Anxiety Disorder

Paul Reller, L.Ac.

Anxiety Disorder is now recognized as the most prevalent psychological problem in the United States, with the National Institute of Mental Health estimating that 40 million Americans today suffer from anxiety disorder. Although we all experience anxiety naturally, the mechanism of persistent unresolved anxiety is a problem that must be addressed therapeutically, and Complementary Medicine has much to offer in a safe, holistic package of care that involves the patient in a proactive approach to achieving natural control of this difficult psychoemotional syndrome. One key to any mental health issue is to first understand that a majority of the population suffers from these health issues and that there is no stigma attached. A second key to resolving the psychoemotional health problem is to first achieve understanding and objectivity in order to reclaim the innate control of our emotional balance and of the mind-body physical responses that get in the way of a healthy and productive life. Emotional responses are very subjective and hard to control, and time spent understanding that these responses are sometimes tied to tangible concrete physical problems, as well as behavioral and cognitive habits that are under your control, helps one to reestablish normal patterns of anxiety resolution.

Anxiety disorder is a combination of learned behavior and cognitive habits coupled with physiological problems in specific areas of the brain and metabolic concerns. It is a mind-body health problem that requires a holistic and thorough approach to fully restore healthy balance.

Much research has revealed that the basic problem in Anxiety Disorders is hyperexcitability in a part of the brain called the amygdala, which is located in the limbic system. This limbic part of the brain is well known as a coordinating center tied to emotional responses as well as the hypothalamic regulation of the neuroendocrine system. When persistent hyperexcitation occurs here this may lead to symptoms associated with the autonomic nervous system or the hormonal responses, and in the same way, when there is hormonal imbalance or autonomic pathology, the emotional excitation in the limbic system may be imbalanced and stressed. Today, doctors refer to this as the mind-body aspect of pathology, and it has been the chief cause of concern in the science of Traditional Chinese Medicine for many centuries. TCM has developed a holistic approach to restoring this mind-body coordination, and this approach has expanded greatly with greater access to research in herbal/nutrient chemistry and functional MRI studies with acupuncture stimulation.

Normally, our brain regulates excitation and inhibition shifts, which are often sudden with emotional stimulation, with a complex response of neurotransmitter production, especially with the neurotransmitter GABA. When the brain is not efficient in regulation of mood shifts, overwhelming symptoms of anxiety will occur, sometimes inexplicably. This is different from the normal fear or fright response, because the anxiety is often not a response to an event, and our coping mechanism is not effective in dealing with the anxiety response. Normal anxiety is directed outward to an object or event that we fear, but unhealthy anxiety is directed inward and tied to persistent worries and insecurities. In these cases, triggering of common anxiety will also trigger a persistent anxious reponse that requires a more complex coping response in our brains. We may have adopted bad habits with this coping mechanism that perpetuates anxiety, in much the same way that we adopt bad postural habits that perpetuate muscle strain and chronic pain. We often must both correct imbalances in the nervous system and correct improper behavior and cognitive habits to fully correct chronic anxiety disorder. This is an example of a mind-body approach to therapy.

Scientists that study Anxiety Disorder have found that anxiety may occur at three levels, the brain, the behavior, and the subjective experience or cognitive level. Resolution of Anxiety Disorder must occur at all three levels, which means that a holistic approach must be taken to therapy. Stimulation of the nervous system with acupuncture, and the taking of key herbal chemicals and nutrient building blocks to facilitate effective neurotransmitters, are proven therapies to effect the brain, but time spent discussing behavior and resolving cognitive problems is also important. The Licensed Acupuncturist often has both the skills to perform therapy and prescribe effective herbal and nutrient medicines, as well as to spend the time to discuss effective strategies to correct behavioral responses and examine the subjective experiences associated with confusing anxiety responses.

Emotional balance has always been an important point of study in TCM, and understanding how we use our various emotions to control and balance emotional response also helps us to exert conscious control over cognitive mechanisms that are usually subconscious. The foundation text of TCM, the Nei Jing de Huang Di, discusses the belief that emotional constraint is the chief underlying cause of internal disease, and discusses many strategies for restoring emotional homeostasis. This text extensively outlines the specific emotional ties to various physical organ systems in the body, matching emotional excesses to symptoms, and explaining how one emotion is generated to control another. The TCM physician may utilize all of this knowledge and various treatment skills to provide a comprehensive package of treatment that balances appropriate aspects of body physiology and cognitive emotional mechanisms. Modern research has also identified restraint as a key aspect in the pathophysiology of anxiety disorder. Physical restraint triggers a response that heightens the physiological responses measured in anxiety states, and similarly, psychological constraints are found to mimic this response, and create a sense of poor control of anxiety. Acupuncture stimulation has been proven to reduce these physiological dysfunctions in the anxiety state, and repeated acupuncture stimulation has been found to nurture a better learned response to these triggers.

Typical symptoms of anxiety include heart racing and palpitation, shortness of breath, feeling of dread, sweat in the palms, irritability, restless sleep, stomach upset, discomfort with swallowing, dizziness, headache, muscle tension, frequent urination, and occasional loose stool. Each patient may experience some but not all of these symptoms. Often, anxiety disorder accompanies chronic depression, but not always. Sometimes, the mild anxiety disorder suddenly becomes a more severe episodic panic attack. Related symptoms, such as visual disturbances, unusual sensitivity to smell and taste, and even tinnitus, may be caused by heightened sensitivity in sensory perception and autonomic nervous responses and adrenal stimulation. Often, there is no actual health problem in these sensory systems, but the unusual symptoms themselves contribute to the anxiety and anticipation of anxiety, and may become triggers of heightened anxiety and panic states. In like manner, the autonomic responses of heart racing and increased force of contraction, and respiratory responses, may be poorly controlled autonomic reactions and not signify actual problems with the heart or lungs, but these reactions often contribute to heightened fears and anxiety. By understanding the mechanisms of anxiety, taking an objective look at the problem, the patient is able to exert more control and is able to understand what specific therapies are needed to cure this disorder. The typical medical treatment utilizes benzodiazepines, such as Lorazepam or Ativan, sometimes with anti-depressant selective serotonin and norepinephrine reuptake inhibitors. This type of treatment is often effective in the short term, but long-term use of benzodiazepines often creates a decreased effectiveness and an alarming withdrawal syndrome when the patient and doctor decides that they are no longer effective or that the side effects outweigh the benefit.

Both benzodiazepine withdrawal and problems with stopping SSNRI medications have become a major concern with physicians around the world, and many books have now been written on these subjects. Patients and doctors are turning to Complementary and Integrative Medicine to help correct the underlying health problems as well as to facilitate a smooth withdrawal and alleviate side effects. Since uncontrolled anxiety, with physical manifestations of racing heart, high blood pressure, etc., is a key symptom of withdrawal from benzodiazepines and SSNRI medications, this presents a problem of drug dependancy for many patients and prescribing physicians. Acupuncture, herbal and nutrient medicine, and behavioral and cognitive stress reduction techniques are now acknowledged as effective parts of the integrative medical strategy for these withdrawal syndromes. Much evidence has been presented to prove that herbal chemicals do have a benzodiazepine-like effect, and that these herbal chemicals are safe and without side effects or dependancy. Herbal and nutrient medicine also provides an improved bioavailability of natural production of neurotransmitters, allowing the patient to correct metabolic deficiencies without taking synthetic substitutes for these chemicals in our brains. Anxyolitic, or anxiety-reducing, chemicals in herbs have been well documented, and the mechanisms of these various herbal chemicals have now been well studied to afford the patient and physician more information to effectively prescribe herbs and dosage.

Understanding the diagnosis in anxiety disorders

There are six major types of anxiety disorders, each with their own distinct symptom profile: generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, post-traumatic stress disorder, and social anxiety disorder. The underlying mechanisms, or pathophysiology, are very similar in these types of anxiety disorder, but the array of treatment options in the holistic protocol are different. Sometimes, behavioral and cognitive changes are needed, and these too need to be understood. Changing behavior and mental habits of cognition are not something that is done to you, but something that you do yourself.

Generalized Anxiety Disorder or GAD

Generalized anxiety disorder is characterized as a constant state of worry and stress, often with restless sleep, insomnia, fatique and upset stomach. This disorder often prompts one to exagerrate problems emotionally and jump to negative conclusions. The high level of stress anxiety may lead you to react excessively to what others do or say, negatively impacting home and work functions. Often, the excessive worry and anxious state leads to worsening problems with muscle tension and chronic pain as well. Sometimes, simple changes in habits will help this disorder, such as reducing consumption of caffeinated drinks, such as coffee, tea and soft drinks, taking time to relax before eating, and addressing work one task at a time, not letting your mind get too far ahead of what you are doing. Stress reduction techniques often will help greatly as well. These range from simple habits of stopping and taking a deep breath, to reserving time for yoga, deep breathing techniques, aerobic excercise, qi gong, tai chi, or some other form of enjoyable therapeutic activity. The first step is, of course, not to get anxious about reserving time for these activities. Cognitive retraining involves taking small steps before attempting a marathon, and stopping your mind from coming up with anxious reasons why you can't. By training yourself to just do the right thing, and not overthink, you will find yourself in a more relaxed place. Time spent with the physician in Complementary Medicine will not only provide you with therapy, but may also reinforce these positive habits and ways of coping. The Licensed Acupuncturist often takes the time to engender habits and reinforce positive therapeutic behavior and cognition.

Underlying health problems may be a significant factor in GAD. Adrenal fatique, or deficiency dysfunction, is commonly seen today, and is often related to subclinical hypothyroid states, hypothalamic dysfunction, and even hyperparathyroid imbalance. Neuroendocrine stress may be a significant factor in generalized anxiety disorder in a number of patients. The whole system and health history should be examined to determine whether the GAD is secondary to other problems. Therapeutic approaches in these cases should first address the primary causes, and then proceed to direct therapy to control anxiety. If the therapeutic approaches described above seem ineffective, you may need to restore healthy function to the neuroendocrine system first.

New approaches and related pathologies being explored to expand treatment of Generalized Anxiety Disorder

One new approach being considered for treatment of GAD in women is the use of a drug to block or antagonize the corticotropin-releasing hormone receptor in the pituitary gland of the brain. Corticotropin is a hormone that stimulates increased adrenal response to stress. Scientific study has linked both adrenal deficiency and dysfunction, as well as hypothalamic deficiency and dysfunction, to generalized anxiety disorder. Hormonal deficiencies and imbalance are common in modern society, with women commonly experiencing problems around the menopausal change, or with menstrual problems such as premenstrual syndrome. Since the hormonal system is a complex feedback system that is also tied intricately to the neurological system, improved health and function of the whole neuroendocrine system is important in resolving all related health problems. To holistically improve the health of the neuroendocrine system, the patient and the physician must look at the health of the kidney adrenals, the hypothalamic function, and the various systems that may impact healthy function of the adrenal-pituitary axis. This includes thyroid and parathyroid function, estrogen-progesterone balance, and sometimes the insulin response. A drug to block specific excess of adrenal stimulation may resolve symptoms of anxiety disorder, but the smart patient will also look to therapies to fix the underlying causes and restore their health, taking the time to obtain an individualized thorough diagnosis and working on restoring healthy function and balance. The end result to this approach is control of anxiety disorder without drug dependancy, and also restoration of overall health to obtain a better quality of life and prevent other serious health problems.

One curious scientific link between hypothalamic dysfunction and anxiety concerns research into the effects of the neurohormone oxytocin. Not long ago scientists considered oxytocin as a hormone related only to birthing and breastfeeding, but now we have discovered many measurable effects of this neurohormone. Oxytocin is mainly produced in the hypothalamus and stored in the pituitary, but neurons in the amygdala may also produce oxytocin. Nasally administered oxytocin has been shown to reduce fear response, possibly by inhibiting the amygdala hyperexcitation. A reduced hypothalamic function could be responsible for poor control of amygdala hyperexcitation, leading to generalized anxiety disorder and exagerrated responses in fearful situations. Oxytocin receptors have also been found in heart tissues, possibly explaining some symptoms of racing heart and palpitations. Reduced oxytocin bioavailability has also been linked to poor sexual arousal, and difficulties maintaining erection, and intitiating female orgasm. Subjects given oxytocin displayed enhanced emotions of trust and were able to take risks more readily in studies. All of these scientific findings may be applicable in some cases to hypothalamic dysfunction and anxiety disorder. A number of nutritional deficiencies have been linked to poor hypothalamic dysfunction, such as calcium AEP (aminoethanolphosphate). Oxytocin bioavailability may also be a problem with deficiency of key amino acids, such as glutamine and tyrosine, and oxtyocin receptors may be inhibited with deficiency of magnesium, and well as a lack of healthy cholesterol. TCM combines these nutrient therapies with herbal formulas and acupuncture to create a thorough treatment protocol.

A 2010 NIH sponsored study at the Cedars-Sinai hospital associated with UCLA Medical College found that deep tissue massage, or physiotherapy, was effective in stimulating increased oxytocin, when compared with normal massage, or surface tissue, or lighter massage. Other beneficial physiological effects included reduced cortisol needs, improved lymphocyte production, and normalization of a variety of excess inflammatory cytokines. These unexpected results, measured in a placebo-controlled study, showed that a combination of TCM therapies, acupuncture, herbal, nutrient, and Tui Na, or deep tissue massage, could be very synergistic in achieving better outcomes. The time spent with the physician, and the resulting cognitive and perhaps behavioral changes than could result, also may improve the outcomes with various anxiety disorders.

Aging, hormonal imbalance, and vulnerability to stress

It has long been observed that with aging comes an increased vulnerability to stress. Researchers in Japan have been trying to better define this phenomenon physiologically and come up with an effective treatment strategy. At the National Institute for Longevity Sciences in Aichi, Japan, researchers found that aging is associated with dysregulation of emotional and endocrine responses in stressful environments, and that repeated stress creates a different set of responses than acute stress. The field of Neuroimmunopsychology has long collected data that proves that cell receptors in the brain often respond not only to neurotransmitters, but to hormones and even immunomodulating cytokines. Aging brings about a slow decline in the efficiency of hormone production and regulation, as well as increased stress on the immune system as aging tissues require more immune response to maintain and repair aging and hardened tissues. Each individual may have a different profile in this regard, and those persons with increased hormonal dysregulation, or chronic inflammatory states, may have a more difficult time with handling common daily stressors. Not only patients with emotional and psychological disorders are vulnerable in this regard. The treatment and health maintenance protocols must reflect this broad holistic aspect of stress-related pathology, especially concerning anxiety disorders.

These researchers in Japan measured cortisone responses and c-Fos immunoreactivity in the brain in response to restraint stress in both young and old laboratory animals. C-Fos is a protein released by a basic gene of the Fos family in our cells that triggers a cascade of responses to stress. The Fos gene family have been identified as integral in regulation of cell proliferation, differentition and transformation, and various Fos genes produce regulatory proteins implicated in a wide variety of brain responses, such as anxiety, addiction, excess appetite, depression, and other stress-related behavioral and cognitive expressions. C-Fos and other Fos gene proteins have been widely studied in relation to cellular dysregulation in cancer, effects of chronic viral illnesses (e.g. some retroviruses express analogues to the human c-Fos protein), and may provide us with a better understanding of the physiological mechanics of these diverse pathologies.

A very complex array of chemicals interact in our cells to properly regulate cell function, proliferation, and normal programmed cell death (apoptosis). When this complex system is disrupted or overstressed, a variety of cellular dysfunctions may occur. In the brain, lack of control of neural firing may result in sudden mood changes or unwanted psychological and emotional reactions to normally benign stressors. Immune cytokines, growth factors, chemicals that act both as immune modulators and neurotransmitters (e.g. serotonin), and protective chemicals such as tumor necrosis factor (TNF), all interact with c-Fos expression. Cortisone, or corticosterone, is a key hormone produced by the adrenal gland of the kidneys that is first responder to stress, as well as immune-related inflammatory needs. We now know that cortisone is not only an immune and inflammatory modulator, but the constant level of corticosterone in circulation, or diurnal cortisone response, is integral to proper control of emotional states, hormonal regulation, sleep quality, and a variety of other key functions that we take for granted. Cortisone is easily converted according to our body's needs into other hormones, and a bioavailability of cortisone must be maintained. For example, pregnenelone is a precursor hormone to cortisone, and cortisone may convert to adosterone, an adrenal hormone that controls sodium and potassium levels in our body, as well as blood pressure via the renin-angiotensin system.

In this research concerning aging and stress, it was found that animals that are older and experience repeated stress react to acute stress with higher cortisone concentrations in the blood circulation, and decreased c-Fos expression in key areas of the brain, such as the amygdala, pre-frontal cortex, hippocampus, and hypothalamus. This condition made the aging patient with repeated daily stress much more vulnerable to acute stress and produced a wide variety of autonomic nervous reactions, such as racing heart and temperature changes, as well as hormonal problems. The effects on cortisone regulation could impact blood pressure, sleep quality, and even metabolic controls, explaining changes in blood sugar metabolism, weight gain, etc. The effects on diurnal cortisone regulation could also have immediate impact and inflammatory mediation, explaining increases in inflammatory pain in relation to acute stress. These neurohormonal changes require attention, and treatment with holistic medicine provides an array of treatments that may significantly improve a number of physiological systems and reduce the effects of acute stress in a patient with age-related and repeat stress-related susceptibility of acute stress, which results in a more severe generalized anxiety disorder.

Researchers at Cambridge, the most prestigious of college in England, in 2004, proved that in women with estrogen deficiencies induced by menopause or hysterectomy, that reductions in available estradiol increased physiological reactions to acute stress, especially with the effects of aging and repeat stress history. Supplementation with 17beta-estradiol significantly improved the physiological adverse reactions to acute stress. Now, it is well documented that treatment with synthetic estrogen, or estradiol variants, comes with considerable risks and side effects. A safer approach is to supplement with a bioidentical estriol in low dosage and topical form, to stimulate a greater estrogen bioavailability. Estriol is the most abundant form of estrogen in the body and converts to estrone and estradiol as needed. Stimulation of estriol metabolism with this herbal treatment will have significant effect upon the 17beta-estradiol bioavailability in the patient. This type of treatment, though, needs to be professionally monitored, and a balance of estrogen and progesterone maintained. The Licensed Acupuncturist and herbalist is a Complementary Medicine physician that may inexpensively monitor active hormone metabolites via saliva testing, and prescribe estriol and progesterone stimulating topical creams, within a comprehensive protocol of treatment, utilizing herbal and nutrient medicine, and acupuncture, as well as deep tissue massage, or TuiNa, to effectively restore neurohormonal balance in these states, and achieve a dramatic improvement in reaction to acute stress.

Panic disorder

Panic is a biological response that generates hightened fear, which overrides other mental and physical responses. A panic attack is a sudden period of intense anxiety that creates alarming symptomatic responses, such as feelings of sudden faintness, nausea, heavy or rapid breathing, rapid heart rate, trembling, shortness of breath, heart palpitations, chest pain, hot or cold sensation, sweating, dizziness, light-headedness, tingling sensations, and choking sensation. The patient often describes a feeling of imminent danger or going crazy, and often goes to the emergency room. There is often no specific trigger, but can be triggered by medications (e.g. Ritalin, antidepressant SSRIs, or even certain antibiotics), withdrawal syndromes (e.g. benzodiazepines, alcohol), stimulants, significant emotional trauma, phobias, or even certain chronic cardiac pathologies. Panic attack is a sudden heightened response of the sympathetic nervous system, and usually controlled by a parasympathetic response. Panic Disorder is a syndrome with recurrent panic attacks. Many patients with panic disorder acquire anticipatory anxiety that cause another panic attack when mild symptoms occur. Studies also show that as many as 36% of patients with panic disorder also acquire a separate problem called agoraphobia because of the anticipation of, or fear of, panic attacks, avoiding many public or social situations where a panic attack would be embarrassing, such as travel on an airline. Agoraphobia might also be linked to chronic use of benzodiazepines taken to decrease anxiety. For this reason, many patients and doctors have turned to Complementary Medicine to provide a safer and less problematic treatment than pharmaceuticals afford.

Social Anxiety Disorder

Social Anxiety Disorder is characterized by distress and impaired function resulting from a persistent chronic fear of being adversely judged and embarassed by others. While this disorder may stem from some psychological trauma early in life, the inability to cope and adjust implies a likely problem with mechanisms of trust and identity, sometimes related to deficiencies of neurohormonal modulators in the brain. Symptoms of excessive blushing, sweating, trembling, palpitations, nausea or stammering may occur. Many scientists speculate that problems with serotonin and dopamine metabolism are related, and increased serotonin and dopamine transporter binding has been found to be consistent in patients. Low dopamine receptor type 2 binding has also been noted. Excess norepinephrine (adrenalin) and deficient GABA have also been implicated. The result of these findings again suggests that a restoration of neurohormonal health is important, and that specific allopathic treatments may not be completely effective. Like other anxiety disorders, underlying problems with the hypothalamic and adrenal functions, metabolic concerns and nutrient chemical deficiencies, and cognitive and behavioral problems could all be contributing.

Social Anxiety Disorder is addressed extensively in classic Traditional Chinese Medicine (TCM), with a variety of diagnostic and treatment differentiations, and treatment protocols with acupuncture. For example, the eight extraordinary meridians, or patterns of point prescription in TCM, are a set of systems that describe coordination of various unique systems that function holistically in the body, and provide systemic effects and balance in homeostasis. The Dai Mai, or girdling meridian, one of the eight extraordinary meridians, describes a neurohormonal system that may be integral to emotional disorders causing physical manifestations resulting from a lack of emotional support, or girdling, in life. Emotional trauma and a feeling that a parent, sibling, friend or supervising adult did not provide the expected support and protection needed during a tramatic time, may create a chronic sense of abandonment, and leave one with emotional constraints and chronic anxiety in social situations where emotional memories trigger responses. In ancient China, this was addressed with use of the prescription of points along the Dai Mai meridian, along with counseling, and use of herbal formula. These points are documented as affecting the central nervous system, the amygdala, and hypothalamic control of neurohormonal physiology today with fMRI studies.

Herbal and Nutrient Remedies tested for treatment of anxiety disorder

Much research has been performed confirming the scientific efficacy of various herbal anxiolytics and nutrient supplements. Other herbal and nutrient remedies involve indirect treatment of the causes of anxiety disorder. The data is too large ot present here in total, but a few well known herbs and supplements are presented, and links to studies are also presented below.