Anxiety: Prevention and Complementary Therapies

Taken from some online continuing education material on Medscape, I think that this is a great summary of therapies for anxiety that can be utilized at home.

From MedscapeCME Pediatrics
Anxiety: Prevention and Complementary Therapies for Children and Adolescents
Kathi J. Kemper, MD, MPH

Prevalence

Anxiety disorders, including panic attacks, phobias, separation anxiety, social anxiety, obsessive-compulsive disorder, generalized anxiety disorder, and PTSD, affect about 1 in 10 children and nearly 1 in 3 adults. The annual adult prevalence is 13% to 18%, with rates in women twice as high as rates in men. Anxiety is more common than attention-deficit/hyperactivity disorder, autism, or schizophrenia.

Definition

Fear occurs in response to a specific threat, whereas anxiety is a general feeling or a response to an uncontrollable or unavoidable stress. Anxiety is an unpleasant emotional, cognitive, and physiologic state. Physical symptoms include stomach aches, headaches, sweating, jitteriness, trembling, restlessness, dizziness, palpitations, dry mouth, lump in the throat, shortness of breath, chest pain, nausea, aches and pains, numbness or tingling in the fingers or toes, hot flushes, and cold sweats; anxious people may tire easily or feel fatigued, sleep poorly, have trouble concentrating, or feel restless, tense, or irritable. Some have trouble concentrating or remembering things, while others cannot stop thinking about their worries. No specific brain imaging, blood tests, assays, or other objective physiologic measures are diagnostic for anxiety. Medical evaluations help rule out other conditions that mimic anxiety such as hypoglycemia, thyroid conditions, asthma, hypoxia, cardiac arrhythmias or other cardiac problems, cancer, autoimmune disorders, allergies, reflux, gluten-sensitive enteropathy, and seizure disorders.
Consequences of Anxiety
Anxiety is not only uncomfortable; it can be disabling. Social anxiety can prevent people from attending social events or even venturing out to work or school. The unpleasant sensations associated with anxiety may mimic serious medical disorders and lead to costly and invasive evaluations. Trying to dull the pain of anxiety can lead to smoking, drinking, and drug abuse. Using prescription anxiety medications chronically can result in addiction or dependence.
Treatments

Medications

Medications and cognitive-behavioral therapies can be effective treatments for anxiety disorders. However, the focus of this review is complementary therapies because they are so commonly used and because clinicians have often not received formal training about them. The most commonly used lifestyle and complementary therapies reported by patients suffering from anxiety include:
• Stress management practices;
• Exercise;
• Nutrition;
• Dietary supplements, including vitamins, minerals, and herbs;
• Environment -- more music and nature, less upsetting TV and radio;
• Eye movement desensitization and reprocessing (EMDR; this has become a fairly mainstream therapy and will be covered only briefly here);
• Cranial electrostimulation;
• Massage;
• Therapeutic touch, healing touch, and Reiki; and
• Acupuncture.
To counsel patients responsibly about the potential benefits and risks of these therapies, clinicians need evidence-based information.

Managing Stress

Because stress is the most common trigger for anxiety, stress management practices provide an important foundation for effective lifestyle interventions to help manage anxiety. No single stress management technique works for all people. A large repertoire of effective stress management techniques are available to assist in lowering baseline stress and recovering from stressful events quickly and skillfully. Regular exercise, restful sleep, a calm, supportive environment, and optimal nutrition can help decrease stress and are discussed separately. This section focuses on emotional, mental, and spiritual stress management practices. Meditation, relaxation exercises, guided imagery, self-hypnosis, autogenic training, biofeedback, journaling, and prayer have all proven helpful.
Practice, warm-up, and coaching are important elements of all stress management programs, just as they are with athletic or musical training. Developing and strengthening any kind of skill takes practice. Practice means that these techniques are most effective if used on a regular basis, not just when stress occurs. Similarly, warming up or using a stress management skill in anticipation of a stressful event is usually more effective than waiting until a stress has occurred. Finally, as with musical or athletic skills, performance can be enhanced with good coaching. In the case of stress management skills, coaches could be meditation teachers, pastoral counselors, psychologists, social workers, or primary care clinicians.

Meditation
The word "meditation" comes from the same root as the word medicine. There are many kinds of meditation practice, but they can be summed up as: paying attention on purpose (or intentional attention). Recent studies have demonstrated that meditation practice may have profound and sustained benefits for children, teens, and adults. The 2 major kinds of meditation are:
• Concentration (focusing on a thought, word, phrase, emotion, action. or object); and
• Mindfulness (nonjudgmental moment-to-moment awareness of sensations, emotions, and thoughts).
Concentration and mindfulness may ease anxiety when practiced regularly.[1-5] The usual practice is 10-30 minutes once or twice daily. Many major medical centers offer training in concentration-type (such as Harvard's Benson-Henry Institute for Mind-Body Medicine) or mindfulness-type (such as the University of Massachusetts Center for Mindfulness in Medicine, Healthcare and Society) meditation. These programs and Dr. Jim Gordon's Center for Mind-Body Medicine also offer books, CDs, and other resources for clinicians and patients interested in meditation as a stress management skill.

Relaxation Training
Progressive muscle relaxation is a technique in which muscle groups are intentionally tensed and then relaxed. Intentionally contracting muscles and then relaxing them leads to greater relaxation than simply telling oneself to relax. Regular practice can reduce anxiety.[6,7] Training and videos on this stress management technique are available through groups such as the Mayo Clinic, which offers several DVDs in conjunction with Gaiam.
Guided Imagery/Self-Hypnosis
Three particular guided imagery techniques are particularly helpful for enhancing a sense of safety, security, and greater calm: Safe Place, Wise Guide, and Caring Circle. The Safe Place guided imagery helps patients experience a real or imagined place in which they are completely safe, either alone or with real or imagined characters who are reassuring. The Wise Guide technique encourages patients to access inner sources of wisdom and strength through an imagined wise guide. The Caring Circle technique helps a patient imagine they are surrounded by caring, supportive beings that have their best interest at heart. Clinicians can learn to provide these kinds of guided images through workshops sponsored by the American Society for Clinical Hypnosis or the Society for Developmental and Behavioral Pediatrics. Patients may also be referred to psychologists, social workers, or other health professionals skilled in teaching these techniques. Guided imagery CDs and MP3 files to help manage stress and anxiety are available through several companies.

Autogenic Training
Autogenic training is a self-hypnosis technique developed by the German psychiatrist Johannes Schultz in 1932. The training consists of learning to repeat a set series of phrases such as: "My arms and hands are heavy and warm; my legs are heavy and warm; my heartbeat is calm and regular; my forehead is cool; my breathing is easy." Typically, each phrase is slowly repeated 3 times before going to the next phrase.
Repeating these phrases for 10-15 minutes can lead to a profound sense of calm and relaxation, improve sleep, and reduce reactivity to stress.[8-10]

Biofeedback
Biofeedback can help reduce anxiety and enhance sleep.[11] A variety of devices are available for home use. Devices can give feedback about temperature (raising hand or finger temperature promotes relaxation), breathing (slower is more peaceful), muscle tension (relaxing muscles leads to a sense of calm), and heart rate variability (certain patterns are associated with greater calm and even serenity). Computer-based biofeedback programs (such as Healing Rhythms® [Wild Divine, San Diego, California] and emWave® PC [HeartMath LLC, Boulder Creek, California]) are available for home use by both children and adults. Newer portable devices (emWave® PSR, HeartMath LLC) are also available.

Prayer and Participation in Religious Community
Prayer for help, guidance, direction, and support or even simple prayerful repetitions of a spiritually significant word can offer tremendous comfort and effectively ease anxiety.[12] Prayers of gratitude promote a sense of security and trust. Participation in a spiritual or religious community and pastoral counseling can also offer solace and support.[13-16] The type of religion appears to be less important than regular activity and participation.

Journaling
Regularly writing about the day's events and concerns is another helpful and inexpensive stress management strategy. There is some controversy about whether it is more helpful to write about positive events (a gratitude journal) or negative events, and there is likely to be some individual variability in response to this exercise.[17] Some psychologists recommend combining journaling with creative writing, encouraging patients to develop a "new ending" for fearful situations.[18]

Exercise

Regular exercise lowers stress hormone levels. Studies indicate that exercise may help reduce anxiety and panic attacks.[19,20] Both aerobic conditioning and weight training are helpful. Exercise combined with breathing exercises and meditation, such as Tai Chi, Qigong, and yoga, seem to be particularly effective in reducing stress and anxiety.[21-23]

Nutrition

Clinicians should encourage patients to eat breakfast and avoid skipping meals to ensure stable blood sugar. Avoid high glycemic index foods, focusing instead on whole grains, fruits, vegetables, and healthy proteins and fats. For some sensitive people, artificial flavorings (MSG), colorings, and sweeteners may be linked to anxiety. A careful dietary and symptom diary can help sort out dietary triggers. For people who seem to be sensitive to more than one food, a short trial (2-4 weeks) of a diet eliminating foods that commonly cause trouble (such as gluten, dairy, soy, seafood, eggs, and nuts) may be worthwhile to see how well symptoms abate without them, gradually adding them back as tolerated.[24]
Counsel patients to avoid using toxins such as tobacco and alcohol; both are common self-management strategies for anxiety, but both can lead to devastating physical, mental, and social consequences.
For patients who take vitamins, counsel against taking large doses of niacin without other B vitamins; niacin can lead to flushing and feeling anxious. For patients who use niacin to help manage cholesterol, slow-release forms can offer similar effectiveness without the flushing.
Advise patients to reduce caffeine intake because caffeine can mimic symptoms of anxiety. A good substitute is decaffeinated green tea, which contains theanine; theanine may help promote a sense of calm and may also reduces stress.[25,26]

Vitamins, Minerals, and Other Dietary Supplements
Before entering a discussion about vitamins, minerals, fish oils, and herbal products, healthcare providers should impress on patients and caregivers that the quality of supplements can often vary from manufacturer to manufacturer and even from batch to batch.
When patients and caregivers do ask about the products, the following information can help the healthcare provider respond.
Vitamins. Multivitamins may reduce anxiety and stress, even in healthy young adults who appear to be well-nourished.[27,28] B vitamins are often marketed to help reduce stress, and several are important cofactors in the production of neurotransmitters that are essential to maintaining a sense of calm. For example, vitamin B6 is essential in metabolizing tryptophan to serotonin. Inositol in doses of 12-18 g daily has been helpful in several preliminary studies for people suffering from obsessive-compulsive disorder and panic attacks.[29-31] Vitamin C may also help reduce the subjective sense of stress[32]; adult supplements generally range from 500 to 1000 mg daily. Vitamins B and C are water soluble and readily excreted; toxicity is uncommon. Excessive vitamin C can cause diarrhea.
Minerals. Deficiencies of calcium, magnesium, iodine, selenium, and iron are associated with stress, insomnia, and anxiety.[33] Approximately half to two thirds of American children and adolescents do not meet their recommended intake for calcium.
• Many anxiety sufferers have low magnesium levels. At least 1 study has suggested that supplemental magnesium can help ease anxiety.[34] Magnesium-rich foods include dark green leafy vegetables, beans and bean products, seeds, soybeans, nuts, whole grains, shellfish, and citrus fruits. Although some patients take a calcium/magnesium combination, absorption is improved if magnesium is not taken at the same time as iron or zinc supplements. Magnesium supplements are generally safe; excessive doses can cause diarrhea.
• Iodine deficiency and selenium deficiency can impair thyroid function, which is associated with anxiety.[35-37] Advise patients to ensure that the salt they use at their own table is iodized and that they regularly eat ocean fish or ocean vegetables (seaweed) and garlic to prevent deficiencies.
• Iron deficiency can contribute to a sense of stress and feeling overwhelmed.[38] Iron deficiencies are most common in young children, vegetarians, and women who lose iron in their monthly menstrual cycles. Excessive iron is not helpful in reducing anxiety and can cause cardiac and hepatic toxicity.
Clinically, it is prudent to ensure that patients consume a diet rich in vitamins and minerals and, if they are deficient, that deficiencies be corrected through supplementation.
Other dietary supplements. Fish oil contains the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Fish oil supplementation is linked to decreased aggression and anxiety in people who are stressed and in those with alcohol and drug problems.[39,40] Fish oil supplements are generally well-tolerated, particularly the newer formulations that are molecularly distilled (minimizing the fishy taste and belching associated with older formulas). Testing of some products has revealed no significant contamination with mercury, dioxins, or other contaminants in molecularly distilled fish oil products. Clinicians can also consider encouraging patients to eat fish rich in omega-3 fatty acids and low in mercury, PCBs, and dioxin (such as sardines, herring, salmon, or mackerel) twice weekly,[1] or to consider a supplement containing between 500 and 3000 mg of omega-3 fatty acids.
GABA is an amino acid and an important neurotransmitter linked to feeling calm. Although we have historically believed that little GABA crosses the blood-brain barrier, some research suggests that GABA supplements may boost GABA levels in the brain, promoting relaxation and easing anxiety.[41] There is likely to be substantial individual variability in response to GABA supplements, but they generally appear to be safe.
Tryptophan and 5-HTP supplements are amino acid precursors to serotonin and melatonin. Supplementation with 200 mg of 5-HTP has effectively reduced symptoms for patients suffering from panic disorder.[42,43] For patients with obsessive-compulsive disorder whose symptoms had not improved with medications alone, tryptophan supplements have provided relief.[44,45] Side effects are uncommon, but some patients have more aggressive feelings and behavior when they start tryptophan supplements.
Herbs. Mildly sedative herbs such as chamomile, hops, lemon balm, passion flower, and valerian may help promote sleep, relaxation, and reduced stress.[46-53] These herbs are generally safe; allergies are possible but uncommon. However, because some of these herbs can cause sleepiness, advise patients not to take them just before driving, taking an exam, or working with dangerous devices.
Brahmi or bacopa monnieri is a traditional remedy from India used to treat anxiety. A few small studies support its benefits for calm and clarity[54]; serious side effects have not been reported. However, safe, reliable supplies of high-quality bacopa may be difficult to find in the United States.
While most people think of ginkgo as a memory enhancer, some research suggests 240-480 mg daily of the European ginkgo product EGb 761 can also help anxious adults feel more calm.[55] However, ginkgo may cause bleeding problems, particularly in patients taking medications that affect clotting; avoid ginkgo for patients taking anticoagulant medications and those who have a bleeding diathesis.
Kava kava (Piper methysticum) is a traditional Polynesian herb that has been used to treat anxiety and stress-related insomnia.[56,57] However, its severe hepatotoxic side effects (including liver failure and death) have curtailed recent use.[58-60] For patients who continue to use kava despite warnings about toxicity, it is prudent to monitor liver function closely.
Lavender is used mainly as aromatherapy to reduce agitation, restlessness, nervousness, or stress and to promote relaxation and sleep.[61-66] It is used in some hospitals and hospice centers as a safe, low-cost strategy to decrease anxiety and improve a sense of well-being.
Rhodiola or arctic root is a Russian remedy used to reduce anxiety, improve the ability to cope with stress, and as a general tonic. A UCLA study showed that 340 mg of rhodiola supplements daily helped reduce anxiety in patients diagnosed with general anxiety disorder.[67] Rhodiola is generally safe, but as with all herbal products, some people get an upset stomach and a few have allergic reactions.
St. John's wort is used to treat anxiety as well as depression. Results of clinical studies have been mixed; it appears to be more helpful for those with mild symptoms than those suffering from severe anxiety, obsessive-compulsive disorder, or panic attacks.[68-70] Typical adults doses are 900 mg daily. Although it generally has fewer side effects than medications, St. John's wort can negatively affect the effectiveness of many other medications, including oral contraceptive pills. St. John's wort can also trigger manic symptoms in patients with bipolar disorder.

Environment

Simple environmental measures such as listening to music, spending more time in nature, and minimizing exposure to upsetting media can also help reduce anxiety.
Music eases anxiety in people of all ages, including infants.[71,72] Music has been used in hospitals, surgery centers, dental offices, and airports to promote greater calm and confidence; it is also a part of most military traditions as an effective strategy to strengthen courage. Personal preference should generally guide musical choices; music designed to induce binaural beats, putting brain waves into delta or theta rhythms,[73-75] can be even more helpful in reducing anxiety than music without these tones. Nature sounds (waterfalls, ocean waves, crickets, bird song) can also be very soothing. Music is a safe, simple strategy to promote calm and courage; keep stress levels down (and ears safe) by keeping the volume down. Rousing marches and upbeat tunes are better choices for daytime, while soft, calm sounds are better for bedtime listening.
Few patients would invite a guest back into their home if he tried to induce terror, fear, or anxiety. Yet, the media do this daily. The "if it bleeds, it leads" philosophy has affected not only the evening news but also many dramatic shows. In the most extreme cases, PTSD can occur, not just in people who directly experience a life-threatening event, but those who watch such events repeatedly on TV.[76] Encourage patients to be as mindful of their use of media as they are of what they eat, drink, and breathe. It may be particularly useful to avoid watching upsetting news or programming within the hour before bed.

Eye Movement Desensitization and Reprocessing

Another effective therapy for anxiety, particularly PTSD, is called eye movement desensitization and reprocessing (EMDR). EMDR has become fairly widespread based on the results of a handful of controlled trials.[77-79] For example, one study showed that EMDR had better lasting benefits than medications in treating PTSD.[80] It is usually covered by insurance when provided by a psychologist, physician, or licensed professional counselor.

Cranial Electrotherapy Stimulation

Cranial electrotherapy stimulation (or "electrosleep"; CES) was originally developed in Russia in the mid-20th century to promote sleep and relieve anxiety. CES devices provide very-low-intensity currents via electrodes attached to the skin of the earlobes or just behind the ears. They do not require surgery and do not send the kind of strong current used in electroconvulsive shock therapy or transcranial magnetic stimulation. The device is used 20-30 minutes daily for several days or weeks. Controlled studies from Russia and France, primarily done in the 1970s, linked CES stimulation to anxiety relief and better sleep.[81-86] Although CES has not caught on as a mainstream approach to managing anxiety in the United States, devices such as the Alpha-Stim® (Electromedical Products International, Inc., Mineral Wells, Texas) are available, although they require a prescription from a health professional. They cost several hundred dollars and are not typically covered by insurance plans. No serious adverse effects have been reported from using CES, but patients who have implanted pacemakers, defibrillators, or insulin pumps should avoid using them.

Massage

Therapeutic massage contributes to increased blood flow and lymphatic drainage, muscle relaxation, and stress reduction. Physiologically, massage seems to decrease cortisol levels and increase levels of serotonin and dopamine. Research supports the benefits of massage on sleep and reducing stress and anxiety.[86-92] Therapeutic massage is safe, even for small infants. Massage is generally safe if care is taken to avoid wounds, burns, intravenous lines, pumps, or other subcutaneous devices and vigorous strokes in patients with low platelet counts. Careful discussion and respect for individual patients is extremely important for patients with a history of physical or sexual abuse. Massage therapists are licensed as health professionals in most states, with strict requirements for training and continuing education. Although it can be very helpful, ongoing professional massage therapy can be costly and may not be reimbursed by insurance. Training a trusted family member or friend can enable patients to receive the benefits of regular massage within a budget.

Therapeutic Touch, Healing Touch, and Reiki

Therapeutic touch, healing touch, and Reiki are classified as biofield therapies by the National Institutes of Health's National Center for Complementary and Alternative Medicine. Although the mechanism for their effects remains a matter of speculation and dispute, research suggests that many patients find these therapies comforting and calming. Most of the studies evaluating them have been conducted in medical rather than psychiatric settings and have shown that they can help relieve anxiety and promote a sense of calm and well-being among patients with serious or life-threatening illnesses.[93-99] They are safe. When provided by licensed healthcare providers, these services may be covered by insurance.

Acupuncture

Although many people think of acupuncture as anxiety-provoking, it has actually proved to be a useful therapy in decreasing anxiety in both adults and children.[100-104] For example, acupressure and acupuncture are used to reduce the fear of dental, medical, and surgical procedures.[91,105-107] In one study, acupuncture also proved useful in treating PTSD.[108]
Acupuncture is generally safe, though minor bleeding and bruising are possible with any treatment involving needles. Acupuncture can cause sleepiness or deep relaxation; this may be of benefit for patients suffering from insomnia secondary to their anxiety.[109-115] Acupuncture needles are regulated by the US Food and Drug Administration, and most practitioners use disposable needles; this means that needles used in the United States must meet certain manufacturing and labeling standards, and that the risk of acquiring an infection from treatment are exceedingly low. In 2 studies that each examined over 30,000 acupuncture treatments, no serious adverse events were reported[116,117]; serious side effects are possible, but they are extremely rare.

Summary
Anxiety is common and can lead to significant disability, expensive medical evaluations, and long-term addictions to alcohol, tobacco, and drugs. Although the primary mainstream therapies are cognitive-behavioral therapy and medications, a number of natural therapies have both common sense and evidence-based benefits. Among the most helpful are mind-body stress management practices such as meditation and biofeedback, optimizing exercise and nutritional patterns, selective use of dietary supplements, attention to environment (more uplifting and calming music and nature and less frightening media exposure), cranial electrostimulation, and professionally provided therapies such as EMDR, massage, and acupuncture. Many families are already using these therapies to prevent or treat anxiety. Armed with this information, clinicians can provide appropriate, evidence-based advice, and researchers can evaluate those therapies of great public health importance.