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What is anxiety? How do we treat it?

Updated: Jan 7, 2019

In an anxiety-related disorder, the fear or worry does not subside without treatment and can get worse over time. It can interfere with activities of day living, as school, work and relationships. Fear, stress, and anxiety are "normal feelings and experiences" but they are different from any of the seven diagnosable disorders plus substance-induced anxiety, obsessive-compulsive disorders, and trauma- or stressor-related disorders. UpToDate, an online resource for medical providers, informs "epidemiological studies have shown that anxiety disorders are among the most common mental health problems in the United States." Anxiety, when not addressed, can become excessive and cause stress to the body, contributing to, for example, heart disease, suicidality, and reduced quality of life. If not reduced through effective interventions, high anxiety can contribute to overall morbidity and decrease quality of life. Symptoms of anxiety may include excessive anxiety about everyday things, inability to control constant worries, free floating anxiety, distress or worry that is disproportionate to the situation, inability to relax, difficulty concentrating, feeling on edge and startling easily, difficulty with falling asleep or staying asleep, fatigue, tendency to jump to the worst conclusions, headaches, stomach aches, muscle aches, or other unexplained pains, difficulty swallowing, shakiness or twitching, irritability, profuse sweating, light-headedness and/or breathlessness, frequent need to urinate.


For anxiety disorders, the medical recommendation is psychotropic medication alone or in combination with talk therapy. The National Institute of Mental Health informs that Psychotherapy or “talk therapy” can help people with anxiety disorders. To be effective, psychotherapy must be directed at the person’s specific anxieties and tailored to his or her needs.


Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is an example of one type of psychotherapy that can help people with anxiety disorders. It teaches people different ways of thinking, behaving, and reacting to anxiety-producing and fearful objects and situations. CBT can also help people learn and practice social skills, which is vital for treating social anxiety disorder.

Cognitive therapy and exposure therapy are two CBT methods that are often used, together or by themselves, to treat social anxiety disorder. Cognitive therapy focuses on identifying, challenging, and then neutralizing unhelpful or distorted thoughts underlying anxiety disorders. Exposure therapy focuses on confronting the fears underlying an anxiety disorder to help people engage in activities they have been avoiding. Exposure therapy is sometimes used along with relaxation exercises and/or imagery.

CBT can be conducted individually or with a group of people who have similar difficulties. Often “homework” is assigned for participants to complete between sessions.


Complementary and alternative treatments may be added as adjuncts to the prior treatments. Complementary and alternative treatments for anxiety include physical, cognitive, or spiritual activities, including yoga, acupuncture, and herbal remedies and dietary supplements. Individuals diagnosed with a psychiatric illness may be likely to use these therapies, especially patients with elevated anxiety or anxiety disorders, in part because many who are treated psychiatrically respond only partially to treatment and have residual symptoms and impairment.


Available research evidence is supportive, to varying degrees, of efficacy in reducing anxiety for the physical, meditative, and spiritual/religiousactivities. Minimal adverse effects have been reported for the physical, meditative, and spiritual/religious activities.


PHYSICAL ACTIVITIES

YOGA — Yoga is a practice of breathing, mindfulness, spirituality, body, and the connection among these factors. Through its three main components (postures, breathing, and meditation), as well as nonspecific events, yoga appears to be safe and to improve multiple parameters of health and quality of life.

Multiple review articles, including one principally of articles from Indian journals, concluded from small randomized and nonrandomized trials that the practice of yoga reduced anxiety levels.


TAI CHI— Tai chi (also known as taiji or tai chi chuan) is a form of mind-body exercise that originated in China and involves martial arts, meditation, and dance-like movements that focus on the mind and body connection.

A 2014 review of 35 clinical trials studied the efficacy of tai chi (Qigong exercises) for anxiety and depression in 2765 participants, finding that the intervention reduced anxiety symptoms with a small-to-moderate effect size compared with control conditions.

Physical Exercise- research finds it is beneficial and produces health effects. UpToDate quotes " only 30 percent of American adults achieve the recommended amount of exercise per week." Clinical trials suggest that exercise may decrease symptoms in patients with anxiety symptoms or disorders. 


MINDFULNESS MEDITATION — Mindfulness has been defined as "paying attention in a particular way: on purpose, in the present moment, and non judgmentally. "Basic elements include self-regulation of attention and taking a nonjudgmental stance towards one’s experience. The practice of mindfulness meditation or mindfulness to relieve human suffering has existed for over 2500 years. Mindfulness has been applied to psychological health issues in a Western, secular context since the 1970s.

A 2014 systematic review and meta-analysis of 47 trials with 3515 participants found that mindfulness meditation programs had moderate evidence of reducing anxiety (effect size, 0.38 [95% CI 0.12-0.64] at eight weeks and 0.22 [0.02-0.43] at three to six months).

Mindfulness and its clinical variants such as mindfulness-based cognitive therapy have been used in the treatment of multiple psychiatric disorders, with varying degrees of supporting research evidence.  

As an example, a clinical trial compared an eight-week group mindfulness-based stress reduction program to stress management education in 93 patients with generalized anxiety disorder (GAD). Compared with the education-only group, the mindfulness group experienced greater improvement in anxiety symptoms and in overall symptoms, and lower anxiety symptoms in response to a stressful challenge.

Although the mechanisms by which meditation may improve symptoms of anxiety disorders are not known, biological, behavioral, and cognitive frameworks for anxiety disorders have shaped research investigation:

●Biological theories, such as the false suffocation alarm and hyperventilation, focus on the role of respiratory abnormalities in anxiety. Meditation and relaxed breathing can reverse these abnormalities and alter the anxiogenic effects of biological challenges. Meditation has been found to reduce cortisol and catecholamine levels, such as epinephrine and norepinephrine, which would otherwise set off a biologically-based anxiety response.

●From a learning perspective, individuals can develop an anxiety disorder through classical conditioning, vicarious conditioning, and operant conditioning. In line with research on reciprocal inhibition, meditation may serve to create a newly conditioned response, resulting in the extinction of the anxious or fear-related conditioned response.

●From a cognitive perspective, people with anxiety disorders tend to overestimate danger and its potential consequences. Meditation helps the individual remain detached yet able to detect and change the cognitive distortions that accompany anxiety.


SPIRITUALITY AND RELIGION — Spirituality and religious activities, in general, can be thought of as relating to or affecting the human spirit or soul, as opposed to material or physical things. Religion typically involves, in addition, a relationship with God or a higher power. Spirituality and religion can supply a robust and flexible framework for understanding the world and the self, which may foster increased tolerance to uncertainty, enhanced coping, resourcefulness, and optimism. Religions can also offer a community of support, which reduces social isolation.

Researchers have sought to determine whether a spiritual component is critical to the anxiety reducing effects of mediation, but available evidence from clinical trials is insufficient to provide an answer.

Spiritual meditation — Many cultures around the world integrate meditation into their religious and spiritual disciples. Transcendental meditation and qigong meditation, types of spiritual meditation, have been tested for their effect on anxiety.

Transcendental meditation — Transcendental meditation (TM) involves the use of a mantra, while sitting comfortably, twice daily with eyes closed for 15 to 20 minutes. TM has a spiritual dimension; its practice moves the mind away from physical affairs to a focus on the larger universe and the individual’s place within it. The use of a mantra involves focusing on its sound, as opposed to its conceptual meaning, allowing the mind to fully transcend into an unbounded field of pure being. These qualities distinguish TM from secular forms of meditation, such as mindfulness meditation.

A meta-analysis of 16 clinical trials with 1295 participants found that transcendental meditation reduced trait anxiety compared with treatment as usual (d = -0.62 [95% CI -0.82 to -0.43]) and compared with active alternative treatments (10 trials; d = -0.50 [95% CI -0.70 to -0.30]). Populations with elevated initial anxiety levels (eg, patients with chronic anxiety, veterans with posttraumatic stress disorder, and prison inmates) showed larger effects sizes (-0.74 to -1.2). No adverse effects were reported.

Qigong meditation — Qigong meditation is an ancient Chinese health practice that integrates movement, breathing, and meditation into one multifaceted practice [84]. The meditative practice utilizes breath awareness, mantra, chanting, sound, visualization, and focus on concepts such as qi circulation, aesthetics, and moral values. Qigong treatment incorporates mind-body operational skills or techniques that integrate body, breath, and mind adjustments into Oneness [85]. Qigong meditation focuses on the flow of qi, which is a universal, spiritual power that is a central force in all living things.

Clinical trials that included assessment of qigong therapy’s effect on anxiety have found mostly positive but mixed results in diverse populations [84,86-88]:

●A trial of 65 subjects diagnosed with a cardiac disease were assigned to receive either progressive muscle relaxation or qigong training [88]. Each participant received eight 20-minute training sessions. At the end of treatment, improvements in anxiety and 12-item General Health Questionnaire scores were seen in both treatment groups.

●A trial of 86 male patients with heroin dependence undergoing medically supervised withdrawal were randomly assigned to the qigong treatment, medication treatment (with lofexidine, an alpha-2 adrenergic agonist), or to a no-treatment control group [86]. Individuals in the qigong group experienced a reduction in anxiety and a more rapid reduction of withdrawal symptoms compared with the other two groups.

Devotional meditation — Devotional meditation, also referred to as contemplative prayer, is a form of Christian prayer with an emphasis on meditation – connecting to the Christian God in an open, passive, and nondemanding way [89-91]. Clinical trials have found mixed results for devotional meditation compared with control conditions.

As an example, a clinical trial randomly assigned 36 college-age students to devotional meditation training, progressive muscle relaxation, or a no-treatment control group [92]. The two intervention groups received three training sessions weekly. Participants from all three groups had their muscle tension monitored daily. After two weeks, the devotional meditation group reported less anxiety and anger when compared with the other two groups, and had less muscle tension as measured by electromyography activity.

●A clinical trial compared a group of 42 participants from similar religious and cultural backgrounds assigned to devotional meditation, progressive muscle relaxation, or a control group [93]. After 10 days, the researchers found significant reductions in subjective stress for the two experimental groups.

●A clinical trial randomly assigned 36 college-age students to training in a form of devotional meditation, progressive muscle relaxation, and a no-treatment control group [92]. All three groups received an initial assessment and daily monitoring of their muscle tension. The two intervention groups received six sessions of training over two weeks. After two weeks, the devotional meditation group reported less anxiety and anger compared with the other two groups, and had less muscle tension, as measured by electromyography activity.

Centering prayer — Centering prayer is a contemporary approach, developed in 1974, as a more accessible alternative to contemplative prayer [94,95]. Special attention is given to posture, breath, and the space one occupies. Similar to mindfulness meditation, the goal of centering prayer is not to empty the mind, but rather to exercise a willingness to let thoughts come and go, while using a sacred word as a refocusing tool. Centering prayer differs from secular forms of meditation because the emphasis is on "intention" (a shared experience with God’s presence) rather than attention or concentration.

Uncontrolled trials found several weeks of daily centering prayer to be associated with decreased anxiety in small samples.


SUMMARY

●Sixty-two percent of adults in the United States utilize some form of complementary and alternative medical treatments; the most commonly used are mind-body therapies. Individuals diagnosed with a psychiatric illness may be more likely to use these therapies compared with the general population, especially patients with anxiety.

●Yoga, a practice of breathing, mindfulness, spirituality, and body, has been shown in multiple clinical trials to reduce anxiety in practitioners compared with non-practitioners. Its effects compared with stretching and other physical exercise is unclear.

●Tai chi is a form of mind-body exercise that originated in China and involves martial arts, meditation, and dance-like movements that focus on the mind and body connection. A meta-analysis concluded that tai chi reduced anxiety in trial participants compared with active and inactive controls.

●Routine physical exercise is recommended for all adults by the US Department of Health and Human Services, among other groups, citing research findings of its beneficial health effects.

●Mindfulness meditation has been defined as paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally. Basic elements include self-regulation of attention and taking a nonjudgmental stance towards one’s experience. A meta-analysis of 47 trials with 3515 participants found that mindfulness meditation programs had moderate evidence of reducing anxiety.

●Transcendental meditation and qigong meditation are forms of spiritual meditation that have been shown in clinical trials to reduce anxiety. There are fewer clinical trials of devotional meditation and anxiety; study of centering prayer and anxiety is limited to case reports/series.

●Evidence of efficacy for the interventions above has significant methodologic limitations. Further clinical trials are needed with larger sample sizes, more appropriate control groups, standardized interventions, and participants with higher levels of anxiety and diagnosed anxiety disorders at enrollment.

●The UpToDate researches state that they are generally supportive of the physical, meditative, and spiritual/religious activities described above because these methods may be helpful and are unlikely to be harmful. However, they caution not to use them as a substitute for psychiatric treatment for anxiety disorders, because evidence of their efficacy is generally much weaker. They recommend that these activities may be of use as adjunctive treatments or primary treatments in patients with low anxiety (eg, beneath the diagnostic threshold of anxiety disorder diagnoses).

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