ANXIETY An integrative model of prevention and treatment David Becker, MD, MPH, MA, LMFT Clinical Professor, UCSF Department of Pediatrics UCSF Osher Center for Integrative Medicine Co-Medical Director, Pediatric Pain Management Clinic
DISCLOSURES • Mine is one voice among many that are more accomplished, more experienced, and better communicators. • Training, experience, and practices I have no financial relationships or conflicts of interest to disclose
OBJECTIVES ¡ Describe definitions and conceptualizations of anxiety ¡ Describe approaches to assessment in general practice ¡ Describe a cognitive reframing strategy ¡ Develop the skills to speak with patients and families about psychotherapy – the different types of providers and models of therapy.
ANXIETY ¡ Definitions ¡ The emotional state and body sensations that occur along with a belief that, in a certain situations “something bad’s going to happen” ¡ DSM : GAD, OCD, Phobias, Separation… ¡ When is it a problem? ¡ When functioning is impaired and/or the internal thoughts/worries are intrusive
ANXIETY - DIVERSITY ¡ Develop deeper awareness of our own background and less-conscious assumptions. They influence every clinical encounter ¡ Stance of humility vs competence ¡ Words, labels and diagnoses: variations in meaning, implication and degrees of shame ¡ Shift focus away from labels and towards wellbeing, life disruption and goals
¡ Anxiety can be a superpower ¡ But super heroes don’t have their super power activated all the time
¡ Biological, genetic, and environmental factors influence our coping capacities ¡ Anxiety is usually not something to get rid of or avoid – it is something to go through
ANXIETY - ASSESSMENT ¡ Type and extent of assessment depends on your role (training and chosen clinical scope of practice) ¡ Pre-teens and younger – meet with parents alone ¡ Symptom patterns, circumstances, frequency, timing, and degree of distress and functional impairment, family history ¡ Specific topics to include: ¡ Sleep, physical activity, nutrition ¡ Current coping strategies and capacity ¡ Clues to specific anxiety disorders
ANXIETY – PRIMARY PREVENTION ¡ For pediatricians: start with the pre-natal visit ¡ By the time your Spidy-sense is tingling, you’re past primary prevention ¡ How well do you feel you cope with stressful times in your life? ¡ What tools do you have? ¡ Level of insight?
ANXIETY ¡ Primary and secondary prevention: ¡ Exercise ¡ Sleep ¡ Nutrition ¡ Environment ¡ Mind-body ¡ Communication (self and with others) ¡ Manual therapies https://unsplash.com/photos/wNeuMUuGiPM
ANXIETY ¡ Lifestyle changes: ¡ We know what to recommend, but in general we’re terrible in facilitating change ¡ Agree on one or two domains and focus on that ¡ Motivational interviewing style
ANXIETY – PHYSICAL ACTIVITY ¡ A Review of 37 meta-analyses of RCTs and observational studies with a total of 42,264 participants reported that exercise had a small but meaningful average anxiolytic effect size of 0.34 in patients with diagnosed anxiety disorders, similar to the average effect size of 0.37 reported in published antidepressant trials. ¡ This effect size increased when only RCTs were included. ¡ Most studies evaluated the effect of aerobic exercise, although strength training may be effective as well. ¡ Another meta-analysis including only RCTs found an effect size of 0.48 for exercise in reducing anxiety symptoms.
ANXIETY – BOTANICALS AND SUPPLEMENTS ¡ Inositol ¡ Valerian root ¡ Kava Kava ¡ Chamomile ¡ B vitamins, Vitamin D, Omega 3
ANXIETY - INOSITOL ¡ A pseudo-vitamin (essential but able to be produced in the body) ¡ In PCOS, the administration of inositol has produced the remission of symptoms as well as a reduction in male hormone secretion, a regulation of the cholesterol level, and a more efficient fat breakdown. ¡ Inositol can stimulate glucose uptake in skeletal muscle cells which allows the decrease in blood sugar levels. ¡ In the cases of infertility, inositol has been proven to increase sperm count and motility, as well as increase the overall quality of oocytes and embryos. ¡ In cancer research, inositol has gained interest as it can act as an antioxidant, anti- inflammatory and it seems to enhance immune properties.
ANXIETY - INOSITOL ¡ In the brain, inositol has been shown to produce an increase in serotonin receptor sensitivity. This activity produces an increase in GABA release. ¡ Some of the effects observed in the brain produced a relief in symptoms of anxiety and obsessive-compulsive disorders. ¡ In high doses, it has been shown to even reduce panic attacks.
ANXIETY - INOSITOL
ANXIETY - VALERIAN ¡ “Anxiety . There is contradictory evidence about the effectiveness of valerian for anxiety. One preliminary study shows that taking valerian 100 mg three times daily for 21 days reduces anxiety in patients with mild anxiety (19401). Preliminary clinical research has also reported that taking 1-2 capsules valerian root 50 mg and St. John's wort 100 mg (Sedariston, Steiner Arzneimittel) twice daily for 2 weeks improves symptoms of moderately severe anxiety more effectively than diazepam 2 mg twice daily (19404). However, other preliminary research seems to suggest that valerian extract (valepotriates) 81.3 mg daily for 4 weeks has no beneficial effects on generalized anxiety disorder (GAD) compared to diazepam 6.5 mg or placebo (9896). Also, other research suggests that two valerian softgel capsules each containing 3.2 mg valerenic acids daily before bed does not affect mild anxiety compared to placebo (15046). The reason for these inconsistencies may be due to dosage used, the type and severity of anxiety being treated, or the concentration of valepotriates or valerenic acids contained in the valerian preparation.” https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=870
ANXIETY – KAVA KAVA (PIPER METHYSTICUM) Kava: a review of the safety of traditional and recreational beverage consumption. WHO Technical Report, 2016 Naturalmedicines.com database ¡ Extensive traditional use in the South Pacific for ceremonial purposes – a concoction from roots/rhizomes ¡ Moderate, short-term consumption not associated with significant ill health effects (but poor standardization of preparation) ¡ Excessive use: nausea, weight loss, skin rash, elevated GGT – all appear reversible ¡ Reports of hepatotoxicity: more than 100 case reports ¡ Changing positions of Canadian and German review bodies
ANXIETY - CHAMOMILE ¡ Long, established safety record ¡ Single randomized clinical trial ¡ 57 adults ¡ “pharmaceutical grade” extract ¡ 220mg and 1.2% apigenin
ANXIETY – VITAMIN D, OMEGA-3’S, AND B VITAMINS ¡ Very little data specifically about anxiety
ANXIETY – PHARMACEUTICALS ¡ Can be part of an integrative plan ¡ Family history can sometimes help guide selection ¡ More data in adolescents with fluoxetine and sertraline ¡ Caution with citalopram (less so with escitalopram) – QTc prolongation ¡ Overall data ¡ Publication bias
MIND-BODY TOOLS Progressive relaxation/Body scan Routines (sleep, meals, exercise, regular Meditation practices activities) Biofeedback Positive self-talk Self- Mind-body regulation Journaling Autogenics techniques practices Humor Clinical Hypnosis Taking a break Guided imagery Talking to someone Yoga, Tai Chi, others you trust
MIND-BODY TOOLS ¡ http://korumindfulness.org ¡ http://go.osu.edu/mindfulness; http://go.osu.edu/heartpractices; http://go.osu.edu/relaxationresponse; http://go.osu.edu/guidedimagery. And our online course for health professionals: http://mind-bodyhealth.osu.edu ¡ https://keltymentalhealth.ca/mindfulness; http://mindfulnessforteens.com/: Dzung Vo, MD ¡ Apps: ¡ Calm ¡ Headspace ¡ Insight Timer ¡ Many more
ANXIETY ¡ https://calendar.spiritrock.org/events/anxiety-its-not-all-in-your- mind-2020/ ¡ Description: Anxiety is prevalent, it’s pervasive, and it’s something that most of us deal with daily on some level. The seeds of anxiety are thoughts, and the fertilizer is a story, which is usually about something that hasn’t yet occurred. How we skillfully work with the mind, and how we include the body in the process, is pivotal to quelling anxiety when it is present and before it wreaks havoc.
PSYCHO-EDUCATION Logical mind Anxious mind Wise mind
PSYCHOTHERAPY ¡ Psychodynamic therapies ¡ Parent-Child Interaction Therapy ¡ Psychiatrists (PCIT) ¡ Psychologists (PhD, PsyD) ¡ Play therapy ¡ Marriage and Family Therapists (MFT) ¡ Group therapy ¡ Social workers ¡ Family therapy ¡ CBT and DBT ¡ LPCCs ¡ Relational therapies ¡ Eclectic practitioners
PSYCHOTHERAPY: THE COMMON FACTORS Developed from psychology research about what works in • psychotherapy Psychodynamic vs CBT vs Relational vs Brief structured vs • Gestault vs Jungian… No clear winner • So what factors are important? •
World Psychiatry 2015;14:270–277
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