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Integrative Medicine Epidemiologist, Cary, NC
Dr. Fahey reports no financial relationships relevant to this field of study.
SYNOPSIS: The emotional freedom technique is a new approach to treating post-traumatic stress disorder in veterans that uses genomic science.
SOURCE: Church D, Yount G, Rachlin K, et al. Epigenetic effects of PTSD remediation in veterans using emotional freedom techniques: A randomized controlled pilot study. Am J Health Promot 2018;32:112-122.
The obstinate nature of post-traumatic stress disorder (PTSD) toward current treatments has been explored in the literature.1 The prevalence of PTSD in the general population is about 6.8%.2 According to the National Comorbidity Survey Replication (2001-2003), the prevalence of lifetime PTSD was around 9.7% in the female general population, 13.4% in female veterans, 3.6% in the male general population, and 7.7% in male veterans.3 The numbers are higher in veterans who have served in wars or conflicts, especially Operation Iraqi Freedom and Operation Enduring Freedom (13.8%), the Gulf War (Operation Desert Storm, 10.1%), and the Vietnam War (26.9% for women and 30.9% for men). Women are more than twice as likely as men to develop PTSD.3
The emotional freedom technique (EFT) is a therapy that has emerged over the last 20 years. EFT is simple to learn. Videos demonstrating the therapy are available online, and a manual that is updated periodically can be downloaded for free.4,5 EFT relies on a combination of techniques of tapping on or massaging acupuncture points (acupressure) while saying an activating phrase. The phrasing comes from cognitive behavioral therapy and is used to identify the issue. A sample phrase would be, “Even though I have this fear of spiders, I deeply and completely accept myself.” While repeating the phrase (specific to the patient’s specific issue), the patient taps on the points in the order shown in the figure available at:
Despite its ease of use, EFT has had difficulty crossing the translational gap.7 It takes an average of 17 years for a new approach to be incorporated into the medical model, with only about 20% of new techniques accepted. EFT is emerging in the literature, partly because it meets evidence-based standards set by the American Psychological Association.7,8
Church et al designed their study to understand the role EFT plays in the treatment of PTSD. Sixteen veterans were randomized to an EFT group or a treatment-as-usual (TAU) group. Patients in the EFT group participated in one-hour EFT sessions each week for 10 weeks. All participants were given several questionnaires (Symptom Assessment 45, Hospital Anxiety and Depression Scale, Insomnia Severity Scale, SF-12v.2 health survey, Brief Pain Inventory, Rivermead Post-concussion Symptoms Questionnaire) before, during, and after treatment. The researchers monitored 93 genes that encode the key regulators of glucocorticoid signaling, inflammation, and innate immune signaling, as well as the transporters and receptors for these key regulators linked to PTSD, using the Student t test and post-hoc analyses. They drew blood samples before and after EFT treatment, extracted mRNA, and measured the product levels (proteins) for the above genes. The premise was that EFT would act via epigenetics to influence gene expression to decrease the creation of proteins linked to inflammation, the immune system, and the cortisol cycle. These products were measured by recording the amount of the proteins and/or hormones in the blood before and after EFT treatment.
In the EFT group (n = 18), PTSD symptoms decreased (-53; P < 0.0001), with these results still present at the six-month follow-up. Six genes involved in stress response, cellular immunity, and inflammation had a strong signal-to-noise ratio (P < 0.05) when levels were compared before and after treatment with EFT. (See Table 1.) Post-hoc analyses were performed to detect any changes in gene expression pre- and post-EFT treatment; 12 genes were identified. (See Table 2.) Student t test and log transformed ratios (P < 0.05) found six genes with > 15%-fold changes, and two previously unidentified genes had significant differential gene expression. After both TAU and EFT groups received EFT treatments, a two-sample Student t test of the fold changes showed no significant differences (P > 0.05) in gene expression.
PTSD remains a difficult disorder to treat and has inspired the development of new treatment modalities, including EFT. Research about the mechanisms behind the success of EFT has been increasing. EFT has been shown to treat the phenomenon of recalled pain that causes chronic pain.9,10 When a nerve has been injured, the damage may change epigenetic markers on the genes of these nerve cells. Denk et al identified nerve cells that performed normally but had genetic changes that showed the cell had a memory of the original injury. When this memory is triggered by epigenetic mechanisms, recall of the original trauma by the injured nerve cell could be the reason for apparently random attacks of pain that some patients with chronic pain experience.10
Swingle et al monitored electroencephalogram (EEG) patterns of patients before and after EFT treatment for injuries from motor vehicle collisions (t = 7.25; P < 0.01).11 Lambrou et al studied the EEG patterns of the effect of EFT on claustrophobia (P < 0.001).12 EFT has been shown to be effective on fear, anxiety, and trauma-based symptoms.13 In functional magnetic resonance imaging studies, Dhond et al demonstrated that acupuncture works by down-regulating neural output from the limbic system, which is triggered by fear.14 EFT is the manual stimulation of 14 identified acupuncture points, using phrasing from cognitive behavioral therapy.15 The practice of EFT has evolved over the years, and new practitioners are asked to add an element of their own personal work and rename the technique.
Researchers have explored the mechanism of action of EFT, such as in a triple-blind, randomized, controlled trial on how EFT affects the release of hormones from endocrine cells to target cells. Key psychological signs were compared with cortisol levels in 83 participants who were divided into three groups before and after one treatment of EFT.16 Cortisol levels decreased in all three groups: The EFT group (-24.39%; standard error [SE], 2.62) had a larger decrease in levels than the supportive interview (-14.25%; SE, 2.61) and no treatment (-14.44%; SE, 2.67) groups (P < 0.03). The EFT group displayed statistically significant recoveries in anxiety (-58.34%; P < 0.05), depression (-49.33%; P < 0.002), total severity of indicators (-50.5%; P < 0.001), and symptom scope (-41.93%; P < 0.001).16 Once again, fear was the underlying emotion addressed. PTSD is unique as an illness because a patient had to experience a trauma to develop the disorder.17 The more traumas or fears experienced in childhood, the more likely someone will develop PTSD or other disorders as a result.
The link established between EFT and down-regulation of the limbic system created new areas of research into the epigenetic effects of EFT. Its mechanism of action may be that it interacts with the epigenetic process that controls the development and continuation of symptoms. Genetic structures are thought to be stable throughout the organism’s lifetime while epigenetic activities are labile, continuously changing gene expression as a response to environmental stimuli. This discussion can get complicated because epigenetic responses vary from cell to cell and from organism to organism.18 EFT therapy has been linked to the stress response and the limbic system, which is regulated by the epigenetic response to environmental stimuli.
Until now, the research on the epigenetic effects of EFT only focused on DNA methylation, the most investigated epigenetic mechanism in mammals, and its connection to the possibility of development of PTSD and conditioned fear.19,20 A series of epigenetic studies have connected the onset of PTSD to effects of DNA methylation levels at specific points in the genome.21,22 The literature supports the theory that there is communication among the inborn genes, the number of individual traumas experienced in childhood, and the development of PTSD.23 Authors of further studies have suggested that the epigenetic processes of the stress response act via cortisol on the hypothalamic-pituitary-adrenal (HPA) axis. The increased risk of mental health issues in adulthood may be caused by the accumulated traumas of childhood that have induced DNA demethylation of the FK506 binding protein (FKBP5) gene, an important regulator of the stress hormone system. The results of the study indicated that demethylation amplified stress-dependent gene transcription and consequential continued impairment of HPA axis regulation.24
The results confirm and advance the epigenetic research that three genes related to the immune system are under-expressed (P < 0.05) in the peripheral blood of individuals with PTSD.25 A study on whole blood identified four genes in veterans with combat-induced PTSD and found four genes (P < 0.05) that were involved in the regulation of the inflammatory response.26,27,28
There were several limitations to the study, including a small sample size. Several studies cited issues with recruiting yields of 3-5.5% when targeting veterans with PTSD to obtain an appropriate sample size,29 illustrating issues identified with getting members of this target group to complete an entire study. The TAU group was treated with EFT after the study ended, which ruled it out as a long-term comparison group. Another control group should be added for cognitive behavioral therapy or other similar treatment modality to establish a proper comparison with a current successful therapy. Two pilot studies comparing cognitive behavioral therapy with EFT in adolescents and adults indicate that EFT is credible enough to merit additional study.30,31
Among the patients studied, 83% reported a prior diagnosis of PTSD. Although this can be verified through medical records, it would have benefited the study to have a mental health practitioner evaluate each participant for PTSD before and after each treatment. Another limitation was the inability to control for analgesics in the study.
There are potential harms associated with EFT when working with veterans diagnosed with PTSD. The adverse effects mentioned in the literature surrounding EFT identify issues with negative emotions, a resurgence of symptoms, and not responding to EFT at all. Patients should work with certified EFT practitioners within the context of a holistic team led by a mental health practitioner.
PTSD is a serious, sometimes labile, condition, and practitioners should work within teams in the healthcare system to provide a holistic, interdisciplinary approach to treat PTSD patients. Some of the emerging evidence, including the findings from this study, shows that EFT might be part of an integrative treatment plan that also continues with proven conventional therapies.
Financial Disclosure: Integrative Medicine Alert’s Executive Editor David Kiefer, MD; Peer Reviewer Suhani Bora, MD; AHC Media Executive Editor Leslie Coplin; Editor Jonathan Springston; and Editorial Group Manager Terrey L. Hatcher report no financial relationships relevant to this field of study.