, UK: Oxford University Press.
(8) NCTSN. 2013. PTSD Awareness.
(9) VA. 2013. PTSD Awareness Month.
(10) Goldstein, Joshua S. 2001. War and Gender: How Gender Shapes the War System. Cambridge: Cambridge University Press
(11) Santiago, P.N., Ursano, R.J., Gray, C.L., Pynoos, R.S., Spiegel, D., Lewis-Fernandez, R., J. Friedman, M.J., & C.S. Fullerton. “A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: intentional and non-intentional traumatic events.” PLoS One
(12) Bonanno, G.A., & A.D. Mancini. 2008. “The Human Capacaity to Thrive in the Face of Potential Trauma.” Ped. 121(2):369-75.
(13) Dryden T, Fitch P. 2000. “Recovering body and soul from post-traumatic stress disorder.” Massage Ther J. 39:41-60.
(14) Nicholl, C., & A. Thompson. 2004. “The psychological treatment of Post Traumatic Stress Disorder (PTSD) in adult refugees: a review of the current state of psychological therapies.” J. Men. Health 13(4):351-62.
(15) Field, T., Hernandez-Reif, M., Diego, M., Schanberg, S. & C. Kuhn. 2005. “Cortisol decreases and serotonin and dopamine increase following massage therapy.” Neurosci 115(10):1397-1413.
(16) Field, T., Seligman, S., Scafidi, F., & S. Schanberg. 1996. “Alleviating posttraumatic stress in children following Hurricane Andrew.” J Appl Develop Psych, Vol 17(1), Jan-Mar 1996, 37-5
(17) Rattray, N. 2012. “The utility of energy therapy for student veterans at the University of Arizona.”
(18) Strauss, J.L. & A.J. Lang. 2012. “Complementary and Alternative Treatments for PTSD.” PTSD Research Quarterly, 23(2).
(19) Strauss, J.L., Coeytaux, R., McDuffie, J., Nagi, A., & Williams, J.W. 2011. Efficacy of complementary and alternative therapies for posttraumatic stress disorder. VA-ESP Project #09.010
Comments from original Massamio post:
Good article. Hope we can help our veterans. They have helped others and deserve the same. — Posted @ Sunday, June 23, 2013 12:56 PM by joy
Thanks, Joy, and I couldn’t agree more! — Posted @ Sunday, June 23, 2013 1:23 PM by Naomi Oliviae