FINAL THESIS

Running head: A HOLISTIC VIEW ON PTSD A Holistic View on PTSD Noelle Morra JFK University TPC 5104 Summer 2014 1 A HOLISTIC VIEW ON PTSD ABSTRACT The Veterans Administration has addressed a large spectrum of challenges that the mental health profession are up against when treating PTSD. A considerable amount of time, effort and resources are contributed to Veterans in the hope that lives will be improved for those who have honorably served our country. It is vital to understand how and to what extent stress contributes to mental dysfunction in terms of its chemistry, its stages, and its origins. It is also vital to have strong understanding of the introduction of stress education and stress interventions as they should be a critical component during the counseling process because of both emotional imbalance and chemical imbalance it generates in the brain and body. In addition, by improving various aspects of prolonged exposure therapy, focusing on cardiovascular health and improving on basic life skills in PTSD patients, veterans can significantly increase the quality of long term recovery. A HOLISTIC VIEW ON PTSD 3 In this essay, I intend to explore several different themes that expand on the knowledge and wisdom I have gained while attending John F. Kennedy University. During my time at JFKU, I have experienced numerous personal revelations that have contributed to my interests in entrepreneurialism, the physical ramifications of stress on the human body, and my continued interest in health and wellness. I will also be talking about my personal story and how the trauma I have experienced in my own life have led me to dive deeper into understanding the components of stress and how it affects other individual’s lives. There is a significant role stress can play in day to day functioning. How and to what extent stress contributes to mental dysfunction in terms of its chemistry, its stages, and its origins are areas therapists need to be aware of while working clinically. Also included are an introduction of stress education and stress interventions as they should be a critical component during the counseling process because of both emotional imbalance and chemical imbalance it generates in the brain and body. Prolonged exposure therapy can be improved upon with cardiovascular health and basic life skills for PTSD patients. Personal In the fall of 2010 I was diagnosed with PTSD as a result of sexual trauma from my childhood. At the time, I never received therapy or guidance about how to deal with it and how it had impacted me. Needless to say, it was quite an experience to be told that I had a stress condition. This information seemed to shift everything about the way that I saw the world, and it sent me into a major depression that I wasn’t sure how to manage. For 9 months my level of functioning went from being productive, having a full time job, and being in a relationship to sleeping all day and going to therapy. I hoped that Prolonged Exposure Therapy was the answer to ridding me of the stress I was holding onto in my mind and body. After 16 weeks of this A HOLISTIC VIEW ON PTSD 4 therapy, the doctor told me that she felt I had improved, yet I began to question how prolonged exposure therapy worked and whether I had really felt any benefits. I eventually moved on to receive follow up care at the Veteran’s Center in Redwood City. For few months the therapist worked more in a relational way and addressed how my relationships had been impacted in the past and how they were being impacted in the moment. While it was beneficial to a point, I still felt like there was more to explore. I still had pain in my body and the stress really didn’t appear to be resolving. It became apparent that I needed to do more research and acquire better resources that would move me towards a lasting path of healing. In the Fall of 2011, I started my Masters at JFKU specializing in Somatic Psychology which seemed to be the avenue that would best help me understand what had happened to me, how it had affected me, and give me resources that would aid in my recovery. It was at this point I was introduced to a therapist who had been practicing for over 30 years and was well versed on the impact of sexual trauma. He could see the emotional disturbances and inconsistencies that were happening in my life, in my relationships, and in my belief of who I was as a woman. He could see how unsettled I was. It was at this time that I realized that I was a traumatized grad student, who had intellectualized everything in my life and who thought I had been in touch with my body, but I was not aware of what my own stress was doing to me. During the course of work with my therapist, I realized that repeated exposure to certain levels of emotional distress and constant navigation of what the truth was in my relationship with my father was taking its toll on me. I had to reevaluate the picture that he had painted of my mother, my feelings around what I did professionally and the constant need to achieve seemed to all come to a head when my relationship with someone I loved fell apart. When breaking down the components that affected me, I found that the stress that was brought on in a variety of ways. A HOLISTIC VIEW ON PTSD 5 I was challenged daily whether or not I felt good about myself and whether my relationship with my father was appropriate or not. It showed up where I was using a lot of energy to navigate and rationalize his inappropriate behavior. This, in turn, made me constantly feel like I had to be on my toes about how to respond to him and how to respond to my life. A very reactionary mode in my behavior developed and my sensitivities to criticism didn’t leave me much room to explore what was really true for me in my own life. Time and time again, good people in both friendships and intimate relationships would walk away from me after they would meet my unhealthy family. Due to my unprocessed stress, in relationships I would deliver the message of what my family had been through by reaching out to others that I wanted to be close to as a longing for a healthy attachment. I knew unconsciously that there was something healthy out there and that it did exist, but I was very unclear on how to attain it or what steps I needed to take to attain it. Part of my process was that I felt this need to muscle through the stress I was experiencing. It was a compound affect, one layer of stress on top of another. First, I had never processed what had happened with my family and this very intense relationship with my father, where he drove how our relationship would play out. Additionally, my mother was totally unaware of how her schizophrenia was affecting herself and those around her. It impacted me to constantly try to be the best I could and be a good example for my sister and brother. It was a constant push and pull dynamic of wanting to be close to the family and then stepping away from it because I questioned the events that had happened and were continually going on. Something I recently recognized as part of my stress was that my heart had never been nurtured in a fashion that allowed me to fully focus on how to love myself or how to love others. This always added a level of stress because I wasn’t clear on why people weren’t staying in my life. A HOLISTIC VIEW ON PTSD 6 It now seems as though the entire healing process was just yesterday, but it reminds me of how slow change can occur and what sort of willingness has to take place for anyone in order to surrender to the fact that I really didn’t have all the best tools for coping in my life. The largest impact the healing process has had on me, has been my positive belief in myself. There has been a significant shift in letting go of the stress that would circulate in my body and mind. I am replacing it with belief in beauty, belief in others, and belief in the fact that I serve a purpose on this earth. That is still developing, but I no longer feel the need to put others down, nor am I insecure about what I have to offer to those I am in relationship with in my life. My relationship with women has also gotten a lot better. I always had great girlfriends, but I would always find new women intimidating. Especially women that looked like they had it all together. Which as interesting for me because people would always tell me that I looked like I had it all together. On a day to day basis it was always something. Whether someone has a nicer car then me or nicer house. I can remember sitting at parties and being in so much pain about what people thought about me or if I was my boyfriend at the time wanted. It was like a revolving door. No matter how much I told myself things weren’t true, I found a way to make them true. I found reasons to say that my boyfriend was looking at someone else or that he was interested in someone else and didn’t love me. When he did. It was scary how much I rejected love and how much stress my body was under because of how I felt about myself. I believe at times it was because I didn’t know what love was supposed to look like or how it was supposed to feel because my family has displayed such a slanted view of what love was growing up. Love that portrayed as being positive, but then gave me the impression that it was filled with deceit and lying and always trying to get around the people that someone was surrounded with. Love was expressed in a way where now I know it was the opposite of love. I have learned love is not A HOLISTIC VIEW ON PTSD 7 confusing. Love treats others with respect. Love doesn’t tell me I am wrong for feeling a certain way. Love tells me when something has gone wrong and I think I have been hurt. Love doesn’t give me a life sentence to dealing with erratic emotions and polarizing feelings about whether I am whole or good. As I continue to work on this, I do not have the same somatic response that I used to when I see people enjoying women in an emotional way or when I see strong women who are put together with a certain amount of success. I realize we all struggle in some fashion and regardless, I was meant to go through the struggle of dealing with a stress condition to wake me up to the possibility of what life would be like after I had healed to a degree. Theoretical It is important to understand the stages that stress develops in, so that in the work with clients we can have a stronger understanding of how to incorporate interventions at appropriate times and get a felt sense for what they are experiencing at the time. Before starting with clients, in order to assess what stage they possibly could be in, it is vital discuss somatic symptoms that may be clear indications for what stage the client may be in. Questions like, “Do you have high blood pressure?” or “Does your heart rate excel even when sitting?” are examples. If these questions are confirmed, that would indicate that the client might be experiencing the day to day stress. It can show up when someone uses a lot of energy to navigate and rationalize, like I did in the inappropriate behavior alarm stage. Symptoms such as headaches, chest pressure, being breathless and stomach issues are indications that someone may be in the resistance stage. Lastly the exhaustion stage may show up in physical ways such as acid reflux, pain in the body and just being very tired. Exploration of what the stages look like and the parts of the body they affect are essential to know in order to move forward and create a treatment plan that would be A HOLISTIC VIEW ON PTSD 8 effective for clients. The first stage of the stress response is the Alarm Stage. Hans Selye (1976) describes this as the stage of the stress response in which the organism meets face to face with the stressor and mobilizing energy. The organism needs to protect the body from the stressor, the stimulus that provokes a stress response, and initiate an alarm reaction. At this point, adrenaline will be released, and cortisol is activated. Both the reptilian brain and amygdala are activated in the brain at this point. Blood pressure can go up, and heart rate can excel. During this time something called the cortisol drip can occur where cholesterol will build up and the body responds in a variety of different ways. The reaction can provoke both good and bad events, and only in this phase can something like happy stress be discussed (p. 30). An example of this would be winning a game or seeing friends someone hasn’t seen in a long time. This may show up in physical features such as whiteness in the skin or the eyes can bug out looking as if body is trying to escape. This can be seen in therapy with clients, it is fundamental to make sure that the approaches are slow and mindful with an unhurried reduction of the stress. Psycho-emotional mechanisms can show up in the therapeutic relationship as a person sitting with their arms crossed, not making eye contact, and making contact with their own body when they talk about certain situations and how it impacts them physically. The second phase of stress is known as the resistance stage. The increase of secretion of glucocorticoids play a major role, intensifying the systemic response. They have lypolytic, catabolic and anabolic effects. Moreover, they cause higher doses of cortisol levels and can bring the body to a state known as hyper-aldosternoism. Y. Sun (2006) explains that the leading cause of hyper-aldosternoism is the skyrocketing increases in salt and potassium in the body. This results in hypertension and high blood pressure for individuals (p. 300). In clients this may A HOLISTIC VIEW ON PTSD 9 show up as having low energy or problems with their adrenals where they have been to see a doctor concerning the health of how their adrenals and if they are functioning properly. Additionally, cortisol levels continue to be released at this stage. This causes a feedback loop with double the amount the chemicals that are being released. It is important to address the trouble underneath the anxiety. It is vital as a clinician to deal with this level of psychophysiological symptom, rather than just talk about the emotional component. Clients need tools to go home with to use in their life so they don’t keep returning to this state. This is a perfect opportunity to give clients actual resources that they can use at home. Mindful walking is one of those tools. John Kabit Zinn (1990) discusses the ability to have clients switch from an automated response into a mindful response and intentionally doing something different to have a different experience (p. 54). By using a mindful tool like this, it assists with the prevention of an additional stressor causing a client to move into the 3rd stage, exhaustion. In the third stage exhaustion occurs. Hans Selye (1976) discusses a constant leaking of energy in the alarm and resistance stages, results in exhaustion. When exhaustion occurs, all of the body’s ability to function is significantly compromised. A client may talk about always being tired or having troubles sleeping at this moment (p. 150). Exhaustion is a very tricky stage to deal with in that a client may be only interested in barely holding it together and may continue on the same path for long periods of time and after prolonged stress, the body loses its ability to maintain health on a day-to-day basis, slowly breaking down its natural ability to ideally function. This is very dangerous as the body can finally succumb to adaptation. This is described as a longer period of time where stress has a longer term effect on the body. Chronic or long-term stress will turn the body against itself. By the time someone reaches stage 3 they are most likely suffering classic burn-out. Even though a client may be in the exhaustion stage, A HOLISTIC VIEW ON PTSD 10 other stages can reappear and the system begins to shut down. Recovery is the optimal scenario in the case of going through high levels of stress. This stage follows when the system’s compensation mechanisms have successfully overcome the stressor effect. Recovery stage happens when restoration of homeostasis and regeneration of cells allows the autonomic nervous system to kick in and allow the body and mind to recover. This is an additional stage that is not found in most professional documentation, but it is important to address as it is vital for clients to know that stress can be managed. This phase is also important as it is essential to have a focal point to come back to while going through treatment. This would involve a balance of approaches that are used to address chemical, behavioral and physical modifications that need to be adjusted so the client can be more balanced in the world. Having a goal in mind is essential for a client’s effort and time they invest in taking the very courageous step of addressing how stress impacts them in their lives. Part of a recovery model for clients would include the use of daily mindfulness techniques that become part of their lifestyle. Moving on to psycho-education that needs to occur while clients are seeing therapists, it is important to address a pioneer, Dr. Karl Albrecht (2010), who is a speaker and author based in California, develops stress-reduction techniques for businesspeople. Time stress, anticipatory stress, situational stress and encounter stress are 4 focal areas in his book Stress and the Manager (p. 25). These are important differences and are essential to helping a client break down how they are affected in different ways. Albrecht (2010) explains the first type, time stress is when clients worrying about time. They may say they would never be able to get to what they want because time is always a factor (p. 45). When a client is worrying about whether a team member is going to get their part of the project done on time or they feel like they spend too much time commuting on the road, which may take away from their overall productivity, these are examples of how time stress can come A HOLISTIC VIEW ON PTSD 11 into a client’s life. Time stress is one of the most popular types of stress that people experience today. It is imperative to learn what habits can be made by understanding more about when their energy is good during the day and when they have had enough output of energy over a long period of time. First, it is essential for clients to learn good time management skills. This can include using to-do lists, managing many simultaneous projects, and developing action programs. Action programs can be made up of distinct timelines and goals to achieve. Next, make sure to devote enough time to important priorities. It is very easy to get lost small items and lose sight on the big picture of what is trying to be attained. Karl Albrecht talks about how this can leave someone feeling exhausted: The important tasks are usually the ones that will help them reach their goals, and working on these projects is a better use of your time. Later on there will be more description on The Urgent/Important Matrix. This explains how to balance urgent and important tasks, and our article on prioritization helps separate tasks that clients need to focus on from those that clients can safely put off (Karl Albrecht, 2010, p.78). If clients often feel like they don’t have enough time to complete all tasks, it is vital to learn how to create more time during the day. This could mean that the client goes into work early or stays late, which can allow for more quiet time. Also, it is useful for the client to concentrate on the most important tasks first, which can greatly increase efficiency. Albrecht explains for instance: If they are a morning person, they should schedule the tasks that need the greatest concentration during this time. This morning task guideline helps them learn how to prioritize their tasks and schedule them during the most productive times of day. They can leave less important tasks, like checking email, for times when energy levels drop. A HOLISTIC VIEW ON PTSD 12 Also, make sure to be polite but assertive about saying “no” to tasks that they don’t have the capacity to do (Karl Albrecht, 2010, p. 167). Worrying about a future event can elicit great stress in clients. Albrecht (2010) wrote, “Anticipatory stress describes stress that you experience concerning the future” (p.78). Public speaking is an example of anticipatory stress as it may bring up a certain level of anxiety around being in front of a group, whether a client’s speaking skills are good enough or if they feel they are confident in front of a group. However, anticipatory stress can also be something that is difficult for clients to describe or express. Because anticipatory stress is future-based, start by helping them recognize that the event doesn’t need to be the sole focus of their day. Positive visualization techniques can be used to have the client can start to experience less anxiety around the upcoming event. Research shows that the mind processes both a visualized event and an event that actually in the same fashion. Meditation can also help a client develop more focus on what is occurring right now, rather than in an imagined future. It is essential for clients to set aside time daily, even if it’s only five minutes, to meditate. As mentioned before, Albrecht talks about a situation in which the client might be stressing over a presentation: They are afraid that their presentation won’t be interesting. Often, addressing these personal fears directly will lower their stress. In this example, by putting in extra time to practice and prepare for tough questions, they will likely feel more prepared for the event. Lastly, learning how to overcome a fear of failure by making contingency plans and analyzing all of the possible outcomes will aid in preparing for future scenarios (Karl Albrecht, 2010, p. 200). When control is taken away from a client, they often can experience another type of stress, called situational stress. An example of this could be an emergency that can include A HOLISTIC VIEW ON PTSD 13 family, friends or coworkers. An event may happen suddenly such as, being told their partner wants to get a divorce or child facing hardships at home are examples of events that can cause situational stress. A key to managing situational stress is to help a client weigh out the possible ways they are impacted when such scenarios arise. Karl Albrecht (2010) describes that this means having the client become more aware of how their body is responding to certain events. For example, if someone cannot communicate with someone because they feel unable to articulate the words that would seem appropriate, this can cause situational stress (p.129). Conflict can be managed by utilizing effective communication skills. Integrating new ways of thinking about how they process their emotions can be a significant way of improving how to process stress. Situational stress can show up in their lives in a variety of ways such as angry outbursts when questioned about their performance. For instance, if an individual’s natural tendency is to withdraw emotionally, then the focus should be about allowing the space for them to talk openly. This process will significantly aid in helping a client keep emotional and chemical balance when in scenarios where they are dealing with others in challenging situations. Encounter stress is the final type of stress that Karl Albrecht refers to in his book. Clients who have worked in large corporate organizations or take care of children who are in distress are people who would run into encounter stress more often. Often being accepted by a certain group in these environments or wondering if a client is contributing in a positive fashion would also contribute to encounter stress that they might experience. They experience encounter stress when they worry about interacting with a certain person whom they have had previous issues with or just do not experience as being a positive person. Albrecht (2010) explains certain career fields experience more stress than other career-fields. When people are deeply upset or are going through challenging times, the client may take on certain levels of energy that may not be A HOLISTIC VIEW ON PTSD 14 healthy for them. Contact overload is a term that is used when they feel overwhelmed or drained from interacting with too many people. Because encounter stress is focused on how clients relate to others, focusing on how a client experiences another person is a great way to figure out less stressful ways of responding (p. 175). By addressing these aspects of how clients relate to others, this will raise the level of functioning that they will be able to operate at and will also improve the levels of stress that come in and out of their lives. Another way of working with encounter stress is to enhance a client’s emotional intelligence. Albrecht (2010) wrote, “Emotional intelligence is the ability to recognize the emotions, wants, and needs of one’s self and of others” (p.95). This is an important skill for the client to learn how to build healthy relationships. Another vital aspect of overall stress management is helping a client understand when they have had too much social interaction and need to take a break. Encounter stress shows up differently for each client, but often time’s clients would rather resolve to limit themselves on how many people they make contact with on a day to day basis. This sort of response has a direct correlation to the quality of one’s social interactions with others. Whether they are active in a conversation or share experiences and also listen to another person, says wonders about the ability to have long term healthy relationships. While every client may not understand the value of managing their stress, it is also important to allow space for them to ask questions about what is healthy appropriate in social settings. By addressing these types of stress responses in the therapeutic process, clients awareness how they might best respond or feel like they have some level of choice in the matter, will be very powerful to their recovery of PTSD. Furthermore, it is important to examine other contributing aspects such as neurochemical and developmental areas that may impact the way a client experiences stress and can contribute to mental dysfunction. A HOLISTIC VIEW ON PTSD 15 Adult and animal studies have expanded the understanding of how trauma affects the brain and has helped researchers to understand the chemical changes that happen. Yana Suchy (2011) explains, “There is a systematic biochemical response to stress in the brain and it is vital to have an appreciation for an alternative course of brain development that would impact the quality of how an individual experiences life” (p.211). There are physical and behavioral compromise that happens when a client has been mistreated in the past. As such, this literature reviewed gives greater understanding of how the entire body impacts emotional response patterns. The traumatic stress response starts with the brain registering that a threatening event is occurring. That in turn elicits a neurochemical chain of events to help the client give the most accurate response to how it impacts them in the moment. After a response occurs, the client then balances out both in the body and in the mind temporarily. (Bevans et al., 2005, p. 420). The chemicals in the brain are impacted to a much larger degree in a traumatic response and their ability to return to homeostasis is significantly compromised. (Weber & Reynolds, 2004, p. 118). The functioning of the brain is then locked into a maladaptive feedback cycle that exists on a day to day basis which creates a very vicious process when a person goes to approach a task. The already existing anxiety then causes distraction, which then causes more stress for the person. This stress can cause an environment where clients can become disinterested in certain activities, as they do not have a positive experience attempting challenging tasks (Vasterling & Brailey, 2005, p. 220). This cycle directly affects brain regions and how the mind processes the balance of chemicals. There are different opinions on parts of the brain are impacted. For example, Heim and Nemeroff (2001) outline the 13 corticotrophin releasing factor neurotransmission effects on the A HOLISTIC VIEW ON PTSD 16 hypothalamus, central nervous system, and autonomic nervous system in their working model (p.1030). Disseth (2005) has a much broader view and includes the hypothalamus-pituitaryadrenal axis, the sympathetic and parasympathetic nervous systems, and neurotransmitter systems in his model (p.80). De Bellis (2005) on the other hand only includes the hypothalamuspituitary-adrenal axis and limbic system (p.160). Each philosophy emphasizes on different parts of the brain, but each one has valuable insight on the process that the brain goes through during the stress response. There is further research to describe how there is considerable overlap between models due to the “genetically predetermined stress response”: The human body is intricately interconnected, with alterations from the traumatic stress response theoretically leaving all other systems susceptible to dysregulation as well. However, there is also variability between models based upon on which chain reaction of events are examined. Most researchers agree that the traumatic stress response is a neurochemical cascade that involves neurotransmitter activation of the hypothalamicpituitary-adrenal axis, the locus coreulus, the prefrontal cortex, and the limbic system (De Bellis, 2005, p. 160, Disseth, 2005, p. 87). The hypothalamus-pituitary-adrenal axis (HPA-axis) plays a vital role in the stress response. Bevans (2005) explains that “the main function of the HPA-axis is to assess threat, trigger a neuroendocrine cascade to initiate behavior response, and to terminate that cascade with the cessation of the threat” (p.419). These actions are performed first by increasing the amount of cortisol in the body, then weakening the immune system, increasing glucose and lowering the client’s ability to actually respond to the threat and remain in homeostasis (Disseth, 2005, p. 85). A HOLISTIC VIEW ON PTSD 17 This explanation shows a clear chemical difference in the change that occurs with the client when experiencing stress. Corticotrophin-releasing-factor (CRF) is released through the hypothalamus after a stressor occurs. The primary purpose of the HPA-Axis in the brain is to prevent spreading of the actual stress that the client may experience (Vermetten & Bremner, 2002a, p.140, 2002b, p. 20). CRF is essential to the body’s response because it affects the brain’s ability to function on a day to day basis. It facilitates brain functioning by heightening an “on-guard” state that may include alertness and readiness, which can be combined to create anxiety-like behavior (Vermetten & Bremner, 2002a, p. 140, 2002b, p.22). Adrenocorticotropic hormone (ACTH) is also released in the stress response, stimulates the pituitary gland and drives certain erratic behaviors when a client is under stress (Disseth, 2005, p.18). Bevans describes how “dysregulation” occurs: The HPA-axis functions in response to stressors and should stop cortisol production when the stressor is removed. One of the major means of detecting HPA-axis dysregulation is through cortisol changes. There is a natural diurnal fluctuation in cortisol and a natural cortisol increase when threat is assessed (as cited in Bevans et al., 2005, p. 420). Both the HPA-Axis and the prefrontal cortex play a vital role in the management of cortisol levels. The role of the therapist at this point is to help a client get these cortisol levels back in alignment so the body can experience homeostasis. Without this balance in the body, any recovery will be hard to accomplish as the body cannot absorb new ways of being if the chemical state of the body is imbalanced. Another area of focus for clients that is helpful to focus on is how they are currently living and how the quality of their lives are impacted in day to day tasks, A HOLISTIC VIEW ON PTSD 18 what their awareness is like in certain situations and how they treat themselves. The prefrontal cortex (PFC) impacts quality of life and it is important to know when it has been compromised. The primary role of the prefrontal cortex (PFC) as it relates to the traumatic stress response is to hold attention, create memories, sort out sensory input for relevant information, and regulate inhibitory responses (Weber & Reynolds, 2004, p. 120). A healthy PFC functions to assess to threat and mobilize other parts of the brain to keep a client safe. Once the threat is taken away, the PFC neurons signals to other parts of the brain, such as the HPA Axis. Thus, the PFC acts as the light-switch when stress occurs and the HPA Axis is activated. In order to serve this to occur, the PFC must be functioning properly. The PFC is predominately made up of dopamine receptors. Dopamine receptors have a direct correlation to how a client is motivated, seeks pleasure, remembers life events and how their body moves and functions on a day to day basis. Excessive dopamine can cause dysregulation by blocking excitatory glutamate, enhancing inhibitory Gamma-amino-butyricacid (GABA) and thus causing the PFC to be hypo-responsive. This hypo-responsiveness reveals itself in lower communication regions of the brain and stops the HPA-Axis’ ability activate the fear response (Cohen et al., 2002, p. 187). Additionally, there is a failure in assigning appropriate emotional response to sensory stimuli, which also inhibits the hippocampus from operating to its full potential (Liberon & Martis., 2006, p. 95; Shin et al., 2006, p.80). Clinically, the medial PFC has a significant difference in size in adults with PTSD. These clients are hypo-responsive during times of high stress and their ability to express emotions become significantly diminished (Shin et al., 2006, p.84). A HOLISTIC VIEW ON PTSD 19 The limbic system is a major focus in PTSD treatment. The limbic system consists of two additional areas, the thalamus and the hypothalamus. While there has been discussion of the amygdala and the hippocampus, the thalamus and hypothalamus are central areas for emotional regulation of the brain. Vermetten & Bremmer, (2002) explain, “Threat stimulates the locus coeruleus, which is a part of the brain that is set off when panic and stress are increased. In addition, the brain produces noradrenaline, which plays a huge role when clients are experiencing fluctuation in heart rate, whether it is going up or decreasing” (p. 130). Watching a friend die in battle is an example of how a client’s chemical response is affected. There is plenty of literature discussing the effects on the amygdala, hippocampus, and hypothalamus when traumatic stress is experienced. The role of the amygdala is to provide an emotional response to a perceived threat. The amygdala regulates the body by combining glutamine-induced excitation with GABE-mediated inhibition to keep neural communication, memory formation and learning balanced within the body (Shekhar, Truitt, Rainnie, & Sajudyk, 2005, p. 212). First, stress produces corticotrophinreleasing factor (CRF). CRF has the ability to suppress heighten emotional inflammation, so this is an important area to pay attention to when the client is experiencing high levels of anxiety, because the CRF may have used up all of its ability to suppress emotions that have become overwhelming to the client (Weber & Reynolds, 2004, p. 20). When a client is functioning optimally, both the amygdala and the hippocampus work in conjunction to activate a defensive response when the threat is re-encountered. Unfortunately, under high levels of stress, a “kindling” effect happens and the body actually responds to nonthreatening situations in a defensive manner. Teicher (2002) explains, “Kindling resembles seizure like behavior neurologically and is described clinically as dissociative symptoms” (p. A HOLISTIC VIEW ON PTSD 20 84). It is hypothesized that kindling in the amygdala leads to eventual hyper-arousal and diminished behavior inhibitions. A client can end up getting stuck in a cycle where their trauma stays present instead of healing and moving on in their lives (Cohen et al., 2002, p. 172; Shin et al., 2006, p. 80). Animal researchers have highlighted the interrelationship of the amygdala and other brain regions in emotional memory. Phelps (2004) reviews animal literature and gives a stronger understanding of how the amygdala plays a role in channeling emotions. This review explains that the amygdala can trigger both physical and mental stimuli even if the arousal was not experienced at encoding. Encoding can show up in a variety of ways in the human experience such as the way that a client remembers touch, the way they hear certain sounds or how they visually experience the world. This is also activated by the amygdala and the hippocampus working together to create appropriate emotions and the prefrontal cortex exercising the extinction of fear (p. 45). Understanding the amygdala is relevant to stress education intervention for clients as it gives a direct frame of reference to having certain difficult emotional experiences. While knowing the exact details of every aspect of the brain may not be essential, it is vital to understand to have clients understand what parts of themselves have been impacted by stress. The hippocampus plays a huge role when a client remembers an event or not. During PTSD, the glucocorticoid receptors are the main part of the hippocampus that are impacted. These receptor are impacted by cortisol and start to go into a process called neuronal degradation. During neuronal degradation, neurons in the brain die (Harvey et al., 2006, p. 885). The body adapts to these stressors by increasing cortisol and activates the glucocorticoid stressor so that the client can survive. These receptors are only meant to activate for a certain period. A HOLISTIC VIEW ON PTSD 21 When they burnout, all neurons suffer. This is called a negative feedback loop. When the negative feedback loop occurs, all neurons suffer damage from the loss of connection and is known as a loss of neurogenesis. Neurogenesis is a term that is used when the development of new neurons occurs. An imbalanced hippocampus has a direct correlation to the quality of how a client thinks on a day to day basis (Teicher, Tomodoa & Andersen, 2006, p. 318). It is relevant to treatment of PTSD because clients may at some point have to process the loss of functioning in their body. Additionally, and it may help to have the client have a deeper understanding of how to develop new ways of living with PTSD. Thus, in adult human studies and animal studies, there is a neurochemical cascade of events in the brain that follows exposure to stress. Glaser (2005) discusses this traumatic stress response affects many different regions of the brain including the HPA- Axis, the pre-frontal cortex and the limbic system. Following traumatic stress, the HPA-Axis does not produce cortisol in response to following stressors to the same extent or in the same direction as previously demonstrated. The pre-frontal cortex which is dysregulated by traumatic stress. With this dysregulation happening, people with PTSD cannot properly assess for threat and provide neurofeedback to regulate the HPA-Axis response (p.248). Disorganization is exacerbated and individuals are primed to misperceive threat and engage their maladaptive stress response system. De Bellis (2005) sums it up by saying that individuals overly emotionally respond to events going on in their lives, and present a disorganized and overdramatic behavior response to perceived stress (p.177). PTSD patients may understand better why, when they are under stress they have poor cognitive responses, or emotional outbursts. Knowing that this is a chemical response may help some clients feel like it is not their fault and that their body just was responding to certain events that happened to them. A HOLISTIC VIEW ON PTSD 22 Clients responded to trauma a variety of different ways from isolation, to not being social, to not wanting to be in social groups, and speaking out against the violations that had occurred. In working with clients 1:1, the state of hypertension was a constant challenge, and it was difficult to get them to notice their constant stress/tension. During my clinical approach, it was vital to me that I always included work that took care of the heart by using certain somatic practices that we learned in the program, and I also recognized the experience in which anxiety and stress had affected them. As part of my guidance, giving psychoeducation around how the heart is affected when under stress was an important part of my work. While working with clients, Take a Load off your Heart by Joseph Piscatella was a wonderful resource. In this reference book, he discusses how stress works against the heart. This information helped in developing the relationship and helped them gain trust with my expertise in the field and as a trainee. This approach was delicately layered in the client as they told me about themselves and educated me on where they have run into troubles in life. Clinically, it is in the intention of this explanation to be able to express a way to diversify the layers of treatment that occur for veterans who are exposed to the care that is provided in the VA System. Clinical The beginning of treatment at the VA for Veterans, who have been diagnosed with PTSD, includes a 16-week treatment called prolonged exposure therapy. While this form of treatment has does well for some veterans, it is only addressing a very small portion of how stress lives in the mind and body. The goals of this therapy are to hope that by repetition of the event that was traumatic to the brain will somehow normalize that event, thus making it in sync A HOLISTIC VIEW ON PTSD 23 with what the individual experiences on a day to day basis. While it seems that this works for some clients, it does not work for others. Part of the advancement to understand how PTSD affects patients is to address the cognitive portion, also the impact on the heart, and the consequences related to their social f experiences Stress elevates blood pressure. The “flight or fight” response causes a temporary increase in blood pressure. When stress is occasional, such as an increase does not usually present a healthy problem, but in the case of PTSD, frequent elevation can lead to a permanent establishment of a new high or low blood pressure level. By repeating the event over and over, such as in prolonged exposure therapy, the stabilization that is needed to occur in the body is not addressed, and the heart is not taken into consideration to be part of the body that also needs to heal. Physically stress causes arterial inflammation and powerful hormones travel through the bloodstream every time the body responds to acute stress. In order to address this part of the experience of having PTSD, the clinician must include an additional phase of therapy where the quality of the heart is addressed. There are a variety of other modalities to complete all the dimensions of recovery, but as an additional phase of treatment to prolonged exposure therapy would be including High Intensity Interval Training (HIIT). HIIT is cardiovascular training that alternates between anaerobic and aerobic training by the use of intervals. Martin Gibala (2012) who is a professor at McMaster University in Montreal, Canada and studies the cardiovascular implications of HIIT on the heart has done extensive research on the ability to impact clients who have suffered from Type II Diabetes. Through his research, he has made a direct correlation of maximizing the heart rate, recovering the body and repeating this effort to strengthen the heart (p. 1077). The value in adding this component to the therapeutic approach after going through the prolonged exposure therapy A HOLISTIC VIEW ON PTSD 24 would be to address one of ways the body has been impacted by stress. By experiencing a very traumatic event, the heart has experienced certain spiking of the heart rate when they remember the trauma. Veterans would receive a positive experience with raising their heart rates, experience balancing their serotonin levels and also get a new experience with how they relate to their bodies. This is a vital aspect to take advantage of for veterans especially since they have been exposed to high levels of training. Exercise training is proven to improve the quality of how the heart exists. Since the heart is a muscle, the stronger the heart is, the more veterans will be able to handle the emotional process of therapy. HIIT would help break up the sedentary lifestyle that can be taken on by veterans when they are suffering from PTSD. However, it is vital to address any pre-existing conditions that veterans may have and cater the training to a various levels within a group that is tolerable or appealing for some individuals. Therefore it is important to design a more practical model of low-volume HIIT that is time efficient while also having wider application to a larger demographic of types of bodies and physical capabilities. To make this happen, decreasing the absolute intensity of the workouts, but increasing the duration and shortening the rest intervals. The new practical HIIT model consists of 10 × 60 second workout intervals that reach 90% maximal heart rate. Then the client would rest for 60 seconds. The protocol literally cuts the time of exercise in half by maximizing the heart rate. For example, a workout that may last 20 minutes if done at a lower heart rate, can be done in 10 minutes HIIT. It is a fundamental concept to address the psycho-physical elements of humans that have experienced trauma and suffer from some level of imbalance in their stress levels. When signals in the body elicit greater feelings of helplessness and isolation, patients have a tendency to avoid them or push them away. As a result, the client can suffer from uncontrollable rage and stress A HOLISTIC VIEW ON PTSD 25 hormones that flood the body. By incorporating HIIT in addition to the therapeutic model of prolonged exposure therapy, elevated heart rate and blood pressure start to become a normalized event. In order to overcome the effects of physical hyper-arousal that may occur, it becomes critical for the therapist guides to find ways to become more in touch with how their heart impacts them emotionally. It is fair to say that hyper-arousal will occur again, but it is more temporary and would assist the client having this become a more normalized state. Instead of suppressing these emotions or masking them, this allows the client to access physically how their heart feels. Addition of HIIT starts to lessen the degree to which the actual hyper-arousal that they may re-experience from events. While this approach may not be the first choice in starting to work with these clients, those that still hold anger and resentment as predominate emotions, would greatly benefit from this type of therapy. However, this can create a level of polarization that not all clients may be ready for right away, but it does support any wounding that occurs when resources in the body are supporting a sense of well-being. HIIT addresses a person’s physical and psychological integrity and challenges the body to exhaust itself of emotions and wounds that may be stuck and preventing them from growing and maturing. Re-establishing a healthy relationship with their body will allow a client to reengage with how they feel in that moment. Whether they are exhausted or out of breath, an elevated heart rate signifies a level of awareness surrounding the traumatic experience, but in a safe setting. By utilizing HIIT, another level of somatic awareness can occur while enhancing certain anatomical and psychological functions. For a client to experience this felt sense of physical performance, they must start to experience the body in the way that it is meant to function. Part of movement therapy work will give the client more of a relationship to the A HOLISTIC VIEW ON PTSD 26 activation of the nervous system in a safe environment. The client can become more in tune with the activation of their heart rate for the positive health benefits instead of associating it with negative emotions. Understanding what HIIT involves and how it impacts the heart in a positive manner, would contribute to the healing of veterans with PTSD. During aerobic exercise, Gibala (2012) states “that the quality of the heart is made up of 4 things: contraction of the heart, stroke volume, amount of blood pumping through the heart and the heart rate” (p.1077). Both the blood flow and oxygen supply are significantly increased to assist the client to meet the physical changes the body goes through when the intensity of the heart rate is accelerated during the training. Joyner & Coyle (2008) further explain that aerobic performance is determined by how the blood flows back to the heart and how the activity of activating the skeletal muscle increases that blood flow. This is known as preload. (p.39). The heart becomes stronger by increasing intervals at points in the HIIT training. This routine over a period of time will create a new way of breathing and also resource the client in a new way physically. VO2max is a way to calculate how well the client has the ability to use oxygen and disperse it through the body. VO2max is also is a good predictor of how intense a client is performing in their exercise. VO2 max is determined by how much oxygen can be taken in and used in the body in one minute time frames (Bartels, Bourne & Dwyer, 2010, p.151) By using HIIT, the body has the ability to improve its cardiovascular capability. Daussin et al. (2008) measured VO2max responses in a group during a 8-week HIIT program and there was a 6% increase in the amount of oxygen that flowed through the body after doing the training in comparison to other fitness programs (p.70). This sort of training is valuable for clients with PTSD as there has already been a compromise to the heart in exposure to a traumatic event, thus A HOLISTIC VIEW ON PTSD 27 making them more susceptible to cardiovascular diseases and other heart related problems. Although there are thousands of other types of fitness programs out there, improvements from interval training happen in a shorter time which maximizes the recovery that a client has when they are recovering from PTSD. A HIIT program involves three areas: the time and intensity, how long the interval will last and how long the recovery time period will be for the exercise. The work interval can last anywhere from 5 seconds to 8 minutes. Some higher level performing athletes work shorter periods of time with less recovery time, whereas working with veterans there would be more variance on work level and recover periods (Kubukeli, Noakes & Dennis 2002, p. 495). Many studies have introduced HIIT training where the client uses a variety of different ratios with the exercises. This can be done in a 1:1, 1:2 ratio where 30 seconds of working out are followed by 30 seconds of rest. The intervals can increase over time with more intense workout period and less recovery. The value of this sort of training is that there is much variety and the therapist can use a level of creativity providing the client with the best possible results. The following is an example: PROGRAM 1: Run 1 mile- jog at a comfortable pace to where the client will feel their heart accelerate, but not overwhelm them. The key here is to reserve energy for the rest of the workout. 1. 20 Jumping Jacks 2. 20 Bicep Curls 3. 20 Shoulder Presses 4. 20 V-Sits A HOLISTIC VIEW ON PTSD 5. 20 Dips 6. Recover for 2 minutes 7. Repeat as many times as a client can in 45 minutes 28 The success of integrating these workouts would help address the quality of oxygen intake by those who suffer from PTSD, and how the quality of how the heart pumps oxygen and blood through the body. Breathing is something that clients can take for granted. Those with PTSD may think it’s just part of being alive, however, breathing has far reaching implications that can produce heightened or exacerbate symptoms for those suffering from PTSD. Unhealthy breathing patterns can contribute to anxiety, panic attacks, depression, muscle tension, fatigue and more. Breathing awareness may sound trite to some, but it’s a main aspect of the selfmanagement for PTSD sufferers. Carbon dioxide is produced when the client breathes in oxygen in the mouth and exhale through the nose. Rolf Sovik (2000) describes how breathing and the emotional state play an interrelated role between one another. Both the upper and lower respiratory’ system work with the cardiovascular system to make sure the entire body has plenty of oxygen. The efficiency of how that oxygen moves is dependent on the respiratory’s system ability to consume oxygen and the cardiovascular system’s ability to be able to disperse it to all parts of the body (p.495). This is vital to understanding how stress moves through the body and how it can be regulated by use of the breathe. It is also vital to understand the respiratory process and the anatomy involved in order for the therapist to progress with a client. This lays the foundation to understanding how poor breathing causes issues with a client’s response to past events. A. Guz (1997) explains there are two types of breathing: chest, also known as thoracic, and abdominal, also known as A HOLISTIC VIEW ON PTSD 29 diaphragmatic (p. 200.). The first being unhealthier, and the second a much healthier means of breathing. Now before a client says, "I've tried changing my breathing but failed", there are ways of checking to see if the client is breathing correctly. Abdominal breathing happens during sleep. This is also the type of breathing performed naturally as a baby. So while breathing during the day is usually with the chest, while sleeping, the client is actually breathing via his/her abdomen. The point being, is to not allow the client to try and dictate for clinicians what can or can’t be done, because the brain already automatically performs abdominal breathing the moment we fall asleep (p.200). By practicing these exercises, clients will become more in touch with the regulation of their own breathing patterns. They will start to notice how their breathing feels when they are not stressed versus in a high stress state. This is particularly important to address with veterans and why breathing techniques need to be utilized. Chest breathing is a very common way of breathing. When one inhales, the chest opens up and their shoulders lift as oxygen fills the lungs. There are two areas that need to be addressed with this type of breathing however, first: this type of breathing is shallow which contributes to stress in the body. Decreasing oxygen levels also inhibits the ability for carbon dioxide to leave the body. This can lead to fatigue and depression. Secondly, during chest breathing, a client is more at risk for other problems which may include dizziness and the inability to breath while sleeping. On the extreme end of this pattern, individuals may have gets an imbalance between the inhale versus exhale ratio, and the end result can cause hyperventilation. Psychoeducation around breathing can help clients with anxiety and depression learn how breath awareness can improve their symptoms. In further analysis of shallow breathing, it is found that it can lead to a condition called hypercapnia. Gay (1995) provides greater context to treating sleep disorders. A hypopnea event A HOLISTIC VIEW ON PTSD 30 is considered very significant when a client experiences only 70% of oxygen coming through their body for 10 seconds or more. The direct consequence of hypopnea, is there becomes an airway obstruction after the CO2 levels increase at the same time as the oxygen levels decrease. This can show up on a day to day basis as waking up in the middle of the night, being very tired in the middle for no reason and migraine headaches. Most of all, these individuals reach exhaustion much faster due to lack of sleep (p. 328). If veterans are educated about this, they will see getting quality sleep as an important piece of their recovery. Hypopneas can be a central part of an abnormal cycle in breathing effort or obstructive in origin. Unlike obstructive apnea, obstructive hypopneas is when the airway is only partially closed. However, this closure is still great enough to cause a physiological effect resulting in an increase in breathing effort. A hypopnea index (HI) can be calculated taking the number of hours that a client sleeps and dividing that by the number of hypopnea events in that given time. An apnea-hypopnea index (AHI) calculates the severity of apneas and hypopneas and now they impact the client. Gay (1995) explains by combining them both, it gives an overall picture of how a client is impacted by the deficits of having lack of oxygen or obstructions in the breathing effort. Additionally, another tool that is used is called the respiratory disturbance index (RDI). The respiratory disturbance index calculates other areas that disrupt sleep, but don’t necessarily fall into a category of apneas or hypopneas (p.329). Sleep testing may help veterans understand the biological functions that are happening and what they can do to improve it. The topic of hypopnea with veterans is an important one because it can be contributing to their energy levels and mood that they may be experiencing. It’s only when we're awake do we become our own worst enemies, contributing to greater PTSD symptoms. Learning belly breathing teaches clients to focus on a different part of the body that allows them to slow down even more. Our blood is A HOLISTIC VIEW ON PTSD 31 given oxygen when clients inhale and exhale. The body also has the ability to get rid of harmful carbon dioxide more efficiently when the breathe is slowed down. In 1975 Herbert Benson, who was a Harvard researcher, came out with a book entitled The Relaxation Response. In it, Benson discusses the scientific research that shows the value of meditation, breathing properly and how they can help with the way a person responds to stress. In his new book, Relaxation Revolution, Benson states that the expression of our genes can change also by the way we breathe. He claims that by using the breath, one can alter the basic activity of cells with the mind. It helps to support more beliefs of how the mind and body are whole and in the treatment of stress it is vital to address it at the cellular level (p.45). The end result is that the blood is correctly balanced to normalize the heart rate, reduce muscle tension, anxiety, and stress related symptoms. Changing the breathing type when a person is awake takes time, but a client can learn to make this happen within minutes. It will become second nature once the client has developed a habit of noticing when they are breathing improperly and correcting themselves. Also when a client experiences hypo or hyper active symptoms breathing becomes their own exercise. This is when having a private location where the experience can be their own is very important. They should focus to breathing through the nose, not the mouth, especially when conducting breathing for a relaxation exercise as opposed to daily general breathing. As part of the psyhoeducation, one may position the client so they are comfortable, laying down, relaxing against a tree, in their favorite chair, or they can be in a yoga position. They will experience more of a balance in the body which is a healthier way of existing in the world. Have the client lie down in a safe manner that makes them feel comfortable and have them place both their right and left hand on parts of their chest that feels comfortable to them. Breathe in and out normally. Take notice of which hand raises further, the one on chest or the A HOLISTIC VIEW ON PTSD 32 one on the abdomen. If the chest raises further, then they are chest breathing. If the hand on their abdomen raises further, it means they are diaphragmatically breathing. In the management of stress, Joseph Piscatella (2003) discusses the advantages of using breathing to increase flexibility and reduce muscle tension and tightness which allows someone the ability to live a less stressful life (p. 142). In working with veterans, this is an especially important aspect as Vets typically are very self-reliant and display the ability to influence their own life in a positive fashion that is vital to the recovery of PTSD. As a clinician it is vital to give clients multiple tools to use. This isn’t a prefect science, so adjusting to requirements may be needed at times. An example of how to see if a client is breathing abdomens vs. the chest is to have them lay down, place a pillow under their head so you can see the stomach, and then place a book on the abdomen. Have them breathe normally so that the book rises and falls. Exhale forcefully to empty the lungs, which will create a vacuum that pulls a deep breath into the abdomen. When and if they revert to chest breathing, repeat the procedure. Push on the abdomen with the hand, then breathe in with a goal to force the hand up. Alternatively, one can roll onto the stomach, then try and breathe so that the abdomen pushes against the ground while inhaling. Don't panic if the chest moves as well, because it will. It is impossible to breathe through the abdomen without a little movement in the chest, considering that the lungs are located behind an individual’s ribs. The most effective way of breathing is to have the abdomen rise, followed by the middle chest and then the upper chest will rise last. . This is the perfect order for ideal breathing, and ends up being mostly through the abdomen. Once a veteran knows what it feels like to breathe through the diaphragm, they can then concentrate on slowing regulating their breathing. This should be practiced in small increments at first and then moving to longer sessions multiple times a day and then the process will become A HOLISTIC VIEW ON PTSD 33 a natural one that they are breathing through the abdomen. During exercise such as in the HIIT, breathing will ultimately change and move through the chest because of breathing more rapidly during exercise. The more they practice breathing through the diaphragm, the more it will become instinctive and will start happening on a regular basis throughout their daily routines. Breathing can help a client explore into other areas of states of being and can tap into a spiritual side that may have never been experienced. Herbert Benson (1975) left an impression on the capabilities of the breathe when he quoted John of Roysbroeck, a Flemish mystic in the thirteenth century as saying, “….inward exercise man feels a ghostly union with God. Whosoever than has, in his inward exercise, an imageless and free ascent unto his God, and means nought else by the glory of God, must taste of the goodness of God; and he must feel from within a true union with God. And in this union, the inward and spiritual life is made perfect; for in this union, the desirous power is perpetually enticed anew and stirred to new inward activity. And by each act, the spirit rises upward to a new union” (p. 128). By using breathing exercises in the recovery process from PTSD, the client will start to experience a greater sense of self and reintegration into the world around them. Throughout the past 4 years, the process that I have personally gone through while addressing a diagnosis of PTSD has opened my eyes to a world full of options that has expanded the way I live and view my condition. My objective in taking this journey is to now be equipped to work with clients addressing their needs surrounding this prevalent issue in today’s society. I hope to share this gift by providing clients with a variety of helpful therapeutics that they can utilize in their lives and in their relationships. This is an attractive way of living that can often be very attractive for clients, but can be unclear to them about how to get there. Our culture has A HOLISTIC VIEW ON PTSD 34 often neglected ways of dealing with past traumatic events, expecting people to just “deal with it” instead of facing the pain and tragedy in healthier more effective means. I intend to help individuals implement these more effective techniques into their daily lives in order to live a happier and healthier existence. The stress accompanying traumatic events requires out of the box thinking. Using the body in HIIT and through breathing exercises actually equips the client with resources that they can use themselves and they feel an immediate impact on their day to day living. It assists in helping them get a sense of power back into their lives when at one point it was lost. Their bodies can start to speak a new language to them that makes them feel whole. Traumatic stress puts a level of work on the body that is constantly pulling from homeostasis. The overall goal in using HIIT and breathing exercises back into alignment. The use of these techniques help a client get back into their optimal level of stimulation. The respiratory system, cardiac system, nervous system, circulation of blood in the body, muscles in the body are all meant to work together in the progress of recovering from PTSD. Clients are meant to sleep better, breathe better and they are also meant to experience having their hearts beat in an accelerated fashion that feels good to them. Until all of those things are happening with a client, the body will continue to respond in a stressful manner. The stress is a response to not operating in an optimal fashion and the body is meant to do so. The effort that it takes to develop these skills is a very focused one. Over time, if these areas are not addressed a person can lose touch with who they are and the cycle of confusion can continue not only in the body, but on psychological one too. Without additional holistic models added to more traditional cognitive approaches, those with PTSD will become stuck in a certain stage of emotional well-being. This will impact them physically and mentally, but also socially A HOLISTIC VIEW ON PTSD 35 and how well they can develop relationships. It is imperative as clinicians to find what Coach Brown of the University of Texas would refer to as the “optimal level of efficiency”. Figuring out and working through what feels good for a client and determining when it is appropriate to challenge a client on how they see themselves and how they see their experiences. It is also our role as clinicians to plant just a seed that experiences like dissociation, depression, harming one’s self and loss of hope are all areas that a person can heal from with focused guidance. It’s my hope that this paper expresses the value of adding certain dimensions onto the treatment of PTSD. In conclusion, the additional phases of HIIT and breathing exercises into treatment after prolonged exposure therapy, are part of a plan moving forward that be part of a test phase in research that would include further research and understanding of how veterans are impacted by PTSD. Additional measurements of sleep studies, meal design plans focusing on adrenal and thyroid health and specialized focus on recovery would all be measurements to aid in the recovery of veterans A HOLISTIC VIEW ON PTSD 36 References Albrecht, Karl. (2010). Stress and the Manager. New York, New York. Simon & Schuster, Inc. Bartels, M.N., Bourne, G.W., & Dwyer, J.H. 2010. High-intensity exercise for patients in cardiac rehabilitation after myocardial infarction. Physical Medicine and Rehabilitation, 2 (2), 151-55. Bevans, K., Cerebone, A.B., & Overstreet, S. (2005). Advances and future directions in the study of children’s neurobiological responses to trauma and violence exposure. Journal of Interpersonal Violence, 20, 418-425. Cohen, H., & Zohar, J. (2004). An animal model of posttraumatic stress disorder, the use of cut-off behavioral criteria. Annals of the New York Academy of Sciences, 1032, 167-178. Daussin, F.N., et al. (2008). Effect of interval versus continuous training on cardiorespiratory and mitochondrial functions: relationship to aerobic performance improvements in sedentary subjects. American Journal of Physiology: Regulatory, Integrative and Comparative Physiology, 295, R264-72. Delahanty, D., et al. (2008). The Psychobiology of Trauma and Resilience across a Lifespan. Lanham, Maryland. Roman and Littlefield Publishing, Inc. De Bellis, M. D., Hooper, S. R., & Sapia, J. L. (2005). Early trauma exposure and the brain. In J. J. Vasterling & C. R. Brewin (Eds.), Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives (pp. 153-177). New York: Guilford Press. Delgado, M. R., Olsson, A., & Phelps, E. A. (2006). Extending animal models of fear conditioning to humans. Biological Psychology, 73, 39-48. A HOLISTIC VIEW ON PTSD 37 Disseth, T. H. (2005). Dissociation in children and adolescents as reaction to trauma- on overview of conceptual issues and neurobiological factors. Nordic Journal of Psychiatry, 59, 79-91. Gay, PC., & Edmonds, L.C. (1995). Severe hypercapnia after low-flow oxygen therapy in patients with neuromuscular disease and diaphragmatic dysfunction. Mayo Clinic Proceedings, 70(4), 327-330. Gibala, M. (2012). Physiological adaptations to low-volume, high intensity training in health and disease. Journal of Physiology. 1077-1084. Glaser, R. (2005). Stressed induced immune dysfunction: Implications on health. Nature Reviews Immunology, 5, 243-251. Guz, A. (1997). Brain, breathing and breathlessness. Respiration Physiology. 109, 197-204. Harvey, B. H., Bothman, T. Nel, A., Wagner, G., & Stein, D. J. (2005). Involvement of the NMDA receptor, NO-cyclic GMP, and nuclear factor K-B in an animal model of repeated trauma. Human Psychopharmacology Clinical Experiments, 20, 367-373. Harvey, B. H., Brand, L., Jeeva, Z., & Stein, D. J. (2006). Cortical/hippocampal monoamines, HPA-Axis changes and aversive behavior following stress and 17 re-stress in an animal model of post-traumatic stress disorder. Physiology and Behavior, 87, 881-890. Heim, C., & Nemeroff, C. B. (2001). The role of childhood trauma in the neurobiology of mood and anxiety disorders: animal and clinical studies. Society of Biological Psychiatry, 49, 1023-1039. Joyner, M.J., & Coyle, E.F. (2008). Endurance exercise performance: The physiology of champions. Journal of Physiology, 586 (1), 35-44. Kabat-Zinn, Jon. (1990). In Full Catastrophe Living: Using the Wisdom of Your Body and Mind A HOLISTIC VIEW ON PTSD 38 to Face Stress, Pain and Illness. New York, New York. Dell Publishing. Kubukeli, Z.N., Noakes, T.D., and Dennis, S.C. (2002). Training techniques to improve endurance exercise performances. Sports Medicine, 32(8), 489-509. Liberon, I., & Martis, B. (2006). Neuroimaging studies of emotional response to PTSD. Annals of the New York Academy of Sciences, 1071, 87-109. Musa, D.I., et al. 2009. The effect of a high-intensity interval training program on high-density lipoprotein cholesterol in young men. Journal of Strength and Conditioning Research, 23 (2), 587-92. Phelps, E. A. (2004). Human emotion and memory: interactions of the amygdala and hippocampal complex. Current Opinion in Neurobiology, 14, 198-202. Piscatella, J. (2003). Take a Load Off Your Heart: 109 Things You Can Actually Do to Prevent, Halt and Reverse Heart Disease. New York, New York. Workman Publishing, Inc. Seiler, S., & Hetlelid, K.J. 2005. The impact of rest duration on work intensity and RPE during interval training. Medicine & Science in Sports & Exercise, 37 (9), 1601-1607. Selye H. Stress in health and disease. Reading, MA: Butterworth, 1976. Shekhar, A., Truitt, W., Rainnie, D., & Sajdyk, T. (2005). Role of stress, corticotrophinreleasing factor and amygdala plasticity in chronic anxiety. Stress, 8, 209-219. Shin, L. M., Rauch, S. L., & Pitman, R. K. (2006). Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Annals of the New York Academy of Sciences, 1071, 67-97. Sovik, R. (2000). The science of breathing – The yogic view. Progress in Brain Research, 122 (Chapter 34), 491-505 Suchy, Y. (2011). Clinical Neuropsychology of Emotion. New York, New York. Guilford Press. A HOLISTIC VIEW ON PTSD 39 Teicher, M. H. (2002). Scars that won’t heal: the neurobiology of child abuse. Scientific American, 286, 68-76. Teicher, M. H., Tomodoa, A., & Andersen, S. L. (2006). Neurobiological consequences of early stress and childhood maltreatment: are results from human and animal studies comparable? Annals of the New York Academy of Sciences, 1071, 313-323. Vasterling, J. J., Rogers, C., & Kaplan, E. (2000). Qualitative Block Design analyses in posttraumatic stress disorder, Assessment, 7, 217-226. Vermetten, E., & Bremner, J. D. (2002a). Circuits and systems in stress. I. Animal studies. Depression and Anxiety, 15, 126-147. Vermetten, E., & Bremner, J. D. (2002b). Circuits and systems in stress. II. Applications to neurobiology and treatment in posttraumatic stress disorder. Depression and Anxiety, 16, 14-38. Weber, D.A., & Reynolds, C.R. (2004). Clinical perspective on neurobiological effects of psychological trauma. Neuropsychology Review, 14(2), 115-129. Y.Sun et al., (2006). Oxitative Stress in aldosternoism: Cardiovasular Research, Vol. 71, Issue 2, p. 300-309.