July, 2006

Prevalence and Costs
Anxiety disorders are the most common psychiatric condition in the United States, affecting 40 million people annually (NIHM, 2006). In the annual reporting period of 1997-1998, anxiety was responsible for 12.3 million office visits, up from 9.5 million in 1985 (Harmon, Rollman, et al, 2002). 1996, anxiety disorders cost the US economy over $46.6 billion in direct and indirect costs (NCHS, 1997).

What is Anxiety?
Anxiety disorders is an umbrella term used to describe a wide diversity of psychological conditions. The two major anxiety disorders are Generalized Anxiety Disorders (GAD) and Panic Disorders. Others include Post-Traumatic Stress Disorders (PTSD), phobias, separation anxiety, performance anxiety, and Obsessive-Compulsive Disorders (OCD).

All of these conditions are marked by feelings of apprehension, tension, or uneasiness which can range from mild to incapacitating. Physical symptoms can include stress, palpitations, and sweating. The severity of these symptoms can vary. No single cause seems to be responsible for anxiety disorders. Both psychological and physical causes are usually involved. Genetics can also play a role.

Medical Treatment of Anxiety
Treatment depends on the precise anxiety disorder. Serotonin-reuptake inhibitors (SSRIs) are the most frequent initial medications prescribed. Other medications include benzodiazepines, trycyclics (if depression is also involved), MAO inhibitors (for OCD), beta-blockers (for phobias), and clonidine (for PTSD).

Non-Pharmacologic Treatment including Imagery
The most effective approach is cognitive-behavior therapy (CBT). It is usually combined with medication.

Mind-body approaches have proven effective in cases of situational anxiety, such as test-taking (Wachelka and Katz, 1999), fear of flying (Aitken and Benson, 1984), undergoing surgery (Saadat, Drummond-Lewis, et al, 2006; Simmons, Chabal, et al, 2004; Tusek, Church, et al, 1997; Tusek, Cwynar, 1999); and in dealing with illnesses or conditions such as heart trouble (van Dixhoorn & White, 2005; Vila, Benedicto, et al, 2005), cancer (Deng & Cassileth, 2005; Hidderley & Holt, 2004), infertility (Chan, Ng, et al, 2006), pregnancy (Bastani, Hidarnia, et al, 2005; Rees, 1995; Teixeira, Martin, et al, 2005), and childbirth (Almeida, de Sousa, et al, 2005).

Many medical studies confirm the effectiveness of CBT for anxiety disorders (Borkoved & Ruscio, 2001; Butler, Fennell, et al, 1991; Lenz & Demal, 2000; Silverman, Kurtines, et al, 1999; Toren, Wolmer, et al, 2000). CBT can sometimes be so effective that it can replace medication in treating the symptoms of OCD and PTSD (Basco, Glickman, et al, 2000).

Studies also confirm the effectiveness of the mind-body techniques of guided imagery (Rees, 1995; Tusek, Cwynar & Cosgrove, 1999), relaxation (Aitken & Benson, 1984; Eppley, Abrams & Shear, 1989; Mathew, Ho, et al, 1981; Pender, 1985; Wachelka & Katz, 1999; Weber, 1996), hypnosis (Ashton, Whitworth, et al, 1997; Bryant, Moulds, et al, 2005; Benson, Frankel, et al, 1978; Davidson, Farnbach & Richardson, 1978; Stetter, Walter, et al, 1994), meditation (Finucane & Mercer, 2006; Kabat-Zinn, Massion, et al, 1992; Reibel, Greeson, et al, 2001), autogenic training (Hidderley and Holt, 2004; Jorm, Christensen, et al, 2004) and biofeedback (Clark & Hirschman, 1990; Rice, Blanchard & Purcell, 1993).

CBT and/or mind-body therapies have been effective in all types of anxiety disorders and across all age ranges (Barrett, 1998; Barrett, Duffy, et al, 2001; Barrowclough, King, et al, 2001; Craske MG, Golinelli, et al, 2005; Kendall & Southam-Gerow, 1996; Klinger, Bouchard, et al., 2005; Otto & Smits, 2004; Rayburn & Otto, 2003; Stanley, Beck, et al, 2003), and patients reported feeling more in control of their lives (Pender, 1985; Weinman, Semuch, et al, 1983), even when delivery is computer-assisted (Kenardy, Dow, et al, 2003).

These positive benefits have been sustained in follow-ups as long as six years (Barrett; Barrowclough, King et al; Kenardy, Robinson, et al, 2005; Kendall and Southam-Gerrow). In a study of over 1000 patients, behavioral medicine (relaxation response, cognitive restructuring, exercise, and nutrition) was able to significantly reduce anxiety as well as its medical symptoms (Nakao, Fricchione, et al, 2001). A biofeedback study of 45 people with GAD showed “significant reduction” in one measure of anxiety and its physical and psychological symptoms (Rice, Blanchard and Purcell, 1993).

Herbert Benson, a researcher famous for his studies on relaxation, and his colleagues, reported the effectiveness of meditation-based relaxation and self-hypnosis in the treatment of anxiety (Benson, Frankel, et al, 1978). A study of people with OCD showed that mental imagery could be used successfully to “freeze” the anxiety trigger in order to reduce fear and avoidance behavior in subjects (Riskind, Wheeler & Picerno, 1997). Self-help audiotapes and/or multimedia self-help programs have also been effective (Davidson, Farnbach & Richardson, 1978; Finch, Lambert & Brown, 2000).

Reviews of the literature confirm that all forms of CBT are “likely to provide some benefit for adults” (Rodebaugh, Holoway, and Heimberg, 2004), with relaxation techniques having the strongest evidence for generalized anxiety, panic disorders, dental phobia, and test anxiety, and autogenic training and meditation having some evidence to support their effectiness for generalized anxiety (Jorm, Christensen, et al, 2004).

Studies confirm physiological changes occur after using mind body techniques. After using relaxation training, one small study showed that subjects’ anxiety and platelet MAO levels were significantly lower (Mathew, Ho, et al, 1981), while in another study, subjects’ salivary cortisol levels were greatly reduced and salivary immunoglobulin A (sigA) levels significantly increased (Pawlow and Jones, 2005). Another 2005 study confirmed both physiological and psychological changes (Tafet, Feder, et al, 2005).

A program that includes imagery, relaxation, and behavioral changes can be a low cost, effective way for patients to actively participate in managing the symptoms of anxiety disorders.

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