Anxiety

Also indexed as: Nervousness, Panic Attacks

Anxiety describes any feeling of worry or dread, usually about potential events that might happen. Some anxiety about stressful events is normal. However, in some people, anxiety interferes with the ability to function. Severe anxiety usually lasts more than six months, though it may not be a problem every day. Some people who think they are anxious may actually be depressed. Because of all these factors, it is important for people who are anxious to seek expert medical care. Natural therapies can be one part of the approach to helping relieve mild to moderate anxiety.

Checklist for Anxiety

Rating Nutritional Supplements Herbs
3Stars   Kava (take only under medical supervision)
2Stars Inositol
Multivitamin-mineral		 Passion flower (in combination with valerian)
Valerian (in combination with passion flower)
1Star Magnesium
Vitamin B3 (niacinamide)		 American scullcap
Chamomile
Hops
Linden
Motherwort
Oats (oat straw)
Pennyroyal
St. John’s wort
Wood betony
See also:  Homeopathic Remedies for Anxiety
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of anxiety? Physical symptoms of anxiety include fatigue, insomnia, stomach problems, sweating, racing heart, rapid breathing, shortness of breath, and irritability.

How is it treated? Underlying medical conditions, such as excess hormone secretion from the thyroid or adrenal glands, are treated when present. Anti-anxiety medications, such as lorazepam (Ativan®) and alprazolam (Xanax®), or antidepressants, such as fluoxetine (Prozac®), are often prescribed in conjunction with psychological counseling.

Dietary changes that may be helpful: All sources of caffeine should be avoided, including coffee, tea, chocolate, caffeinated sodas, and caffeine-containing medications. People with high levels of anxiety appear to be more susceptible to the actions of caffeine.1

Nutritional supplements that may be helpful: Inositol has been used to help people with anxiety who have panic attacks. Up to 4 grams three times per day was reported to control such attacks in a double-blind trial.2 Inositol (18 grams per day) has also been shown in a double-blind trial to be effective at relieving the symptoms of obsessive-compulsive disorder.3

An isolated double-blind trial found that supplementation with a multivitamin-mineral supplement for four weeks led to significant reductions in anxiety and perceived stress compared to placebo.4

Many years ago, magnesium was reported to be relaxing for people with mild anxiety.5 Typically, 200 to 300 mg of magnesium are taken two to three times per day. Some doctors recommend soaking in a hot tub containing 1–2 cups of magnesium sulfate crystals (Epsom salts) for 15 to 20 minutes, though support for this approach remains anecdotal.

Niacinamide (a form of Vitamin B3) has been shown in animals to work in the brain in ways similar to drugs such as benzodiazepines (Valium®-type drugs), which are used to treat anxiety.6 One study found that niacinamide (not niacin) helped people get through withdrawal from benzodiazepines—a common problem.7 A reasonable amount of niacinamide to take for anxiety, according to some doctors, is up to 500 mg four times per day.

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: The preeminent botanical remedy for anxiety is kava, an herb from the South Pacific (see warning in this section). It has been extensively studied for this purpose.8 One 100 mg capsule standardized to 70% kava-lactones is given three times per day in many studies. Preliminary9 and double-blind trials10 11 have validated the effectiveness of kava for people with anxiety, including menopausal women.12 A previous study found kava to be just as effective as benzodiazepines over the course of six weeks.13 The latest research shows that use of kava for up to six months is safe and effective compared with placebo.14 Although kava rarely causes side effects at the given amount, it may cause problems for some people if combined for more than a few days with benzodiazepines.15

Warning: Reports from late 2001 have indicated that kava may be associated with liver damage.16 17 18 19 20 Until additional information clarifies the extent of the risk involved, it is strongly recommended that all individuals consult their physician before taking kava. In addition, based on the available information, it seems that people with liver disease and those taking medications that have the potential to damage the liver should not take kava.

Several plants, known as “nervines” (nerve tonics), are used in traditional herbal medicine for people with anxiety, with few reports of toxicity. Most nervines have not been rigorously investigated by scientific means to confirm their efficacy. However, one study found that a combination of the nervines valerian and passion flower reduced symptoms in people suffering from anxiety.21 In a double-blind study, 45 drops per day of an extract of passion flower taken for four weeks was as effective as 30 mg per day of oxazepam (Serax®), a medication used for anxiety.22 ®

Other nervines include oats (oat straw), hops, passion flower, American scullcap, wood betony, motherwort, pennyroyal, and linden.

St. John’s wort is very popular for the treatment of mild depression. It has also been reported in one double-blind study to reduce anxiety.23

An old folk remedy for anxiety, particularly when it causes insomnia, is chamomile tea. There is evidence from test tube studies that chamomile contains compounds with a calming action.24 There are also animal studies that suggest a benefit from chamomile for anxiety,25 but no human studies support this belief. Often one cup of tea is taken three or more times per day.

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

Other integrative approaches that may be helpful: Reducing exposure to stressful situations can help decrease anxiety. In some cases, meditation, counseling, or group therapy can greatly facilitate this process.26

Acupuncture has been the subject of limited research as a therapy for anxiety. In an uncontrolled study, eight patients suffering from anxiety were treated with acupuncture three times per week for eight sessions. Six of the eight patients achieved good to moderate improvement.27 However, a trial of acupuncture treatment for anxiety associated with quitting smoking did not provide any evidence of benefit.28 A double-blind study of acupuncture for the treatment of anxiety associated with dental procedures reported that acupuncture and placebo were equally effective.29 Acupuncture remains unproven in the treatment of people with anxiety.

A form of counseling known as Cognitive-Behavioral Therapy (CBT) has been shown to be superior to placebo for managing the symptoms of panic disorder.30 In a controlled trial, six months of CBT produced a response rate of 39.5%, compared to only 13% in the placebo group. When combined with the tricyclic antidepressant drug imipramine (Tofranil®), response rates were even higher (57.1%). For long-term management of panic disorder, imipramine produced a superior quality of response, but CBT had more durability and was better tolerated.

References:

1. Bruce M et al. Anxiogenic effects of caffeine in patients with anxiety disorders. Arch Gen Psychiatry 1992;49:867–9.

2. Benjamin J, Levine J, Fux M, et al. Double-blind, placebo-controlled, crossover trial of inositol treatment for panic disorder. Am J Psychiatry 1995;152:1084–6.

3. Fux M, Levine J, Aviv A, Belmaker RH. Inositol treatment of obsessive-compulsive disorder. Am J Psychiatry 1996;153:1219–21.

4. Carroll D, Ring C, Suter M, Willemsen G. The effects of an oral multivitamin combination with calcium, magnesium, and zinc on psychological well-being in healthy young male volunteers: a double-blind placebo-controlled trial. Psychopharmacology (Berl) 2000;150:220–5.

5. Weston PG et al. Magnesium sulfate as a sedative. Am J Med Sci 1923;165:431–3.

6. Mohler H, Polc P, Cumin R, et al. Niacinamide is a brain constituent with benzodiazepine-like actions. Nature 1979;278:563–5.

7. Vescovi PP, et al. Nicotinic acid effectiveness in the treatment of benzodiazepine withdrawal. Curr Ther Res 1987;41:1017.

8. Pittler MH, Ernst E. Efficacy of kava extract for treating anxiety: Systematic review and meta-analysis. J Clin Psychopharmacol 2000;20:84–9.

9. Neto JT. Efficacy and tolerability of kava extract WS1490 in anxiety states: multicentre Brazilian study. Rev Bras Med 1999;56:280–4.

10. Lehmann EE, Kinzler J, Friedmann J. Efficacy of a special kava extract (Piper methysticum) in patients with states of anxiety, tension and excitedness of non-mental origin. A double-blind placebo-controlled study of four weeks treatment. Phytomedicine 1996;3:113–9.

11. Volz HP, Kieser M. Kava-kava extract WS 1490 versus placebo in anxiety disorders–A randomized placebo-controlled 25-week outpatient trial. Pharmacopsychiatry 1997;30:1–5.

12. Warnecke G. Psychosomatic dysfunctions in the female climacteric. Clinical effectiveness and tolerance of kava extract WS 1490. Fortscher Med 1991;119–22 [in German].

13. Woelk H, Kapoula S, Lehrl S, et al. Treatment of patients suffering from anxiety—double-blind study: Kava special extract versus benzodiazepines. Z Allegemeinmed 1993;69:271–7 [in German].

14. Volz HP, Kieser M. Kava-kava extract WS 1490 vs. placebo in anxiety disorders—A randomized placebo-controlled 25-week outpatient trial. Pharmacopsychiatry 1997;30:1–5.

15. Almeida JC, Grimsley EW. Coma from the health food store: Interaction between kava and alprazolam. Arch Intern Med 1996;125:940–1.

16. Stafford, Ned. Germany may ban kava kava herbal supplement. Reuters, Nov. 19, 2001. http://www.reutershealth.com/frame2/eline.html

17. Escher M, Desmeules J, Giostra E, Mentha G. Hepatitis associated with kava, a herbal remedy for anxiety. BMJ 2001;322:139.

18. Kraft M, Spahn TW, Menzel J, et al. [Fulminant liver failure after administration of the herbal antidepressant Kava-Kava.] Dtsch Med Wochenschr 2001;126:970–2 [in German].

19. Strahl S, Ehret V, Dahm HH, Maier KP. [Necrotizing hepatitis after taking herbal remedies.] Dtsch Med Wochenschr 1998;123:1410–4 [in German].

20. Russmann S, Lauterburg BH, Helbling A. Kava hepatotoxicity. Ann Intern Med 2001;135:68–9 [letter].

21. Brown D. Valerian root: Non-addictive alternative for insomnia and anxiety. Quart Rev Nat Med 1994;Fall:221–4 [review].

22. Akhondzadeh S, Naghavi HR, Vazirian M, et al. Passionflower in the treatment of generalized anxiety: a pilot double-blind randomized controlled trial with oxazepam. J Clin Pharm Ther 2001;26:363–7.

23. Witte B, Harrer G, Kaptan T, et al. Treatment of depressive symptoms with a high concentration Hypericum preparation. A multicenter placebo-controlled double-blind study. Fortschr Med 1995;113:404–8 [in German].

24. Viola H, de Stein ML, et al. Apigenin, a component of Matricaria recutita flowers, is a central benzodiazepine receptors-ligand with anxiolytic effects. Planta Med 1995;61:213–6.

25. Yamada K, Miura T, Mimaki Y, Sashida Y. Effect of inhalation of chamomile oil vapour on plasma ACTH level in ovariectomized rats under restriction stress. Biol Pharm Bull 1996;19:1244–6.

26. Miller JJ, Fletcher K, Kabat-Zinn J, et al. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry 1995;17:192–200.

27. Lo CW, Chung QY. The sedative effect of acupuncture. Am J Chin Med 1979;7:253–8.

28. Lamontagne Y, Annable L. Acupuncture and anxiety. Can J Psych 1979;24:584–5.

29. Taub HA, Mitchell JN, Stuber FE, et al. Analgesia for operative dentistry: a comparison of acupuncture and placebo. Oral Surg Oral Med Oral Pathol 1979;48:205–10.

30. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. A randomized controlled trial. JAMA 2000;283:2529–36.