ANXIETY

FEELING ANXIOUS?? Anxiety + acupuncture care in Warragul

MENTAL HEALTH

While estimates vary, research suggests that between 1-30% of the global population suffer from some form of anxiety(1). There are thirteen different sub-classifications of anxiety disorders listed in the latest Diagnostic and Statistical Manual (used by medical professionals to diagnose and treat psychological and patho-psychological conditions)(2), with symptom presentations and physical manifestations varying considerably. From shortness of breath and variations in heart rate, to full blown and debilitating panic attacks, headaches, pain and insomnia(3), anxiety is a complex, pervasive condition that is generally treated using a pharmacological intervention.

Chinese Medicine (CM) theory has a long history of recognising that the emotional state of a person can both affect and be affected by their state of health and personal circumstances(4). There are four main patterns for anxiety, the identification of which will allow development of a treatment plan that addresses both the presenting symptoms and the underlying disharmony that led to the development of anxiety in the first place. “All the mental activities of the mind” are controlled by the Heart in CM, and when injured by “frightened and distressed thoughts”, “fear and loss of self” are the result; i.e. a 2000-year-old description of modern society’s most prevalent mental disorder (p. 345) (5).

In 2017, The Acupuncture Evidence Project, co-authored by Dr. John McDonald (PhD) and Dr. Stephen Janz (Acupuncturist)(6) was published, providing an up-to-date comparative review of acupuncture-specific scientific literature. This comprehensive document (covering many different conditions categorized into fourteen clinical areas) provides a snap-shot of not only the most current research related to acupuncture and the treatment of anxiety, but also rates the quality of this evidence and compares these to ratings from previous time frames to show if the evidence for acupuncture has decreased, stayed the same or increased in quality. Presented here is a short summary of the research revealed through their work.

CLINICAL RESEARCH FOR ACUPUNCTURE

 McDonald and Janz note acupuncture for the treatment of anxiety has a base-line evidence level of a “potential positive effect”, discovered by utilizing reports created by the Australian Government Department of Veteran’s Affairs (DVA) and the US Department of Veteran’s Affairs (USDVA). Within the last 15 years, both agencies have reviewed high quality research such as systematic reviews (SR) and meta-analyses (MA) surrounding the use of acupuncture for anxiety. McDonald and Janz, while focussing their reviews to newer research, (completed since 2013), have used these agency’s reports to compare the changes from base-line to current evidence levels. Two papers are referred to within the Acupuncture Evidence Project (AEP).

The first is a narrative review - “Current evidence regarding the management of mood and anxiety disorders using complementary and alternative medicine”(7) which is designed to inform practitioners about complementary and alternative medicine (CAM) interventions, including acupuncture, for specific disorders. The review looked at five studies that had different interventions and different outcome measures, and despite noting limitations such as poor quality and methodology, concluded that there was sufficient support for the use of acupuncture in treatment for anxiety.

The second study included in McDonald and Janz’s AEP is a similar, but more current review – “Effects from acupuncture in treating anxiety: integrative review”(8). Included in this review were 19 acupuncture studies, 11 of which the authors found as having “strong evidence levels”, and six articles of which the quality of the evidence was described as “reasonable”. Goyata and colleagues were more thorough when presenting the results of their research, describing the differences between the 19 studies in areas of measurement, of location of trials, scales used to measure anxiety levels and who administered the acupuncture. They also noted the need for improved methodology in acupuncture research, but like the first narrative review, describe acupuncture for the treatment of anxiety as promising.

 BIOCHEMICAL MECHANISMS OF ACUPUNCTURE

The autonomic nervous system (ANS), composed of two branches, the sympathetic (SNS) and the parasympathetic (PNS), regulates the internal conditions necessary for existence (homeostasis)(9). Information is received from the body and external environment and a response is delivered by either the SNS, which releases excitatory signals, or the PNS which releases inhibitory signals. These signals direct the body to react in very different ways, such as increasing the heart rate and contraction force, or by reducing blood pressure and slowing the heart rate(10). It is exciting to know that studies show acupuncture has an effect on both the SNS and the PNS, as some further examples presented below reveal.

When the body is under stress, the hypothalamus region of the brain releases neurochemicals(11), and research shows that acupuncture affects changes to this outflow. Electro-acupuncture at two points activates the amino acid sensors that are involved in the signal pathway of a specific region of the hypothalamus, attenuating the sympathetic excitatory response(12).

The endogenous opioid system, consisting of three peptides (linked amino acids) plays an important role in the regulation of physical and emotional stress responses such as pain and heart rate variability(13). Research suggests acupuncture can increase secretion of the endogenous opioid b-endorphin(14), affect changes in gastric motility that result in down-regulation of sympathetic outflow (15,16), and heart rate and blood pressure (17,18)

USUAL CARE OF ANXIETY

There are novel approaches being studied, such as using a technological interface to deliver treatment for anxiety sufferers(19), but the usual care of anxiety primarily involves either one of two (or a combination of) pharmacological or psychological interventions.

 Pharmacological

 There are several medications that are prescribed for anxiety, including benzodiazepines (alprazolam), selective-serotonin reuptake inhibitors (SSRI’s) such as paroxetine, and tricyclic antidepressants (imipramine), either singularly or in combination(20). According to recent research, around 50% of patients treated pharmacologically for anxiety, have an “inadequate response”(21), meaning that their symptoms are not alleviated to clinically significant levels or that the patient experiences adverse side effects.  Some researchers go so far as to say that pharmacological treatments are “not ideal” in terms of efficacy when employed for both short and long term treatment(22). It is recognised that there is a need to study pharmacological interventions further, as patient tolerability for certain classes of drugs, and the uniqueness of the individual, means a ‘one-size-fits-all’ approach to pharmacological interventions is problematic(23).

Behavioural

Cognitive behaviour therapy (CBT) and mindfulness-based CBT are two other popular and effective interventions for the usual care of anxiety and may be prescribed as stand alone therapies, or in combination with medications(24). CBT is a ‘talking therapy’ that aims to overcome inaccurate or negative thought patterns(25), and has the advantage of flexibility, where ‘talk’ is specific to each individual and their relevant anxiety disorder. This is evidenced by a simple online search (“what is cognitive behaviour therapy” - Google Scholar) that reveals on the first page ten different applications for CBT.

There are ethical and methodological challenges to designing studies that compare the effectiveness of acupuncture to the usual care of anxiety(26,27), so it is very useful for medical and allied health professionals and the general population to have access to up to date evidence summaries such as the work of McDonald and Janz. From this comprehensive document, we are able to determine that acupuncture has potentially positive benefits in the treatment of anxiety, and although comparisons between acupuncture and usual care, (whether pharmacological, psychological or a combination of both), are not easily made, there is evidence for the effectiveness of acupuncture in the treatment of anxiety, and as shown above, several plausible biochemical and biophysical mechanisms that may offer an explanation of how this ancient modality works.

REFERENCES

1.    Baxter AJ, Scott KM, Vos T, Whiteford HA. Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychological Medicine. 2013; 43:897-910

2.    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing. 2013

3.    Health Direct. Anxiety symptoms [Internet].; [cited 28th May 2017]. Available from: https://www.healthdirect.gov.au/anxiety-symptoms

4.    Rossi E. Shen: Psycho-Emotional Aspects of Chinese Medicine. Philadelphia: Churchill Livingstone; 2007.

5.    Macciocia G. The Foundations of Chinese Medicine. 2nd ed. Philadelphia: Churchill Livingstone; 2005.

6.    McDonald J, Janz S. The Acupuncture Evidence Project: A Comparative Literature Review. Australian Acupuncture and Chinese Medicine Association Ltd. 2017.

7.    Bazzan AJ, Zabrecky G, Monti DA, Newberg AB. Current evidence regarding the management of mood and anxiety disorders using complementary and alternative medicine. Expert Rev Neurother. 2014;14:411- 23.

8.    Goyata SL, Avelino CC, Santos SV, Souza Junior DI, Gurgel MD, Terra FS. Effects from acupuncture in treating anxiety: integrative review. Rev Bras Enferm. 2016 Jun;69(3):602-9.

9.    Encyclopaedia Britannica. Homeostasis [internet].; [cited 20the May 2017]. Available from https://www.britannica.com/science/homeostasis

10.  Merck Manuals. Autonomic nervous system: Overview [Internet].; [cited 20th May 2017]. Available from http://www.merckmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/autonomic-nervous-system-disorders/overview-of-the-autonomic-nervous-system

11.  Abboud FM, Harwani SC, Chapleau MW. Autonomic neural regulation of the immune system: implications for hypertension and cardiovascular disease. Hypertension. 2012;59:755-62

 

12. Guo ZL, Longhurst JC. Expression of c-Fos in arcuate nucleus induced by electroacupuncture: relations to neurons containing opioids and glutamate. Brain Research. 2007;1166:65–76.

13.  Ribeiro SC, Kennedy SE, Smith YR, Stohler CS, Zubieta JK. Interface of physical and emotional stress regulation through the endogenous opioid system and m-opioid receptors. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2005;1264-1280.

14. Harbach H, Moll B, Boedeker RH, et al. Minimal immunoreactive plasma b-endorphin and decrease of cortisol at standard analgesia or different acupuncture techniques. European Journal of Anaesthesiology. 2007; 24:370-6

15.  Li M, Tjen-A-Looi SC, Longhurst JC. Electroacupuncture enhances preproenkephalin mRNA expression in rostral ventrolateral medulla of rats. Biol Psychiatry. 2010;477:61-5

16.  Yin J, Chen J, Chen JDZ. Ameliorating effects and mechanism of electroacupuncture on gastric dysrhythmia, delayed emptying and impaired accommodation in diabetic rats. The American Journal of Physiology. 2010; 298:G563-G570

17.  Agelink MW, Sanner D, Eich H, Pach J, Bertling R, Lemmer W, Klieser E, Lehmann E. Does acupuncture influence the cardiac autonomic nervous system in patients with minor depression or anxiety disorders? Fortschritte der Neurologie-Psychiatrie. 2003;71:141-9

18.  Haker E, Egekvist H, Bjerring P. Effect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in health subjects. Journal of the Autonomic Nervous System. 2000;79:52-9

19.  Loo-Gee B, Griffiths K, Gulliver A. Effectiveness of mobile Technologies delivering Ecological Momentary Interventions for stress and anxiety: a systematic review. 2016;23:221-9

20.  Rickels K, Rynn M. Pharmacotherapy of generalized anxiety disorder. J Clin Psychiatry. 2002;63:Suppl 9-16

21.  Generoso MB, Trevizol AP, Kasper S, Cho HJ, Cordeiro Q, Shiozawa P. Pregabiln for generalized anxiety disorder: an updated systematic review and meta-analysis. 2017;32:49-55

22.  Baldwin D, Hou R, Gordon R, Huneke N, Garner M. GAD: experimental medicine models, emerging targets: Pharmacotherapy in generalized anxiety disorder: novel experimental medicine models and emerging drug targets CNS drugs [internet].; [cited 20th May 2017]. Available from https://eprints.soton.ac.uk/406180/

23.  Perna G, Alciati A, Riva A, Micieli W, Caldirola D. Long-Term Pharmacological Treatments of Anxiety Disorders: An Updated Systematic Review. Curr Psychiatry Rep. 2016;18:23

24.  Cuijpers P, Sijbrandij M, Koole S, Huibers M, Berking M, Andersson G. Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psychology Review. 2014; 34:130-140

25.  Mayo Clinic. Cognitive behavioural therapy [internet].; [cited 2oth May 2017]. Available from http://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/home/ovc-20186868

26.  Hopton A, MacPherson H. Acupuncture for Chronic Pain: Is Acupuncture More than an Effective Placebo? A Systematic Review of Poled Data from Meta-analyses. Pain Practice. 2010; 10:94-102

27.  Nardini C. The ethics of clinical trials. Ecancermedicalscience. 2014;8:387

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