Integrative approach to anxiety

 

IHMT ANXIETY

 

 

  1. Overview
    1. Anxiety disorders in ¼ adolescents & ~ 1/5 adults
    2. Main driver of anxiety is often thoughts and images. Focusing on breath helps people get out of this mind trap.
    3. Often co-morbid with depression, substance abuse
    4. Commonly have impaired judgment & memory, vague somatic sx
    5. Patterns include generalized anxiety, panic, OCD, PTSD, phobias. Many patients do not meet DSM specific criteria for a discrete sub-type.
      1. Panic attacks
        1. May have different sx with different attacks in same pt.
        2. ½ become depressed.
        3. Often associated with chronic medical conditions such as asthma, COPD, arrhythmias, hyperthyroidism
      2. Risk & aggravating factors:
        1. High stress load, insomnia, losses
        2. Lack of exercise
  • Poor diet, esp. high GL, low Mg, B6, B12, Folate, Vit. D
  1. Food scarcity
  2. Meds/substances:
    1. Rx: Sympathomimetics, Beta agonists, Corticosteroids, OCPs
    2. OTC: Energy drinks, SAMe (esp. > 1 G/d), Guarana, Yerba mate
    3. Drug abuse: Cocaine, Meth, ETOH
  3. Diagnosis:
    1. Clinical
      1. BAI
      2. Visceral Sensitivity Index – validated for GI anxiety (Jerndal, P. 2010, 920367800)
  • Ddx:Disease States Associated with Anxiety
    1. Endocrine: Hypo- or hyperthyroidism, Hyperadrenalism, Pheo
    2. Vestibular dysfunction
    3. Cardiac: CHF, arrhythmia
    4. Respiratory: COPD, PE, Pneumonia, Hyperventilation, Oxygen Hunger
    5. Vitamin B12 deficiency
    6. Porphyria
    7. Neoplasms
    8. Encephalitis
    9. Drugs: methamphetamine, cocaine, stimulants
  • Munchausen’s Syndrome
  • Environmental: Lead toxicity, Pesticide exposures

 

  1. Studies
    1. HRV
    2. EDST (Electro dermal skin testing) may differentiate responders to relaxation and energy therapies
  2. Labs:
    1. R/O anxiety mimics: e.g. TSH, RBC Mg
    2. FLP: Anxiety increases T. cholesterol (depressed pts. tend to have low T. cholesterol)
  • Serum or salivary cortisol increases (burnout or chronic fatigue associated with low awakening cortisol)
  1. Treatment overview: Allow several months for patient to implement suggestions, one simple small change a week.
    1. Avoid stimulants such as:
      1. Mental/Emotional: Horror/action movies, Media news of crimes
      2. Avoid/resolve angry or conflicted relationships
  • Medications: Decongestants such as phenylephrine, appetite suppressants, methylphenidate and other drugs to treat ADHD, migraine meds that contain caffeine such as Excedrin, albuterol, corticosteroids (check with your doctor first of course)
  1. Eliminate all caffeine: coffee, strong tea, sodas, energy drinks.
  2. Stimulating herbs: yerba mate, guarana, high dose SAMe
  1. Healthy lifestyle:
    1. Re-connect with the body to help ground the mind and avoid un-anchored imagination that drives much anxiety. The body is designed to move and needs to do so for health and wholeness. It is our friend and unlike our ordinary mind it never lies, guiding us on how we reallyfeel. Virtually all physical tensions are a sign of lack of emotional clarity – of blockage of the flow of our body’s energy. Listen to and learn to trust the body’s deep wisdom.
      1. Regular physical activity – aerobics, strength, mind-body
      2. Meditation
    2. Whole foods: Key aspects:
      1. Low glycemic load, especially commercial baked (i.e. flour) products including whole wheat
      2. Adequate healthy fat:
        1. Balance Omega 3/6 fatty acids:
        2. Use extra-virgin olive oil as a main cooking oil.
        3. Fat in avocado, omega-3 eggs support brain functions.
      3. Vegetables 5 – 7 servings daily
      4. Magnesium– def. can trigger anxiety and depressive sx. Sources: nuts, green vegetables
      5. Vitamin D
  • Healthy sleep.
    1. Insomnia (in 80% of psych dx, 25% of children) is prodromal, exacerbating and comorbid with most anxiety & depression – all ‘feed on each other’.
    2. Decrease REM latency leads to REM replacing deep restful sleep early in night.
    3. Loss of REM leads to lack of nocturnal suppression of CNS neurotransmitters and lack of normal down regulation of amygdala based emotional reactivity. Anxiety suppresses REM, leading to more emotional reactivity and a vicious cycle. – See Sleep handout
  1. Exercise:
    1. Contralateral movements such as walking establish healthy rhythms in the brain
  2. Gut microbiome normalization:
    1. Bifidobacterium longum NCC3001 normalized anxiety-like behavior and levels of brain-derived neurotropic factor in mice with infectious colitis(Bercik, 2011).
  3. Psychotherapeutic approaches with clinical research support:
    1. CBT, DBT – (involves moderating their emotions, rather than talking a lot), Exposure therapy have less relapse rate than treatment with just medications.
      1. Panic with abnormal HRV responds to CBT but not very well to pharmaceuticals
    2. Online & telephone mental health programs – preliminary studies show benefit
  • Situation-specific anxiety tx, e.g. phobias, PTSD:
    1. Virtual Reality Graded Exposure Therapy (VRGET) – preliminary evidence of benefit for phobias, GAD, Panic, PTSD
    2. Systematic desensitization,
    3. Clinical hypnosis and other similar techniques.
    4. Kundalini yoga left-nostril breathing technique reduces OCD sx in a small controlled trial.
  1. Relaxation (all require regular practice)
    1. Mindfulness alone or as part of MBSR
    2. Autogenic training, Guided imagery, Clinical hypnosis
    3. Progressive Muscular Relaxation (PMR): isolate 1 muscle group, tense for 10 sec, then let go all at once. Muscles if not moved will continue to relax further.
      1. PMR can help OSA, CPAP adherence, anxiety, sleep, caregiver stress, pain.
    4. Breathing techniques:
      1. ‘Breathing is the bridge between mind and body, the connection between consciousness and unconsciousness, the movement of spirit in matter’ ‘The single most effective relaxation technique I know is conscious regulation of the breath’ – A. Weil.
      2. Bridge between the voluntary and involuntary nervous systems.
  • Exhalation is ‘first’ in some cultures.
  1. Most people do not know how to breathe.
  2. Slow deep breathing can improve HR, BP, emotional state
  3. Need to be more alert: Bellow breathe:
    1. 10 – 30 seconds
    2. Stimulating, alerting
    3. Indications: need to be more alert, e.g. driving, on call
  • Need to calm down: 4-7-8 Breath. MUST DO TWICE A DAY, including prior to sleep.
    1. Powerfully balances autonomic tone. The ‘7’ pause is when get strong PNS stimulation. At least a month to see clinical effects. Make take several months to improve excess SNS in some cases.
    2. Breathe in thru nose, out thru mouth with whoosh thru pursed lips.
    3. Start 4 cycles (after a month can increase to 8 cycles), at least twice a day. Can do as many times per day as needed for facilitating calmness, but no more than 8 cycles at a time. Lowers BP, HR. Helps sleep, digestion. May help PTSD, A fib, etc.
  • Other calming breathwork minis:
    1. Ten to one: Count down from 10 to 1 on slow outbreaths
    2. 1,2,3, 4: As breathe in count slowly from 1 to 4, as breathe out also count slowly from 1 to 4.
    3. Breathe counting: count 1,2,3 between in & outbreaths
    4. In & out: Inbreathe ‘I am’, outbreath ‘at peace’
    5. Square breathing: Inbreathe visualize vertical & horiz, outbreath vertical & horiz. to form square.
    6. Alternate nostril breathing in 90 minute cycle. Stimulates contralateral brain hemisphere.
  1. Craniosacral therapy works with restoring the ‘CNS respiratory cycle’ called ‘primary respiration’, which can be disturbed by birth trauma, lack of a large first breath of life, extreme emotional trauma or any trauma in early life if no crying or screaming. Need evidence base.
  2. Biofeedback such as Heart Rate Variability (HRV).
  1. Psychopharmaceuticals
    1. DOC: SSRIs, e.g. paroxetine; SNRIs, e.g. venlafaxine.
      1. Start low, build up
      2. Adverse effects: transient nausea, headache; drowsiness, decreased sex function
  • Folate 1 –5 mg/d can augment SSRI, SNRIs (caution with excess folate)
  1. Benzodiazepines (not to be used beyond 2–4 wks.). Occasional prn use ok. Dependency issues. ~1/2 get withdrawal after only 1 month of use.
  2. Antihistamines: hydroxyzine
  3. TCAs: Imipramine tx GAD and panic, clomipramine tx OCD.
    1. TCAs have more side effects than either SSRIs or venlafaxine, so are generally used when patients do not tolerate or respond to SSRI/SNRI therapy. TCAs should be avoided in patients considered at risk of suicide, due to their potential cardiac and CNS toxicity after overdose.
  4. Buspirone 5-HT1A receptor,
    1. Indications: GAD. Up to two weeks to begin working.
    2. SEs:generally well tolerated, adverse effects include headache, nausea, dizziness and nervousness, insomnia
  5. Beta-blockers
    1. Indications:not FDA approved but used for physical symptoms of anxiety and panic, such as trembling and sweating, e.g. when person with social phobia must face a stressful situation, such as giving a speech.
    2. Dose:propranalol
      1. Adverse effects:caution in diabetics as it can mask symptoms of hypoglycemia. The most common side effects are dizziness and fatigue.
  • Contraindicated: asthma, severe heart failure
  1. Pregabalin (Lyrica) (not FDA approved for anxiety)
  2. Hydroxyzine (takes up to 6 weeks to have an effect?)

 

  1. Supplements/ Botanicals: Best evidence is for Kava kava & Inositol, others have modest evidence
  2. Kava Kava( Piper methysticum)
    1. Indications:Good evidence for GAD, anxiety symptoms associated with menopause, likely effective and safe approach for discontinuing benzodiazepines following chronic use
    2. Dose:standardized kava preparations (use dried root powder or aqueous extracts only) 100–200mg/day. For benzodiazepine withdrawal, titrate up to 300mg/day while tapering off benzo’s
    3. Adverse effects: Kava is generally well tolerated. Uncommon adverse effects include GI distress, rash, headaches and dizziness. More serious questions of its safety were raised after case reports suggested that it might cause liver damage.
      1. Traditionally, kava was made into tea by adding water to the roots. Almost all cases of liver damage that have been reported were from kava products that had been extracted with alcohol and/or acetone or used areal parts. Patients should purchase kava from a reputable manufacturer and only use dried powdered root (not an extraction), or until the evidence is clearer, look for products sold as “aqueous” extracts, meaning that water was used as a solvent instead of acetone or alcohol.
    4. Interactions:kava interacts with numerous drug metabolizing enzymes

 

  • Inositol: part of the vitamin B-complex is required for proper formation of cell membranes and is important for nerve transmission.
    1. Indications: Good evidence that Inositol in doses up to 20g/day reduces the severity and frequency of panic attacks. RCT: inositol 12 g/day and imipramine equally effective in reducing the frequency and severity of panic attacks and agoraphobia (Benjamin, 1995). RCT: inositol (up to 18g/day) and fluvoxamine (up to 150mg/day) had similar efficacy in reducing the frequency of panic attacks (Palatnik, 2001).
    2. Dose:start with 2–4 grams BID, increasing to 4–6 grams TID as needed e.g. in juice. Titrate up gradually to avoid GI distress. The powder provides 2.4 grams per teaspoon or 7.2 grams per tablespoon.
    3. Adverse effects:Well tolerated. GI distress

 

  • 5-HTP & L-tryptophan
    1. Background:L-tryptophan and 5-hydroxytryptophan (5-HTP) are essential precursors for serotonin synthesis and there are small studies evaluating their role in anxiety. 5-HTP is extracted from the G. simplicifolia, a plant native to West Africa. In a double-blind study, 58% of generally anxious patients (N=79) randomized to L-tryptophan 3g/day reported significantly greater reductions in baseline anxiety compared to placebo. Preliminary findings suggest that 5-HTP may inhibit panic attacks.
    2. Indications:Anxiety, panic, insomnia. Likely safe to use with SSRIs but monitor for Serotonin syndrome (rare)
    3. Dose:5-HTP at 50mg to 100mg, three-times-daily is generally well tolerated without excessive daytime sedation. Gradually increasing 5-HTP in increments of 50mg to 200 to 400mg at bedtime often reduces daytime anxiety and improves the quality of sleep in chronically anxious patients. 5-HTP at 50mg to 100mg TID is generally well tolerated without excessive daytime sedation.
    4. Adverse effects:In 1989 and 1990, ingestion of contaminated l-tryptophan caused an epidemic of eosinophilia myalgia syndrome (EMS) that affected over 1500 people and caused at least 38 deaths (FDA 1998). There have only been a very small number of cases (10) of EMS possibly linked to the use of 5-HTP in more than 20 years of use and most experts believe the risk is rare to non-existent.
    5. At dosages of less than 50 mg/kg/day, there appear to be no toxicities associated with 5-HTP administration (Semont, et al. 2000). Serotonin syndrome has not been observed in patients administered 5-HTP in combination with SSRIs or MAOIs. Thus, it appears that 5-HTP may be safely combined with conventional anti-anxiety drugs, though, it is still prudent to monitor for treatment-emergent symptoms of serotonin syndrome including insomnia, agitation and nervousness (Turner, 2006).
    6. Side effects include nausea, vomiting and insomnia and are related to dose and can minimized when 5-HTP is started at doses of 25mg/day and gradually increased over several weeks to a daily regimen that is well tolerated and produces consistent anti-anxiety effects.

 

  • Bacopa (Bacopa monnieri)
    1. Background:Bacopa leaf is used in Ayurvedic medicine to help with memory, cognition, as a treatment for epilepsy and enhance learning.
    2. Indications:Anxiety, cognition? Bacopa in combination with gotu kola (Centella asiatica) has been shown in DBRCT to effectively reduce general anxiety symptoms.
    3. Dose:200–400 mg per day in 2-3 divided doses of standardized extract (20% bacosides A + B).
    4. Adverse effects: Safety studies are very reassuring.
    5. Interactions?

 

  • Gotu Kola (Centella asiatica)
    1. Background:Gotu kola leaf has been valued as a medicinal herb in India, China and Indonesia for millennia. It was traditionally used to heal wounds, enhance cognition, improve circulation and treat leprosy. Clinical studies support some of these uses including the treatment of wounds and burns, improve chronic venous insufficiency, and improve insomnia. A animal study demonstrated anxiolytic activity.
    2. Indications:Gotu kola in combination with Bacopa monnieri has been shown in DBRCTs to effectively reduce general anxiety symptoms.
    3. Doseis generally 1 gram 2–3 times per day of leaf or 300 mg standardized extract (10% asiaticosides) taken twice daily
    4. Adverse effects
    5. Interactions:

 

  • Lemon Balm (Melissa officinalis)
    1. Background:Member of mint family used to relieve stress and anxiety for millennia. ESCOP (European Scientific Cooperative On Phytotherapy) endorses lemon balm for tenseness, restlessness, irritability, and symptomatic treatment of digestive disorders, such as minor spasms, and externally for herpes labialis (ESCOP, 1997). The German Commission E approves the internal use of lemon balm for nervous sleeping disorders and functional gastrointestinal complaints.
    2. Few studies evaluating the use of lemon balm for anxiety as a monotherapy. Studies of the combination of lemon balm and valerian (Valeriana officinalis) suggest it is beneficial for anxiety and insomnia.
    3. Indications:Adjunct for anxiety
    4. Dose:~ 1 G of lemon balm herb BID
    5. Adverse effects:Lemon balm is quite safe and may be taken as tea or in capsule.
    6. Interactions:

 

  • L-Theanine
    1. Background: L-theanine is an amino acid extracted from green tea (Camellia sinensis). Widely used to treat anxiety symptoms and depressed mood in Japan and other Asian countries. Studies demonstrate a calming effect within 30 to 40 minutes after ingestion when taken at doses of 50 to 200 mg. The calming effect lasts approximately 8–10 hours. Theanine is also found in some mushrooms. Theanine has historically been used for its relaxing and anti-anxiety effects. It’s thought that theanine might work for anxiety by increasing levels of GABA and serotonin.
    2. Indications:Anxiety
    3. Dose:Use Sun L-theanine. Moderate anxiety symptoms often improve with a regimen of 200mg once or twice daily. More severe anxiety symptoms may require doses up to 600mg to 800mg daily, taken in increments of 100mg to 200mg evenly spaced throughout the day.
    4. Adverse effects:L-theanine does not cause drowsiness, slowed reflexes or impaired concentration, there is no risk of developing tolerance or dependence, and there have been no reports of serious adverse side effects
    5. Interactions:no known interactions with other natural products, benzodiazepines or other pharmacological agents. Might mildly lower BP, so might be additive with anti-hypertensives.

 

  • Passion flower(Passiflora incarnata)
    1. Background:The dried aerial parts of passion flower (Passiflora incarnata) were traditionally used as a sedative and it is approved by the German Commission E, as well as in France and other European countries, for the treatment of insomnia and nervousness. Passion flower extract is commonly used to treat anxiety; however, few double-blind, placebo-controlled studies have been done. In one small study, passion flower extract 45 drops/day and oxazepam (a benzodiazepine) were equally effective in reducing generalized anxiety (Akhondzadeh, 2001). Patients taking oxazepam reported significant impairments in job performance at doses that lowered anxiety however patients in the passion flower group did not experience similar impairments.
    2. Indications:adjunct to tx anxiety, often mixed with other herbs
    3. Dose:500–2000 mg per day
    4. Adverse effects:
    5. Interactions:

 

  • Rhodiola (Rhodiola rosea)
    1. Background:Rhodiola (Rhodiola rosea) or Arctic root or golden root, used in traditional medicine in Russia and the Scandinavian countries for centuries. There are many possible actives in rhodiola but the most striking appear to be rosavins, rosiridin and salidroside.
    2. Indications:Anxiety, fatigue. Small studies show improved anxiety with 340 mg rhodiola extract per day for 10 weeks.
    3. Dose:SHR-5 is a proprietary extract standardized to 3% rosavin and 0.8% salidroside (Swedish Herbal Institute, Vastra Frolunda, Sweden). The dose used in clinical trials ranges from 200–680 mg/d. It is wise to start with the lower dose (100–150 mg/d) for 1–2 weeks and then increase up to a dose of 340–400 mg/d.
    4. Adverse effects:Generally well tolerated. Can cause agitation and irritability, dizziness, dry mouth
    5. Interactions:

 

  • Valerian  (Valeriana officinalis)
    1. Background:Traditional use & lower quality studies support mild sedative and anxiolytic. Commission E approved as an anxiolytic and a sleep aid. May combine with St. John’s wort (Hypericum perforatum) for the treatment of depression and depression with co-morbid anxiety, combined with lemon balm (Melissa officinalis) for relaxation & insomnia in adults & children.
    2. Indications:Anxiety, chronic insomnia
    3. Dose:The dose range for anxiety is typically 2-6 grams per day of valerian root in capsule or extract.
    4. Adverse effects:smells like dirty socks
    5. Contraindications:The German Commission E lists no contraindications, ESCOP contraindicates its use in children under 3 years, the World Health Organization (WHO) contraindicates is use in pregnancy.
    6. Interactions:
  • N-Acetylcysteine (NAC)
    1. Background: When used as add-on therapy, acetylcysteine has produced favorable results in patients with autism, OCD, bipolar disorder, or schizophrenia;
      1. See: NAC for Neuropsych disorders – Am J Health-Syst Pharm—Vol 72 Jun 1, 201
      2. Oral acetylcysteine for neuropsychiatric disorders – Am J Health-Syst Pharm—Vol 72 Jun 1, 2015 p 923 – 928
    2. Indications: OCD and it’s variants, other Neuropsych disorders
    3. Dose: Average effective dose is about 1200 mg – 2 G/day. Can start at 600 mg/day.
    4. Adverse effects: generally safe and well tolerated
    5. Contraindications:
    6. Interactions:
  1. Calm Aid or Silexan (Natures Way) for anxiety has been clinically studied and is comparable to lorazepam. Int J Neuropsychopharmacol.2014 Jun;17(6):859-69. doi: 10.1017/S1461145714000017. Epub 2014 Jan 23. Efficacy of orally administered Silexan in patients with anxiety-related restlessness and disturbed sleep – A randomized, placebo-controlled trial Siegfried Kasper Ion Anghelescu, Angelika DienelDOI: http://dx.doi.org/10.1016/j.euroneuro.2015.07.02. (some funding bias possible).

 

 

  1. Combination botanicals:
    1. Phytocalm
  2. Aromatherapy
    1. Essential oils can have potent effects on balancing autonomic nervous system, esp. Lavender or Bergamot in limited studies.
    2. Aromatherapy, a complete guide to the healing art, by Keville and Green; Crown publishing group, Random house

 

 

  1. Energy Medicine
    1. Regular Reiki treatments –preliminary evidence helps anxiety
    2. Healing Touch (HT) and Therapeutic Touch (TT) –preliminary evidence helps anxiety, effect may last 2 weeks
      1. TT studies show benefit for chronically anxious patients and in anxious non-demented elderly nursing home patients but there is limited evidence for anxiety reducing effects of TT in healthy adults. High patient satisfaction
    3. Emotional Freedom Technique – basic tutorial at: http://www.emofree.com/eft-tutorial/tapping-basics/how-to-do-eft.html
      1. Emotional Freedom Technique (EFT) is “an emotional, needle free form of acupuncture.” invented by Gary Craig from his work with Roger Callahan and Thought field theory, a branch of psychology aimed at overcoming phobias. EFT is an energy psychology technique that uses fingertip tapping of facial and chest points to move energy and help shift psychological difficulties. It is advertised to be an effective treatment for eating disorders, fears, phobias, depression, PTSD, and addiction. Practitioners of EFT state that EFT often works when nothing else does, and that it works for almost everything. Research is lacking for EFT; there are a few small studies published with promising results for phobias fibromyalgia, PTSD, and anxiety.
      2. Certification in EFT is obtained by studying course material by video and completing 100 treatment sessions. The material may be downloaded off the EFT website, www.emofree.com. Patients can work with a practitioner, or learn the points and treat themselves on a regular basis.
  • Basic premise of EFT: “The cause of all negative emotions is a disruption in the body’s energy system.” Once one finds those energy disruptions, use the tapping process to correct them. The EFT Tapping Basic Recipe blends focused wording with a 9 point Tapping sequence.
  1. Basic steps EFT:
    1. Choose a target for EFT – an emotion, block, belief or abundance issue.
    2. Scale the intensity of the belief or issue (1 – 10)
    3. Tap Karate chop point while repeating the set up statement, e.g. ‘Even though I have these money blocks, I deeply and completely accept myself’
    4. Negative tapping sequence Say your reminder phrase at each tapping point, e.g.“these money blocks” (8 points, 7 – 10X each): Top of head, eyebrow (at the beginning of the eyebrow, just above and to one side of the nose),side of eye (on the bone bordering the outside corner of the eye), under eye (on the bone under an eye about 1 inch below your pupil),under nose (on the small area between the bottom of your nose and the top of your upper lip),chin (midway between the point of your chin and the bottom of your lower lip), collarbone (the junction where the sternum collarbone and the first rib meet), under arm (on the side of the body, at a point even with the nipple (for men) or in the middle of the bra strap (for women). It is about 4 inches below the armpit)
    5. Positive tapping sequence: (same points, positive statement(s) – same or different each point), e.g. “I cultivate abundance’, ‘I choose peace’, ‘I embrace change’
    6. Finish with two deep breaths.Can rescale issue to assess for change
  2. Evidence for EFT: Small RCTs show benefit for anxiety (UI: 27125158, UI: 26539218), in war-injured vets (UI: 25530137), tension headaches (UI: 23452711). Promising results from WHEE (wholistic hybrid derived from eye movement desensitization and reprocessing and Emotional Freedom Techniques (WHEE), Emotional Freedom Techniques (EFTs), and cognitive behavioral therapy (CBT) (UI: 19913760, UI: 16290899).
  1. Traditional Chinese medicine (TCM)
    1. Balance of Yang (energy, alerting) predominant during day, and Yin, predominant during night. Shen – spirit or mind shines out thru the eyes. At night, with adequate Yin, Shen returns to rest in the heart.
    2. Depression – three forms:
      1. Lack of Yang vitality. Example: SAD – tx w light therapy
      2. Chi stagnation (liver depression) The liver is in charge of the smooth flow of all the energy (chi) in the body. Depression, irritability. Acupuncture & exercise ideal for this form of depression. Modern sedentary society leads to chi stagnation.
  • ‘Dampness clouding the heart’ – Shen or spirit gets stuck in the heart. Lifestyle change and herbals main therapeutics. Acupuncture not as helpful.
  1. Anxiety – lack of Yin calmness leads to scattered, agitated mind. Yin is the foundational ‘ballast’ for the mind.
    1. Menopause with drop of estrogen (which is yin) leads to anxiety and insomnia
  2. Bipolar – complex. Swings from yang and yin deficiency
    1. Liver depression/ chi stagnation often severe – becomes ‘hot’, transforming into ‘fire’ – mania.
    2. Severe dampness congeals into phlegm which can overheat and become ‘phlegm fire’ with disordered thinking.
  3. PTSD/major stress – auricular 5 needle nada protocol
  4. Drug addiction/ psychosis – auricular acupuncture plus biway at top of head
  5. Oil/fat is Yin and calms the brain.
  6. Chinese herbal formulas for many mental illnesses. Includes ‘dragon bones’ – fossilized dinosaur bones, ground pearls, resins such as amber are in formulas to calm the spirit – ‘shen calming’.
  7. Acupuncture & Qigong – Preliminary evidence of benefit for anxiety
  8. Resources Licensed acupuncturists:National Certification Commission for Acupuncture and Oriental Medicineor the American Academy of Medical Acupuncture
  9. Tai chi – good evidence of benefit for anxiety
  10. Massage– some evidence benefit for anxiety. Can be used even in ICU preemies, with benefit such as weight gain.
  11. http://www.amtamassage.org/findamassage/index.html?utm_source=%2ffindamassage%2flocator.aspx&utm_medium=web&utm_campaign=redirect
  12. http://www.ncbtmb.org/tools/find-a-certified-massage-therapist
  13. Music – particular types of music likely ease anxiety. RCT conventional cognitive therapy versus music-assisted reframing showed latter had greater reductions in overall anxiety (Kerr, 2001).
  14. Binaural sound: When headphones are used to route slightly different frequencies of sound to the right and left hemispheres, the brainstem constructs binaural beats on the basis of the frequency difference between sounds. Particular binaural beats consistently induce a calm, relaxed state, while others facilitate increased attention or arousal (Atwater, 1999).

Sample Protocol‐Anxiety

  • Inositol‐ 4 to 6 grams bid or tid
  • 5HTP 50 to 200 mg tid
  • Relaxation, meditation, walking, yoga, journaling
  • Psychotherapy, EMDR if trauma
  • L‐theanine 200 to 400mg bid
  • No caffeine
  • If obsessive: NAC 600‐1200mg bid