Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions
- Alexander Bystritsky, MD, PhD
Alexander Bystritsky, MD, PhD
- Professor of Psychiatry and Biobehavioral Sciences Director,
- Anxiety Disorders Program, David Geffen School of Medicine, University of California, Los Angeles
Epidemiologic studies have shown that anxiety disorders are among the most common mental health problems in the United States. Many patients with anxiety disorders find that conventional treatments are insufficient and turn to complementary and alternative medicine (CAM) as an adjunct to or substitute for Western mental health care.
Epidemiologic studies suggest that 30 to 43 percent of patients treated in primary care for anxiety use CAM remedies as at least part of their treatment [1-3]. Clinicians should be well prepared with knowledge about the efficacy and safety of CAM treatments marketed, available and/or used for anxiety and anxiety disorders.
Complementary and alternative treatments involving physical, cognitive, or spiritual activities for anxiety symptoms and disorders are described here. Herbal remedies and dietary supplements used as complementary and alternative medical treatments for anxiety symptoms and disorders are described separately. Yoga is discussed in greater detail separately. Acupuncture is discussed separately. (See "Complementary and alternative treatments for anxiety symptoms and disorders: Herbs and medications" and "Overview of yoga" and "Acupuncture".)
Anxiety, when not addressed, can become excessive and cause stress to the body, contributing to, for example, heart disease, suicidality, and reduced quality of life [4-7]. If not reduced through effective interventions, high anxiety can contribute to overall morbidity and decrease quality of life [5,8-10].
Sixty-two percent of adults in the United States utilize some form of complementary and alternative medical treatments ; the most commonly used are mind-body therapies. Individuals diagnosed with a psychiatric illness may be more likely than the general population to use these therapies, especially patients with elevated anxiety or anxiety disorders [11,12], in part because many who are treated psychiatrically respond only partially to treatment and have residual symptoms and impairment , for which further treatment options may be sought.
- Bystritsky A, Hovav S, Sherbourne C, et al. Use of complementary and alternative medicine in a large sample of anxiety patients. Psychosomatics 2012; 53:266.
- Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008; :1.
- Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004; :1.
- Brezo J, Paris J, Turecki G. Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review. Acta Psychiatr Scand 2006; 113:180.
- Olatunji BO, Cisler JM, Tolin DF. Quality of life in the anxiety disorders: a meta-analytic review. Clin Psychol Rev 2007; 27:572.
- Roest AM, Martens EJ, de Jonge P, Denollet J. Anxiety and risk of incident coronary heart disease: a meta-analysis. J Am Coll Cardiol 2010; 56:38.
- Segerstrom SC, Miller GE. Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull 2004; 130:601.
- Li AW, Goldsmith CA. The effects of yoga on anxiety and stress. Altern Med Rev 2012; 17:21.
- Mojtabai R. Unmet need for treatment of major depression in the United States. Psychiatr Serv 2009; 60:297.
- Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 2007; 370:841.
- Konnopka A, Leichsenring F, Leibing E, König HH. Cost-of-illness studies and cost-effectiveness analyses in anxiety disorders: a systematic review. J Affect Disord 2009; 114:14.
- Kessler RC, Soukup J, Davis RB, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry 2001; 158:289.
- Hoffman DL, Dukes EM, Wittchen HU. Human and economic burden of generalized anxiety disorder. Depress Anxiety 2008; 25:72.
- Pilkington K, Kirkwood G, Rampes H, Richardson J. Yoga for depression: the research evidence. J Affect Disord 2005; 89:13.
- Kirkwood G, Rampes H, Tuffrey V, et al. Yoga for anxiety: a systematic review of the research evidence. Br J Sports Med 2005; 39:884.
- Khalsa SB. Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian J Physiol Pharmacol 2004; 48:269.
- Broota A, Sanghvi C. Efficacy of two relaxation techniques in examination anxiety. J Pers Clin Stud 1994; 10:29.
- Sahasi G, Mohan D, Kacker C. Effectiveness of yogic techniques in the management of anxiety. J Pers Clin Stud 1989; 5:51.
- Wolever RQ, Bobinet KJ, McCabe K, et al. Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial. J Occup Health Psychol 2012; 17:246.
- Smith C, Hancock H, Blake-Mortimer J, Eckert K. A randomised comparative trial of yoga and relaxation to reduce stress and anxiety. Complement Ther Med 2007; 15:77.
- Corey SM, Epel E, Schembri M, et al. Effect of restorative yoga vs. stretching on diurnal cortisol dynamics and psychosocial outcomes in individuals with the metabolic syndrome: the PRYSMS randomized controlled trial. Psychoneuroendocrinology 2014; 49:260.
- Cognition and Stress: Advances in Basic and Translational Research. National Institutes of Mental Health 2009. http://www.nimh.nih.gov/research-funding/scientificmeetings/2007/cognition-and-stress-advances-inbasic-and-translational-research/index.shtml (Accessed on January 06, 2015).
- Shannahoff-Khalsa DS, Ray LE, Levine S, et al. Randomized controlled trial of yogic meditation techniques for patients with obsessive-compulsive disorder. CNS Spectr 1999; 4:34.
- Wang F, Lee EK, Wu T, et al. The effects of tai chi on depression, anxiety, and psychological well-being: a systematic review and meta-analysis. Int J Behav Med 2014; 21:605.
- Yin J, Dishman RK. The effect of Tai Chi and Qigong practice on depression and anxiety symptoms: A systematic review and meta-regression analysis of randomized controlled trials. Ment Health Phys Act 2014; 7:135.
- Li X. Influence of middle-age women's anxiety by Taiji practice. J Sports Med Adult Ed 2012; 28:36.
- Li Z. The effect of Taiji to depression and anxiety of chronic obstructive pulmonary disease. Chinese Journal of Aesthetic Medicine 2011; 20:129.
- Chang MY, Yeh SC, Chu MC, et al. Associations between Tai Chi Chung program, anxiety, and cardiovascular risk factors. Am J Health Promot 2013; 28:16.
- Exercise (2011). http://www.merriam-webster.com/dictionary/exercise (Accessed on December 15, 2014).
- US Department of Health and Human Services. Physical Activity Guidelines for Americans. US Department of Health Services, Washington, DC 2008.
- Asmundson GJ, Fetzner MG, Deboer LB, et al. Let's get physical: a contemporary review of the anxiolytic effects of exercise for anxiety and its disorders. Depress Anxiety 2013; 30:362.
- Merom D, Phongsavan P, Wagner R, et al. Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders--a pilot group randomized trial. J Anxiety Disord 2008; 22:959.
- Broocks A, Bandelow B, Pekrun G, et al. Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder. Am J Psychiatry 1998; 155:603.
- Saeed SA, Antonacci DJ, Bloch RM. Exercise, yoga, and meditation for depressive and anxiety disorders. Am Fam Physician 2010; 81:981.
- Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, Hyperion, New York 1994.
- Keng SL, Smoski MJ, Robins CJ. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev 2011; 31:1041.
- Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med 2014; 174:357.
- Koszycki D, Benger M, Shlik J, Bradwejn J. Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behav Res Ther 2007; 45:2518.
- Williams JM, Russell I, Russell D. Mindfulness-based cognitive therapy: further issues in current evidence and future research. J Consult Clin Psychol 2008; 76:524.
- Piet J, Hougaard E, Hecksher MS, Rosenberg NK. A randomized pilot study of mindfulness-based cognitive therapy and group cognitive-behavioral therapy for young adults with social phobia. Scand J Psychol 2010; 51:403.
- Woods DW, Wetterneck CT, Flessner CA. A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behav Res Ther 2006; 44:639.
- Baer RA, Fischer S, Huss DB. Mindfulness and acceptance in the treatment of disordered eating. J Ration Emot Cogn Behav Ther 2005; 23:281.
- Kristeller JL, Hallett CB. An Exploratory Study of a Meditation-based Intervention for Binge Eating Disorder. J Health Psychol 1999; 4:357.
- Bowen S, Witkiewitz K, Dillworth TM, et al. Mindfulness meditation and substance use in an incarcerated population. Psychol Addict Behav 2006; 20:343.
- Witkiewitz K, Marlatt GA, Walker D. Mindfulness-based relapse prevention for alcohol and substance use disorders. J Cogn Psychother 2005; 19:211.
- Williams JM, Teasdale JD, Segal ZV, Soulsby J. Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. J Abnorm Psychol 2000; 109:150.
- Teasdale JD, Moore RG, Hayhurst H, et al. Metacognitive awareness and prevention of relapse in depression: empirical evidence. J Consult Clin Psychol 2002; 70:275.
- Crane C, Barnhofer T, Duggan D, et al. Mindfulness-based cognitive therapy and self-discrepancy in recovered depressed patients with a history of depression and suicidality. Cogn Ther Res 2008; 32:775.
- Kuyken W, Byford S, Taylor RS, et al. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psychol 2008; 76:966.
- Barnhofer T, Crane C, Hargus E, et al. Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary study. Behav Res Ther 2009; 47:366.
- Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006; 63:757.
- Hoge EA, Bui E, Marques L, et al. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. J Clin Psychiatry 2013; 74:786.
- Klein DF. False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. Arch Gen Psychiatry 1993; 50:306.
- Chiang LC, Ma WF, Huang JL, et al. Effect of relaxation-breathing training on anxiety and asthma signs/symptoms of children with moderate-to-severe asthma: a randomized controlled trial. Int J Nurs Stud 2009; 46:1061.
- Gilbert C. Clinical applications of breathing regulation. Beyond anxiety management. Behav Modif 2003; 27:692.
- Brand S, Holsboer-Trachsler E, Naranjo JR, Schmidt S. Influence of mindfulness practice on cortisol and sleep in long-term and short-term meditators. Neuropsychobiology 2012; 65:109.
- Ng BH, Tsang HW. Psychophysiological outcomes of health qigong for chronic conditions: a systematic review. Psychophysiology 2009; 46:257.
- Jung YH, Kang DH, Jang JH, et al. The effects of mind-body training on stress reduction, positive affect, and plasma catecholamines. Neurosci Lett 2010; 479:138.
- Barlow DH. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic, 2nd ed, The Guildford Press, New York 2002.
- Bouton ME, Mineka S, Barlow DH. A modern learning theory perspective on the etiology of panic disorder. Psychol Rev 2001; 108:4.
- Wolpe J. Psychotherapy by Reciprocal Inhibition, Stanford University Press, Stanford, CA 1958.
- Clark DM. Anxiety disorders: why they persist and how to treat them. Behav Res Ther 1999; 37 Suppl 1:S5.
- Keefe FJ, Affleck G, Lefebvre J, et al. Living with rheumatoid arthritis: the role of daily spirituality and daily religious and spiritual coping. J Pain 2001; 2:101.
- King MB, Koenig HG. Conceptualising spirituality for medical research and health service provision. BMC Health Serv Res 2009; 9:116.
- Koenig HG. Research on religion, spirituality, and mental health: a review. Can J Psychiatry 2009; 54:283.
- Pargament KI. Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred, The Guilford Press, New York 2007.
- Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol 2003; 84:377.
- Pace TW, Negi LT, Adame DD, et al. Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress. Psychoneuroendocrinology 2009; 34:87.
- Sternthal MJ, Williams DR, Musick MA, Buck AC. Depression, anxiety, and religious life: a search for mediators. J Health Soc Behav 2010; 51:343.
- Ferguson JK, Willemsen EW, Castaneto MV. Centering Prayer as a Healing Response to Everyday Stress: A Psychological and Spiritual Process. Pastoral Psychology 2010; 59:305.
- Wachholtz AB, Pargament KI. Is spirituality a critical ingredient of meditation? Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. J Behav Med 2005; 28:369.
- Orme-Johnson DW, Barnes VA. Effects of the transcendental meditation technique on trait anxiety: a meta-analysis of randomized controlled trials. J Altern Complement Med 2014; 20:330.
- Manzaneque JM, Vera FM, Rodriguez FM, et al. Serum cytokines, mood and sleep after a qigong program: is qigong an effective psychobiological tool? J Health Psychol 2009; 14:60.
- Liu T. Qigong Study in Chinese Medicine. A Textbook for Colleges and Schools of Chinese Medicine, China Publisher of Chinese Medicine, Beijing 2005.
- Li M, Chen K, Mo Z. Use of qigong therapy in the detoxification of heroin addicts. Altern Ther Health Med 2002; 8:50.
- Stenlund T, Birgander LS, Lindahl B, et al. Effects of Qigong in patients with burnout: a randomized controlled trial. J Rehabil Med 2009; 41:761.
- Hui PN, Wan M, Chan WK, Yung PM. An evaluation of two behavioral rehabilitation programs, qigong versus progressive relaxation, in improving the quality of life in cardiac patients. J Altern Complement Med 2006; 12:373.
- Leech K. Soul Friend: A Study of Spirituality, Sheldon Press, London 1977.
- Finney J, Malony H. An empirical study of contemplative prayer as an adjunct to psychotherapy. J Psychol Theol 1985; 13:284.
- Finney J, Malony H. Contemplative prayer and its use in psychotherapy: A theoretical model. J Psychol Theol 1985; 13:172.
- Carlson CA, Bacaseta PE, Simanton DA. A controlled evaluation of devotional meditation and progressive relaxation. J Psychol Theol 1988; 16:362.
- Elkins D, Anchor KN, Sandler HM. Relaxation training and prayer behavior as tension reduction techniques. Behav Eng 1979; 5:81.
- Keating T. Invitation to Love: The Way of Christian Contemplation, The Continuum Publishing Company, New York 1997.
- Keating T. Intimacy with God: An Introduction to Centering Prayer, The Crossroad Publishing Company, New York 2009.
- Johnson ME, Dose AM, Pipe TB, et al. Centering prayer for women receiving chemotherapy for recurrent ovarian cancer: a pilot study. Oncol Nurs Forum 2009; 36:421.