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Background |
Types of anxiety |
Risk factors |
Causes |
Signs and symptoms |
Diagnosis |
Complications |
Treatment |
Integrative therapies |
Prevention |
Author information |
Bibliography
Anxiety disorders
Anxiety is an unpleasant complex combination of emotions often accompanied by physical sensations such as heart palpitations (irregular heart beat), nausea, angina (chest pain), shortness of breath, tension headache, and nervousness.Anxiety disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year. Only about one-third of those suffering from an anxiety disorder receive treatment. Anxiety disorders are reported to cost the United States more than $42 billion a year.
Unlike the relatively mild, brief anxiety that can be caused by a stressful event (such as testing, a job interview, the death of a loved one, or public performance/speaking), anxiety disorders last at least six months and can become worse if not treated.
Anxiety disorders can commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, depression, or bipolar illness, which may mask anxiety symptoms or make them worse.
Individuals with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than non-sufferers.
Background
Anxiety is an unpleasant complex combination of emotions often accompanied by physical sensations such as heart palpitations (irregular heart beat), nausea, angina (chest pain), shortness of breath, tension headache, and nervousness.Anxiety disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year. Only about one-third of those suffering from an anxiety disorder receive treatment. Anxiety disorders are reported to cost the United States more than $42 billion a year.
Unlike the relatively mild, brief anxiety that can be caused by a stressful event (such as testing, a job interview, the death of a loved one, or public performance/speaking), anxiety disorders last at least six months and can become worse if not treated.
Anxiety disorders can commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, depression, or bipolar illness, which may mask anxiety symptoms or make them worse.
Individuals with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than non-sufferers.
Types of anxiety
Generalized Anxiety Disorder (GAD): Most people experience anxiety at some point in their lives and some nervousness in anticipation of a real situation. However, if a person cannot shake unwarranted worries, or if the feelings are jarring to the point of avoiding everyday activities, he or she most likely has an anxiety disorder. GAD is characterized by excessive, unrealistic worry that lasts six months or more. In adults, the anxiety may focus on issues such as health, money, or career. Physical symptoms may also appear such as nervousness or heart palpitations. GAD affects about 5% of Americans in the course of their lives and is more common in women than in men. Some experts believe that it is under diagnosed and more common than any other anxiety disorder. GAD usually begins in childhood and often becomes a chronic ailment, particularly when left untreated. Depression in adolescence may be a strong predictor of GAD in adulthood. Depression commonly accompanies this anxiety disorder.Obsessive compulsive disorder (OCD): In OCD, individuals are plagued by persistent, recurring thoughts (obsessions) that reflect exaggerated anxiety or fears. Typical obsessions include worrying about being contaminated with germs or fears of behaving improperly or acting violently. The obsessions may lead an individual to perform a ritual or routine (compulsions) such as washing hands, repeating phrases, or hoarding. Obsessive-compulsive disorder occurs equally in men and women, and it affects about 2-3% of people over a lifespan. About 80% of people who develop OCD show signs of the disorder in childhood, although the disorder usually develops fully in adulthood.
Panic attacks and panic disorder: Panic disorder is characterized by repeated, unexpected panic attacks. These panic attacks strike without warning and usually last a terrifying 15-30 minutes. Panic disorder may also be accompanied by agoraphobia, which is a fear of being in places where escape or help would be difficult in the event of a panic attack. Agoraphobia is characterized by individuals likely to avoid public places such as shopping malls or confined spaces such as an airplane. Studies indicate that the prevalence of panic disorder among adults is between 1.6-2% and is much higher in adolescence, 3.5-9%. In one study, 18% of adult patients with panic disorder reported the onset of the disorder before ten years of age. In general, however, panic disorder tends to begin in late adolescence and peaks at around 25 years of age.
Post traumatic stress disorder (PTSD): PTSD can follow an exposure to a traumatic event such as a sexual or physical assault, witnessing a death, the unexpected death of a loved one, or natural disaster. There are three main symptoms associated with PTSD: "reliving" of the traumatic event (such as flashbacks and nightmares); avoidance behaviors (such as avoiding places related to the trauma) and emotional numbing (detachment from others); and physiological arousal such as difficulty sleeping, irritability or poor concentration. Researchers now know that anyone, even children, can develop PTSD if they have experienced, witnessed, or participated in a traumatic occurrence-especially if the event was life threatening. Studies estimate a lifetime risk for PTSD in the United States of up to 8%. People exposed to traumatic events, of course, are at highest risk, but many people can go through such events and not experience PTSD. Studies also estimate that 6-30% or more of trauma survivors develop PTSD, with children and young people being among those at the high end of the range. Women have the twice the risk of PTSD as men. PTSD can also occur in people not directly involved with a traumatic event.
Phobias: A phobia is an unrealistic or exaggerated fear of a specific object, activity, or situation that in reality presents little to no danger. Common phobias include fear of animals such as snakes and spiders, fear of flying, and fear of heights. In the case of a severe phobia, one might go to extreme lengths to avoid the thing feared.
Separation anxiety: Separation anxiety is a normal part of child development. It consists of crying and distress when a child is separated from a parent or away from home. If separation anxiety persists beyond a certain age or interferes with daily activities, it may be a sign of separation anxiety disorder.
Social anxiety / social phobia: Social anxiety disorder (SAD) is characterized by extreme anxiety about being judged by others or behaving in a way that might cause embarrassment or ridicule. This intense anxiety may lead to avoidance behavior. Physical symptoms associated with this disorder include heart palpitations, faintness, blushing and profuse sweating. Performance anxiety (better known as stage fright) is the most common type of social phobia. Social phobia is currently estimated to be the third most common psychiatric disorder in the United States. Studies have reported a prevalence of 7-12% in Western nations.
Risk factors
Gender: With the exception of obsessive-compulsive disorder (OCD) and possibly social anxiety, women have twice the risk for most anxiety disorders as men. A number of factors may increase the reported risk in women, including hormonal factors, cultural pressures to meet everyone else's needs except their own, and fewer self-restrictions on reporting anxiety to doctors. Pregnant women and women experiencing menopause may be more susceptible to symptoms of anxiety. Also, women have about twice the risk for panic disorder as men.Age: In general, phobias, OCD and separation anxiety show up early in childhood, while social phobia and panic disorder are often diagnosed during the teen years. Reports have estimated that approximately 3-5% of children and adolescents have some type of anxiety disorder. This number may be low, particularly since symptoms in children may differ from those in adults. Reports indicate that if such children could be identified as early as two years of age they possibly could be treated to avoid later anxiety disorders.
Environmental factors: A person's environment can play a huge role in the development of anxiety disorders. Difficulties such as poverty, early separation from the mother, family conflict, critical and strict parents, parents who are fearful and anxious themselves, and the lack of a strong support system can all lead to chronic anxiety. Studies report that anxiety in the new mother can affect their infants. One study reported a higher rate of crying and an impaired ability to adapt to new situations in infants of mothers who had been stressed and anxious during pregnancy. In another, infants of mothers with panic disorder had higher levels of stress hormones and more sleep disturbances than other children.
Personality traits: Personality differences can affect whether or not an anxiety disorder develops. People with anxiety disorders often are very self-conscious, have poor coping skills, and have low self-esteem. Children's personalities may indicate higher or lower risk for future anxiety disorders, such as extremely shy children and those likely to be the target of bullies, who are at a higher risk for developing anxiety disorders later in life.
Heredity: Anxiety disorders tend to run in families. People with anxiety disorders often have a family history of anxiety disorders, mood disorders, or substance abuse.
Causes
Brain chemistry: Studies suggest that an imbalance of the brain's neurotransmitters (chemical messengers) such as serotonin, gamma-amino butyric acid (GABA), epinephrine, and norepinephrine may contribute to anxiety disorders. Abnormalities in the stress hormone cortisol, produced by the adrenal glands, have also been found. Most medications prescribed for anxiety disorders aim to readjust the brain's chemical balance.Trauma: An anxiety disorder may develop in response to a traumatic event, such as a car accident or a marital separation. Anxiety may also have its roots in early life abuse or developmental trauma. Trauma in infancy and early childhood can be particularly damaging, leaving a pervasive and lasting sense of helplessness that can develop into anxiety or depression in later life.
Medications: Some prescription and non-prescription medications may cause symptoms of anxiety, including caffeine and other stimulants, drugs such as heroin, cocaine, and amphetamines, over-the-counter medications such as decongestants, steroids such as cortisone and prednisone, inhalers and other respiratory medications, some herbal supplements such as ephedra (no longer available on the U.S. market), Citrus aurantium, yerba mate tea, and guarana, weight loss products, high blood pressure medications, withdrawal from alcohol, ADHD medications (Ritalin®, Adderall®, Dexedrine®), withdrawal from benzodiazepines (Xanax®, Valium®), and hormones such as birth control pills and thyroid medications.
Medical conditions: Many medical conditions can cause or mimic symptoms of anxiety disorders. They include thyroid disorders, diabetes, hypoglycemia (low blood sugar), asthma, sleep disorders, adrenal disorders, epilepsy (seizures), heart conditions including arrhythmias (irregular heart beat), migraine headaches, certain psychiatric illnesses, such as bipolar disorder (characterized by mania and depression) and depression.
Nutritional deficiencies: Nutritional deficiencies stemming from poor diet and/or digestion can also contribute to anxiety. Depleted levels of minerals, especially magnesium and zinc, have been linked to the presence of anxiety. A deficiency of B vitamins, especially vitamin B-12, can be a significant contributing factor to the development of anxiety disorders.
Signs and symptoms
The primary symptoms of anxiety disorders are fear and worry. However, anxiety disorders are also characterized by additional emotional and physical symptoms.Physical: Physical symptoms include heart palpitations (irregular heartbeat), angina (chest pain), hot flashes or chills, cold and clammy hands, stomach upset or queasiness, frequent urination, diarrhea, shortness of breath, sweating, vertigo (dizziness), tremors, muscle tension or aches, fatigue (tiredness), and insomnia (inability to sleep).
Emotional/Psychological: Emotional or psychological symptoms can include apprehension, uneasiness, dread, impaired concentration or selective attention, feeling restless or on edge, avoidance, nightmares, irritability, confusion, behavioral problems (especially in children and adolescents), nervousness, jumpiness, self-consciousness, insecurity, fear of dying or going crazy, and a strong desire to escape.
Generalized Anxiety Disorder (GAD): Specific symptoms for GAD can include chronic, exaggerated worry, tension, and irritability that appear to have no cause or are more intense than the situation warrants. Physical signs, such as restlessness, trouble falling or staying asleep, headaches, trembling, twitching, muscle tension, or sweating, often accompany these psychological symptoms.
Panic disorder: Panic disorder symptoms include heart palpitations (irregular heart beat), angina (chest pain), lightheadedness or dizziness, nausea, shortness of breath, feelings of imminent danger, shaking or trembling, choking, fear of dying, sweating, feelings of unreality, numbness or tingling, hot flashes or chills, and a feeling of going crazy. Since many of the symptoms of panic disorder mimic those found in illnesses like heart disease, thyroid problems and breathing disorders, people with panic disorder often make multiple visits to emergency rooms or doctors' offices, convinced they have a life-threatening illness (hypochondriac).
Social anxiety disorder (SAD): Specific symptoms for SAD include blushing, sweating, trembling, nausea, rapid heartbeat, dizziness, and headaches. Some people may have an intense fear of a single social or performance circumstance such as giving a speech, talking to a salesperson or making a phone call, but be perfectly comfortable in other social settings. Others may have a more generalized form of SAD, ranging from such behaviors as becoming anxious in a variety of routines, to clinging behavior, and throwing tantrums.
Post traumatic stress disorder (PTSD): People with PTSD typically avoid situations that remind them of the traumatic event, because they provoke intense distress or even panic attacks. PTSD is characterized by three main types of symptoms including: re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks and nightmares; emotional numbness and avoidance of places, people and activities that are reminders of the trauma; and increased arousal including difficulty sleeping and concentrating, feeling jumpy, and becoming easily irritated and angered.
Obsessive-compulsive disorder (OCD): Common obsessions include constant, irrational worry about dirt, germs or contamination, nagging feelings that something bad will happen if certain items aren't in an exact place, position or order, fear that one's negative or blasphemous thoughts or images will cause personal harm or harm to a loved one, preoccupation with losing or throwing away objects with little or no value, and rumination about accidentally or purposefully injuring another person. Common compulsions include repeatedly washing one's hands, bathing or cleaning household items, often for hours at a time; checking and re-checking, several to hundreds of times per day, that the doors are locked, stove is turned off, hairdryer is unplugged, etc., unable to stop repeating a name, phrase or tune, an excessive, methodical, and painstakingly slow approach to daily activities, and hording such as saving useless items like old newspapers or magazines, bottle caps or rubber bands.
Obsessions and rituals can substantially interfere with a person's normal routine, schoolwork, job, family or social activities. Many hours of each day may be spent focusing on obsessive thoughts and performing rituals, and normal concentration and the performing of daily functions becomes very difficult.
Children can also suffer from OCD, but unlike adults, children with OCD do not realize that their obsessions and compulsions are excessive and ritualistic.
Phobias: Specific phobias are characterized by strong, irrational, involuntary fear reactions to a particular object, place or situation. The reactions to these fears lead the individual to dread confronting common, everyday situations, or avoid them altogether, even though they logically know there isn't any threat of danger. Symptoms of phobias include heights, flying in airplanes, insects, snakes and other animals, dental procedures, thunder, public transportation, and elevators. The fear doesn't make any sense, but nothing seems to be able to stop it. When confronted with the feared situation, someone with a phobia may even have a panic attack.
Diagnosis
Generalized Anxiety Disorder (GAD): GAD diagnosis is when an individual spends at least six months worried excessively about everyday problems. However, incapacitating or troublesome symptoms warranting treatment may exist for shorter periods of time.Panic disorder: Panic disorder (or panic attack) is diagnosed by either four attacks within four weeks or one or more attacks followed by at least a month of persistent fear of having another attack. Also, a minimum of four of the symptoms listed for panic disorders developed during at least one of the attacks. Most panic attacks last only a few minutes and up to an hour in rare cases. They can occur at any time, even during sleep.
Phobias: Phobia present with extreme anxiety with exposure to the object or situation. The individual recognizes that his or her fear is excessive or unreasonable, and finds that normal routines, social activities, or relationships are significantly impaired as a result of these fears.
Obsessive-compulsive disorder (OCD): A mental health professional will diagnose obsessive-compulsive disorder after a thorough evaluation. Criteria are based upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), a clinical book of mental illness diagnoses. OCD diagnosis is based upon recurrent and persistent thoughts, impulses or images that are intrusive and cause distress, thoughts that aren't simply excessive worries about real problems, an attempt to ignore or suppress these thoughts, images or impulses, and the recognition that these thoughts, images and impulses are a product of the mind.
Compulsions must meet specific criteria including repetitive behaviors, such as hand washing, or repetitive mental acts, such as counting silently, that the individual feels driven to perform. These behaviors or mental acts are meant to prevent or reduce distress about unrealistic obsessions.
Post traumatic stress disorder (PTSD): Although many of the symptoms of PTSD may be an appropriate initial response to a traumatic event, they are considered part of a disorder when they persist beyond three months.
Complications
Anxiety can also worsen many pre-existing medical conditions, such as ulcers, hypertension (high blood pressure), asthma, and chronic obstructive pulmonary disease (COPD). Anxiety may also be associated with mitral valve prolapse (condition where the mitral valve does not close properly), chronic fatigue syndrome (CFS), sleep apnea, irritable bowel syndrome (IBS), and chronic (long-term) tension headaches.Depression: Anxiety and depression usually go hand in hand, in both the young and old. The combination of depression and anxiety may increase both substance abuse and suicide.
The lifetime risk for depression in people with anxiety disorders may be higher than 70%. Most patients with generalized anxiety disorder (GAD) will experience at least one episode of significant depression and many develop recurrent episodes. In patients with both disorders, GAD usually precedes the onset of depression. Social anxiety during adolescence or young adulthood has been associated with a higher risk for depression, and the presence of both increases the chances for severe depression. People with post traumatic stress disorder (PTSD) are four to seven times as likely to be depressed as are people without PTSD.
Bipolar Disorder: Symptoms of panic disorder are very common in people with bipolar disorder (manic-depression). In fact, people with bipolar disorder have 26 times the rate of panic disorder as in the general population. To complicate matters, anxiety can worsen bipolar disorder.
Suicide: Anxiety disorders may also contribute to an increased risk for suicide, developing alcoholism and other forms of substance abuse, overeating, may have very negative effects on work, school, and relationships, and decrease the individuals overall health.
Physical injury: Individuals with obsessive-compulsive disorder (OCD) may experience physical injury such as skin problems from excessive washing, injuries from repetitive physical acts, and hair loss from repeated hair pulling (trichotillomania). Studies have reported that PTSD may be associated with shrinkage in the brain associated with memory and learning, possibly due to the continued release of the stress hormone cortisol.
Physical Effects of Anxiety on Children: Anxiety may be associated with a higher risk for sleep disorders in children, such as frequent nightmares, restless legs syndrome (RLS), and bruxism (grinding and gnashing of the teeth during sleep).
Treatment
Psychotherapy techniques:Generally, anxiety disorders are treated with medications, specific types of psychotherapy, or both. Treatment choices depend on the symptoms and the preference of the doctor and patient.
Psychotherapy: Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what causes an anxiety disorder and how to deal with its symptoms.
Cognitive-Behavior Therapy (CBT): Many therapists use a combination of cognitive and behavior therapies, this is often referred to as CBT. Cognitive-behavioral therapy is based on the scientific fact that thoughts cause feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that an individual can change the way they think to feel and act better even if the situation causing the problem does not change.
Relaxation Techniques: Relaxation Techniques help individuals develop the ability to more effectively cope with the stresses that contribute to anxiety, as well as with some of the physical symptoms of anxiety. The techniques taught include breathing re-training and exercise.
Anti-anxiety medications:
Benzodiazepines: Benzodiazepines are fast-acting sedatives that typically relieve anxiety symptoms within 30 minutes to one hour. The rapid relief when using benzodiazepines makes them very effective when taken during a panic attack or another overwhelming anxiety episode.
Unfortunately, benzodiazepines can be addictive. If taken regularly for more than a couple of weeks, physical and psychological addiction is likely to occur. Benzodiazepine may create tolerance, with larger doses needed to achieve the same effect, and serious withdrawal symptoms can occur when going off the medication, including increased anxiety, depression, and insomnia. Some benzodiazepines, including diazepam (Valium®) have a longer half-life in the body, meaning they stay in the body longer. The addictive potential is why benzodiazepines are usually recommended only for short-term. To minimize the withdrawal reaction, it is important to slowly taper off these medications.
Some examples of benzodiazepines include alprazolam (Xanax®), chlordiazepoxide (Librium®), clonazepam (Klonopin®), clorazepate (Tranxene®), lorazepam (Ativan), oxazepam (Serax), diazepam (Valium). Clonazepam (Klonopin®) is commonly used for social phobia and GAD, lorazepam (Ativan®) is used for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and generalized anxiety disorder (GAD).
Most common side effects include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat.
Azapirones: Azapirones were developed more recently than benzodiazepines, and are anti-anxiety drugs prescribed for GAD and obsessive compulsive disorder (OCD). Compared to benzodiazepines, the azapirones are slow acting, taking from two to four weeks to provide anxiety symptom relief. Advantages of these drugs over benzodiazepines include less sedation and effects on coordination, and less memory impairment. Withdrawal effects with azapirones are minimal compared to benzodiazepines. Buspirone (Buspar®) is the only azapirone approved for medical use.
Side effects may include nausea, headaches, dizziness, drowsiness, upset stomach, constipation, diarrhea, and dry mouth. Azapirones are not to be taken with monoamine oxidase inhibitors (MAOIs, a type of antidepressant) due to the increase risk of life-threatening high blood pressure.
Antidepressant medications:
Selective serotonin reuptake inhibitors (SSRIs): SSRIs are antidepressants that alter the levels of the neurotransmitter serotonin in the brain. SSRIs have been used to treat panic disorder, obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD). They are often prescribed because they have less severe side effects than the older antidepressants.
Some SSRIs used in anxiety disorders include fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) which are commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. SSRIs generally are started at low doses and gradually increased until they have a beneficial effect.
Tricyclic antidepressants (TCAs): TCAs are older antidepressants that may be prescribed for panic disorder, obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD). Tricyclics can also be prescribed for anxiety disorders co-occurring with depression. The tricyclics typically take around two weeks to provide symptom relief.
Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.
Monoamine oxidase inhibitors (MAOIs): MAOIs are the oldest class of antidepressant medications.
The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia.
Atypical antidepressants:
There are several newer atypical antidepressants which target other neurotransmitters either alone or in addition to serotonin. Some of the brain chemicals they affect include norepinephine and dopamine.
Venlafaxine (Effexor®), an atypical antidepressant, is used to treat GAD.
Antidepressants take up to four to six weeks to begin relieving symptoms, so they aren't helpful if first taken during a panic attack.
Antidepressants are often prescribed instead of benzodiazepines because the risk for dependency and the abuse is less.
Antidepressant can cause loss of sexual desire, nausea, insomnia, sweating, nervousness, dizziness, weight gain or weight loss, dry mouth, constipation, and blurred vision. MAOIs also have severe interactions with certain foods, drinks, and medications. When an individual takes an MAOI, he or she must carefully monitor what is eaten and what drugs are taken. Items that are restricted include many cheeses, chocolate, wine, and beer.
Beta-blockers:
Beta blockers are type of drug used to treat high blood pressure and heart problems. In anxiety, beta blockers can help control physical symptoms such as nervousness, rapid heart rate, trembling voice, sweating, dizziness, and shaky hands. Beta blockers are prescribed off label for anxiety.
Because they don't affect the emotional symptoms of anxiety such as worry, beta blockers are most helpful for phobias, particularly social phobia and performance anxiety (such as a speech or being in front of an audience).
Examples of beta blockers include propranolol (Inderal®), metoprolol (Lopressor®) and atenolol (Tenormin®).
Side effects include light-headedness, sleepiness, short-term memory loss, unusually slow pulse, fatigue, insomnia, diarrhea, cold hands and feet, and sexual side effects.
Integrative therapies
Strong scientific evidence:Kava: Kava kava (Piper methysticum) is a shrub from the South Pacific islands that has been used for centuries to produce calming effects in humans. Studies have found moderate benefit of kava in the treatment of anxiety, and preliminary evidence suggests that kava may be equivalent to benzodiazepine drugs such as diazepam (Valium®). In one human study, kava's effects were reported to be similar to the prescription drug buspirone (Buspar®) used for generalized anxiety disorder (GAD). However, a recent study found no effect in generalized anxiety disorder. The kava supplement should be standardized for best results.
There is concern regarding kava's potential toxicity, based on multiple reports of liver damage in Europe and a number of cases in the United States, including hepatitis, cirrhosis, and liver failure. The U.S. Food and Drug Administration (FDA) has issued warnings to consumers and physicians. Kava should not be used in individuals with pre-existing liver conditions or a history of alcohol or drug abuse. Caution is advised when taking kava as numerous adverse effects including sedation and drug interactions are possible. Kava should not be used if pregnant or breastfeeding.
Music therapy: Music is an ancient tool of healing. Many different forms of music intervention have been used to reduce anxiety in a variety of medical conditions and medical procedures. Most studies have positive findings, although not all do. There is evidence that music interventions help reduce anxiety related to cataract surgery, sigmoidoscopy, bronchoscopy, breast biopsy, cesarean delivery, colonoscopy, esophagogastroduodenoscopy, cardiac catheterization, hospitalized asthmatic patients, psychotherapy, general medical procedures, radiation therapy, treatment for acute myocardial infarction, preparation for surgery, total knee arthroplasty, ventilator-dependence and transurethral resection of the prostate (TURP). Many of these studies have found reduced blood pressure and heart rate as well. A minority of studies found no benefit including studies related to mammogram, ischemic heart disease, pediatric outpatient surgery, and cardiac catheterization. The choice of music may be a factor in outcomes: listening to music of one's preference has been found to be an important consideration. Overall, the evidence favors use of music interventions for anxiety, although more studies are needed to determine what forms work best.
Good scientific evidence:
Aromatherapy: Fragrant oils have been used for thousands of years. Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Several small studies report that lavender essential oil aromatherapy is able to cause reductions in anxiety levels. Additionally, rosemary (Rosmarinus officinalis) essential oil is frequently used in aromatherapy for treatment of a variety of conditions, including anxiety. Early study has shown benefit in reducing stress levels and increasing alertness. More study is needed to draw a firm recommendation. The use of aromatherapy for anxiety disorders needs more research.
Art therapy: Art therapy may enable the expression of inner thoughts or feelings when verbalization is difficult or not possible. Some evidence suggests that creative expression programs in schools involving art therapy may help alleviate problems of self-esteem and can improve social functioning in school age children. However, there is some evidence suggesting that art therapy may not benefit children with PTSD symptoms. Limited evidence suggests that art therapy, in the context of group psychotherapy, may contribute to reduction of symptoms of emotional distress in military personnel receiving mental health treatment.
Hypnosis: Hypnosis is associated with a deep state of relaxation. Several studies support the use of hypnosis to reduce anxiety, particularly prior to dental or medical procedures, or in the management of phobias. Early evidence suggests that these effects may last for up to three years with benefits reported in children and adults.
Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). Psychotherapy, especially cognitive behavioral therapy, may help decrease the symptoms of anxiety disorders when used along with medications, including GAD, OCD, panic disorder, and PTSD.
Relaxation therapy: Clinical studies suggest that relaxation techniques may be beneficial in patients with anxiety, although these approaches do not appear to be as effective as psychotherapy. Numerous human studies report that relaxation techniques (for example using audio tapes or group therapy) may moderately reduce anxiety, particularly in individuals without significant mental illness. Relaxation may be beneficial for phobias such as agoraphobia (fear of crowds), panic disorder, work-related stress, and anxiety due to serious illnesses, prior to medical procedures, or during pregnancy. However, there are many types of relaxation techniques used in studies, and many trials do not clearly describe design or results.
Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Yoga may reduce daily stress and anxiety in healthy people when practiced several times weekly. Several human studies support the use of yoga therapy in the treatment of clinical anxiety disorders, including generalized anxiety and OCD. Available data remains inconclusive, yet thousands of years of effectiveness in India for stress and anxiety must be appreciated.
Unclear or conflicting scientific evidence:
Acupressure: Acupressure, or shiatsu, has been used in China for thousands of years for health and healing. Preliminary clinical trials suggest that acupressure may significantly reduce general and pre-operative anxiety. However, these studies have been small and poorly designed, warranting better-quality research.
Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. Several studies have reported benefits in anxiety disorders, but the studies have been small and poorly designed, leaving the scientific evidence on acupuncture use in anxiety inconclusive.
Bacopa: Bacopa (Bacopa monnieri) is commonly called "brahmi" and is used in the Ayurvedic system of medicine in India. Although bacopa is traditionally used for anxiety, high-quality clinical trials are lacking. The one weak study below found some evidence that bacopa reduces clinical anxiety. However, more independent research is needed. Caution is advised when taking bacopa supplements as numerous adverse effects including heart palpitations are possible.
Gotu kola: In the traditional Indian system of Ayurvedic medicine, gotu kola is said to develop the crown chakra, the energy center at the top of the head, and to balance the right and left hemispheres of the brain. It has traditionally been used by yogis as a food for meditation. Animal research has demonstrated anxiolytic (anxiety reducing) properties of gotu kola, but human studies are lacking. A single randomized trial assessing the effects of gotu kola on startle responses in healthy (non-anxious) individuals has reported some benefits. These preliminary findings are promising, although further research should be performed. Gotu kola is not related to the cola nut, and does not contain caffeine. Gotu kola is generally reported as safe when used in humans for short term use.
Guided imagery: Guided imagery may include a number of techniques, such as metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Initial evidence suggests that guided imagery relaxation audiotapes may reduce anxiety after surgeries, and may improve healing. More studies are needed.
Healing touch (HT): Preliminary data from an uncontrolled trial suggests HT may help reduce symptoms of PTSD in women. More studies are needed.
Lemon balm: Preliminary human evidence has been published that supports the use of lemon balm (Melissa officinalis) for anxiety. In a large case series that included 1,599 patients with symptoms of anxiety, a combination of lemon balm and valerian (Valeriana officinalis) was found to improve symptoms of anxiety, including nervousness, fatigue, and sleep disturbances in over 90% of the patients. Although only mild side effects were reported, caution is advised when taking lemon balm supplements as numerous adverse effects including drowsiness and drug interactions are possible.
Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Several human trials have assessed the effects of massage in patients with anxiety, including those with cancer or chronic illnesses, hospitalized for psychiatric disorders, pre-operative anxiety (anxious about themselves or for family members having surgery), dementia, multiple sclerosis, before/during medical procedures, depressed adolescent mothers, women with premenstrual syndrome, patients with fibromyalgia and in elderly institutionalized patients. Additional research is necessary in order to form a scientifically based recommendation.
Meditation: Various forms of meditation, including mindfulness, transcendental meditation®, and "meditation-based stress reduction programs" have been studied for their effects on anxiety. Better studies are needed.
Qi gong: Qi gong is a type of Traditional Chinese Medicine (TCM) that is thought to be at least 4,000 years old. Preliminary study shows that Qi gong may be beneficial for relieving stress. Available data remains inconclusive, yet thousands of years of effectiveness in China for stress and anxiety must be appreciated.
Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. There is preliminary evidence that reflexology may be useful for relaxation and to decrease anxiety. However, it is not clear that reflexology is equivalent or superior to massage or other types of physical manipulation. Better research is needed in this area.
Therapeutic touch: Results of different studies do not agree with each other, and therefore it is currently unclear if therapeutic touch is a useful anxiety treatment. Some trials report benefits, while others find no effects. Also, there is early evidence that therapeutic touch may reduce anxiety in children with life-threatening illnesses, reduce stress in teenagers with psychiatric disease, and help relax premature infants. Most studies have not been well designed, and better research is necessary in order to draw firm conclusions.
Valerian: Valerian (Valeriana officinalis) has traditionally been used for sleep improvement and for stress and anxiety. Studies have generally been of poor methodological quality, and several have used valerian in combination with other herbs, such as passion flower (Passiflora incarnata), lemon balm (Melissa officinalis), and St. John's wort (Hypericum perforatum). Studies report that valerian is generally well tolerated for up to four to six weeks in recommended doses. Caution is advised when taking valerian supplements as numerous adverse effects including drowsiness, sedation, and drug interactions are possible. Do not use valerian if pregnant or breastfeeding.
Prevention
Diet: Nutritional deficiencies originating from poor diet and/or digestion have been found to contribute to anxiety. Adequate levels of minerals such as magnesium and zinc, as well as sufficient intake of B vitamins, especially vitamin B-12, may be beneficial for treatment and prevention of anxiety disorders. It is also important for patients to eat a well-balanced diet and to reduce or eliminate caffeine and alcohol.Exercise: The benefits of regular exercise are relevant for many different conditions. Patients with anxiety disorders may benefit from introduction of exercise into their daily schedule.
Substance abuse counseling: Some prescription and non-prescription substances may cause symptoms of anxiety, including caffeine, nicotine, and other stimulants, drugs such as heroin, cocaine, and amphetamines, and some herbal supplements such as ephedra (no longer available on the U.S. market), Citrus aurantium, yerba mate tea, and guarana.
Sleep: Adequate sleep is important for many different conditions. Patients with anxiety are advised to get enough sleep every night.
Stress reduction: Relaxation methods help individuals develop the ability to more effectively cope with the stresses that contribute to anxiety, as well as with some of the physical symptoms of anxiety. Techniques such as guided imagery, Qi gong, meditation, relaxation therapy, and music therapy may be helpful for prevention of anxiety.
Author information
Natural Standard is an international research collaboration that aggregates and synthesizes data on complementary and alternative therapies. Using a comprehensive methodology and reproducible grading scales, information is created that is evidence-based, consensus-based, and peer-reviewed, tapping into the collective expertise of a multidisciplinary Editorial Board. The mission of this collaboration is to provide objective, reliable information that aids clinicians, patients, and healthcare institutions to make more informed and safer therapeutic decisions. Natural Standard is widely recognized as one of the worlds premier sources of information in this area.Bibliography
Anxiety Disorders of America. www.adaa.org
Mental Health America. www.nmha.org
National Institute of Mental Health. www.nimh.nih.gov
Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com. Copyright © 2008.
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Natural Standard Bottom Line Monograph, Copyright © 2009 (www.naturalstandard.com). Commercial distribution prohibited. This monograph is intendedfor informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions.
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