Presented by: Caroline Meyer, ND At the OAND Annual Convention
On 18 November 2014
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The Impact of Trauma When you're born a light is switched on, a
light which shines up through your life. As you get older the light
still reaches you, sparkling as it comes up through your memories.
And if you're lucky as you travel forward through time, you'll
bring the whole of yourself along with you, gathering your skirts
and leaving nothing behind, nothing to obscure the light. But if a
Bad Thing happens part of you is seared into place, and trapped for
ever at that time. The rest of you moves onward, dealing with all
the todays and tomorrows, but something, some part of you, is left
behind. That part blocks the light, colours the rest of your life,
but worse than that, it's alive. Trapped for ever at that moment,
and alone in the dark, that part of you is still alive. Michael
Marshall Smith, Only ForwardMichael Marshall Smith, Only
Forward
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Learning Objectives: Understand the prevalence of trauma in the
general female population Learn how to recognize the features of
trauma in women in the clinical setting Review recent research on
the impact of trauma to the CNS and hormonal system Review
conventional medical treatment of trauma Explore naturopathic
approaches in the treatment of trauma, including dietary,
nutraceutical, lifestyle, counselling,botanical and homeopathic
prescriptions
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First, Some Definitions Trauma: any experience that interferes
with normal physiological, mental-emotional, social functioning
PTSD, according to new DSM V criteria (1), includes: 1) Experience
of a stressor (acute, chronic, witnessing, and/or indirect) 2)
Intrusive symptoms (1) 3) Avoidance symptoms (1) 4) Negative
changes in mood & cognition (2) 5) Changes in reactivity &
arousal (2) 6) Duration of sx last more than 1 month Patient also
can have dissociative sx and may have delayed onset of sx
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Prevalence of Trauma According to Stats Can, it is estimated
that 50% of Canadian women and 1/3 of men have survived at least
one incidence of sexual or physical abuse (2) Even though boys and
girls are equally likely to be exposed to family violence, 4 out of
5 victims of family-related sexual violence are girls (2) Similar
findings in US studies
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Health Impacts of Trauma From the ACE (Adverse Childhood
Events) study involving 17 000 respondents (3): Having 4 or more
indices of childhood trauma significantly increases risk of:
Depression Suicide attempt COPD Addiction, including risk of
becoming a smoker and/or alcohol dependent Liver disease, Early
death and more medical conditions
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More Health Impacts People with PTSD have increased
self-reported experience of pain and increased impairment in daily
activities to pain (4)
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Trauma Changes The Brain Lang, a leader in neurobiology of
trauma, proposed that emotionally-charged memories are held in
associative networks that impact many different structures and
functions in the brain (5) Trauma appears to negatively impact the
functioning of the brains cortex as well as brain stem In people
with PTSD, the prefrontal cortex & particularly the anterior
cingulate (which governs rationality/reason) is smaller along with
shrinking of hippocampus (6) Emotionally based memories are stored,
too, in the amygdala and trauma can increase the sensitivity of the
amygdala to non-threatening stimuli (6)
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Trauma Destabilizes the Autonomic Nervous System PTSD
associated with impaired parasympathetic control (as measured by
low respiratory sinus arrhythmia) along with increased sympathetic
sensitivity (7 ) Clinically, this presents as overstimulation-
based symptoms (eg. anxiety) along with under-arousal symptoms (eg.
depressed mood)
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Trauma and Neurotransmitters Trauma has been associated with
lowered GABA levels especially in the anterior cingulate and this
corresponds with increased insomnia severity (measured by ISI
scores) (8) Again, Lang has shown that trauma often induces
dysregulation of serotonin and dopamine pathways in the CNS
(5)
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Hormonal Effects of Chronic Stress vs. PTSD in Adults (6,9,10)
Chronic Stress PTSD Increased cortisol Increased CRF (ie. Abnormal
negative feedback loop) Tendency for insensitivity of
glucocorticoid receptors Lowered or normal cortisol Increased CRF
(ie. normal negative feedback loop) Tendency for heightened
sensitivity of glucocorticoid receptors
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Hormonal Impact of PTSD in Children PTSD appears to affect
children differently: Initially (shortly after traumatizing event),
high evening cortisol and elevated IL-6 are predictive of
developing PTSD within six months of event (11) Six months after
trauma event, cortisol levels return to normal but catecholamines
levels higher (11)
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Generational Impact of PTSD Adults with PTSD may confer
alterations of stress hormone responses in their children Children
of Holocaust survivors with PTSD as well as mothers pregnant during
9/11 who reported symptoms of PTSD had: Lower urinary excretion of
cortisol and lower salivary cortisol levels (compared to children
of parents who experienced these traumatic events but didnt have
PTSD) (12,13)
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Conventional Treatment of Trauma: Therapy Usually involves
combination of trauma-specific therapy and psychoactive medications
(14) Main therapeutic approaches include: EMDR (Eye Movement
Desensitization & Reprocessing) CBT, has been shown to be
effective in both adults and particularly with children and
adolescents (15) Exposure therapy (a form of behaviour
therapy)
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Therapeutic Approach: Judith Herman Judith Herman published
Trauma and Recovery (16), a classic book on the healing of trauma
Her approach includes the following steps: Developing A Healing
Relationship Creating Therapeutic Safety Remembrance and Mourning
Reconnection Commonality
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Therapeutic Approach: Peter Levine Another classic approach
developed by Peter Levin takes its inspiration from observations in
the animal world; that is, observing how animals in the wild
respond to acute trauma(17) Levines key elements of trauma therapy
include: Establishing sense of relative safety Encouraging patients
self-awareness of body sensations Decoupling & discharging body
sensations from the memories of trauma
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Conventional Treatment of Trauma: Medication First-line
medications include SSRIs and SNRIs (eg. Venlafaxine/Effexor) (14)
Second-line medications include tricyclic antidepressants,
mirtazapine/Remeron, anticonvulsants, and MAO inhibitors Adjunct
treatment can involve antipsychotic meds, benzopdiazapines, and
Prasozin/Alpha-adrenergic blocker (15)
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Novel Conventional Treatment of Trauma: Cortisol Low dose oral
cortisol tx for 4 weeks significantly reduced the recall of
traumatic memories for people with PTSD (18) without major adverse
effects
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Novel Conventional Treatment of Trauma: MDMA & Cannabinoids
These psychoactive components appear to positively impact the
process of fear conditioning and reduce anxiety (15, 19) This
research is in its first stages, and the long-term effects of MDMA
and cannabinoids are unclear Nevertheless, these findings may
explain in part why people with PTSD often use psychoactive drugs
to self-medicate
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Recognizing Trauma in Clinical Practice: Red Flags Beyond the
typical clinical symptoms of PTSD, look for: Never Well Since .
Unexplained physical symptoms that do not fit neatly into
diagnostic categories, including recurrent abdominal pain,
idiopathic infertility I have found that people with certain
medical conditions are more likely to have a traumatic past,
including endometriosis, fibromyalgia, and BPD (borderline
personality disorder)
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Naturopathic Treatment of Trauma: Initial Steps (20) 1) Ensure
that patient is safe and not at immediate risk of harming self or
others 2) Where PTSD and/or trauma is significantly impacting your
patient and you determine it is beyond your scope of practice,
refer patient for care with psychologist, psychiatrist,
psychotherapist, or another practitioner with experience in trauma
3) Even if referral is made, naturopathic medicine has much to
offer patients in supporting them in healing from trauma and
co-managed care is often optimal
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Naturopathic Treatment of Trauma: Ongoing Steps 4) As you
continue to work with a patient undergoing treatment for trauma, it
is important to ensure patient has a crisis management plan. The
healing path is circuitous especially with trauma, and acute
distress can occur. 5) May be obvious but ongoing self-care for you
as the practitioner is essential because treating patients with
trauma histories can be emotionally intense and draining
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Naturopathic Treatment of Trauma: Creating Safety in the
Clinical Setting When a patient has disclosed a history of trauma,
I always take care to: Clarify what feels safe in terms of physical
touch for physical exams, acupuncture, etc. Set very clear
professional boundaries Remain mindful that it is not always
necessary (or therapeutic) for the patient to divulge details of
her trauma history Ensure that the patient feels grounded at the
end of the visit, and leaving adequate time for closure
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Naturopathic Treatment: Adrenal Support Regular Daily Routine
Most effective adrenal support is the cultivation of daily habits
done at regular times of the day (ie. Meal times, sleeping &
waking times, time for physical exercise, etc) The mind-body
responds positively to the regularity of routine Use Adrenal Tonics
over adrenal stimulants in most cases (21)
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Naturopathic Treatment: Neurotransmitter Support Given that
trauma appears to disrupt neurotransmitter function in CNS,
replenishing neurotransmitters can be effective therapeutic
approach (22) Also consider use of precursors to neurotransmitters,
including 5-HTP, Tryptophan, P5P, magnesium, phenylalanine,
tyrosine
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Naturopathic Treatment: Mind-Body Approaches Loving
Kindness/Metta Meditation Pilot study published in 2013 on loving-
kindness/metta meditation sessions lasting over 12 weeks showed
significant improvement in PTSD symptoms immediately at the end of
the program and at the 3-month follow-up (23, 24)
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Naturopathic Treatment: Mind-Body Approaches Yoga Again, small
studies involving yoga has shown moderate positive effect on PTSD
symptoms (25,26) A pilot study involving women found that women
with PTSD in the yoga group had lowered suppression of emotional
expression and increased psychological flexibility by the end of
the program compared to the control group, resulting in reduction
of intensity of PTSD symptoms (25)
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Naturopathic Treatment: Body-Focused Therapy Emotional Freedom
Technique (EFT)/ Tapping Tapping, or Emotional Freedom
Technique/EFT, has shown promising results for treating trauma in
several small pilot studies (27,28) One study done in Rwanda with
50 orphaned adolescent genocide survivors showed a dramatic
reduction in self-reported and caretaker ratings of trauma-induced
symptoms, including flashbacks, depression, enuresis, nightmares,
and impaired concentration (27)
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Naturopathic Treatment: Meditation A small pilot study (only
involving 9 participants) found that after an 8-week
mindfulness-based stress reduction (MBSR) program, people with PTSD
experienced a significant reduction in PTSD & depression
symptoms, as well as shame-based trauma appraisals (29) Also,
acceptance of the emotional impact of trauma was increased over the
course of the program
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Naturopathic Treatment: Acupuncture Again, some promising
results for constitutional acupuncture in reducing the intensity of
PTSD symptoms (30) Range of different protocols have been shown to
be effective, including constitutional acupuncture with or without
electrostim; with or without moxa Auricular acupuncture also
effective
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Naturopathic Treatment: Acupuncture Clinically, I have seen
positive impact of NADA auricular protocol for managing symptoms of
PTSD NADA protocol includes: Shen Men, Autonomic point, C. Kidney,
Lungs, Liver I often add in Point Zero, Brain & Limbic System
Trauma can clearly damage Kidneys, grief can drain Lung qi and
suppression of emotions and/or anger can stagnate Liver qi
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Naturopathic Treatment: Flower Essences Clinically, I have
found that flower essences can powerfully facilitate the healing of
trauma Bach Flower Essences Star of Bethlehem releases shock,
useful for acute trauma Aspen removes fears that are not clearly
defined White Chestnut heals recurrent upsetting & intrusive
thoughts Elm transforms sense of overwhelm Rock Rose helps to
resolve fears that keep patient frozen, unable to react Sweet
Chestnut restores faith/hope that all will be okay
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Naturopathic Treatment: Constitutional Homeopathy One of my
favorite and most effective ways to fortify and balance the vis,
thus helpful in healing trauma Case #1: 35 year old woman
presenting with social anxiety and dysmenorrhea Started in early
20s while in undergrad More problematic now that she is in
relationship and has a young daughter; wants to be present and
supportive in her family relationships Feels better when doing
intense physical exercise; has recently discovered Crossfit
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Naturopathic Treatment: Constitutional Homeopathy Desires to
feel strong, powerful and in control, but knows that this also
results in her feeling emotionally shut down and isolated from
others During treatment, patient develops an acute hamstring injury
(from overtraining at Crossfit ) I prescribe acutely Arnica 1M once
per day for three days (31) Patient returns with revelation of
sexual abuse as child and sexual assault in undergrad; feels free
and more emotionally open in sharing her experience with her
partner and close friends
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Naturopathic Treatment: Constitutional Homeopathy Patient
continues to respond well to Arnica but I eventually prescribe a
single dose of 10M After the 10M dose, the patients dysmenorrhea
significantly reduces 18 months after first taking Arnica 1M (and
with follow-up remedy of Lac-maternum 200C(32), patient has a child
of her own; something she never thought possible physically or
emotionally
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Naturopathic Treatment: Constitutional Homeopathy Case # 2: 56
year old patient presents with HTN, obesity, hypothyroidism and FM
of 10+ years duration When I asked for a medical timeline, patient
returns with a chronological history of severe physical and sexual
abuse from ages 3 to 45 She has several other medical supports
including weekly psychiatrist appointments, reiki practitioner, and
First Nations elder Patient also experiences dissociative symptoms
in which she can lose several hours of a day; happens a few times
per month Has intense dreams of flying quickly, being at
height
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Naturopathic Treatment: Constitutional Homeopathy Patient
describes FM pain as heavy, constricted around muscles and when BP
is high, she feels constricted feeling in chest with palpitations
Patients weight has fluctuated greatly in past 10 years, gaining
and losing and then gaining 100lbs. She has had several drug
experiences earlier in life but has been sober for over 10 years
Has intense dreams of flying quickly, being at height Often has
headaches with dissociative episodes characterized by crushing,
constrictive pain that is worse with closing eyes
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Naturopathic Treatment: Constitutional Homeopathy I prescribe
patient Anhalonium LM4 once per day for 7 days in a row (LM because
I was concerned about possible aggravation) Commonly known as
Peyote, member of Cactaceae family (31) Keynote sensations:
Constrictive, oppressive, heavy Some keynote rubrics for
Anhalonium: Generalities; pain; crushing, as if Mind; delusions;
enlarged
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Naturopathic Treatment: Constitutional Homeopathy In first
& second follow-ups (4 & 8 weeks later), she reports having
intense dreams on the first 3 nights of taking the remedy; all
involve her totem animal showing her book of wisdom and various
crystals Feels grounded and no dissociative symptoms since taking
the remedy FM pain has improved and she is able to exercise daily
Reduced appetite and has lost 10 pounds since taking remedy
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Prevention: Building Trauma Resilience Key components of
preventing traumatic experience from developing into PTSD/chronic
trauma symptoms (16): Access to social support networks Placing
traumatic event in broader context, giving the experience a deeper
meaning Healing by helping others
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Prevention: Building Trauma Resilience Interesting genetic
research on neuropeptide Y whose presence seems to confer a
protective benefit for prevention of chronic trauma(33) Mixed
results in the research for traditional talk therapy and debriefing
sessions after traumatic event as effective means for primary
prevention of PTSD(34)
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Spiritual Journey of Trauma Intense life experiences, whether
positive or negative, have the potential to transform our lives The
suppression of traumatic memories and emotions consumes an enormous
amount of energy; as trauma heals, that well of energy is available
for patient to use Levine has observed that when trauma is healed,
patients often have intense spiritual experiences not unlike the
generation of Kundalini energy or Satori within meditative
practices (17)
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The Promise of Healing Trauma The wound is the place where the
Light enters you. RumiRumi
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References 1. American Psychiatric Association. DSM-V.
Arlington, VA; American Psychiatric Assoc; 2013. 2. Johnson H &
Sacco VF. Researching violence against women: Stats Cans national
survey. 1995. Cdn J Criminiology. 3. Anda R, Felitti VJ. 2014. The
adverse childhood experiences study: Center for Disease Control
& Prevention website.http://www.cdc.gov/ace/findings.htm.
Accessed on 25 July 2014.http://www.cdc.gov/ace/findings.htm 4.
Powers A et al. Childhood abuse and the experience of pain in
adulthood. 2013. Psychosomatics. Oct 23. Epub ahead of print. 5.
Lang PJ, McTeague LM, Bradley MM. Pathological anxiety and
function/dysfunction in the brains fear/defense circuitry. 2014.
Restor Neurol Neurosci; 32(1):63-77.
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References 6. Yehuda R. Biology of posttraumatic stress
disorder. 2001. J Clin Psychiatry. 62 Suppl 17:41-6. 7. Blechert J,
Michael T et al. Autonomic and respiratory characteristics of
posttraumatic stress disorder and panic disorder. 2007. Psychosom
Med. Dec;69(9):935-43. 8. Meyerhoff DJ et al. Cortical
gamma-aminobutyric acid and glutamate in posttraumatic stress
disorder and their relationships to self-reported sleep quality.
2014. Sleep. May 1; 37(5)_893-900. 9. Jones T, Moller MD.
Implications of hypothalamic-pituitary-adrenal axis functioning in
posttraumatic stress disorder. 2011. J Am Psychiatr Nurses Assoc.
Nov-Dec; 17(6): 393-403. 10. Wahbeh H, Oken BS. Salivary cortisol
lower in posttraumatic stress disorder. 2013. J Trauma Stress. Apr;
26(2):241-8.
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References 11. Pervanidou P. Biology of post-traumatic stress
disorder in childhood and adolescence. 2008. J Neuroendocrinol.
May; 20(5):632-8. 12. Yehuda R, Bierer LM. Transgenerational
transmission of cortisol and PTSD risk. 2008. Prog Brain Res. 167:
121-35. 13. Lehrner A Bierer LM et al. Maternal PTSD associates
with greater glucocorticoid sensitivity in offspring of Holocaust
survivors. 2014. Psychoneuroendocrinology. Feb; 40:213-20. 14.
Jeffreys M, Capehart B, Friedman MJ. Pharmacoptherapy for
posttraumatic stress disorder: review with clinical applications.
2012. J Rehabil Res Dev. 49(5): 703-15. 15. Kerbage H, Richa S.
Non-antidepressant long-term treatment in post-traumatic stress
disorder. 2013. Curr Clin Pharmacol. Feb 4 [Epub ahead of
print].
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References 16. Herman J. Trauma and recovery (rev). New York:
Basic Books; 1997. 17. Levine PA. In an unspoken voice: how the
body releases trauma and restores goodness. Berkley CA; North
Atlantic Books: 2010. 18. deQuervain DJ, Margraf J. Glucocorticoids
for the treatment of post-traumatic stress disorder and phobias: a
novel therapeutic approach. 2008. Eur J Pharmacol. Apr 7;
583(2-3):365-71. 19. Passie T, et al. Mitigtion of post-traumatic
stress symptoms by Cannabis resin: a review of the clinical and
neurobiological evidence. 2012. Drug Test Anal.
Jul-Aug;4(7-8):649-59.
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References 20. Talbot C et al. Coalescing on women and
substance use: violence, trauma and substance use. Trauma-Informed
Online Tool. BC Centre of Excellence for Womens Health.
www.coalescing- vc.org. Accessed on 25 July 2014.www.coalescing-
vc.org 21. Bone K & Mills S. Principles and practice of
phytotherapy (2 nd ed). London UK; Churchill Livingstone: 2012. 22.
Braverman ER. The edge effect: achieve total health and longetivity
with the balanced brain advantage. New York NY; Sterling: 2005. 23.
Wahbeh H et al. Complementary and alternative medicine for
posttraumatic stress disorder symptoms: a systematic review. 2014.
J Evid Based Complementary Altern Med. Mar 27; 19(3):161-75.
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References 24. Kearney DJ, Malte CA et al. Loving-kindness
meditation for posttraumatic stress disorder: a pilot study. 2013.
J Trauma Stress. Aug;26(4):426-34. 25. Dick AM et al. Examining
mechanisms of change in a yoga intervention for women: the
influence of mindfulness, psychological flexibility, and emotional
regulation on PTSD symptoms. 2014. J Clin Psychol. May 28 [Epub
ahead of print]. 26. Mitchell KS et al. A pilot study of a
randomized control trial of yoga as an intervention for PTSD in
women. 2014. J Trauma Stress. 19(6): 19-28.
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References 27. Sakai CE, Connolly SM, Oas P. Treatment of PTSD
in Rwandan child genocide survivors using thought field therapy.
2010. Int J Emerg Ment Health. Winter;12(1):41-9. 28.Ortner N. The
tapping solution: a revolutionary system for stress- free living.
Carlsbad CA; Hay House: 2013 29. Goldsmith RE et al.
Mindfulness-based stress reduction for posttraumatic stress
symptoms: building acceptance and decreasing shame. 2014. J Evid
Based Complementary Altern Med. [Epub ahead of print]. 30. Kim YD,
Heo I et al. Acupuncture for posttraumatic stress disorder: a
systematic review of randomized controlled trials and prospective
clinical trials. 2013. Evid Based Complement Alternat Med.
2013:615857.
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References 31. Sankaran R. An insight into plants: vol 1.
Mumbai: Homeopathic Medical Publishers; 2002. 32. Assilem M.
Matridonal remedies of the humanun family: gifts of the mother.
Tunbridge Wells Kent UK; Helios Pharmacy: 2009. 33. Sah R, Ekhator
NN et al. Cerebrospinal fluid neuropeptide Y in combat veterans
with and without PTSD. 2014.Psychoneurendocrinology. Feb; 40:
277-83. 34. Skeffington PM et al. The primary prevention of PTSD: a
review. 2013. J Trauma Dissociation. 14(4): 404-22.