Psychiatric Times.
No. 13
INTEGRATIVE MEDICINE
Integrative Management of Anxiety, Part 1
By James Lake, MD |
November 1, 2007
Dr Lake is in private practice in Monterey, Calif, and is on the clinical faculty in the department of psychiatry and behavioral sciences at Stanford University Hospital. He chairs the American Psychiatric Association Caucus on Complementary, Alternative, and Integrative Care (www. APACAM.org) and is author of the Textbook of Integrative Mental Health Care (Thieme, 2006).
Meditation and mindfulness trainingMeditation practices are used in many cultures to reduce anxiety and maintain optimal psychological and spiritual health. Beneficial physiological effects of meditation include decreased oxy-gen consumption, respiratory rate, and blood pressure, as well as EEG changes associated with decreased autonomic arousal.40 Mindfulness-based stress reduction (MBSR) is an integrative approach pioneered by Kabat-Zinn41 that has been validated as highly effective in reducing the physical, emotional, and cognitive consequences of chronic stress. MBSR incorporates elements of different Eastern meditation practices and Western psychology.
Research findings show that the consistent practice of mindfulness meditation, in which the patient practices detached self-observation, significantly reduces generalized anxiety and other anxiety symptoms.35,42 Ninety-three percent of patients (N = 322) who started a 10-week MBSR program successfully completed it, and the majority reported significantly decreased physical and emotional distress, improved quality of life, a greater sense of general well-being, increased optimism, and increased feelings of control.43 Patients with irritable bowel syndrome (IBS), a frequent concomitant of generalized anxiety, experienced significantly fewer symptoms of both IBS and anxiety when they engaged in 2 brief (15- minute) daily sessions of mindfulness meditation.44 The cultivation of self-awareness through mindfulness training assists anxious patients in avoiding potentially stressful situations and engaging in more effective coping when stress is unavoidable.45
Virtual reality graded exposure therapy
Controlled studies confirm that VRGET is more effective than conventional imaginal exposure therapy (ie, the use of mental imagery to provoke a feared object or situation) and has comparable efficacy to in vivo exposure therapy.46,47 Anxious or phobic patients are frequently unable to tolerate conventional exposure therapy and remain chronically impaired because they never become desensitized to a feared object or situation. As in imaginal exposure and in vivo therapy, VRGET has the goal of desensitizing the patient to a situation or object that would normally cause anxiety or panic.
Research findings support the use of VRGET as a treatment for many anxiety disorders, including specific phobias, generalized anxiety, panic disorder with agoraphobia,48 and posttraumatic stress disorder (PTSD).49 In a controlled study, VRGET and conventional CBT were equally effective in the treatment of panic disorder with agoraphobia; however, patients who underwent VRGET required 33% fewer sessions.50
Case reports and controlled studies have demonstrated the efficacy of VRGET for many specific phobias, including fear of flying,51,52 heights, animals, and driving.53-55 In one controlled study (N = 45), 65% of anxious adults who had a specific anxiety disorder according to DSM-IV criteria reported significant reductions in 4 of 5 anxiety measures.56 VRGET is as effective as conventional exposure therapy for fear of flying, and is more cost- effective because both patient and therapist avoid the expense and time commitments required for in vivo desensitization.51,53,54 In a preliminary study, persons who overcame fear of flying using VRGET combined with biofeedback (including respirations, galvanic skin response [GSR], and heart rate) were able to fly without the use of conventional medications or alcohol(Drug information on alcohol) 3 months posttreatment.52
VRGET is also beneficial in traumatized patients in whom PTSD has been diagnosed. A virtual environment that simulates the devastation following the September 11, 2001, attacks on the World Trade Towers has been successfully used to treat individuals with severe PTSD.57
Emerging evidence suggests that combining VRGET with d-cycloserine, a partial NMDA agonist, results in greater improvement in acrophobic symptoms compared with treatment with VRGET alone. Findings from ani-mal studies and a randomized clinical trial suggest that d-cycloserine functions as a cognitive enhancer by stimulating NMDA receptors, and may facilitate extinction of conditioned fear in patients with phobia.58 Twenty-eight patients with a DSM-IV diagnosis of acrophobia were randomized to receive either 500 mg of d-cycloserine or placebo in combination with 2 sessions of VRGET in a virtual glass elevator environment. Patients receiving d-cycloserine experienced significantly greater improvement in phobic symptoms than matched patients being treated with VRGET alone.59 This difference was noticeable 1 week following treatment and was maintained at 3-month follow-up.
VRGET will become more available as technology costs continue to decrease, and it will probably become a widely used and cost-effective approach for outpatient treatment of panic attacks, PTSD, agoraphobia, social phobia, and other specific phobias. Several basic VRGET tools are available over the Internet, permitting mental health professionals to guide patients in the use of these computer-based advanced exposure protocols through real-time videoconferencing anywhere high-speed Internet access is available.60 In the near future, the integrative management of phobias, panic attacks, and other severe anxiety syndromes will combine VRGET, biofeedback, and pharmacological treatment in outpatient settings. Patients with severe phobia will also have the option of gaining access to Web-based VRGET tools via high-speed Internet connections.
Patients who are considering using VRGET should be aware of infrequent but significant safety issues. Fewer than 4% of persons experience transient symptoms of disorientation, nausea, dizziness, headache, and blurred vision when in a virtual environment. "Simulator sleepiness" is a feeling of generalized fatigue that occurs infrequently. Intense sensory stimulation during VRGET can trigger migraine, seizures, or gait abnormalities in persons who are prone to these medical conditions, and VRGET is therefore contraindicated in these populations. Anxious patients who are actively abusing alcohol or narcotics should not use VRGET. Patients who have disorders of the vestibular system should be advised against trying VRGET. Patients with psychosis should not use VRGET because immersion in a virtual environment can exacerbate delusions and potentially worsen reality testing.61
EMG, GSR, and EEG biofeedback training
Biofeedback has nonspecific beneficial effects on many anxiety symptoms. EMG, GSR, and EEG biofeedback training are effective treatments for generalized anxiety.62-64 Patients with chronic anxiety trained in EEG or EMG biofeedback achieve symptom reduction similar to those taking conventional anti-anxiety medications.65,66 The long-term benefits of EEG biofeedback for anxious patients have not been clearly established. One study evaluated 2 EEG biofeedback machines on patients complaining of anxiety and "burnout" in an addiction treatment center.67 Although patients experienced immediate reductions in state anxiety during biofeedback training, long-term effects on burnout were not maintained following discontinuation of treatment.
Microcurrent electrical stimulation
Microcurrent electrical stimulation, also called "cranial-electrotherapy stimulation" (CES), is an effective treatment for generalized anxiety. Quantitative EEG studies have confirmed beneficial changes in brain electrical activity when this approach is used.68A meta-analysis of double-blind, controlled trials comparing CES with a sham treatment (ie, electrodes applied, but with no current) concluded that measures of generalized anxiety improved in 7 of 8 studies, and the magnitude of improvement reached statistical significance in 4 of these.69 A larger review encompassing 34 sham-controlled trials conducted between 1963 and 1996 concluded that regular CES treatments resulted in short-term symptomatic relief of generalized anxiety symptoms mediated by direct effects on autonomic brain centers.70
In a 10-week open trial of daily, self-administered CES therapy in 182 individuals with DSM-III anxiety disorders, 73% of patients reported significant reductions in anxiety that were maintained at 6-month follow-up.71 Significantly, conventional drugs had failed in 25% of patients in the study, and 58% had received no previous treatment of any kind for their anxiety symptoms. In general, patients who receive at least 4 to 6 CES treatments experience more sustained reductions in anxiety than patients who receive fewer treatments. The results of a small, double-blind, sham-controlled study (N = 20) suggest that a single CES treatment in patients who report generalized stress results in beneficial changes in autonomic arousal that are sustained at least 1 week following treatment, as measured by decreases in EMG and heart rate.72
Patients with one or more phobias reported significant reductions in state anxiety when exposure to the anxiety-inducing stimulus was followed by 30 minutes of CES treatment.73 Comparable anxiety reduction was achieved with CES and conventional anti-anxiety medications, suggesting that CES may be an effective approach for patients with phobia who wish to discontinue conventional drugs.
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