Estudos de Psicologia
Estudos de Psicologia, 24(3), julho a setembro de 2019, 237-246
237
A systematic review of somatic intervention treatments in PTSD:
Does Somatic Experiencing® (SE®) have the potential to be a
suitable choice?
Ana Kelly Almeida. Universidade Federal do Rio Grande do Norte
Sayonara Christiane Gomes de Melo Macêdo. Universidade Potiguar
Maria Bernardete Cordeiro de Sousa. Universidade Federal do Rio Grande do Norte
Abstract
The psychophysiological substrate of Post-traumatic stress disorder (PTSD) is associated with deregulation of neural networks
involving mind-body interaction and is the subject of considerable research. It has been managed using pharmacological
treatment associated or not with complementary treatments. The aim of this study was to systematize the knowledge about the
types and effectiveness of complementary treatments using somatic interventions in the PTSD setting. According to the revised
literature, the complementary approaches are based on Somatic Experiencing®, meditation and brainspotting techniques, and
are anchored in the search for regulating the underlying neural mechanisms. However, there is little scientific production on
these treatments, despite the positive clinical impact of their results, particularly for Somatic Experiencing®, which has presented
good results. For the authors, further controlled trials involving improvement of symptoms and their association with possible
biological markers are necessary to corroborate the efficacy of this therapy.
Keywords: post-traumatic stress disorder; complementary treatments; somatic interventions; Somatic Experiencing®.
Resumo
Uma revisão sistemática de tratamentos de intervenção somática em PTSD: a Experiência Somática® tem o potencial para ser uma
escolha adequada? O transtorno de estresse pós-traumático (TEPT),cujo substrato psicofisiológico é associado à desregulação de
redes neurais que envolvem a interação mente-corpo, é objeto de muitas pesquisas e vem sendo manejado usando tratamento
farmacológico associado ou não a tratamentos complementares.O objetivo desse estudo foi sistematizar o conhecimento
sobre os tipos e eficácia de tratamentos complementares que utilizam intervenções somáticas no quadro do TEPT. Segundo a
literatura revisada, as intervenções somáticas são baseadas em técnicas de experiência somática, meditação, brainspotting e
estão ancoradas na busca da regulação dos mecanismos neurais subjacentes. Todavia, constatou-se baixa produção científica
destes tratamentos, apesar do impacto clínico positivo de seus resultados, particularmente para experiência somática® que
apresentou bons resultados. Para os autores, mais estudos controlados envolvendo melhora dos sintomas e sua associação a
possíveis marcadores biológicos são necessários para corroborar a eficácia desta terapia.
Palavras-chave: transtorno de estresse pós-traumático; tratamentos complementares; intervenções somáticas; experiência somática®.
Resumen
Una revisión sistemática de tratamientos de intervención somática en el trastorno de estrés postraumático: ¿tiene la experiencia
somática® el potencial de ser una opción adecuada? El trastorno de estrés postraumático (TEPT), cuyo sustrato psicofisiológico está
asociado a la desregulación de redes neuronal que involucran la interacción mente-cuerpo, es objeto de muchas investigaciones y viene
siendo manejado usando tratamiento farmacológico asociado o no a tratamientos complementarios. El objetivo de este estudio fue
sistematizar el conocimiento sobre los tipos y la eficacia de los tratamientos complementarios que utilizan intervenciones somáticas
en el trastorno de estrés postraumático. De acuerdo con la literatura revisada, las intervenciones somáticas se basan en técnicas de
experiencia somática, meditación, braquines y están ancladas en la búsqueda de la regulación de los mecanismos neurales subyacentes.
Sin embargo, se constató baja producción científica de estos tratamientos, a pesar del impacto clínico positivo de sus resultados,
particularmente para la experiencia somática®, que presentó buenos resultados. Para los autores, más ensayos controlados involucran
la mejora de los síntomas y su asociación a posibles marcadores biológicos son necesarios para corroborar la eficacia de esta terapia.
Palabras clave: trastorno de estrés postraumático, tratamientos complementarios, intervenciones somáticas; experiencia somática®.
DOI: 10.22491/1678-4669.20190025
ISSN (versão eletrônica): 1678-4669
Acervo disponível em http://pepsic.bvsalud.org
A systematic review of somatic intervention treatments in PTSD
sensations enables better connection and understanding in the direction of interoceptive processes and their
relationships with the external environment. These are
usually experienced through muscular and breathing
movements (Haase et al., 2015).
This review started with the hypothesis that the
combined application of drug and psychological therapies is not a common practice, since most patients
are prescribed drugs alone (Druss, 2010), indicating
a predominance of these types of interventions over
their psychological counterparts. As such, applying
both therapies could be more efficient in patients who
are exhibiting severe and persistent symptoms. In this
context, somatic experience® emerges as an important
tool to be explored in relation to increasing the use of
mind-body approaches to balance the neural mechanisms involved in PTSD symptoms improvement.
Post-traumatic stress disorder (PTSD) has been
extensively studied since the confirmation of its diagnosis in DSM-III in 1980. Research on PTSD broadened its
diagnostic criteria after the DSM-IV and DSM-5 revisions
in 1994 and 2013, respectively. PTSD is characterized
by the development of symptoms after exposure to
one or more traumatic events, and can be classified
as developmental trauma directly related to the life
history of an individual, or the shock trauma caused
by an isolated threatening event easily encountered in
one’s everyday environment. PTSD has three classifications regarding its onset: acute onset, chronic onset,
and late onset. Symptoms in the acute form of PTSD last
less than 3 months. Chronic PTSD is characterized when
symptoms last for a minimum of 3 and a maximum of 6
months, while symptoms in delayed-onset PTSD appear
only after at least 6 months after the traumatic event
(American Psychiatry Association [DSM-5], 2013).
Both drug and psychological treatments have
been used after the 2013 revision of PTSD diagnosis (Reis, Motoki, & Neto, 2013). However, there are a
number of little-known somatic intervention approaches
that can mitigate PTSD symptoms (Barnes, Rigg,
& Williams, 2013; Corrigan & Grand, 2013; Dahm, et al.,
2015; Fuzikawa, 2015; Payne, Levine, & Crane-Godreau,
2015; Polusny et al., 2015; van der Kolk et al., 2014).
Psychological vulnerability before any traumatic event
is as important as the related trauma. Family history of
child abuse, substance abuse, and traumatic exposure
to war and urban violence are social factors which
contribute to the development of PTSD. Considerable
evidence also demonstrates that men and women
respond differently to stressors in terms of behavioral outcomes by the activation of the HypothalamicPituitary Adrenal (HPA) axis and the sympathetic
nervous system (McEwen, Gray, & Nasca, 2015).
This revision has the aims to present current scientific knowledge on the efficacy of as yet complementary treatments using somatic interventions to
combat post-traumatic stress disorder and the respective impacts on the clinical evolution of PTSD. These
studies provide updated information on the use of
these complementary therapies applied to treat PTSD.
Moreover, to characterize them in terms of the respective clinical picture and types of somatic approaches
which aim at body awareness. The somatic techniques
associate sensitive, cognitive, motor and affectional
factors, recruiting the main brain areas involved with
the neural circuitries of PTSD. The attention toward
Method
A systematic review was conducted between
January 2010 and June 2018 in a number of databases,
including Google Scholar, SciELO, Web of Science and
Pubmed/Medline regarding the types and efficacy of
treatments for post-traumatic stress disorder that use
complementary conducts. The search was directed using
the following keywords: post-traumatic stress disorder
and treatments, psychotherapeutic treatments and PTSD,
PTSD and complementary treatments for articles published between 2010 and 2018, as well as any updated
data since the last revision found in the literature.
The review was performed by three researchers.
The first and third authors were in charge of searching,
analyzing and summarizing the articles. The third author
guided and revised all the text. Articles in Portuguese,
Spanish and English were included. Articles containing
only conventional psychotherapeutic treatments such as
those using Cognitive-behavioral therapy and Dynamic
psychotherapy were excluded. There was no randomized data due to the small number of articles which met
the criteria. The articles were similar at baseline regarding the most important prognostic indicators and the
eligibility criteria. Thus, the number of eligible articles
was insufficient to perform a meta-analysis.
Results
According to the articles analyzed and summarized in the present revision, somatic intervention
approaches have seldom been used in clinical medicine
Estudos de Psicologia, 24(3), julho a setembro de 2019, 237-246
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M. B. C. Souza, A. K. Almeida, S. C. G. M. Macêdo
despite their important efficacy in treating war veterans
and civilians diagnosed with PTSD. Psychological therapy
studies are primarily conducted on men, despite the fact
that PTSD is twice as prevalent in women. Moreover,
evidence indicates that men and women respond
Identification
differently to stressors in terms of behavioral outcomes,
activation of the HPA axis and the sympathetic nervous
system (Larsen, 2016).
Data on study selection, classification and criteria
are presented in the flowchart (Figure 1).
Eletronic search:
Google Scholar, SciELO, Web of Science and Pubmed/Medline
(N= references)
Other sources (books)
(n=3)
Articles selected
(n=102)
Screening
Articles not related to the
proposed issue (n = 57)
Studies selected for evaluation
of the complete text
(n=45)
Studies excluded after reading
(n=22)
Eligibility
Included
Studies included in the review
(n=23)
Studies included in the
quantitative synthesis (reviews)
(n=6)
Studies included in the
quantitative synthesis
(n=17)
Figure 1. Flowchart: Study Selection. Registrations Identified between 2010 and 2018.
Six systematic reviews were found between 2012
and 2018, one in Portuguese and five in English. The
first was conducted by Libby, Pilver and Desai (2012)
and aimed at somatic intervention treatments for
PTSD, suggesting the combined use of somatic and
drug therapies. The second was by Reis et al. (2013)
and limited to Brazilian studies, discussed the types
of somatic interventions and the importance of providing more efficient treatment to patients with PTSD.
As such, the authors underscore the need for both
Estudos de Psicologia, 24(3), julho a setembro de 2019, 237-246
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A systematic review of somatic intervention treatments in PTSD
somatic intervention and drug follow-up. This review
demonstrated that 20% of follow-ups contained combined therapy, 25% somatic interventions and the remaining 55% were not specific. The review also highlights
the scarcity of studies in Brazil.
The third review was by Fodor et al. (2014)
and discussed the extent of research on the issue.
Corroborating the previous article, it described the lack
of studies in Brazil, accounting for only 1% of scientific
production, and the fact that research is more concentrated in North America (50%) and Europe (20%).
The three other reviews showed that Yoga
contributed to a significant overall reduction in PTSD
symptoms by about 60%. The findings suggest that
meditation and yoga are promising complementary
approaches in treating PTSD among adults and warrant
further study, although many studies are limited by
methodological weaknesses. Recent publications have
evidenced increasing rigor and treatment combination,
with the results for mindfulness, yoga, and relaxation
looking promising.
For instance, in the fourth revision, the efficacy
of a yoga intervention employing yoga postures in a
variety of traumatized populations (e.g., veterans, survivors of childhood abuse and interpersonal violence, and
survivors of natural disasters) was examined in relation
to improving PTSD symptomatology utilizing a validated PTSD assessment. Yoga could potentially be a viable
alternative treatment for PTSD for several reasons such
as benefits of behavioral and cognitive performance,
causing a decrease of intrusive symptoms (Sciarrino,
DeLucia, O’Brien, & McAdams, 2017).
In the fifth revision conducted by Gallegos, Crean,
Pigeon and Heffner (2017), the effects of yoga on PTSD
had a minor impact and were comparable to mindfulness
and meditation approaches. These results indicate that
somatic approaches to treating PTSD such as meditation
or yoga had a moderate effect on the symptoms among
veterans and non-veterans. These results indicate that
both complementary therapies increase patient availability
of options for other complementary treatments for PTSD.
According to the authors, limitations of the revision include
the small number of studies available to conduct some of
the moderator analyses.
Finally, in the sixth review (Niles et al., 2018), the
designated studies using mindfulness, yoga, and relaxation provide support for somatic treatments for PTSD.
Mind-body interventions may give patients the opportunity to manage their emotional skills related to negative
physical and emotional states for individuals with PTSD.
In this review, a Pilot study using completer analyses was
evaluated, in which the post treatment assessment indicated that those who performed yoga had significantly
greater reductions in self-reported PTSD than the waitlist
control, with a small to moderate effect size. Another
study showed that significant and lasting benefits were
noted following a short period of time in a small study
which examined Sudarshan Kriya yoga, a breathing-based
meditation. A study that examined relaxation in comparison to three other active treatments (prolonged exposure,
cognitive restructuring, and the two combined) found
large treatment effects on both self-reported and clinician-assessed PTSD for all four treatments.
Recommendations for designing future mind-body
trials are offered by different authors such as randomized controlled trials (RCT) vs. uncontrolled trials. Another
important contribution from these reviews shows that
complementary therapies using somatic interventions
are increasing in PTSD patients. Recent use estimates a
range from 26% to 39% in PTSD populations.
The types and efficacy of somatic intervention treatments, sample characteristics, and pertinent
observations regarding somatic interventions collected from the non-revision studies are shown in Table 1.
With respect to treatments aimed at somatic interventions processes, six techniques were identified: Somatic
Experiencing®, mindfulness, brainspotting, yoga, transcendental meditation and the use of mantras. All of
these exhibited positive results with an average of
between three and twenty sessions, and 44.1% to 90%
improvement in PTSD symptoms.
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M. B. C. Souza, A. K. Almeida, S. C. G. M. Macêdo
Table 1. Types and Efficacy of Complementary Somatic Treatments.
Type of
psychotherapy
Somatic
Experiencing®
Mindfulness
Brainspotting
Type of study
Sample
characteristics:
Sample number/
nationality/sex
Positive effect (s) on
reducing symptoms
Reference (s)
Observations
Case studies
1. Man (n=1)
4 sessions;
2.Woman (n=1)
15 sessions
90%
Payne, Levine, & CraneGodreau, 2015.
Bonzon, 2013
Body symptoms are understood as
a nervous system survival response
and it becomes coping strategies for
patients.
Therapy reduces medication.
Randomized
controlled
outcome study
3.Men (n=31)
Women (n=32) /
15 sessions
44.1% absence of
symptoms of PTSD
Brom, Stokar, Lawi,
Nuriel-Porat, Ziv,
Lerner,… Ross, 2017
Further studies look at SE
effectiveness on more specific groups
such as military trauma, sexual
assault, and complex trauma.
Randomized
Controlled
Trial
4.Cohort of patients
(n = 1045)
Reduction of the number
of PTSD symptoms
compared with TAU
Andersen, Lahav,
Ellegaard, & Manniche,
2017
A brief additional SE intervention
was found to have a significant effect
on PTSD and fear of movement
compared to TAU alone.
Study group
1.Men (n=58)
9 sessions
49% during treatment,
53% 2 months later
Polusny, et al, 2015
Study conducted with control group
(n=58).
Comparing
group
mindfulnessbased
psychotherapy
against group
presentcentered
psychotherapy
2.Groups (n=4 of 20
men) 8 sessions
75%
Dahm, Meyer, Neff,
Kimbrel,Gulliver, &
Morissette, 2015
Study conducted with control group
(n=17).
3. Men (n=116)
Veteran’s
Association
participants
No difference between
the treatment and
control group
Lee & Hoge, 2017
Mindfulness may provide one
modality that supports the relaxation
component of PTSD treatment
but should remain no more than
adjunctive to established evidencebased treatments.
Group study
1.Men and women
(n= 22 men and
women) /3 sessions
90% Reduction of
the number of PTSD
symptoms
Fuzicawa, 2015.
Indicate brainspotting as promising
new approach psychotherapy for
trauma treatment
More research is needed to replicate
the results and to evaluate effects in
different samples e.g., clients with
substance use disorders and
comorbid
2. Total sample=76
(men and women)
Yoga
Transcendental
meditation
Longitudinal
study (with two
comparison
groups)
2.1. *EMDR (n=23)
2.2. **BSP(n=53)
3 sessions
Both, EMDR and BSP
were successful in
treating clients with
traumatic experiences
Hildebrand, Grand, &
Stemmler, 2017.
Study group
1.Women (n=64)/
10 sessions;
52%
van der Kolk et al., 2014. Study on interpersonal violence in
women
2. Women (n=64)/
12 sessions.
50%
Mitchell et all, 2014
Holistic treatment program for
veterans
3.Couples (n=149)/
8 sessions
60%
Monk, Ogolsky, &
Bruner, 2016.
Despite limitations, the results of
the study offer a number of useful
findings for both research and
practice
Qualitative
Descriptive
analysis
4.Women (n=31)/
10 sessions
Some participants
recognized a greater
ability to tolerate
trauma-related stimuli
and verbally express
themselves
West, Liang, &
Spinazzola, 2017.
Study related to chronic childhood
trauma
Study group
Men (n=74)
Regular meditation
for one month
83.7%
Barnes, Rigg, &
Williams, 2016.
Study performed with a control
group.
Therapy reduces medication use
continue...
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A systematic review of somatic intervention treatments in PTSD
Table 1. Continuation
Type of
psychotherapy
Mantra
Type of study
Randomized
ClinicalTrial
Sample
characteristics:
Sample number/
nationality/sex
Men (n=173)
veterans diagnosed
with militaryrelated PTSD
1. The mantram
group (N=89)
2. The comparison
group (N=84)
Both treatments
were delivered
individually in eight
weekly 1-hour
sessions.
Positive effect (s) on
reducing symptoms
Greater reductions
in PTSD symptom
severity and insomnia
for veterans compared
with present-centered
therapy.
Reference (s)
Observations
Bormann, Thorp, Smith,
Glickman, Beck, Plumb,
Zhao, … Elwy, 2018.
Significantly greater improvements
in CAPS**** score than the presentcentered therapy.
Note. *EMDR- Eye movements desensibilization and reprocessing; **BSP – Brainspotting; *** (TAU) - Treatment-as-usual for patients with chronic low back pain. This treatment
consisted of supervised exercises for low back pain delivered in 4–12 sessions and performed by physiotherapists in the Centre or in primary sector clinics according to the European
guidelines for the management of chronic low back pain; **** CAPS - Clinician-Administered PTSD Sca
Somatic Experiencing® guides the patient’s attention towards an interoceptive, synesthetic and proprioceptive experience. Three studies are available in the
literature using SE®. According to Levine (2015), inwardly-directed attention, in addition to the use of synesthetic and interoceptive images, may resolve chronic
and traumatic stress symptoms, thereby increasing an
individual’s resilience and well-being. Sensory experiencing has proven to be an effective approach to intervene
in complex trauma (Rossi & Neto, 2013).
Two case studies, one using one man, and
the other one woman, show that practicing SE® is an
important complement for both cognitive and exposure
therapies (Payne et al., 2015) and to reduce the use of
medication (Bonzon, 2013), respectively (Table 1).
In the study by Brom et al. (2017), the enrolled
participants presented a wide variety of traumatic events
triggering PTSD in Israel, including vehicle accidents,
assault cases, and terrorist attack cases of death or
injury of a family member, cases of medical trauma, and
combat and threat cases. The intervention was conducted during a period of ongoing collective trauma and
unsafety due to political unrest in Israel, which included
toward and ongoing terrorist attacks. The results presented in this study showed a large positive size effect with a
large effect size for all cases (Table 1).
A brief additional SE® intervention was found to
have a significant effect in patients who were under
management of chronic low back pain that met the
criteria for possible sub-clinical or clinical PTSD as
measured by the Harvard Trauma Questionnaire part IV,
between 18-65 years of age (Andersen, Lahav, Ellegard,
& Manniche, 2017) (Table 1).
Three studies were found that used occidental
meditation as mindfulness using groups of patients suggesting a reduction of PTSD symptoms (Dahm et al., 2015; Lee
& Hoge, 2017; Polusny et al., 2015). One study conducted
with Afghanistan veterans at nine weekly group sessions
focused on their current life problems (Polusny et al., 2015),
in which subjects were assessed before, during and after
two months of treatment, and around 50% of PTSD
symptoms were demonstrated to have been reduced.
In the second study, self-reports confirmed a
53% improvement in the severity of PTSD symptoms
(Dahm et al., 2015). However, no differences between
the treated and control groups were demonstrated in
the third study (Lee & Hoge, 2017) (Table 1).
In relation to mindfulness, this technique involves awareness, attention and memory, and its practical
proposal is to continuously identify one’s own feelings,
emotions and thoughts in an attempt to remove those
regarding the trauma. In this respect, individuals
concentrate on what they are doing or feeling and are
aware of the evolution of their body and behaviors. This
requires them to shift from a reactive mind and from
automatic and unconscious responses to conscious
ones (Vásquez-Dextre, 2016).
Only two articles were found on brainspotting
(Fuzikawa, 2015; Hildebrand, Grand, & Stemmler, 2017),
an approach created by the psychotherapist David
Grand in 2011. The article describes its development,
principles and clinical use, in addition to neurobiological
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M. B. C. Souza, A. K. Almeida, S. C. G. M. Macêdo
Discussion
hypotheses and a preliminary clinical study. It was
conducted with individuals diagnosed with PTSD in
order to assess the efficacy of the technique, which
seems to combine knowledge of Somatic Experiencing®
and EMDR (eye movement desensitization and reprocessing). International publications describe the therapy
as a rapid and effective strategy (Fuzikawa, 2015).
However, there are no empirical studies on the efficacy
of brainspotting, in addition to the aforementioned preliminary study since, as in SE®, these results
are generally presented in books and at congresses
(Hildebrand et al., 2017) (Table 1).
The body interventions of these new somatic
approaches also use ancient techniques such as yoga,
and have been used with a complementary treatment
for post-traumatic stress disorder. It is known that
trauma affects body physiology and that its memories
are somatically stored. The authors concluded that
yoga can improve the functioning of traumatized
individuals, helping them tolerate physical and sensory
experiences of fear and associated impotence. The
studies provided insight into how participants felt the
practice of yoga led to benefits in their lives on and off
the yoga mat, such as the power to make choices and
determine the direction of their lives; develop strong
connections to others; accept and appreciate themselves and their life experiences; and cultivate a sense
of calm and internal balance (Mitchell at al., 2014;
Monk et al., 2016; van der Kolk et al., 2014; West,
Liang, & Spinazzola, 2017).
One study developed by Barnes, Monto, Rigg
and Williams (2016), showed that regular transcendental meditation decreased the need for psychotropic medications required for post-traumatic stress
disorder (PTSD) management and increased psychological well-being and resilience. In a previous article
(Barnes et al., 2013), the researchers referred to earlier
studies including one in 1985 with Vietnam veterans,
showing that soldiers who engaged in transcendental
meditation instead of taking medication exhibited significantly reduced PTSD symptoms (Table 1).
The mantra therapy program study was effective in decreasing PTSD symptoms in war veterans,
managing sleep disturbance as insomnia. However,
the results of this study cannot be generalized because
the sample size was limited to veterans who reported
substance abuse (Bormann et al., 2018) (Table 1).
Complementary treatments seem to have
good potential to manage PTSD. Somatic intervention
approaches share a common characteristic, namely
the use of focused attention in cognitive and physiological processes to assess the pathological behavioral
changes. This indicates mind-body interactions and also
reinforces the importance of neurobiological investigations, highlighting their significant role in identifying
PTSD as an organic disorder, in addition to psychopathological alterations. However, exploring the differences
between techniques is necessary, since both Somatic
Experiencing® and brainspotting address traumatic
memories more directly.
Somatic Experiencing® offers an intervention
pathway in non-completed neuromuscular patterns
of traumatic responses by screening body feelings
and anchoring images related to traumatic events,
enabling patients to describe a stress pattern as
if their bodies were about to do something. Thus,
the traumatic responses gradually decline and are
completed, as non-declarative memory becomes a
declarative memory. On the other hand, stimulation of
a brainspot makes it possible to observe whether there
are traumatic experiences underlying the complaints or
symptoms shared by the patient. To that end, associations with prior disturbing experiences which contributed to shaping their self-image are analyzed. As with
Somatic Experiencing®, brainspotting ensures that the
blocked orientation response in the nervous system due
to a traumatic event is completely concluded.
The somatic approaches presented in this review
showed a positive impact of the complementary treatments, associated or not with conventional pharmacological approaches, producing perceptible physiological,
psychological and behavioral results. In some cases, the
effects were better with SE® and brainspotting (between
80% and 90%), yoga (60%), as well as a combination of
mindfulness and transcendental meditation (83,7%).
Thus, both SE® and brainspotting techniques have the
greater potential to be an important tool to help in the
PTSD treatment.
It is important to mention that in the first article
published in 2008 about Somatic Experiencing®, its
efficacy was demonstrated in 150 victims of Tsunami with
only three interventions (Parker, Ronald, & Selvam, 2008).
The authors used three instruments to monitor their
study (17-item Post-Tsunami Symptom Checklist and the
Estudos de Psicologia, 24(3), julho a setembro de 2019, 237-246
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A systematic review of somatic intervention treatments in PTSD
Impact of Events Scale–Revised–Abbreviated (IES–R–A),
Subjective Units of Distress (SUD), before and after the
treatment using SE®. Improvement in symptoms reached
75% (somewhat better) and 85% (completely well) at
4-week and 8-month follow-ups, respectively.
Regarding Somatic interventions, we were unable
to analyze the use of Somatic Experience® or brainspotting in this review, or confirm how they are being
applied, whether alone or associated with conventional treatments. Although 80% of the articles show
a significant decline in PTSD symptoms with a combination of somatic interventions and medication, we
found no studies where this interaction was satisfactorily explored, although they can decrease drug doses.
Given the improvement in symptoms with the use of
SE® and brainspotting, these should be thoroughly
investigated in news studies, as well the combination of
somatic approaches and medication to treat PTSD. This
is indicated in order to broaden the choice of treatment
or combined therapies, and in the latter case, review
the types of drugs and their respective doses.
Another important finding of this systematic review
is related to intervention programs used by the United
States Defense Department for returning war veterans and
their families. These programs are often in the form of a
retreat, and are used to avoid the development of PTSD or
diagnosis or treat it when necessary. Combined therapies
programs open a range of opportunities for using somatic
interventions and measuring instruments to monitor the
progress of each patient and tailor treatments to individual
patients (Libby et al., 2012). The intervention programs for
war veterans deserve attention, and can serve as models
to provide new treatment facilities within communities
and university hospitals. These include the formation
of therapeutic groups with well-defined goals, couples
counseling and relaxation activities.
PTSD can be characterized by two extremes of
emotional dysregulation as hyperarousal and hypoarousal.
The complexity of these symptoms appears to be represented in the neural network related to the emotional
motor system underlying PTSD involving the insula, the
medial prefrontal cortex, the anterior rostral cingulate
cortex and the amygdala (Payne et al., 2015; Yehuda et
al., 2015). For this reason, it is known that the response
to PTSD treatment differs substantially between patients.
However, the implementation of complementary interventions used in the therapeutic process has proved to be
successful through significant evidence, thus broadening
scientific research and mainly contributing to the debate
of clinical practice. Nevertheless, much more empirical
studies are required to establish their efficacy.
As aforementioned, the body-brain connection is
valued by somatic interventions. The techniques presented
in this article provide an array of opportunities for empirical studies with men and women. However, it is important to underscore that studies on women with PTSD are
scarce, even though they are twice as likely to develop this
disorder (Yehuda et al., 2015). Thus, new investigations
are needed to confirm the efficacy of these treatments
and the neurobiological and physiopathological mechanisms and interactions associated with each, including sex
differences. It has become increasingly evident that the
exclusive use of medication is not enough to improve the
symptoms of individuals diagnosed with PTSD.
The frequent use of medication cannot disregard
the fact that individuals are shaped by their life experiences and social history, with somatic and psychological components acting in conjunction: psychological,
biological and social expressions should be considered
together when selecting a treatment. With respect to
intervention programs, we recommend coordinated and
comprehensive strategies for complementary interventions using somatic intervention treatments in order to
significantly expand their combined use. For instance, SE®
and brainspotting that direct the somatic intervention to
the cause of the symptoms of the traumatic event. In a
broader sense, the focus of SE® is directed to the deeper
levels and regulators of the autonomic nervous system
(SNA), motor emotional system (EMS), reticular activation system (RAS) and limbic system, the so-called nuclear
response network (CRN) by Payne et al. (2015). Thus, the
possibilities involved in active and structured attention
focused on the interoceptive and proprioceptive experience performed in the SE® sessions point to the need for
more research to better understand the dysregulation
of the neural networks involved in PTSD, as well as their
physiological correlates. According to Taylor and SaintLaurent (2017), SE® also has the potential to be used in
groups, especially for collective trauma. Although gender
differences in acute PTSD cases show higher prevalence
in women, the use of somatic therapies may be sufficient
for both men and women. Moreover, increasing research
using the specific somatic experience approach deserves
much broader implementation, as it has the potential to
benefit those affected by PTSD. Additionally, the investigation of possible biological markers associated to SE® interventions also seems to be important, as demonstrated in
relation to other neuropsychiatric disorders.
Estudos de Psicologia, 24(3), julho a setembro de 2019, 237-246
244
M. B. C. Souza, A. K. Almeida, S. C. G. M. Macêdo
Limitations
Bormann, J. E., Thorp, S. R., Smith, E., Glickman, M., Beck, D., Plumb., …
Elwy, A. R. (2018). Individual treatment of Posttraumatic Stress
Disorder using mantram repetition: A randomized clinical trial.
American Journal of Psychiatry, 175(10), 979-988. doi: 10.1176/
appi.ajp.2018.17060611
Somatic intervention approaches have the
potential to be very helpful to patients, either isolated
or when combined with complementary drug treatment, but must be conducted in a safe and scientifically rigorous manner. However, in the case of Somatic
Experiencing® regarding the actual context where the
number of publications is still small and limited to specific clinical conditions or case studies presented at SE®
seminars and training, and therefore the current results
should be analyzed with caution. In fact, most of the
analyzed articles had a small sample size without a
control group, and did not report follow-ups. Thus, a
stronger investment based on clinical trials, including
controlled and/or randomized clinical trials, is needed
to measure the efficacy of SE® in short- and long-term
prospects, and using specific groups related to traumatic events.
Brom, D., Stokar,Y., Lawi, C., Nuriel-Porat, V., Ziv, Y., Lerner, K., ... Ross,
G. (2017). Somatic Experiencing® for Posttraumatic Stress Disorder:
A randomized controlled outcome study. Journal of Traumatic Stress,
30(3), 304-312. doi: 10.1002/jts.22189
Corrigan, F., & Grand, D. (2013). Brainspotting: Recruiting the midbrain for
accessing and healing sensorimotor memories of traumatic activation.
Medical Hypotheses, 80, 759-766. doi: 10.1016/j.mehy.2013.03.005
Dahm, K. A., Meyer, E. C., Neff, K. D., Kimbrel, N. A., Gulliver, S. B., &
Morissette, S. B. (2015). Mindfulness, self-compassion, posttraumatic
stress disorder symptoms, and functional disability in U.S. Iraq and
Afghanistan war veterans. Journal of Traumatic Stress, 28, 460-464.
doi: 10.1002/jts.22045
Druss, B. G. (2010). The changing face of U.S. mental health care. American
Journal of Psychiatry, 167, 1419-1421. doi: 10.1176/foc.9.2.foc221
Fodor, K. E., Unterhitzenberger, J., Chou, C. Y., Kartal, D., Leistner,
S., Milosavljevic, M.,… Alisic, E. (2014). Is traumatic stress
research global? A bibliometric analysis. European Journal of
Psychotraumatology, 5, 1-7. doi: 10.3402/ejpt
Fuzikawa, C. (2015). Brainspotting: uma nova abordagem psicoterápica
para o tratamento do trauma. Revista Debates em Psiquiatria, 3,
26-30. Retrieved from http://abpbrasil.websiteseguro.com/portal/
wp-content/upload/rdp_15/03/RDP_3_2015_geral1.pdf
Conflict of interest
The authors declare that there is no financial
involvement that could lead to a conflict of interest.
Gallegos, A. M., Crean, H. F., Pigeon, W. R., & Heffner, K. L. (2017).
Meditation and yoga for posttraumatic stress disorder: A meta-analytic
review of randomized controlled trials. Clinical Psychology Review,
58, 115-124. doi: 10.1016/j.cpr.2017.10.004
Acknowledgement
Grand, D. (2011). Brainspotting a new brain-based psychotherapy
approach. Trauma and Gewalt, 3, 276-85.
We are grateful to professors Priscila Fernandes
(UFRN), Dina Azevedo (UFRN) and Denis Donald
Moorman (Somatic Experiencing® Trauma Institute) for
their comments and assistance.
Haase, L., Stewart, J. L., Youssef, B., May, A. C., Isakovic, S., Simmons, A.
N., … Paulus, M. P. (2015). When the brain does not adequately feel
the body: Links between low resilience and interception. Biological
Psychology, 113, 37-45. doi: 10.1016/j.biopsycho.2015.11.004
Hildebrand, A., Grand, D., & Stemmler, M. (2017). Brainspotting – the
efficacy of a new therapy approach for the treatment of Posttraumatic
Stress Disorder in comparison to Eye Movement Desensitization and
reprocessing. Mediterranean Journal of Clinical Psychology, 5(1),
1-16. Retrieved from http://cab.unime.it/journals/index.php/MJCP/
article/view/1376/pdf_2
References
American Psychiatry Association (2013). DSM-5: Diagnostic and statistical
manual of mental disorders 5. Washington, DC: American Psychiatry
Association.
Larsen, C. (2016, January). Emerging pharmacotherapy options
for PTSD: We need backup! South Texas Veterans Health Care
System, San Antonio, Texas. Retrieved from https://sites.utexas.
edu/pharmacotherapy-rounds/files/2016/01/larsen29jan2016.pdf
Andersen, T. E., Lahav, Y., Ellegaard, H., & Manniche, C. (2017).
A randomized controlled trial of brief Somatic Experiencing® for
chronic low back pain and comorbid post-traumatic stress disorder
symptoms. European Journal of Psychotraumatology, 8, 1-9.
doi: 10.1080/20008198.2017.1331108
Lee, J. D., & Hoge, W. C. (2017). Significant methodological flaws limit
conclusions drawn by authors of a recent PTSD mindfulness study.
Evidence Based Mental Health, 20(1), 31. doi: 10.1136/eb-2016-102595
Barnes, V. A., Monto, A., Rigg, J. L., & Williams, J. J. (2016). Impact of
transcendental meditation on psychotropic medication use among
active duty military service members with anxiety and PTSD. Military
Medicine, 181(1), 56-63. doi: 10.7205/MILMED-D-14-00333
Levine, P. (2015). Trauma and memory: Brain and body in a search for
the living past: a practical guide for understanding and working with
traumatic memory. Berkeley California: North Atlantic Books.
Libby, D. J., Pilver, C. E., & Desai, R. (2012). Complementary and
alternative medicine in VA Specialized PTSD Treatment Programs.
Psychiatric Service, 63, 1134-1136. doi: 10.1176/appi.ps.201100456
Barnes, V. A., Rigg, J. L., & Williams, J. J. (2013). Clinical case series:
Treatment of PTSD with transcendental meditation in active duty
military personnel. Military Medicine, 178(7), e836-840. doi: 10.7205/
MILMED-D-12-00426
McEwen, B. S., Gray, J. D., & Nasca, C. (2015). Recognizing resilience:
Learning from the effects of stress on the brain. Neurobiology of
Stress, 1, 1-11. doi: 10.1016/j.ynstr.2014.09.001
Bonzon, R. (2013). Intervenção da experiência somática em caso de TEPT
complexo. In C. P. Rossi & L. Netto (Eds.), Práticas psicoterápicas
e resiliência: diálogos com a experiência somática (pp. 246-261).
São Paulo: Scortecci.
Mitchell, K. S., Dick, A. M., DiMartino, D. M., Smith, B. N., Niles, B., Koenen,
K. C., … Street, A. (2014). A pilot study of a randomized controlled trial
Estudos de Psicologia, 24(3), julho a setembro de 2019, 237-246
245
A systematic review of somatic intervention treatments in PTSD
of yoga as an intervention for PTSD symptoms in women. Journal of
Trauma Stress, 27, 121-128. doi: 10.1002/jts.21903
Rossi, C. P., & Netto, L. (2013). Práticas psicoterapêuticas e resiliência:
diálogos com a Experiência Somática. São Paulo: Scortecci.
Monk, J. K., Ogolsky, B. G., & Bruner, V. (2016). Veteran couples integrative
intensive retreat model: An intervention for military veterans and their
relational partners. Journal of Couple & Relationship, 15, 158-176.
doi: 10.1080/15332691.2015.1089803
Sciarrino, N. A., DeLucia, C., O’Brien, K., & McAdams, K. (2017).
Assessing the effectiveness of yoga as a complementary and
alternative treatment for Post-Traumatic Stress Disorder: A review and
synthesis. The Journal of Alternative and Complementary Medicine,
23(10), 747-755. doi: 10.1089/acm.2017.00360
Niles, B. L., Mori, D. L., Polizzi, C., Kaiser, A. P., Weinstein, E. S.,
Gershkovich, M., & Wang, C. (2018). A systematic review of
randomized trials of mind-body interventions for PTSD. Journal of
Clinical Psychology, 74(9), 1485-1508. doi: 10.1002/jclp.22634
Taylor, P. J., & Saint-Laurent, R. (2017). Group psychotherapy informed
by the principles of somatic experiencing: moving beyond trauma to
embodied relationship. International Journal of Group Psychotherapy,
67(Suppl. 1), S171-S181. doi: 10.1080/00207284.2016.1218282
Parker, C., Ronald, M., & Selvam, R. (2008). Somatic Therapy Treatment:
Effects with tsunami survivors. Traumatology, 14, 103-109. doi:
10.1177/1534765608319080
van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak,
M., … Spinazzola, J. (2014). Yoga as an Adjunctive Treatment for
Posttraumatic Stress Disorder: A randomized controlled trial. Journal
of Clinical Psychiatry, 75, 559-565. doi: 10.4088/JCP.13m08561
Payne, P., Levine, P. A., & Crane-Godreau, M. A. (2015). Somatic experiencing:
Using interoception and proprioception as core elements of trauma
therapy. Frontiers in Psychology, 6, 1-18. doi: 10.3389/fpsyg.2015.00093
Vásquez-Dextre, E. R. (2016). Mindfulness: conceptos generales,
psicoterapia y aplicaciones clínicas. Revista de Neuro-Psiquiatría,
79, 42-51. doi: 10.20453/rnp.v79i1.2767
Polusny, M. A., Christopher, R. E., Thuras, P., Moran, A., Lamberty, J.
G., Collins, C. R., … Lim, K. O. (2015). Mindfulness-based stress
reduction for posttraumatic stress disorder among veterans. JAMA
Network, 314, 456-465. doi: 10.1001/jama.2015.8361
West, J., Liang, B., & Spinazzola, J. (2017). Trauma sensitive yoga
as a complementary treatment for posttraumatic stress disorder:
A qualitative descriptive analysis. International Journal of Stress
Management, 24(2), 173-195. doi: 10.1037/str0000040
Reis, B. M., Motoki, A. S. B., & Neto, W. M. F. S. (2013). Transtorno de
Estresse Pós-Traumático: um Estudo Bibliométrico. Perspectivas
em Psicologia, 17(2), 147-169. Retrieved from http://www.seer.ufu.
br/index.php/perspectivasempsicologia/article/view/28355/15704
Yehuda, R., Hoge, C. W., McFarlane, A. C., Vermetten, E., Lanius,
R. A., Nievergelt, C. M., .... Hyman, S. E. (2015). Post-traumatic stress
disorder. Nature Reviews, 15057, 1-22. doi: 10.1038/nrdp.2015.57
Ana Kelly Almeida, Mestre em Filosofia pela Universidade Federal
do Rio Grande do Norte - UFRN, doutoranda em Psicobiologia na
Universidade Federal do Rio Grande do Norte - UFRN. Endereço
para correspondência: Av. Antônio Basílio, 3006, Shopping Lagoa
Center Business, sala 602, Lagoa Nova, Natal – RN, CEP 59.056-500.
Telefone: +55(84)988170858. Email: anakelly.almeida@gmail.com
Sayonara Christiane Gomes de Melo Macêdo, Especialista em Língua
Inglesa (Educação) pela Universidade Potiguar – UNP,
é Professora do Programa saúde e qualidade de vida no CEMURE
(Centro Municipal de Referência em Educação Aluísio Alves) na
secretaria Municipal de Natal. Email: sayonaramacedopsi@gmail.com
Maria Bernardete Cordeiro de Sousa, Doutora em Neurofisiologia
pela Faculdade de Medicina de Ribeirão Preto – Universidade
de São Paulo (USP), Pós-Doutora em Physiological Ethology pela
Wisconsin National Primate Research Center - University of
Wisconsin (UW), USA, é Professora Titular do Instituto do Cérebro
da Universidade Federal do Rio Grande do Norte (UFRN).
Email: mbcsousa@neuro.ufrn.br
Received in 28.jan.19
Revised in 08.aug.19
Accepted in 16.oct.19
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