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Anxiety disorders



Related Terms
  • Adrenal, agoraphobia, angina, antidepressants, arrhythmias, asthma, azapirones, benzodiazepines, beta blockers, bipolar disorder, bruxism, CFS, chronic fatigue syndrome, cortisol, depression, diabetes, DSM-IV-TR, ephedra, epilepsy, epinephrine, fatigue, GABA, GAD, gamma-amino butyric acid, generalized anxiety disorder, hypochondriac, hypoglycemia, IBS, irritable bowel syndrome, migraine headaches, mitral valve prolapse, norepinephrine, obsessive compulsive disorder, OCD, palpitation, panic attacks, panic disorder, phobias, post traumatic stress disorder, PTSD, restless leg syndrome, RLS, SAD, separation anxiety, serotonin, sleep apnea, sleep disorders, social anxiety disorder, tension headaches, thyroid disorders, trauma, trichotillomania, vertigo.

Background
  • Anxiety is an unpleasant complex combination of emotions often accompanied by physical sensations such as heart palpitations (irregular heart beat), nausea, angina (chest pain), shortness of breath, tension headache, and nervousness.
  • The National Institute of Mental Health (NIMH) estimates that anxiety disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year. Only about one-third of those suffering from an anxiety disorder receive treatment. Anxiety disorders are reported to cost the United States more than $42 billion a year.
  • Unlike the relatively mild, brief anxiety that can be caused by a stressful event (such as testing, a job interview, the death of a loved one, or public performance/speaking), anxiety disorders last at least six months and can become worse if not treated.
  • Anxiety disorders can commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, depression, or bipolar illness, which may mask anxiety symptoms or make them worse.
  • According to the Anxiety Disorders Association of America (ADAA), individuals with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than non-sufferers.

Signs and symptoms
  • The primary symptoms of anxiety disorders are fear and worry. However, anxiety disorders are also characterized by additional emotional and physical symptoms.
  • Physical: Physical symptoms include heart palpitations (irregular heartbeat), angina (chest pain), hot flashes or chills, cold and clammy hands, stomach upset or queasiness, frequent urination, diarrhea, shortness of breath, sweating, vertigo (dizziness), tremors, muscle tension or aches, fatigue (tiredness), and insomnia (inability to sleep).
  • Emotional/Psychological: Emotional or psychological symptoms can include apprehension, uneasiness, dread, impaired concentration or selective attention, feeling restless or on edge, avoidance, nightmares, irritability, confusion, behavioral problems (especially in children and adolescents), nervousness, jumpiness, self-consciousness, insecurity, fear of dying or going crazy, and a strong desire to escape.
  • Generalized Anxiety Disorder (GAD): Specific symptoms for GAD can include chronic, exaggerated worry, tension, and irritability that appear to have no cause or are more intense than the situation warrants. Physical signs, such as restlessness, trouble falling or staying asleep, headaches, trembling, twitching, muscle tension, or sweating, often accompany these psychological symptoms.
  • Panic disorder: Panic disorder symptoms include heart palpitations (irregular heart beat), angina (chest pain), lightheadedness or dizziness, nausea, shortness of breath, feelings of imminent danger, shaking or trembling, choking, fear of dying, sweating, feelings of unreality, numbness or tingling, hot flashes or chills, and a feeling of going crazy. Since many of the symptoms of panic disorder mimic those found in illnesses like heart disease, thyroid problems and breathing disorders, people with panic disorder often make multiple visits to emergency rooms or doctors' offices, convinced they have a life-threatening illness (hypochondriac).
  • Social anxiety disorder (SAD): Specific symptoms for SAD include blushing, sweating, trembling, nausea, rapid heartbeat, dizziness, and headaches. Some people may have an intense fear of a single social or performance circumstance such as giving a speech, talking to a salesperson or making a phone call, but be perfectly comfortable in other social settings. Others may have a more generalized form of SAD, ranging from such behaviors as becoming anxious in a variety of routines, to clinging behavior, and throwing tantrums.
  • Post traumatic stress disorder (PTSD): People with PTSD typically avoid situations that remind them of the traumatic event, because they provoke intense distress or even panic attacks. PTSD is characterized by three main types of symptoms including: re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks and nightmares; emotional numbness and avoidance of places, people and activities that are reminders of the trauma; and increased arousal including difficulty sleeping and concentrating, feeling jumpy, and becoming easily irritated and angered.
  • Obsessive-compulsive disorder (OCD): Common obsessions include constant, irrational worry about dirt, germs or contamination, nagging feelings that something bad will happen if certain items aren't in an exact place, position or order, fear that one's negative or blasphemous thoughts or images will cause personal harm or harm to a loved one, preoccupation with losing or throwing away objects with little or no value, and rumination about accidentally or purposefully injuring another person. Common compulsions include repeatedly washing one's hands, bathing or cleaning household items, often for hours at a time; checking and re-checking, several to hundreds of times per day, that the doors are locked, stove is turned off, hairdryer is unplugged, etc., unable to stop repeating a name, phrase or tune, an excessive, methodical, and painstakingly slow approach to daily activities, and hording such as saving useless items like old newspapers or magazines, bottle caps or rubber bands.
  • Obsessions and rituals can substantially interfere with a person's normal routine, schoolwork, job, family or social activities. Many hours of each day may be spent focusing on obsessive thoughts and performing rituals, and normal concentration and the performing of daily functions becomes very difficult.
  • Children can also suffer from OCD, but unlike adults, children with OCD do not realize that their obsessions and compulsions are excessive and ritualistic.
  • Phobias: Specific phobias are characterized by strong, irrational, involuntary fear reactions to a particular object, place or situation. The reactions to these fears lead the individual to dread confronting common, everyday situations, or avoid them altogether, even though they logically know there isn't any threat of danger. Symptoms of phobias include heights, flying in airplanes, insects, snakes and other animals, dental procedures, thunder, public transportation, and elevators. The fear doesn't make any sense, but nothing seems to be able to stop it. When confronted with the feared situation, someone with a phobia may even have a panic attack.

Diagnosis
  • Generalized Anxiety Disorder (GAD): GAD diagnosis is when an individual spends at least six months worried excessively about everyday problems. However, incapacitating or troublesome symptoms warranting treatment may exist for shorter periods of time.
  • Panic disorder: Panic disorder (or panic attack) is diagnosed by either four attacks within four weeks or one or more attacks followed by at least a month of persistent fear of having another attack. Also, a minimum of four of the symptoms listed for panic disorders developed during at least one of the attacks. Most panic attacks last only a few minutes and up to an hour in rare cases. They can occur at any time, even during sleep.
  • Phobias: Phobia present with extreme anxiety with exposure to the object or situation. The individual recognizes that his or her fear is excessive or unreasonable, and finds that normal routines, social activities, or relationships are significantly impaired as a result of these fears.
  • Obsessive-compulsive disorder (OCD): A mental health professional will diagnose obsessive-compulsive disorder after a thorough evaluation. Criteria are based upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), a clinical book of mental illness diagnoses. OCD diagnosis is based upon recurrent and persistent thoughts, impulses or images that are intrusive and cause distress, thoughts that aren't simply excessive worries about real problems, an attempt to ignore or suppress these thoughts, images or impulses, and the recognition that these thoughts, images and impulses are a product of the mind.
  • Compulsions must meet specific criteria including repetitive behaviors, such as hand washing, or repetitive mental acts, such as counting silently, that the individual feels driven to perform. These behaviors or mental acts are meant to prevent or reduce distress about unrealistic obsessions.
  • Post traumatic stress disorder (PTSD): Although many of the symptoms of PTSD may be an appropriate initial response to a traumatic event, they are considered part of a disorder when they persist beyond three months.

Complications
  • Anxiety can also worsen many pre-existing medical conditions, such as ulcers, hypertension (high blood pressure), asthma, and chronic obstructive pulmonary disease (COPD). Anxiety may also be associated with mitral valve prolapse (condition where the mitral valve does not close properly), chronic fatigue syndrome (CFS), sleep apnea, irritable bowel syndrome (IBS), and chronic (long-term) tension headaches.
  • Depression: Anxiety and depression usually go hand in hand, in both the young and old. The combination of depression and anxiety may increase both substance abuse and suicide.
  • The lifetime risk for depression in people with anxiety disorders may be higher than 70%. Most patients with generalized anxiety disorder (GAD) will experience at least one episode of significant depression and many develop recurrent episodes. In patients with both disorders, GAD usually precedes the onset of depression. Social anxiety during adolescence or young adulthood has been associated with a higher risk for depression, and the presence of both increases the chances for severe depression. People with post traumatic stress disorder (PTSD) are four to seven times as likely to be depressed as are people without PTSD.
  • Bipolar Disorder: Symptoms of panic disorder are very common in people with bipolar disorder (manic-depression). In fact, people with bipolar disorder have 26 times the rate of panic disorder as in the general population. To complicate matters, anxiety can worsen bipolar disorder.
  • Suicide: Anxiety disorders may also contribute to an increased risk for suicide, developing alcoholism and other forms of substance abuse, overeating, may have very negative effects on work, school, and relationships, and decrease the individuals overall health.
  • Physical injury: Individuals with obsessive-compulsive disorder (OCD) may experience physical injury such as skin problems from excessive washing, injuries from repetitive physical acts, and hair loss from repeated hair pulling (trichotillomania). Studies have reported that PTSD may be associated with shrinkage in the brain associated with memory and learning, possibly due to the continued release of the stress hormone cortisol.
  • Physical Effects of Anxiety on Children: Anxiety may be associated with a higher risk for sleep disorders in children, such as frequent nightmares, restless legs syndrome (RLS), and bruxism (grinding and gnashing of the teeth during sleep).

Treatment
  • Psychotherapy techniques:
  • Generally, anxiety disorders are treated with medications, specific types of psychotherapy, or both. Treatment choices depend on the symptoms and the preference of the doctor and patient.
  • Psychotherapy: Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what causes an anxiety disorder and how to deal with its symptoms.
  • Cognitive-Behavior Therapy (CBT): Many therapists use a combination of cognitive and behavior therapies, this is often referred to as CBT. Cognitive-behavioral therapy is based on the scientific fact that thoughts cause feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that an individual can change the way they think to feel and act better even if the situation causing the problem does not change.
  • Relaxation Techniques: Relaxation Techniques help individuals develop the ability to more effectively cope with the stresses that contribute to anxiety, as well as with some of the physical symptoms of anxiety. The techniques taught include breathing re-training and exercise.
  • Anti-anxiety medications:
  • Benzodiazepines: Benzodiazepines are fast-acting sedatives that typically relieve anxiety symptoms within 30 minutes to one hour. The rapid relief when using benzodiazepines makes them very effective when taken during a panic attack or another overwhelming anxiety episode.
  • Unfortunately, benzodiazepines can be addictive. If taken regularly for more than a couple of weeks, physical and psychological addiction is likely to occur. Benzodiazepine may create tolerance, with larger doses needed to achieve the same effect, and serious withdrawal symptoms can occur when going off the medication, including increased anxiety, depression, and insomnia. Some benzodiazepines, including diazepam (Valium®) have a longer half-life in the body, meaning they stay in the body longer. The addictive potential is why benzodiazepines are usually recommended only for short-term. To minimize the withdrawal reaction, it is important to slowly taper off these medications.
  • Some examples of benzodiazepines include alprazolam (Xanax®), chlordiazepoxide (Librium®), clonazepam (Klonopin®), clorazepate (Tranxene®), lorazepam (Ativan®), oxazepam (Serax), diazepam (Valium). Clonazepam (Klonopin®) is commonly used for social phobia and GAD, lorazepam (Ativan®) is used for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and generalized anxiety disorder (GAD).
  • Most common side effects include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat.
  • Azapirones: Azapironeswere developed more recently than benzodiazepines, and are anti-anxiety drugs prescribed for GAD and obsessive compulsive disorder (OCD). Compared to benzodiazepines, the azapirones are slow acting, taking from two to four weeks to provide anxiety symptom relief. Advantages of these drugs over benzodiazepines include less sedation and effects on coordination, and less memory impairment. Withdrawal effects with azapirones are minimal compared to benzodiazepines. Buspirone (Buspar®) is the only azapirone approved for medical use.
  • Side effects may include nausea, headaches, dizziness, drowsiness, upset stomach, constipation, diarrhea, and dry mouth. Azapirones are not to be taken with monoamine oxidase inhibitors (MAOIs, a type of antidepressant) due to the increase risk of life-threatening high blood pressure.
  • Antidepressant medications:
  • Selective serotonin reuptake inhibitors (SSRIs): SSRIs are antidepressants that alter the levels of the neurotransmitter serotonin in the brain. SSRIs have been used to treat panic disorder, obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD). They are often prescribed because they have less severe side effects than the older antidepressants.
  • Some SSRIs used in anxiety disorders include fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) which are commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. SSRIs generally are started at low doses and gradually increased until they have a beneficial effect.
  • Tricyclic antidepressants (TCAs): TCAs are older antidepressants that may be prescribed for panic disorder, obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD). Tricyclics can also be prescribed for anxiety disorders co-occurring with depression. The tricyclics typically take around two weeks to provide symptom relief.
  • Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.
  • Monoamine oxidase inhibitors (MAOIs): MAOIs are the oldest class of antidepressant medications.
  • The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia.
  • Atypical antidepressants:
  • There are several newer atypical antidepressants which target other neurotransmitters either alone or in addition to serotonin. Some of the brain chemicals they affect include norepinephine and dopamine.
  • Venlafaxine (Effexor®), an atypical antidepressant, is used to treat GAD.
  • Antidepressants take up to four to six weeks to begin relieving symptoms, so they aren't helpful if first taken during a panic attack.
  • Antidepressants are often prescribed instead of benzodiazepines because the risk for dependency and the abuse is less.
  • Antidepressant can cause loss of sexual desire, nausea, insomnia, sweating, nervousness, dizziness, weight gain or weight loss, dry mouth, constipation, and blurred vision. MAOIs also have severe interactions with certain foods, drinks, and medications. When an individual takes an MAOI, he or she must carefully monitor what is eaten and what drugs are taken. Items that are restricted include many cheeses, chocolate, wine, and beer.
  • Beta-blockers:
  • Beta blockers are type of drug used to treat high blood pressure and heart problems. In anxiety, beta blockers can help control physical symptoms such as nervousness, rapid heart rate, trembling voice, sweating, dizziness, and shaky hands. Beta blockers are prescribed off label for anxiety.
  • Because they don't affect the emotional symptoms of anxiety such as worry, beta blockers are most helpful for phobias, particularly social phobia and performance anxiety (such as a speech or being in front of an audience).
  • Examples of beta blockers include propranolol (Inderal®), metoprolol (Lopressor®) and atenolol (Tenormin®).
  • Side effects include light-headedness, sleepiness, short-term memory loss, unusually slow pulse, fatigue, insomnia, diarrhea, cold hands and feet, and sexual side effects.

Integrative therapies
  • Strong scientific evidence:
  • Kava: Kava kava (Piper methysticum) is a shrub from the South Pacific islands that has been used for centuries to produce calming effects in humans. Studies have found moderate benefit of kava in the treatment of anxiety, and preliminary evidence suggests that kava may be equivalent to benzodiazepine drugs such as diazepam (Valium®). In one human study, kava's effects were reported to be similar to the prescription drug buspirone (Buspar®) used for generalized anxiety disorder (GAD). However, a recent study found no effect in generalized anxiety disorder. The kava supplement should be standardized for best results.
  • There is concern regarding kava's potential toxicity, based on multiple reports of liver damage in Europe and a number of cases in the United States, including hepatitis, cirrhosis, and liver failure. The U.S. Food and Drug Administration (FDA) has issued warnings to consumers and physicians. Kava should not be used in individuals with pre-existing liver conditions or a history of alcohol or drug abuse. Caution is advised when taking kava as numerous adverse effects including sedation and drug interactions are possible. Kava should not be used if pregnant or breastfeeding.
  • Music therapy: Music is an ancient tool of healing. Many different forms of music intervention have been used to reduce anxiety in a variety of medical conditions and medical procedures. The relaxation response is a physiological state that speeds up many of the body's healing responses. Relaxation leads to reduced heart rate, blood pressure, and tension, as well as many other beneficial changes. Music therapy has been shown to promote relaxation and to be of benefit in stress and anxiety.
  • Most studies have shown positive findings, although not all do. There is evidence that music interventions help reduce anxiety related to cataract surgery, sigmoidoscopy, bronchoscopy, breast biopsy, cesarean delivery, colonoscopy, esophagogastroduodenoscopy, cardiac catheterization, hospitalized asthmatic patients, psychotherapy, general medical procedures, radiation therapy, treatment for acute myocardial infarction, preparation for surgery, total knee arthroplasty, ventilator-dependence and transurethral resection of the prostate (TURP). Many of these studies have found reduced blood pressure and heart rate as well. A minority of studies found no benefit including studies related to mammogram, ischemic heart disease, pediatric outpatient surgery, and cardiac catheterization. The choice of music may be a factor in outcomes: listening to music of one's preference has been found to be an important consideration. Overall, the evidence favors use of music interventions for anxiety, although more studies are needed to determine what forms work best. Music therapy is generally known to be safe.
  • Good scientific evidence:
  • Art therapy: Art therapy may enable the expression of inner thoughts or feelings when verbalization is difficult or not possible. Some evidence suggests that creative expression programs in schools involving art therapy may help alleviate problems of self-esteem and can improve social functioning in school age children. Some evidence suggests that a creative expression program involving art therapy may help alleviate these problems, increase self-esteem, and improve social functioning and transitional stress.
  • Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.
  • Chiropractic, Spinal Manipulative Therapy, Spinal Manipulation: The use of spinal manipulative therapy for the relief of tension headache or migraine headache has been reported in several controlled human trials, systematic reviews, and case reports. Overall, the quality of studies is not high, with incomplete reporting of design, inconsistent use of techniques between studies, and variable results. Despite these methodologic problems, overall the evidence suggests some benefits in the prevention of episodic tension headache. Effects on migraine headache have not been demonstrated. Better quality research is necessary in this area before a firm conclusion can be drawn. Patients should be aware of the safety concerns surrounding cervical/neck manipulation before starting this type of therapy.
  • Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.
  • Hypnosis: Hypnosis is associated with a deep state of relaxation. Several studies support the use of hypnosis to reduce anxiety, particularly prior to dental or medical procedures, or in the management of phobias. Early evidence suggests that these effects may last for up to three years with benefits reported in children and adults. Several promising studies in adults and children report that dental anxiety related to dentist visits can be reduced with the use of hypnotherapy. Benefits may be long-standing (measured at up to three years). However, some research reports that hypnosis may be less effective for this use than group therapy or systematic desensitization therapy. In addition, several studies report improvements in the severity and frequency of tension headaches following several weekly hypnosis sessions. Early research suggests that hypnosis may be equivalent to other relaxation techniques, biofeedback, or autogenic training. Better quality studies are necessary before a conclusion can be made in this area.
  • Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
  • Meditation: Evidence indicates that meditation may help healthy people reduce the effects of stress. More studies are needed to further examine the dynamics of stress and meditation, but meditation may be recommended as a general health-promotion activity.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
  • Music therapy: Many forms of music intervention have been used to reduce anxiety in a variety of medical conditions and medical procedures. Overall, the evidence favors the use of music interventions for anxiety, although more studies are needed to determine what forms work best.
  • The stress response is a physiological state opposite to that of the relaxation response, with increased blood pressure, heart rate, tension, stress hormones (cortisol), and other potentially adverse changes. In cardiac patients, music has been found to reduce blood pressure, respiratory rate, psychological distress, and cardiac complications. Music therapy may be of benefit in stress by reducing levels of stress hormones in the blood including those released in response to invasive medical procedures. Children receiving immunization may have reduced levels of physiological and behavioral distress with the help of lullabies. Finally, there is evidence that music may reduce the stress response when performing stressful mental tasks. Music therapy is generally known to be safe.
  • Peppermint: Application of diluted peppermint oil to the forehead and temples has been tested in people with headache, specifically tension headache. It is not clear if this is an effective treatment.
  • Allergic/hypersensitivity reactions may occur from using peppermint or menthol by mouth or on the skin, including throat closing (laryngeal spasm), breathing problems (bronchial constriction/asthma symptoms), or skin rash/hives/contact dermatitis. People with known allergy/hypersensitivity to peppermint leaf or oil should avoid peppermint products. Peppermint oil may be safe in small doses, although multiple adverse effects are possible. Very large doses of peppermint oil taken by mouth have resulted in muscle weakness, brain damage, and seizure. Peppermint oil should be used cautiously by people with G6PD deficiency or gallbladder disease. Use in infants or children is not recommended due to potential toxicity.
  • Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). Psychotherapy, especially cognitive behavioral therapy, may be of benefit in generalized anxiety disorder or panic disorder. Treatment may also include prescription medication in some cases.
  • Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.
  • Relaxation therapy: Clinical studies suggest that relaxation techniques may be beneficial in patients with anxiety, although these approaches do not appear to be as effective as psychotherapy. Numerous human studies report that relaxation techniques (for example using audio tapes or group therapy) may moderately reduce anxiety and stress, particularly in individuals without significant mental illness. Relaxation may be beneficial for phobias such as agoraphobia (fear of crowds), panic disorder, work-related stress, and anxiety due to serious illnesses, prior to medical procedures, or during pregnancy. However, there are many types of relaxation techniques used in studies, and many trials do not clearly describe design or results.
  • Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.
  • Therapeutic touch: There is some evidence that therapeutic touch may reduce anxiety in chemically dependent pregnant women, reduce stress and anxiety in the work place, and reduce stress in teen-agers with psychiatric disease. Further study is needed to indicate that therapeutic touch is an effective way to reduce stress and promote relaxation. Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.
  • Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Yoga may reduce daily stress and anxiety in healthy people when practiced several times weekly. Several human studies support the use of yoga therapy in the treatment of clinical anxiety disorders, including generalized anxiety and OCD. Available data remains inconclusive, yet thousands of years of effectiveness in India for stress and anxiety must be appreciated.
  • Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
  • Unclear or conflicting scientific evidence:
  • 5-HTP(5-Hydroxytryptophan, L-5-Hydroxytryptophan): 5-HTP is the precursor of the neurotransmitter serotonin. It is obtained commercially from the seeds of the plant Griffonia simplicifolia. Although 5-HTP has been proposed as a possible treatment for anxiety disorders, there is not enough human evidence to make a firm recommendation.
  • Avoid 5-HTP if allergic or hypersensitive to it; signs of allergy to 5-HTP may include rash, itching or shortness of breath. Avoid with eosinophilia syndromes, Down's syndrome, and mitochondrial encephalomyopathy. Use cautiously if taking antidepressant medications such as TCAs, MAOIs, SSRIs, nefazodone, trazodone, venlafaxine, mirtazapine, bupropion; 5-HTP receptor agonists such as sumatriptan, rizatriptan, naratriptan, zolmitriptan, eletriptan, imotriptan, and frovatriptan; and carbidopa, phenobarbital, pindolol, reserpine, tramadol, or zolpidem. Use cautiously with renal (kidney) insufficiency, HIV/AIDS- particularly HIV-1 infection, epilepsy, and/or with a history of mental disorders. Avoid if pregnant or breastfeeding.
  • Acupressure, shiatsu: Acupressure, or shiatsu, has been used in China for thousands of years for health and healing. Preliminary clinical trials suggest that acupressure may significantly reduce general and pre-operative anxiety. However, these studies have been small and poorly designed, warranting better-quality research. With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.
  • Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. Several studies have reported benefits in anxiety disorders, but the studies have been small and poorly designed, leaving the scientific evidence on acupuncture use in anxiety inconclusive.
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Aromatherapy: Lavender aromatherapy may be able to reduce anxiety. However, there have been conflicting results, and more study is needed in this area. It is unclear whether lavender aromatherapy reduces anxiety and stress in intensive unit care patients. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid if history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
  • Art therapy: Limited evidence suggests that art therapy, in the context of group psychotherapy, may contribute to the reduction of symptoms of emotional distress in military personnel receiving mental health treatment. Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.
  • Bach flower remedies: A small number of studies report the effects of Bach flower remedies to be similar to those of placebo for the treatment of anxiety. These studies have not been well designed, and additional research is necessary before a firm conclusion can be drawn.
  • People allergic to certain plants or flowers may be sensitive to Bach flower remedies, although only a small amount of the plant may exist in the solution. There is a lack of available systematic study on the safety of Bach flower remedies. Mantle et al. noted that Bach flower remedies do not appear to have any adverse effects and do not seem to interact with other medicines. Many Bach flower remedies contain alcohol, which may cause nausea and vomiting if taken with metronidazole (Flagyl®) or disulfiram (Antabuse®). Alcohol may also cause drowsiness. Driving or operating heavy machinery may be inadvisable if using Bach therapies with high alcohol concentrations. Back flower remedies should not be used in place of more proven therapies. Alcohol intake should be limited in pregnant or breast-feeding women.
  • Bacopa: Bacopa (Bacopa monnieri) is commonly called "brahmi" and is used in the Ayurvedic system of medicine in India. Although bacopa is traditionally used for anxiety, high-quality clinical trials are lacking. Early study found some evidence that bacopa reduces clinical anxiety. However, more independent research is needed.
  • Caution is advised when taking bacopa supplements as numerous adverse effects including heart palpitations are possible. Use cautiously with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.
  • Black currant: There is currently a lack of information in humans on the effectiveness of black currant seed oil for stress. More research is needed in this area. Avoid if allergic or hypersensitive to black currant, its constituents, or plants in the Saxifragaceae family. Avoid with hemophilia or those on blood thinners unless otherwise recommended by a qualified healthcare provider. Use cautiously with venous disorders or gastrointestinal disorders. Use cautiously if taking monoamine oxidase inhibitors (MAOIs), antidepressants, or vitamin C supplements. Avoid if pregnant or breastfeeding.
  • Black tea: Based on early research, black tea may reduce stress and help patients feel more relaxed. More research is needed to confirm these findings. It should be noted that high doses of caffeine have been linked to anxiety.
  • Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.
  • Borage seed oil: Borage (Borago officinalis) is an herb native to Syria that has spread throughout the Middle East and Mediterranean. Borage flowers and leaves may be eaten and borage seeds are often pressed to produce oil very high in gamma-linolenic acid (GLA). Borage oil may decrease heart changes in acute stress. More high quality studies are needed in this area.
  • Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid in pregnant patients as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as borage oil's GLA. Avoid if breastfeeding.
  • Bowen therapy: Bowen therapy has been used in healthcare settings to reduce job-related stress. Based on a survey of CAM use in the United Kingdom, 66 respondents reported that Bowen therapy was beneficial for stress/anxiety.
  • There is a lack of available scientific study of the safety of Bowen therapy. Based on case study that investigated Bowen therapy as a treatment for frozen shoulder, no adverse effects were reported. Avoid the "Coccyx Procedure" in pregnant women based on recommendations from some Bowen technique practitioners. Avoid the "TMJ Procedure" in people whose jaws have been surgically altered at the condyles based on recommendations from some Bowen technique practitioners. Avoid the "Breast Tenderness Procedure" in women with breast implants based on recommendations from some Bowen technique practitioners. Avoid using the Bowen technique in place of more proven therapies.
  • Gotu kola: In the traditional Indian system of Ayurvedic medicine, gotu kola is said to develop the crown chakra, the energy center at the top of the head, and to balance the right and left hemispheres of the brain. It has traditionally been used by yogis as a food for meditation. Animal research has demonstrated anxiety reducing properties of gotu kola, but human studies are lacking. A randomized trial assessing the effects of gotu kola on startle responses in healthy (non-anxious) individuals has reported some benefits. These preliminary findings are promising, although further research should be performed. Gotu kola is not related to the cola nut, and does not contain caffeine. Gotu kola is generally reported as safe when used in humans for short term use. Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer or diabetes. Avoid if pregnant or breastfeeding.
  • Green tea: L-theanine is a predominant amino acid found in green tea. Preliminary research exists on the effects of this amino acid in comparison with the prescription drug alprazolam on experimentally induced anxiety. No benefit was found. Avoid if allergic or hypersensitive to caffeine or tannin should avoid green tea. Use cautiously with diabetes or liver disease.
  • Guided imagery: Guided imagery may include a number of techniques, such as metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Initial evidence suggests that guided imagery relaxation audiotapes may reduce anxiety and wound healing after surgery. Early research is conflicting on whether the use of imagery may be beneficial for reduction of anxiety in multiple sclerosis. A small study reports increased relaxation in chronic obstructive pulmonary disease (COPD) (emphysema or chronic bronchitis) patients who use guided imagery techniques. Additional research is needed to confirm these results.
  • Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or if a history of trauma or abuse, speak with a qualified health care provider before practicing guided imagery.
  • Hawthorn: Hawthorn, in combination with other herbs, may help to reduce anxiety and anxious mood. It is unknown if hawthorn specifically has beneficial effects. Avoid if allergic to hawthorn or to members of the Crataegus species. Avoid if history of low blood pressure, irregular heartbeat, asthma, low blood pressure when standing or insomnia. Use cautiously in elderly patients. Avoid if pregnant or breastfeeding.
  • Healing touch (HT): Preliminary data from an uncontrolled trial suggests HT may help reduce symptoms of PTSD in women. More studies are needed. Evidence is mixed over whether a series of HT treatments over time may aid in stress reduction in individuals experiencing academic or caregiver stress. More studies of stronger design are necessary before definitive recommendation for or against the use of HT for stress reduction can be made. HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.
  • Kava: Early study results suggest that kava and valerian may be beneficial to health by reducing the body's reactions during stressful situations and stress induced insomnia. Further research is needed to confirm these results. Avoid if allergic to kava or kavapyrones. Avoid with liver disease, Parkinson's disease, a history of medication-induced extrapyramidal (the motor system related to the basal ganglia) effects, and chronic lung disease. Avoid if taking medications for liver disease or CNS depressants such as alcohol or tranquilizers. Avoid while driving or operating heavy machinery (may cause drowsiness). Use cautiously with depression or if taking antidpressants. Avoid if pregnant or breastfeeding.
  • Lavender: Lavender aromatherapy is traditionally used for relaxation. It is reported to help relieve anxiety in several small studies, although negative results have also been reported. Better research is needed before a strong recommendation can be made. Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia) or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
  • Lemon balm: Preliminary human evidence has been published that supports the use of lemon balm (Melissa officinalis) for anxiety. In a large case series that included 1,599 patients with symptoms of anxiety, a combination of lemon balm and valerian (Valeriana officinalis) was found to improve symptoms of anxiety, including nervousness, fatigue, and sleep disturbances in over 90% of the patients. Although only mild side effects were reported, caution is advised when taking lemon balm supplements as numerous adverse effects including drowsiness and drug interactions are possible.
  • Based on available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks. Evidence for topical administration of cream suggested minimal side effects for up to 10 days of application. Avoid if allergic or hypersensitive to lemon balm. Avoid with Grave's disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.
  • Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Several human trials have assessed the effects of massage in patients with anxiety, including those with cancer or chronic illnesses, hospitalized for psychiatric disorders, pre-operative anxiety (anxious about themselves or for family members having surgery), dementia, multiple sclerosis, before/during medical procedures, depressed adolescent mothers, women with premenstrual syndrome, patients with fibromyalgia and in elderly institutionalized patients. Additional research is necessary in order to form a scientifically based recommendation. A 15-minute weekly massage has been studied for the reduction of physical and psychological stress in nurses. Massage was not beneficial for physical stress, but was found beneficial in reducing psychological stress levels. Further study is warranted.
  • Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously if history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
  • Meditation: Various forms of meditation, including mindfulness, transcendental meditation®, and "meditation-based stress reduction programs" have been studied for their effects on anxiety. Better studies are needed.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
  • Passion flower: Passion flower has a long history of use for symptoms of restlessness, anxiety, and agitation. Early evidence from animal studies and weak human trials supports these uses. Better research is needed before a firm conclusion can be drawn. Avoid if allergic to passion flower or any of its constituents. Avoid consuming raw Passiflora fruit (Passiflora adenopoda), due to possible cyanide constituents. Avoid driving or operating heavy machinery while taking passion flower. Use cautiously with low blood pressure. Avoid if pregnant or breastfeeding.
  • Prayer, distant healing: Prayer has been studied in patients with anxiety but results are mixed. Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers. Based on limited available clinical study, patients certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know they were being prayed for.
  • Psychotherapy: Children ages 8-15 who maintain active involvement in therapy may respond well to cognitive-behavioral psychotherapy. More study is needed in the area of anxiety in children.
  • Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.
  • Qi gong: Qi gong is a type of Traditional Chinese Medicine (TCM) that is thought to be at least 4,000 years old. Preliminary study shows that Qi gong may be beneficial for relieving stress. Available data remains inconclusive, yet thousands of years of effectiveness in China for stress and anxiety must be appreciated. Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders.
  • Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. There is preliminary evidence that reflexology may be useful for relaxation, reducing stress, or relieving anxiety. However, it is not clear that reflexology is equivalent or superior to massage or other types of physical manipulation. Better research is needed in this area.
  • Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.
  • Rolfing® Structural Integration: Structural Integration may help treat anxiety, although early research is unclear. Further research is needed.
  • Rolfing® Structural Integration should not be used as the sole therapeutic approach to disease, and it should not delay the time it takes to speak with a healthcare provider about a potentially severe condition. Rolfing® Structural Integration is generally believed to be safe in most people. Avoid in patients taking blood thinners and in patients with broken bones, severe osteoporosis, disease of the spine or vertebral disks, skin damage or wounds, bleeding disorders, blood clots, tooth abscesses, acute disc problems, aneurysm, fever, recent scar tissue, connective tissue disease, cancer, and in patients who have just received cortisone shots or on chronic cortisone therapy. Use cautiously in patients with varicose veins or phlebitis, joint diseases, psychosis or bipolar disorder, severe kidney, liver, or intestinal disease, diabetes, menstruation, infectious conditions, colostomies, high blood pressure, and stenoses or strictures.
  • Rosemary: Rosemary extract is frequently used in aromatherapy for treatment of a variety of conditions, including anxiety and stress, mood enhancement, alteration of pain perception, and to increase alertness. Early study has shown benefit in reducing stress levels and increasing alertness. More study is needed to make a conclusion.
  • Avoid if allergic/hypersensitive to rosemary, its constituents, or members of the Labitae/Lamiaceae family. Use cautiously if prone to atopic or hypersensitivity reactions. Use cautiously with a history of iron deficiency anemia. Use cautiously with coagulation disorders, hypotension, diabetes, and peptic ulcer disease. Use cautiously if taking anticoagulation/antiplatelet agents, antihyperstension agents, agents for cancer or chemotherapy drugs, medication for high cholesterol, herbs or drugs metabolized by cytochrome P450 pathways, diuretics, estrogen or estrogenic herbs, or medications for osteoporosis. Avoid if taking lithium. Avoid if pregnant or breastfeeding.
  • Sandalwood: Sandalwood is frequently used in incense and aromatherapy. Early study indicates that sandalwood may reduce anxiety in palliative patients. Additional study is needed in this area. Avoid if allergic or hypersensitive to sandalwood (Santalum album), its constituents, or related members of the Santalaceae family. Avoid if pregnant or breastfeeding.
  • St. John's wort: Extracts of Hypericum perforatum L. (St. John's wort) have been recommended traditionally for a wide range of medical conditions. Overall, there is currently not enough evidence to recommend St. John's wort as a primary treatment for anxiety disorder.
  • Avoid if allergic or hypersensitive to plants in the Hypericaceae family. Rare allergic skin reactions like itchy rash have been reported. Avoid with HIV/AIDS drugs (protease inhibitors) like indinavir (Crixivan®), or non-nucleoside reverse transcriptase inhibitors, like nevirapine (Viramune®). Avoid with immunosuppressant drugs (like cyclosporine, tacrolimus or myophenic acid). Avoid with organ transplants, suicidal symptoms or before surgery. Use cautiously with history of thyroid disorders. Use cautiously with drugs that are broken down by the liver, with monoamine oxidase inhibitors (MAOI) or selective serotonin reuptake inhibitors (SSRIS), digoxin, or birth control pills. Use cautiously with diabetes or with history of mania, hypomania (as in Bipolar Disorder), or affective illness. Avoid if pregnant or breastfeeding.
  • Sweet almond: It is unclear whether sweet almond improves anxiety in palliative care patients, but more research investigating sweet almond as the active treatment is needed to make a firm recommendation. Avoid if allergic or hypersensitive to almonds or other nuts. Use cautiously with heart disease, diabetes, or low blood sugar. Use cautiously if taking cardiovascular agents (including antilipemics), antidiabetics, estrogens, phytoestrogens, and fertility agents. Use cautiously if pregnant or breastfeeding.
  • Tai chi: Tai chi may reduce stress in various populations of people, including HIV patients. Early study suggests that tai chi practice may be effective in reducing the impact of tension headaches and may also be effective in improving perceptions of some aspects of physical and mental health.
  • Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.
  • Thymus extract: Thymus extract has been investigated for use in acute anxiety and stress and adaptive disorders. More clinical trials are required before recommendations can be made involving thymus extract for this use.
  • Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.
  • Valerian: Valerian (Valeriana officinalis) has traditionally been used for sleep improvement and for stress and anxiety disorders. Studies have generally been of poor methodological quality, and several have used valerian in combination with other herbs, such as passion flower (Passiflora incarnata), lemon balm (Melissa officinalis), and St. John's wort (Hypericum perforatum). Studies report that valerian is generally well tolerated for up to four to six weeks in recommended doses. Caution is advised when taking valerian supplements as numerous adverse effects including drowsiness, sedation, and drug interactions are possible. Do not use valerian if pregnant or breastfeeding. Use with caution if allergic to members of the Valerianaceae family. Avoid if driving or operating heavy machinery, as it may cause drowsiness. Avoid with liver disease. Avoid if pregnant or breastfeeding.
  • Strong negative scientific evidence:
  • Trigger point therapy: Release of trigger points can reduce tension, stress and anxiety, aid in circulation, and induce relaxation. The goal of trigger point therapy for relaxation is to alter the autonomic system. Limited available study demonstrated that this therapy might be effective for induction of relaxation. Because the implications of these findings of alterations in blood pressure and other autonomic functions, the results of this study warrant future investigations with more stringent study guidelines.
  • Use cautiously with local or systemic infection, anticoagulation or bleeding disorders, or acute muscle trauma. Avoid aspirin ingestion within three days of injection. Avoid with extreme fear of needles, large bruises, phlebitis, varicose veins, undiagnosed lumps, or open wounds. Avoid if allergic to anesthetic agents (mainly caused by aminoester agents). Use cautiously during pregnancy.

Prevention
  • Diet: Nutritional deficiencies originating from poor diet and/or digestion have been found to contribute to anxiety. Adequate levels of minerals such as magnesium and zinc, as well as sufficient intake of B vitamins, especially vitamin B-12, may be beneficial for treatment and prevention of anxiety disorders. It is also important for patients to eat a well-balanced diet and to reduce or eliminate caffeine and alcohol.
  • Exercise: The benefits of regular exercise are relevant for many different conditions. Patients with anxiety disorders may benefit from introduction of exercise into their daily schedule.
  • Substance abuse counseling: Some prescription and non-prescription substances may cause symptoms of anxiety, including caffeine, nicotine, and other stimulants, drugs such as heroin, cocaine, and amphetamines, and some herbal supplements such as ephedra (no longer available on the U.S. market), Citrus aurantium, yerba mate tea, and guarana.
  • Sleep: Adequate sleep is important for many different conditions. Patients with anxiety are advised to get enough sleep every night.
  • Stress reduction: Relaxation methods help individuals develop the ability to more effectively cope with the stresses that contribute to anxiety, as well as with some of the physical symptoms of anxiety. Techniques such as guided imagery, Qi gong, meditation, relaxation therapy, and music therapy may be helpful for prevention of anxiety.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. Anxiety Disorders of America. . Accessed February 26, 2009.
  2. Mental Health America. . Accessed February 26, 2009.
  3. National Institute of Mental Health. . Accessed February 26, 2009.
  4. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed February 26, 2009.

Causes
  • Brain chemistry: Studies suggest that an imbalance of the brain's neurotransmitters (chemical messengers) such as serotonin, gamma-amino butyric acid (GABA), epinephrine, and norepinephrine may contribute to anxiety disorders. Abnormalities in the stress hormone cortisol, produced by the adrenal glands, have also been found. Most medications prescribed for anxiety disorders aim to readjust the brain's chemical balance.
  • Trauma: An anxiety disorder may develop in response to a traumatic event, such as a car accident or a marital separation. Anxiety may also have its roots in early life abuse or developmental trauma. Trauma in infancy and early childhood can be particularly damaging, leaving a pervasive and lasting sense of helplessness that can develop into anxiety or depression in later life.
  • Medications: Some prescription and non-prescription medications may cause symptoms of anxiety, including caffeine and other stimulants, drugs such as heroin, cocaine, and amphetamines, over-the-counter medications such as decongestants, steroids such as cortisone and prednisone, inhalers and other respiratory medications, some herbal supplements such as ephedra (no longer available on the U.S. market), Citrus aurantium, yerba mate tea, and guarana, weight loss products, high blood pressure medications, withdrawal from alcohol, ADHD medications (Ritalin®, Adderall®, Dexedrine®), withdrawal from benzodiazepines (Xanax®, Valium®), and hormones such as birth control pills and thyroid medications.
  • Medical conditions: Many medical conditions can cause or mimic symptoms of anxiety disorders. They include thyroid disorders, diabetes, hypoglycemia (low blood sugar), asthma, sleep disorders, adrenal disorders, epilepsy (seizures), heart conditions including arrhythmias (irregular heart beat), migraine headaches, certain psychiatric illnesses, such as bipolar disorder (characterized by mania and depression) and depression.
  • Nutritional deficiencies: Nutritional deficiencies stemming from poor diet and/or digestion can also contribute to anxiety. Depleted levels of minerals, especially magnesium and zinc, have been linked to the presence of anxiety. A deficiency of B vitamins, especially vitamin B-12, can be a significant contributing factor to the development of anxiety disorders.

Risk factors
  • Gender: With the exception of obsessive-compulsive disorder (OCD) and possibly social anxiety, women have twice the risk for most anxiety disorders as men. A number of factors may increase the reported risk in women, including hormonal factors, cultural pressures to meet everyone else's needs except their own, and fewer self-restrictions on reporting anxiety to doctors. Pregnant women and women experiencing menopause may be more susceptible to symptoms of anxiety. Also, women have about twice the risk for panic disorder as men.
  • Age: In general, phobias, OCD and separation anxiety show up early in childhood, while social phobia and panic disorder are often diagnosed during the teen years. Reports have estimated that approximately 3-5% of children and adolescents have some type of anxiety disorder. This number may be low, particularly since symptoms in children may differ from those in adults. Reports indicate that if such children could be identified as early as two years of age they possibly could be treated to avoid later anxiety disorders.
  • Environmental factors: A person's environment can play a huge role in the development of anxiety disorders. Difficulties such as poverty, early separation from the mother, family conflict, critical and strict parents, parents who are fearful and anxious themselves, and the lack of a strong support system can all lead to chronic anxiety. Studies report that anxiety in the new mother can affect their infants. One study reported a higher rate of crying and an impaired ability to adapt to new situations in infants of mothers who had been stressed and anxious during pregnancy. In another, infants of mothers with panic disorder had higher levels of stress hormones and more sleep disturbances than other children.
  • Personality traits: Personality differences can affect whether or not an anxiety disorder develops. People with anxiety disorders often are very self-conscious, have poor coping skills, and have low self-esteem. Children's personalities may indicate higher or lower risk for future anxiety disorders, such as extremely shy children and those likely to be the target of bullies, who are at a higher risk for developing anxiety disorders later in life.
  • Heredity: Anxiety disorders tend to run in families. People with anxiety disorders often have a family history of anxiety disorders, mood disorders, or substance abuse.

Types of anxiety
  • Generalized Anxiety Disorder (GAD): Most people experience anxiety at some point in their lives and some nervousness in anticipation of a real situation. However, if a person cannot shake unwarranted worries, or if the feelings are jarring to the point of avoiding everyday activities, he or she most likely has an anxiety disorder. GAD is characterized by excessive, unrealistic worry that lasts six months or more. In adults, the anxiety may focus on issues such as health, money, or career. Physical symptoms may also appear such as nervousness or heart palpitations. GAD affects about 5% of Americans in the course of their lives and is more common in women than in men. Some experts believe that it is under diagnosed and more common than any other anxiety disorder. GAD usually begins in childhood and often becomes a chronic ailment, particularly when left untreated. Depression in adolescence may be a strong predictor of GAD in adulthood. Depression commonly accompanies this anxiety disorder.
  • Obsessive compulsive disorder (OCD): In OCD, individuals are plagued by persistent, recurring thoughts (obsessions) that reflect exaggerated anxiety or fears. Typical obsessions include worrying about being contaminated with germs or fears of behaving improperly or acting violently. The obsessions may lead an individual to perform a ritual or routine (compulsions) such as washing hands, repeating phrases, or hoarding. Obsessive-compulsive disorder occurs equally in men and women, and it affects about 2-3% of people over a lifespan. About 80% of people who develop OCD show signs of the disorder in childhood, although the disorder usually develops fully in adulthood.
  • Panic attacks and panic disorder: Panic disorder is characterized by repeated, unexpected panic attacks. These panic attacks strike without warning and usually last a terrifying 15-30 minutes. Panic disorder may also be accompanied by agoraphobia, which is a fear of being in places where escape or help would be difficult in the event of a panic attack. Agoraphobia is characterized by individuals likely to avoid public places such as shopping malls or confined spaces such as an airplane. Studies indicate that the prevalence of panic disorder among adults is between 1.6-2% and is much higher in adolescence, 3.5-9%. In one study, 18% of adult patients with panic disorder reported the onset of the disorder before ten years of age. In general, however, panic disorder tends to begin in late adolescence and peaks at around 25 years of age.
  • Post traumatic stress disorder (PTSD): PTSD can follow an exposure to a traumatic event such as a sexual or physical assault, witnessing a death, the unexpected death of a loved one, or natural disaster. There are three main symptoms associated with PTSD: "reliving" of the traumatic event (such as flashbacks and nightmares); avoidance behaviors (such as avoiding places related to the trauma) and emotional numbing (detachment from others); and physiological arousal such as difficulty sleeping, irritability or poor concentration. Researchers now know that anyone, even children, can develop PTSD if they have experienced, witnessed, or participated in a traumatic occurrence-especially if the event was life threatening. Studies estimate a lifetime risk for PTSD in the United States of up to 8%. People exposed to traumatic events, of course, are at highest risk, but many people can go through such events and not experience PTSD. Studies also estimate that 6-30% or more of trauma survivors develop PTSD, with children and young people being among those at the high end of the range. Women have the twice the risk of PTSD as men. PTSD can also occur in people not directly involved with a traumatic event.
  • Phobias: A phobia is an unrealistic or exaggerated fear of a specific object, activity, or situation that in reality presents little to no danger. Common phobias include fear of animals such as snakes and spiders, fear of flying, and fear of heights. In the case of a severe phobia, one might go to extreme lengths to avoid the thing feared.
  • Separation anxiety: Separation anxiety is a normal part of child development. It consists of crying and distress when a child is separated from a parent or away from home. If separation anxiety persists beyond a certain age or interferes with daily activities, it may be a sign of separation anxiety disorder.
  • Social anxiety / social phobia: Social anxiety disorder (SAD) is characterized by extreme anxiety about being judged by others or behaving in a way that might cause embarrassment or ridicule. This intense anxiety may lead to avoidance behavior. Physical symptoms associated with this disorder include heart palpitations, faintness, blushing and profuse sweating. Performance anxiety (better known as stage fright) is the most common type of social phobia. Social phobia is currently estimated to be the third most common psychiatric disorder in the United States. Studies have reported a prevalence of 7-12% in Western nations.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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