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Taylor is a 30-year-old Veteran of the Marine Corps who did three tours in Iraq. He is married, has two children, and is currently unemployed. He wants to work, but he notes that his anxiety and irritability have made holding down a steady job difficult for him. Taylor has been seen in the VA for the past year, and is treated by both a psychiatrist and a psychologist for severe anxiety. He was not found to have PTSD. Sometimes he feels “a little down,” but he is not depressed, according to his mental health clinicians. Aside from his anxiety, he has few other diagnosed health problems, though he frequently goes to the ED or his primary clinician with concerns about different symptoms that crop up for him, such as palpitations, shortness of breath, and digestive problems.

Taylor heard about Whole Health from his psychologist, and he wants to explore other options for treating his anxiety. He is taking medications as prescribed and receiving regular counseling, but the anxiety continues to be problematic. He is signed up for a Taking Charge of My Life and Health class, and on the recommendation of his psychiatrist, he just began seeing a Whole Health Coach to start setting goals and exploring other options.

When his Whole Health Coach asks him about his mission, aspiration, or purpose, Tyler initially says he mostly wants “to not be so damn scared anymore.” On further discussion, he notes he wants to have a stable income so he can move his family to a better neighborhood with better schools, and into a house big enough that his kids can have their own rooms and he and his wife can consider having another baby. He wants to be able to spend time with his kids and attend their sports games and school events without being “knocked down” by panic attacks.

Taylor’s strengths on his PHI are that he has good relationships with his family and friends, who support him during his “anxious times.” He also stays physically active. He has a good relationship with his psychiatrist and primary care team, including his psychologist, who is part of that team. He notes that he has learned to hide his panic, but it is tough to do that now that it seems to be ramping up.

On the PHI vitality signs, he gives himself a 4 out of 5 for physical well-being, a 2 for mental emotional well-being, and 3 for how it is to live his life. If it were not for the anxiety, he says, he would probably be all fives. He has some good insights into the connection between his physical symptoms and his state of mind.

For more information, refer to Taylor’s PHI.

Feeling a certain amount of stress and fear is intrinsic to human survival. With anxiety, people’s normal fear responses are thrown off; the sympathetic fight or flight response is active to the point where it impedes healthy functioning. Anxiety disorders are among the most common problems seen in primary care; in fact, anxiety disorders are the most common category of psychiatric disorder[1], with 31% of U.S. adults experiencing an anxiety disorder at some point in their lives.[2] In any given year, 19.1% of adults in the United States suffer from an anxiety disorder, and 23% of them experience severe anxiety.[1][2] Only 37% of people with anxiety are receiving treatment, and under 12.7% are receiving “minimally adequate treatment.”[1][3]

Anxiety is one of the most common reasons people choose to use complementary and integrative health (CIH) both nationwide, and in the VA.[4][5] Specific anxiety disorders include generalized anxiety, panic disorder, obsessive-compulsive disorder (OCD), and PTSD (featured in its own overview). The purpose of this Whole Health overview is to offer clinicians suggestions and a review of the evidence regarding how to address anxiety using a Whole Health approach.

According to the fifth edition of the Diagnostic and Statistics Manual (DSM-5), fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat.[6] Anxiety is a signal from the brain indicating that there is a potential danger or threat that needs to be addressed to ensure survival. This potential danger can be real or imagined, and the strength of the signal may be stronger than it needs to be. Treat anxiety if any of the following are true:

• It becomes too intense.
• It occurs many times during the day or most days of the week.
• It inhibits daily activities.

Most people with an anxiety disorder will first identify and seek care for physical symptoms associated with anxiety rather than the anxiety itself. They may present to a clinician with a fast heartbeat, fatigue, restlessness, sweats, sleep problems, irritability, poor concentration, trembling, muscle tension, gastrointestinal (GI) problems, or headaches, among other symptoms. On average, a person with anxiety will see 10 health care professionals before he or she receives the diagnosis.[7]

There is no one specific identifiable cause for anxiety disorders or for their severity; anxiety’s etiology is complex.[8] Evidence suggests that it arises through an interaction between genetics, physiology, life experiences, and environmental interactions.[9] Anxiety problems tend to run in families, though people without any family history may also develop anxiety problems.[10] A variety of genes are involved,[11] as are multiple different regions of the brain.[12] One structure involved is the amygdala, which exchanges signals with the autonomic nervous system to alert the body to perceived dangers.[8]. Animal studies show that neuroepigenetics also plays a role; for example, stress can lead to altered expression of genes that influence the hypothalamic-pituitary-adrenal axis.[13] A 2019 study of over 1,400 people linked anxiety to lower connectivity between the brain’s emotional networks, executive control networks, and other networks[14] scattered throughout the brain. The mix of bacteria in the gut microbiome also has an influence, through the secretion of various hormones and peptides that influence[15] the central nervous system. Neuroinflammation, linked to activation microglia, also plays a role.[16] In panic disorder, cytokine imbalances also have an array of negative effects.[17] Trauma also plays a role. Having four or more adverse childhood experiences increases the odds of having anxiety as an adult by 3.7 times.[18]

Several self-care and professional care approaches can be beneficial for people with anxiety disorders. Some influence anxiety symptoms in general and are useful in addressing all the different subtypes of anxiety disorders. Conversely, others have been studied only for one subtype. For specific information related to PTSD, go to the “PTSD” overview. The emphasis in this overview is on self-care options, prevention, and complementary approaches. Conventional care approaches will be briefly mentioned, and more detailed reviews on medications for anxiety can be found elsewhere.[19][20]

Moving the Body

Exercise (and physical activity in general)

It is intuitive that exercise would help decrease anxiety; however, research has historically been somewhat limited. Most research focuses on effects on overall well-being or symptoms of anxiety, rather than exploring the effects of physical activity on specific populations who have a DSM-based diagnosis. A 2018 review of 15 studies (675 people) concluded that exercise programs are a viable anxiety treatment, noting that higher intensity regimens were more effective than lower intensity ones.[21][22] In one study that found benefit for general well-being, exercise is most effective if it exceeds 12 minutes at a time for at least 12 weeks; maximal effects occur when a person exercises 40 minutes per session.[23] A 2017 meta-analysis and a 2012 meta-review did recommend exercise as being well supported in general.[24][25] A 2014 meta-analysis of eight studies of exercise for serious mental illness did not find a beneficial effect on anxiety.[26] A 2014 systematic review concluded that exercise is effective as an adjunctive treatment, but not as effective as antidepressant medications.[27][28]

Of course, one of the advantages of physical activity in general is that it has numerous other health benefits as well. For general information on the benefits of physical activity and ways to incorporate it into PHPs, go to the “Moving the Body” overview.

Tai chi

Tai chi has shown promise in recent studies, but studies to date have had methodological limitations, according to a 2014 review.[29] That review found two randomized controlled trials (RCTs) and six nonrandomized trials indicating that tai chi was associated with a significant reduction in anxiety. Typically, study participants practiced two to four times a week (30 to 60 minutes per session) for 5 to 24 weeks. A 2015 review of 17 articles concluded that, for all the studies’ flaws, tai chi does have benefit and is quite safe.[30]

Qi gong

Qi gong developed in China and has been used there for thousands of years. It focuses on concentration, relaxation, meditation, breathing regulation, body posture, and movement. A 2014 review found that there are at least two RCTs suggesting an immediate reduction in anxiety after participants did qi gong.[31] A 2019 review noted a potential benefit, but indicated that more studies are needed.[32]

Yoga

The evidence for yoga as a solo therapy or as an adjunctive therapy for anxiety is sparse. A 2018 review looking at Hatha yoga (the type most commonly practiced in the United States) noted that the quality of current research did not allow firm conclusions to be drawn.[33] This is in contrast to a 2014 review that concluded yoga can reduce anxiety symptoms. [34][35]

Surroundings

When supporting people with anxiety disorders, it is important to explore the role of external stressors. When exploring the influence of surroundings on anxiety, be sure to ask about work stress, vulnerability to crime, as well as safety at home. Not surprisingly, intimate partner violence is a risk factor for anxiety disorders.[36] Be careful not to let external factors be the only focus, however; working with anxiety requires that people look within as well.

Media fasts

A number of studies indicate that exposure to violence through the media can enhance anxiety.[37][38] Therefore, it might be helpful to suggest that a person with anxiety avoid the news for a set period of time to see if this is helpful.

Green spaces

A 2018 cross-sectional study found that living in proximity to green spaces (natural outdoor environments) is protective against anxiety and depression.[39] Other studies have come to similar conclusions.[40] Even in the short-term, nature time can be helpful; a 2015 study found that a 15-minute walk in the park can lead to favorable changes in vital signs indicative of parasympathetic activation and decreased sympathetic nervous system activity.[41]

Personal Development

Personal Development includes anything a person can do to grow as an individual. Augmenting financial resources (including escaping from poverty) and furthering education can reduce to stress and anxiety. Exploring creative pursuits and doing volunteer work can reduce anxiety as well.[42] or listening to music can be helpful for a person with anxiety, though more research is needed to see how significant a benefit they have.[43][44]

Food and Drink

Nutritional psychiatry is a rapidly growing field.[45] Diet and anxiety symptoms are linked in many ways.[46] There is research showing that people increase or decrease their food intake when anxious, and their choice of food may move away from usual meal-type foods toward high-fat, highly palatable snacks.[46] Encourage people to pay attention to what they crave.

Animal studies indicate that diet-induced obesity can lead to anxiety-related behaviors in rats,[47] but a link in humans has been less clear.[48] Eating too many calories when younger may make a person more vulnerable to developing anxiety later in life.[49] Eating a high fat diet for four months induces anxiety through a number of inflammatory and other biochemical means.[50] Vegans report lower levels of stress and anxiety than people who eat animal products, as do vegetarians.[51][52]

A study done in Norway suggested that people whose dietary pattern consists mostly of fruits, whole grains, vegetables, and lean red meats are less likely to have either anxiety in general or an anxiety disorder.[53] Conversely, a diet rich in processed meats, pizza, salty snacks, chocolates, sugars and sweets, soft drinks, margarine, French fries, beer, coffee, cake, and ice cream is associated with a significantly increased probability of anxiety. Foods with numerous pro-oxidant compounds seem to worsen anxiety symptoms.[54]

Nutrient levels may also play a role. People with anxiety tend to have lower levels of vitamin D in their blood.[55] People with OCD may have various forms of B12 deficiency.[56] In rats, vitamin E deficiency is associated with more anxiety-like behaviors.[57] Certain amino acids need to be consumed in the diet to protect against anxiety, namely L-Tryptophan and L-Tyrosine, which are precursors to serotonin, dopamine and norepinephrine, as well as glutamate, which is used to create gamma-aminobutyric acid (GABA).[58] Folate and B vitamins also are also needed in these biochemical pathways.

Caffeine, alcohol, and nicotine

Caffeine intake is associated with symptoms of anxiety and depression, and one option for a PHP is to discuss stopping caffeine for a few weeks to see if this is beneficial,[59] noting that people vary genetically in terms of how caffeine affects them.[60] Some research indicates that caffeine can have health benefits, including for mood.[61] That said, overall the evidence seems to support avoiding alcohol and nicotine.[24][62]

Anti-inflammatory diet

Evidence indicates that there is a correlation in some study populations between the presence of neuropsychiatric illness and inflammation.[63] It is thought that oxidative stress may contribute to the development of anxiety in some people, and imaging studies indicate that inflammation affects a number of anxiety-related brain regions.[64] Eating an anti-inflammatory diet may prove helpful, and it will have many other health benefits as well. Refer to “The Anti-Inflammatory Diet” Tool in the Passport to Whole Health for more information

Glycemic index and loads

Refined sugars and carbohydrates can cause sudden changes in insulin and glucose levels. Acute insulin and sugar variations have been linked to anxiety in some people.[65] People who eat lower glycemic load foods have lower odds of having anxiety, so it is worth it for an anxious individual to try a low glycemic index/glycemic load diet for a few weeks to see if he or she notices a benefit.[66]

Probiotics

Probiotics for mental health—psychobiotics—have gotten increased research attention in recent years.[67] A number of studies have found that supplementation with probiotics can help with psychological symptoms, such as anxiety.[68] A trial of a probiotic supplement for a few weeks to see if it is beneficial is reasonable. The “Promoting a Healthy Microbiome with Food and Probiotics” tool has additional information.

Recharge

Sleep is essential for brain healing and function. People with anxiety have difficulties with sleep onset, maintenance, or efficiency. Recent research suggests a bidirectional link between sleep disorders and mood disorders, including anxiety.[69] Sleep disturbance is known to exacerbate symptoms in most anxiety disorders.[70] Furthermore, it is a hypothesized risk factor for the development and maintenance of mood and anxiety disorders;[70] having a diagnosis of insomnia is associated with 3.2 times the odds of developing anxiety.[71] Even relatively short periods of sleep deprivation significantly increase a person’s anxiety levels.[71] Research and clinical practice have demonstrated that treatment of anxiety disorders significantly improves sleep.[72] When a person has anxiety, always consider what can be done to make sleep better. It can also be helpful to focus on how to make vacations and other pauses (e.g. work breaks) as stress-reducing as possible. Refer to the “Recharge” overview.

Family, Friends, & Co-Workers

Relationships clearly influence anxiety levels for people. A 2017 review concluded that the link between anxiety disorders and relationships is bidirectional; having anxiety affects the quality of one’s relationships, and how one’s partner treats him or her can of course have a significant effect on anxiety level.[73] Having anxiety and other mental health disorders increases risk of divorce.[74] People with anxiety disorders tend to avoid social encounters, and encouraging shared medical visits and classes may be helpful.

Loneliness and social isolation are linked to multiple health problems, including anxiety. People who rate themselves as lonely tend to respond to stress more intensely, with higher levels of blood pressure and inflammation.[75] A 2014 study found that people who were more isolated actually benefited more from short-term psychotherapy than others, while people with good support benefited more from long-term therapy.[76]

The effects of animal-assisted therapy (and having pets) on anxiety remains to be elucidated. Interactions with animals seems to have some positive effects, but it can also have its associated stresses (including the likelihood of ultimately having the animal die).[77][78]

Spirit & Soul

Depending on how a person experiences them (and it is important to be very respectful of variations in beliefs), religion and spirituality can have profound positive or negative effects on mental health. There is increasing research favorably linking healthy spirituality and religiosity with less anxiety. A large-scale review done in 2015 found that 147 different studies indicated a positive relationship between spirituality and anxiety, whereas only 33 found a negative effect.[79] A 2015 meta-analysis of 23 studies found a significant effect of religious and spiritual interventions on general symptoms of anxiety.[80] A review of 43 studies found that, specifically for Veterans, well-being is favorably linked to spirituality, and well-being was defined, in part, in terms of anxiety levels.[81] One study found that framing treatment around religion and spirituality is often (though not always) the preferred approach for addressing anxiety in older adults.[82] Meaning in life in general also has a significant inverse relationship with anxiety levels.[79][83][84]

Attunement to the existential aspect of patients’ stories may do much to help them work more successfully with anxiety symptoms.[85] It is always worth asking if spiritual or religious issues (e.g., beliefs about death) are associated with anxiety symptoms. Refer to the “Spirit & Soul” overview.

Power of the Mind

There is little doubt that invoking the mind’s power is essential for most people when it comes to working with anxiety disorders. Psychotherapy, relaxation practices, and other mind-body therapy all can be beneficial. The key is to successfully match the therapeutic approach to each specific individual.

Psychotherapy for Anxiety

A number of psychotherapies can be beneficial for people with anxiety disorders. Cognitive Behavioral Therapy (CBT) is a cornerstone of mental health care. In CBT, the clinician guides the patient in identifying and replacing negative patterns of thinking with more positive and realistic approaches. It includes behavior activation and education about the relationships between thoughts, behaviors, and emotions. CBT involves a limited number of sessions, typically 12. There are specific types of CBT for panic disorder, OCD, and PTSD. CBT is widely available in the VA.

A 2015 review of 19 fMRI studies found that CBT increases the prefrontal part of the brain’s control over the different subcortical structures that function differently in different anxiety disorders.[86] CBT is helpful for people with health anxiety related to having a variety of chronic illnesses.[87] It has been found just as effective as medication treatment for generalized anxiety disorder, and even more effective six months after the start of treatment.[88] A large 2018 meta-analysis confirmed it has a large effect size for treating obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and acute stress; it has a small to moderate effect size for social anxiety disorder (SAD) and panic disorder.[89] CBT is also effective for somatoform disorders and for medically unexplained physical symptoms.[90]

A systematic review of 21 studies found CBT is effective when administered via videoconferencing.[91] A meta-analysis of 100 articles found a 51% remission rate for anxiety with CBT (with the number varying based on how “remission” was defined in each study.[92]

Other types of psychotherapy have also shown benefit. Examples of other approaches include emotion-focused therapy (mostly for GAD), exposure therapy (especially for OCD and PTSD), and group sessions of various types for SAD.[93][94][95] A recent meta-analysis of 14 RCTs totaling 1,073 patients showed Psychodynamic Psychotherapy (PP) is as efficacious as other active treatments that have been studied for anxiety disorders. [96] Limitations of PP include a longer length of treatment; however, longer lasting effects were also found.[96] A 2017 review of 36 trials using Acceptance and Commitment Therapy (ACT) found that it outperformed being on a waitlist as well as treatment as usual; effects were comparable to those of CBT.[97]

Of note, the dropout rate for psychotherapy for people with GAD is 17%, so it is important to support ongoing use of these helpful approaches; Whole Health Partners and Coaches can help with this.[98]

Positive psychology

Positive psychology focuses on helping people build pleasant, engaged, and meaningful lives, in contrast to focusing on reducing negative states, such as anxiety, depression, and anger.[99] This treatment approach helps people develop emotional resilience, rather than directly focusing on decreasing anxiety; it can be a useful adjunct when working with people with anxiety disorders.

Mind-Body Practices

Four mind-body approaches are now covered by VA in some form—Biofeedback, Clinical Hypnosis, Guided Imagery, and Meditations. Whole Health Tools that go into more detail about them are featured in the Passport to Whole Health, Chapter 12.

Various states of relaxation elicit cardiorespiratory coherence, which in turn activates the parasympathetic nervous system and opposes the sympathetic nervous system, which tends to be more active in people with anxiety.[100] Several approaches can decrease anxiety by eliciting the relaxation response. For additional details about each of the approaches listed below, check out the “Power of the Mind” and “Mindful Awareness” overviews and tools.[101][102][103]

Biofeedback

Biofeedback uses various measurement tools to bring greater conscious awareness to what are normally unconscious bodily functions. There are several studies showing that use of biofeedback equipment can reduce anxiety. Heart rate variability biofeedback leads to a large reduction of stress and anxiety, according to a 2017 meta-analysis.[104] Other studies have also found benefit, [105][106] Refer to the “Biofeedback” tool.

Guided Imagery

Mental imagery has been demonstrated to elicit stronger emotions than other mind-body approaches. It has a role in eliciting a sense of calm in patients with anxiety.[107]. Guided Imagery shows promise for improving anxiety in critically ill patients, but more studies are needed.[108] It also decreases anxiety in patients having hemodialysis and people who are about to have surgery.[109][110]

Hypnosis

A 2010 review concluded that hypnosis helps with both state anxiety (anxiety due to a specific situation, like taking a test) as well as anxiety disorders (longer-lived anxiety that recurs).[111] It also seems to reduce anxiety for people who have cancer, are receiving wound care for burns, or about to have dental procedures.[112][113][114]

Meditation

The benefits of mindful awareness are beginning to be understood at a neurobiological level.[101] A 2014 review concluded that meditation programs result in small to moderate reductions in “multiple negative dimensions of psychological stress.”[115] There is still a lack of research on this topic, but a 2017 study of 57 people with GAD found that mindfulness meditation seems to improve occupational function and lead to more appropriate use of health care resources.[116] In a 2010 meta-analysis mindfulness was linked with improved anxiety symptoms.[102] A 2012 review concluded, “The evidence suggests that both mindfulness-based stress reduction and mindfulness-based cognitive therapy have efficacy as adjunctive therapies for anxiety symptoms.”[103]

Progressive Muscle Relaxation

Progressive muscle relaxation decreases anxiety and improves quality of life in a number of different patient groups. Examples include people with acute schizophrenia,[117] chronic lung disease patients,[118] and people with hypertension.[119]

Breathing Exercises

Paced deep breathing is an effective way to elicit increased parasympathetic activity.[120] It changes activity levels in different parts of the brain and alters EEG readings.[121] Breathing retraining has been found to be an effective treatment alone and in conjunction with other treatments for decreasing anxiety and improving anxiety disorders.[122]

The focus of this document is primarily to emphasize approaches that can be used as adjuncts to conventional care. (Note that psychotherapy could also be considered a conventional approach by most, but it was featured in the previous section.) Conventional care (e.g., the use of medications for anxiety) is reviewed extensively elsewhere.[123][124]

Antidepressants benefit 50%-65% of people with anxiety disorders, and medications are considered a first-line treatment. A 2019 review of 89 trials (n=25,441 people) looking at treatments for generalized anxiety disorder found that duloxetine, pregabalin, venlafaxine, and escitalopram were more efficacious than placebo and relatively well tolerated.[125] Smaller sample sizes also indicated potential benefit from mirtazapine, sertraline, fluoxetine, buspirone, and agomelatine. Quetiapine had the largest effect but was not well tolerated. The same was true for paroxetine and benzodiazepines.

In working with people with anxiety, keep in mind that anxiety tends to be linked to a number of other medical and mental health conditions as well, especially for women and those with poorer health-related quality of life.[126] Keep comorbidities in mind. For instance, anxiety has a bidirectional relationship (it both causes and is caused by) with arthritis, and having it is a strong predictor of future gastrointestinal disease. Panic disorder is linked with up to a 45% rate of comorbidities, with 1½ to 2 times the risk of conditions like diabetes, IBS, respiratory diseases (asthma and COPD), and cardiovascular disease.[127] Before diagnosing anxiety, clinicians should rule out other health issues that can mimic it, such as thyroid problems, adrenal tumors, insomnia, and substance use.

Prevention

A 2018 poll by the American Psychiatric Association found that nearly 40% of Americans reported being more anxious now than they were a year ago.[128] Safety, health, and finances were their largest concerns. Bearing this in mind, it is important to focus not only on treating anxiety disorders but also on preventing them, helping people to bolster resilience and manage stress. Using mind-body approaches should ideally be something everyone does, not just something that is considered after problems arise.[96][129][130][131][132][133][134]

Dietary supplements[135]

A number of dietary supplements are used by patients for anxiety, and it is helpful for clinicians to be familiar with them, whether or not they choose to recommend the supplements themselves. Natural Medicines (accessible through VA medical libraries) maintains up-to-date reviews of the literature for supplements, and some of the following information is based on its summaries, as well as several other reviews.[136][137] Keep in mind that some supplements can trigger anxiety symptoms (e.g., ephedra and other sympathomimetic herbals that are used for weight loss). The following list features supplements that have been studied the most for use with anxiety. Note that most herbals for anxiety work by modulating GABA activity.[138] Adaptogenic herbs may also be used, but these are not a focus in this overview.[139]

Cannabis

Anxiety ranks as one of the top five reasons for which people report using medical marijuana.[140] A 2019 systematic review concluded that medical cannabis is safe and likely helps with some anxiety symptoms, but it does not bring about remission.[141] Of course, it should only be used legally.

Folic acid and other vitamins

Folic acid mostly helps antidepressant medications work optimally. It can be given in conjunction with SSRIs for anxiety as well. The dose is 400-800 µg daily, though no direct research has been done to evaluate its effects on anxiety. It may be given as L-methylfolate, which crosses the blood-brain barrier more effectively. Other B vitamins, such as B6 which are linked to the production of neurotransmitters, may also be worth supplementing.

Galphimia glauca

This evergreen shrub, endemic to Mexico, has been used traditionally as an anxiolytic for centuries.[142] A 2018 review concluded it had good research to support its use.[143] It seems to be safe to use, at least in research conducted for up to 15 weeks. A typical dose is 310 mg of dried extract twice a daily. It is best not to use it with other central nervous system depressants.

5-Hydroxytryptophan (5-HTP)

5-HTP is converted into serotonin. It crosses the blood-brain barrier into the central nervous system. It is more commonly used for the treatment of depression, but it is also used for anxiety. In two trials involving 5-HTP, it did reduce symptoms of anxiety when given over several weeks. Research on 5-HTP orally for anxiety is limited. Natural Medicines recommends caution with its use due to concerns of eosinophilia-myalgia syndrome, which has been caused—perhaps by contaminants—by some formulations of L-tryptophan.

Kava

Kava (Piper methysticum) is a drink that has been historically used for ritual purposes by Pacific Islanders for centuries. Many animal models show kava’s efficacy for anxiety; kava has been postulated to act on many neurotransmitters, including GABA. Kava does not seem to cause sedation or mental impairment. The majority of studies have found kava decreases anxiety, as measured by subjective scales.[144] A 2018 review concluded kava appears to be a short-term treatment for anxiety, but not something that replaces other long-term options (no liver toxicity was noted in this study).[145] Another 2018 study concluded Kava has promise but cannot clearly be said, based on the current body of research, to be more effective than placebo for GAD.[146]

Kava has the rare side effect of liver toxicity, and for this reason, several countries banned it. People with liver problems should avoid Kava, and liver function testing is recommended if it is used. Taking doses less than 400 mg daily does not cause serious side effects. A standard dose is 100 mg (70 mg kava lactones) three times daily. It may be necessary to use it for up to eight weeks before an improvement in anxiety is noted.

Lysine

The amino acid lysine has been shown in animals to act as a partial serotonin receptor antagonist. It seems to decrease the brain-gut response to stress as well as reduce serum cortisol levels. A handful of RCTs suggest that L-lysine combined with L-arginine effectively reduces anxiety scores with virtually no reported side effects.[147] The dose is 2-4 gm daily.

Omega-3 fatty acids

Omega-3s mostly have been researched in studies on depression and have been found to improve overall nervous system function because they optimize cell membrane fluidity and modulate neuronal communication. Low omega-3 levels have been linked to both depression and anxiety disorders. A 2018 review and meta-analysis concluded that they may might favorably affect clinical anxiety symptoms.[148] Omega-3s are generally well tolerated, and side effects reported, such as nausea and a fishy aftertaste, are mild and can be overcome by freezing the capsules. Doses range between 2 and 3 gm daily. A study in students found a 20% reduction in anxiety symptoms for people who received omega-3 supplementation.[149]

Passion flower

Passionflower (Passiflora incarnata Linn.) carries a possibly effective, possibly safe rating. It contains apigenin, which is thought to bind to GABA receptors. In mice, its effects have been well documented. One double-blind, placebo-controlled study showed similar efficacy between oxazepam and passionflower.[150] Two other RCTs also showed benefit. Mild adverse events have been reported, including dizziness, drowsiness, and confusion. The typical dose of crude passionflower herb is 0.25-2 gm of the dried, above-ground parts three times daily, or a person can drink a cup of the tea two to three times daily including 30 minutes before bedtime.

St. John’s wort

St. John’s wort (Hypericum perforatum) has a long history of use and benefit for anxiety problems, though it is best known for depression benefits. It affects levels of multiple neurotransmitters. There have been many trials, and their findings are mixed. Only mild to moderate adverse effects were reported; most often these were gastrointestinal upset, dizziness, sleep disturbances, and headaches. Note, however, that St. John’s wort is an inhibitor of cytochrome P450 3A4, which can lead to multiple drug interactions.[151] The dose of St. John’s wort is 100-300 mg of the above-ground parts up to three times daily. Like serotonin specific reuptake inhibitor (SSRI) medications, it may take time for it to take effect.

Skullcap

Preliminary evidence indicates that skullcap (Scutellaria lateriflora) leads to relaxation in healthy people who take a single dose. It is added to many combinations of supplements used for anxiety. A dose of 100 mg (often steeped as a tea) does not seem to have significant side effects, but 200 mg can cause cognitive impairment. Effects of taking repeated doses are not known.

Theanine

Theanine has gained popularity as an anxiety remedy. The main amino acid found in tea, this supplement seems to increase levels of GABA and serotonin. Preliminary evidence suggests taking 200 mg might lead to improved subjective feelings of tranquility. No adverse effects have been reported.

Valerian

Valerian (Valeriana officinalis) contains sesquiterpenes and other compounds that can stimulate GABA receptors and change activity at the serotonin 5-HT_5A receptor. It is known from EEG studies to alter activity in different areas of the brain.[152] Valerian has primarily been studied for its use in insomnia, but it has also shown promise for anxiety at doses ranging from 50 mg three times a day to 150-300 mg in the morning and 300-600 mg at night. It can take weeks to take effect. Research supporting its use for anxiety is limited.

Aromatherapy

The effectiveness of aromatherapy for anxiety remains unclear. A 2019 review did not find benefit for aromatherapy massage for anxiety in palliative care patients, and a 2019 trial did not find rose oil to help anxiety for people undergoing heart bypass surgery.[153][154] A 2014 review of aromatherapy for elderly patients with chronic pain did note an improvement in anxiety and stress levels.[155] A 2011 systematic review based on 16 studies concluded that aromatherapy was generally safe and effective in reducing anxiety symptoms.[156] Those with higher levels of anxiety benefited the most.

Massage

Massage is a popular and safe treatment for anxiety. There are many different types of massage, but few studies have evaluated their use specifically for the treatment of anxiety disorders. A 2010 trial of massage for GAD found that all participants who received 10 sessions of massage for 12 weeks showed significant improvement on the Hamilton Anxiety Rating Scale (HAM-A) after 12 weeks and maintained their gains after 26 weeks.[157] Massage Therapy in combination with Myofascial Release (easing tension in the muscle connective tissue) was not found to reduce anxiety in people with fibromyalgia, but it did help with other symptoms.[158]

Moderate pressure massage is known to reduce anxiety, change EEG patterns, increase vagal activity, and decrease cortisol levels; that is, it elicits the relaxation response.[159] There are many small studies that suggest massage lessens the anxiety associated with various medical conditions.[160].

Energy medicine

There is limited research on energy medicine approaches to anxiety, but a 2017 review concluded that “…biofield therapies show safety and promise in reducing anxiety….”[161] A 2015 Cochrane review concluded that data is insufficient to determine whether or not Reiki is useful for anxiety.[162] Several small studies support the benefits of Therapeutic Touch in people with anxiety.[163] However, no RCTs have been done. Many of the small studies of different energy medicine approaches find subjective reductions in anxiety related to having a procedures or dealing with chronic medical conditions.

Acupuncture

Benefits of acupuncture vary with the type of anxiety disorder. A 2019 review of 10 prior reviews found that acupuncture was more effective than no treatment, noting that study quality was low.[164] In contrast, a 2018 systematic review concluded, “Overall, there is good scientific evidence encouraging [use of ] acupuncture therapy to treat anxiety disorders… with fewer side effects than conventional treatment.”[165]

A 2007 review concluded that research was promising for perioperative anxiety and generalized anxiety disorder (GAD), but more studies are needed.[166] In the studies reviewed, people suffering from GAD had added benefit when acupuncture was used to augment medication therapy. People suffering from OCD found acupuncture, in addition to medical therapy, to be no different from medication alone, but treatments were better tolerated when acupuncture was added. A trial on preoperative neurosurgical patients found that acupuncture at one point, “Yintang,” significantly reduced preoperative anxiety levels.[167]

A 2014 study found that acupuncture decreased anxiety and craving levels in Veterans with substance use problems.[168] Another 2014 study found that auricular (ear) acupuncture was helpful for reducing stress in health care workers.[169] Acupuncture reduced anxiety and improved working memory in 90 students performing a stressful task.[170] Acupuncture seems to help with anxiety in premenstrual dysphoric disorder.[171] Auricular acupuncture (which is focused on acupoints in the ears) reduces anxiety before dental procedures, [172] and also seems to help people with anxiety disorders in general.[173]

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Taylor talked about a number of options for addressing his anxiety with his Whole Health Coach. In fact, he attended several skill-building courses, each of which focused for an hour on different options he could choose related to a different area of self-care. He and his care team came up with two shared goals based on his priorities. Based on those, he created two SMART (Specific, Measurable, Action-Oriented, Realistic, and Timed) goals:

1. The first goal was to try a variety of relaxation practices, see which one he found most helpful, and start using it regularly. After exploring several, including biofeedback, self-hypnosis, breathing exercises, meditation, and therapeutic journaling, he chose to start doing meditation. He signed up for a mindfulness-based stress reduction course being offered at his VA. His goal is to meditate at least 6 days a week, first thing in the morning, for 20 minutes. He finds he prefers seated meditation.
2. The second area he chose to focus on was Personal Development. It is clear that supporting his family and moving to a better location are high priorities for Taylor. He set the goal of applying to an online college course that would help him start moving toward a business degree. For starters, he agreed to share a list of the programs he has applied to with his Whole Health Coach.

In addition, Taylor is going to explore getting therapeutic massage at least once a month because he noted, once he started meditating, that he actually has a fair bit of neck and shoulder pain when he becomes stressed. His enhanced mindful awareness helped him pay closer attention to how anxiety affects his body. He is increasingly optimistic that he can “feel more comfortable in his own skin,” where the anxiety is no longer controlling his life.

• Autogenic Training
• Biofeedback
• Breathing
• Clinical Hypnosis
• Guided Imagery
• Meditation
• Mindful Awareness
• Progressive Muscle Relaxation
• Progressive Relaxation
• The Power of Breath: Diaphragmatic Breathing

• VA Mental Health Resources for Veterans with Anxiety
• Anxiety Disorders, National Alliance on Mental Illness (NAMI) website
• Anxiety and Depression Association of America guide to finding support groups, plus a page for finding professionals
• “Anxiety Resources,” Joseph Bennington-Castro, Everyday Health website.
• VA Primary Care-Mental Health Integration Initiative
• Also consider resources related to the various psychotherapies offered at your VA site, including Interpersonal Psychotherapy (IPT), CBT for Depression, and Problem Solving Therapy (PST). Visit the VA Mental Health website for more information.

“Anxiety” was created and updated by J. Adam Rindfleisch, MPhil, MD building on an original Whole Health tool written by Mario Salguero, MD, PhD (2014, updated 2019).