edic Perspectives on Post Traumatic Stress Disorder by Alakananda Ma Ay There fell in this battle of Marathon, on the side of the barbarians, about six thousand and four hundred men; on that of the Athenians, one hundred and ninety-two. Such was the mamber of the slain on the one side and the other. A strange prodigy likewise happened at this fight. Epizelus, the son of Cuphagoras, an Athenian, was in the thick of the fray, and behaving himself as a brave man should, when suddenly he was siricken with blindness, without blow of sword or dart; and this blindness continued thenceforth during the whole of his after life. The following is the account which he himself, as I have heard, gave of the matter: he said that a gigantic warrior, with a huge beard, which shaded all his shield, stood over against him; but the ghostly semblance passed him by, and stew the man at his side. Such, as T understand, was the tale which Epizelus told Herodotus (6.117 - Rawlinson translation) Although the diagnosis of post traumatic stress disorder or PTSD only made it Diagnostic and Statistical Manual of Mental Disorders (DSMV) in 1980, this conc as ancient as humankind, arising wherever war, rape, natural disasters and abuse are known. Called soldier's heart in the American Civil War, it was known as shell shock in the First World War and war neurosis in WW/IL. In the Vietnam War, the symptoms were described as combat stress reaction, a diagnosis that was gradually reformulated a PTSD. In the quote above from the ancient Greek historian Herodotus, the warrior Epizelus experiences hysterical blindness, an extreme form of PTSD. The Greek playwright Sophocles devotes two dramas, Ajax and Philoctetes, to devastating descriptions of the post-battle breakdowns of great heroes. The hero Ajax kills hundreds of farm animals, believing them to be his commanding officers, and finally commits suicide by falling on the point of his sword. “What should I do?” cries the despairing Ajax. “The gods hate me, the Trojans loathe me, the Greeks despise me!” Today as then, victims of PTSD are known to be at increased risk for homicide and suicide. Chaturanga (four limbs of the armed forces), the ancient Indian precursor of today’s game of chess, was described by the Arab scholar Abu al-Hasan ‘Ali al-Mas'tdi as a tool for military strategy, but also for reliving old battles, perhaps as a form of PTSD therapy. In my own Ayurvedie practice, I have certainly seen my share of combat veterans from the Korean, Vietnam and lraq wars, Holocaust survivors, Palestinians who lived through the intifada and young Israelis who have done intense military service under combat conditions, I have also seen refugees from Bosnia, Tibetan survivors of Chinese prison, and Afghanis who grew up in refugee camps. The horrific experiences many of these individuals have gone through are almost unimaginable and require great empathy on the part of a practitioner. Yet the majority of cases of PTSD which I see almost daily in my clinic have not lived through experiences that made international headlines. Rather, theirs‘was a private, perhaps even a buried or unspoken trauma with few to bear witness, Severe car accidents, particularly for the passenger, who had a sense of complete helplessness in the situation, domestic violence, rape - including the often minimized date rape - and age- inappropriate childhood sexual experiences are extremely common causes of severe and disabling PTSD. Trauma can be passed down in fami ., as in the well-documented case of second and third generation Holocaust Survivor Syndrome. Trauma can also be collective and persistent. The other day, down by Goose Creek in Boulder, some boys were observed playing in the long grass with their toy rifles, Like boys fifty years ago, they were still playing Pearl Harbor. On September 11th 2001, millions of breakfast television viewers witnessed planes flying in to the Twin Towers, occasioning a collective trauma response whose effect on our society will never be truly grasped. Clearly, PTSD with its components of terror, helplessness and horror fits the Ayurvedic understanding of vata invading majja dhatu end manovahasrotas (mind channels). The definition of PTSD is “a pathological anxiety that usually occurs after an individual experiences or witnesses severe trauma that constitutes a threat to the physical integrity or life of the individual or of another person.” (1) After witnessing or experiencing the trauma, the individual develops a set of vata symptoms that include repeatedly re- experiencing the trauma, such as in the form of flashbacks or nightmares, and responses of numbness, avoidance and hyperarousal. Individuals with post traumatic stress may be put to immense inconvenience because of an overwhelming need to avoid people, places or situations that remind them of the trauma, One client reported that forty years after an attempted rape she experienced in her teens, she still had extreme difficulty walking down the bridle path where the experience occurred. Others note that their condition regresses if they are contacted by someone associated with the abuse or even see their name in the pape Hyperarousal is an important vata condition leading to disproportionate responses to stimuli. For example, when an icicle falls from the roof of my healing room, a typical response is to jump or startle and possibly to look around, We observed a combat veteran almost jump out of his seat, turning fully around with fists clenched to mect an imagined threat. Despite his protestations that he was completely unaffected by his combat experience, his body language spoke to a severe state of hypervigilance. A pitta-kapha woman who survived the Troubles in Northern Ireland dived under her desk whenever she heard a loud sound on the street outside. Note carefully the speech patterns of patients in whom you suspect PTSD. They frequently speak rapidly an in an excitable way. One kapha woman who had PTSD was almost unrecognizable as a kapha due to her rapid speech and high vocal pitch, Sleep disorders a frequent accompaniment to a state of hyperarousal and is often the presenting complaint of these clients. ‘Those who suffer from PTSD typically attempt to modulate their hypervigilance through use of ‘downers’ such as alcohol, marijuana, sleeping pills and carbohydrates. This is likely to constitute a majority of PTSD victims seen in a typical Ayurveda practice, to such an extent that it is worth considering PTSD in all your clients with food andsubstance abuse issues. Although nicotine isa stimulant, carbon monoxide, found in cigarette smoke in quite large quantities, is a downer, so PTSD sufferers often smoke to create a false sense of calm for a few moments. Use of stimulants such as cocaine by veterans with PTSD is well documented, but such patients ate more likely to be seen in a drug treatment center than in your practice. Understanding the brain physiology of PTSD is a key to appreciating how Ayurvedic approaches can best be used in this condition. Our emotional life appears to be regulated by the limbic system at the base of the brain. Of the limbic structures, the hypothalamaus, hippocampus and amygdala, it is the amygdala which is chiefly implicated in PTSD (2, 3). The amygdala consists of two almond-shaped masses of neurons on either side of the thalamus at the lower end of the hippocampus, Exposure to trauma activates the amygdala and related structures. At the same time, the medial prefrontal cortex, which includes the anterior cingulate cortex, subcallosal cortex, and medial frontal gyrus, can inhibit the activation of the amygdala and restore normal levels of dopamine, norepinephrine and serotonin (2). The amygdala is responsible for fear responses and fear conditioning and is hyper-responsive in PTSD, resulting in hypervigilance and inappropriate fear responses (4). The medial prefrontal cortex, when functioning correctly, will extinguish fear conditioning, preventing inappropriate fear responses and hypervigilance. Its activity is found to be impaired in PTSD (4). Thus methodologies that help the prefrontal cortex modulate the amygdala’s fear response will prove ‘tremendously helpful in PTSD. A treatment strategy for PTSD must be holistic and multifaceted to be fully effective. A good psychotherapist who can help resolve tae initial trauma is an indispensible part of the care team, and as Ayurveda develops in the Western world there will be increasing demand for therapists who are conversant with principles and practices of yoga and ‘Ayurveda, The usual triad of diet, lifestyle and herbal therapies will of course form the ‘mainstay of chikitsa, but other treatment interventions will include oil therapies and Vedic stress reduction techniques like yoga and meditation ‘There are two important general considerations in working with PTSD. First, patients with PTSD are easily overwhelmed, so less is more. Proceed slowly and patiently. I once heard on the grapevine of a vata patient with PTSD who came to see me and later claimed that she did not return because I “gave her too many things to do.” I ruefully pulled her chart to see the extent of my overkill error and observed that ALL I asked was for her to oil the soles of her feet at bedtime. I had thought of that as a sufficiently minimalist intervention that would slowly allow her vata to calm to the point where she could consider dealing with some herbs or teas! Secondly, empathy is crucial. Reassurance and minimization of trauma are self-protective strategies often used within the medical profession. Some doctors may even consider it their job to provide comfort and reassurance. Although the PTSD suffer does need reassurance to understand that they ate out of harm’s way now (if that is indeed that case), validation of the deva: impact of their initial trauma is the most healing thing you can offer them. Imagine yourself on the battlefield with a wounded war buddy, or lying by the side of the road after a car accident or as a young child terrified in bed waiting for their abuser’s hand ontheir door handle. ‘The more deeply you help them understand how truly destructive and terrifying you appreciate the trauma to have been, the better they will be able to resolve it, for validation will relive the burden of shame and guilt often associated with abuse. Since vata provocation and maja gati vata (invasion of vata into majja dhatu) are central to this condition, treatment approaches are likely to involve vata soothing diet and lifestyle interventions. In chronic PTSD, watch for symptoms of vata ojo vyapat (invasion of vata into ojas), such as extreme fatigue, memory issues and reversal of the diurnal cycle (awake by day and asleep by night). However, because the amygdala is, involved with anger as well as fear, there may well be a strong pitta component or even. pitta ojo vyapat. Appropriate diet and lifestyle suggestions should thus be individually tailored within the prakruti-vikruti paradigm. In terms of herbal therapies, ashwagandha is always of use where there is vata in majja dhatu and is known to support healthy dopamine levels thus mitigating the over- activation of the amygdala (5). Bacopa or brahmi can be used to support serotonin production (6) and can be combined with other nervine and adaptogenic herbs as in the formula Tranquil Mind. To support restful slzep, consider Banyan's I Sleep Soundly formula, For an archived Banyan Vine article on insomnia see this link Vata soothing oil therapies that are valuable in PTSD include abhyanga with dosha specific massage oil such as Vata Massage Cil and shirodhara using Shirodhara Oil which contains nervine herbs such as brahmi, blringaraj, ashwagandha and skullcap. Shirodhara has been shown to help normalize serotonin and noradrenaline levels (7) and reduce anxiety (8) and is traditionally said to remove vata from maja dhatu Sarvangadhara or pizhichil with sesame oil can also be used to calm vata and norma majja dhatu, Meditational therapies are of great importance in helping the prefrontal cortex send calming messages to the amygdala, Both reletive and absolute practices have their place although relative level practices may be of more use initially. Relative practices include visualizations, affirmations, aspirations and relaxation practices. Visualizations work directly on the limbic brain and practices using words work on the prefrontal cortex. Visualization can include creating an image of a safe space and picturing oneself being there and relaxing, This sends messages of safety and relaxation to the limbic system. Affirmations can include phrases such as; “Iam safe, happy and loved,” which help reprogram the prefrontal cortex to send healthy messages to the amygdala. Similarly, an aspiration practice can be used and combined with the breath. Breathe in “May I be happy,” and breathe out “May all beings be happy.” This practice helps the prefrontal cortex and limbic system to function normally (9). Once the mind is calmed by the use of relative practices, absolute practices such as ‘nindfulness meditation can be introduced, These practices help us see beyond the trauma by deepening our understanding of the impermanence of all phenomena, They have also been found to regulate prefrontal activity in favor of positive emotions (10). Although described in psychiatric literature only recently, PTSD is as ancient as trauma itself. It involves dysregulation of the amygdale and prefrontal cortex and correspondsAyurvedically with vata invading maja dhats. The multifaceted approach of Ayurveda offers hope for PTSD suffers because it provides an integrated way to normalize brain function via diet and lifestyle modifications, specific, proven herbal therapies, relaxing oil treatments and meditational therapi 1, T Allen Gore, MD, MBA, CMCM, DFAPA http://emedicine.medscape.com/article/288154-overview 2. Lisa M. Shin, PhD; Scott P. Orr, PhD; Margaret A. Carson, PhD, RN et al, Regional Cerebral Blood Flow in the Amygdala and Medial Prefrontal Cortex During Traumatic Imagery in Male and Female Vietnam Veterans With PTSD, Arch. Gen. Psych. 61, 2 2004. 3. Semple WE, Goyer PF, McCormick R, Donovan B et al, Higher brain blood flow at amygdala and lower frontal cortex blood flow in PTSD patients with comorbid cocaine and alcohol abuse compared with normals. Psychiatry. 2000 Spring;63(1):65-74 4, Lisa M. Shin, Scott L. Rauch,B And Roger K. Pitman, Amygdala, Medial Prefrontal Cortex,and Hippocampal Function in PTSD Ann. N.Y. Acad. Sci. 1071: 67~79 (2006). 5. GL Gupta, AC Rana Plant Review Withaaia somnifera (Ashwagandha): A Review - Pharmacognosy Reviews, 2007 - pheogrev.com 6.C. Stough «J, Lloyd « J. Clarke « L. Downey The chronie effects of an extract of Bacopa monniera (Brahmi) on cognitive function in healthy human subjects Psychopharmacology-Berlin, 2001 7. Kazuo Uebaba, Feng-Hao Xu, Hiroko Ogawa, Takashi Tatsuse, Bing-Hong Wang, Tatsuya Hisajima, Sonia Venkatraman, Psychoneuroimmunologic Effects of Ayurvedic Oil-Dripping Treatment The Journal of Altemative and Complementary Medicine. December 2008, 14(10): 1189-1198. doi:10.1089/acm.2008.0273 8. Fenghao Xu, Kazuo Ucbaba, Hiroko Ogawa, Takeshi Tatsuse, Bing-Hong Wang, Tatsuya Hisajima, Sonia Venkatraman, Pharnaco-Physio-Psychologic Effect of Ayurvedic Oil-Dripping Treatment Using an Essential Oil from Lavendula angustifolia ‘The Journal of Alternative and Complementary Medicine. October 2008, 14(8): 947-956. doi:10.1089/acm.2008.0240 9, Antoine Lutz,1 Julie Brefezynski-Lewis, 2 Tom Johnstone, 3 and Richard J. Davidson Regulation of the Neural Circuitry of Emotion by Compassion Meditation: Effects of Meditative Expertise PLoS ONE. 2008; 3(3): ¢1897 10. Richard J. Davidson, PhD, Jon Kabat-Zinn, PhD et al Alterations in Brain and Immune Function Produced by Mindfulness Meditation Psychosomatic Medicine 65:564- 570 (2003.)