Anxiety Treatment in TCM

Snohomish Brown
DACM, LAc.

History
19th Century De Costa "irritable heart syndrome"
Later on "soldier’s heart", "effort syndrome", "neurocirculatory asthenia"
then "somatoform autonomic dysfunction"

Introduction
About 5% of people in the US will experience Generalized Anxiety Disorder (GAD) in their lifetime.
Each year, about 3% of the US population are newly diagnosed with GAD (approx. 6.5 million).
Nearly twice as many women are affected than men.

Anxiety is one of the leading causes of disability worldwide, ranking sixth in terms of number of years
lived with the disorder. Annual prevalence rates for all anxiety disorders taken as a whole are about
22% in the USA and 14% in the EU.

GAD Definition
Excessive anxiety and worry
People with GAD may experience a few symptoms or may feel overwhelmed by many symptoms. The
key signs of GAD are difficult to control anxiety and worry lasting for at least 6 months.
Occurring more days than not (6 months or more)
Regarding any number of activities or events (work, school, tests, presentations, performances)

Symptoms (at least three must be present for diagnosis – only one required among children)
Restlessness or feeling keyed up or on edge
Easily fatigued
Poor concentration
Irritability
Muscle tension (sometimes achy soreness, tremors, shaking, or trouble swallowing)
Difficulty falling or staying asleep
Poor concentration or the mind going blank
May also include nausea, vomiting, chronic stomach ache, diarrhea, or frequent urination

Etiology
Clinical and animal studies suggest a correlation between anxiety disorders and balance
dysfunction. Shen Qi disturbance: Shen Qi balance disturbance in TCM

Common Symptoms
Neurological system includes sympathetic nerve system disorder
Immunity system
Endocrine system
Muscular skeleton system
Cardiovascular system
Digestion system
Genitourinary system

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Neurobiology
Parabrachial Nucleus Malfunction
Ascending reticular activating system
Connects the reticular formation and related neural structures
Amygdala malfunction coordinates improper signals
Send impulses to the hypothalmus
Emotion learning
Memory modulation
Especially the basolateral amygdala has been implicated in generating anxious feelings

Neurotransmitters
Noradrenaline (norepinephrine, NA)
Attention and responding function
Fight or flight response, hyperarousal or acute stress response
Serotonin (5-hydroxytryptamine, 5-HT)
Control of appetite, mood and anger response
GABA
Reduces activity in the CNS (inhibitory neurotransmitter)
Implicated in low level anxiety disorders

DSM-5 Anxiety Disorders

Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder
Panic disorder
Generalized Anxiety Disorder
Agoraphobia
Substance/medication induced
Due to another medical condition
Other-specified anxiety disorder
Unspecified anxiety disorder

Accompanying Disorders
Depression Disorder, Major Depression
Obsessive Compulsive Disorder
Eating Disorders
PTSD
Hypochondria
Sleep disorder
Pain disorder
Stress related disorder

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TCM Psychiatry Concepts
Jing Qi Shen
Harmony between Earth, Mankind, and Heaven
Syndromes: Dian, Kuang, Xian, Chi Dai, Yu
Dian Kuang theory
Nei Jing principle (medical bible)

Spiritedness (Healthy Shen)

Shen Unity (Integration)
Shen Awareness
Shen Clarity
Shen Flexibility
Shen Stability
Shen Balancing
Shen Power
Shen Reactivity
Shen Initiation
Shen Processing

Consideration of Etiology
Pre-heaven:
Yin and Yang Essence, Inheritance
Post-heaven:
Shen injury, Emotion disharmony, Zang Fu disharmony, Pathogenic factors,
Medications, Shen-related activities, Physical injury, Chemical poisoning

Modern Time Factors:

High speed lifestyle
High stress lifestyle
Abnormal sleep, light control
Low physical activity, sedentary lifestyle
Chemical contamination and substance abuse, unnatural diet

Our Lifestyle Today

Far away from nature or against nature

Spiritlessness – Shen Qi disharmony patterns

Shen Qi Loss
Shen Qi Insufficiency
Shen Qi Numbness
Shen Qi Weakness
Shen Qi Lassitude
Shen Qi Cloudiness
Shen Qi Floating
Shen Qi Over-sensitive
Shen Qi Inflexibility
Shen Qi Irritability
Shen Qi Scattered
Shen Qi Confusion

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Anxiety DSM-V Typology and TCM Treatment
Generalized Anxiety Disorder (GAD)
Shen Qi disharmony pattern: Shen Qi Irritability in different forms
Treatment Principle: Stabilize Shen
Panic Disorder
Shen Qi disharmony pattern: Shen Qi Irritability, Confusion, and Scattering
Treatment Principle: Stabilize and Bind Shen (Shen Processing)
Phobias, Agoraphobia and Social anxiety disorder
Shen Qi disharmony pattern: Shen Qi Irritability, Weakness and Over-sensitivity
Treatment Principle: Stabilize and Empower (strengthen/tonify) Shen
Obsessive Compulsive Disorder (OCD)
Shen Qi disharmony pattern: Shen Qi Irritability and Inflexibility
Treatment Principle: Move and transform/activate Shen
Post-Traumatic Stress Disorder (PTSD)
Shen Qi disharmony pattern: Shen Qi Irritability and Weakness
Treatment Principle: Shen inner experiencing and Shen exercise
Separation Anxiety
Shen Qi disharmony pattern: Shen Qi Irritability and Weakness
Treatment Principle: Stabilize Shen and promote communication

Shen Qi Irritability in complexity

with Depression Disorder
with Sleep Disorder
with Hypochondria
with Pain Disorder
with Chronic Fatigue Syndrome
with Eating Disorder
Anxiety in TCM
Shen Qi Irritability
in different emotion
in different level
in different form
in different system
in different pattern
in different prognosis

Diagnostic Methods (Observation, Listening/Smelling, Inquiry, Palpation)

Observing Shen
From eyes
Facial Emotion Changes
Demeanor and gestures
Shen Interacting Style
Behavior pattern
Listening and Smelling
Verbal skill and ability: Emotional expression
Voice tone, speed and pronunciation
Logic or illogical speech
Reality or fantasy based
Odors and smells

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 Inquiry
Chief Complaint associated with Shen
Current Shen condition: feeling, emotion, activity, schedule and relationship
Past Shen history, family history
Medicine and side effects
Palpation
Body reaction
Tension and muscle strength
Shake, tremor and contraction
Skin temperature
Moisture and dampness
Skin and deep tissue medical conditions
Other Therapeutic and Diagnostic modalities
Activity (in clinical settings)
Art creation in multiple mediums
Relaxation and the imagination
Conversation/Discussion about progress/evaluation
Mental Diagnosis from MDs, or Psychologists, Psychiatrists, etc.
Medication Response

Treatment Technique 1: Create trust and build rapport between doctor and patient
Communication skills with patients
Gentle (soft) touch
More of a partner than doctor

Treatment Technique 2: Patience and Listening

Listening vs. Hearing
Patience vs. Waiting
Wait until the right time

Treatment Technique 3: Sharing Events in Patient’s Lives

Sympathy and Boundaries
Walk through the patient’s Shen world
Discuss the situation in a friendly manner

Treatment Technique 4: Timing and Interfering

When is the right time?
How to Interfere
What is the limitation?
Compliance

Treatment Technique 5: Lifestyle Changing

Eating and Sleeping patterns
Habit and Activity patterns
Friendship patterns
Daily schedule

Treatment Technique 6: Exercise your Shen

Learning from the anxiety

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 Leaning into the anxiety (experiencing)
Try the proper and helpful action
May need to keep journal
Must consult with doctor

Treatment Technique 7: Shen Transformation

Identify the "bad" cycle
Change the behavior in the cycle
Crush the pattern
Change the emotion in the cycle
No shame, no frustration, not giving up
Interrupt the cycle
Recover self empowerment, confidence

Treatment Technique 8: Shen Communication

Find your friends
Maintaining friendships
Sharing your inner feeling
Learning from your friends
Don’t ‘bother’ your friends with burdens

Treatment Technique 9: Shen Qi Disharmony Factor

Diagnose the cause: Shen Qi Irritability, Shen Qi Weakness, etc.
Internal vs. External triggers
Alcohol Avoidance; manage the negative socioeconomic and marital factors
Overcome the imbalance, defeat the trigger
Using Shen Power
Auto suggestion, self soothing during anxiety moment

Treatment Technique 10: Shen Harmony in Nature

Experiencing nature
Breathe fresh air: qi gong cultivation
Lay on the grass: grounding technique
Holding the tree: touching the roots and leaves
Grasping the stones – feeling the earth
Swimming into water – feeling the ocean

Treatment Technique 11: Knowing the emotional cycle

Daily and Seasonal Timing
Possible triggers
Environmental factors
Internal energy and emotions
Keep a journal and observe themselves

Treatment Technique 12: Reviewing the medication

Cooperate with their doctor / healthcare team
Medication lists - Working effectiveness
Method of administration
Side effects and Tapering off

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Acupuncture in Anxiety
Acupuncture Principles
Use fewer points and more accuracy
Proper manipulation on main points
Consider carefully the order of points
Move the Qi in the appropriate manner
Left vs Right - Balance the Qi
Tonifying vs Sedating - Change the Qi
Guiding Qi and Opening/Closing Wisely
Eight Functions of Qi - Yin Style Ba Gua

Shen Qi Acupuncture to treat Anxiety

Shen Qi Irritability
DU 24, GB 13, SP 6, KD 6
with heat
LV 2, GB 43, LI 11, LI 1
with busy mind
Yin Tang, GB 8
Shen Qi Weakness
DU 20, 21, 24
Shen Qi Cloudiness
GB 14, 15, Si Shen Cong
Shen Qi Confusion
Ba Xie/Feng, Jing Well
Shen Qi Inflexibility
GB 8, 18, KD 6, SP 6, An Mian, Yin Tang
Shen Qi Disharmony with Insomnia
HT 7, PC 7, KD 6, An Mian
Shen Qi Scattered
RN 6, 14, 17, Yin Tang, DU 20, Back Shu
Shen Qi Floating
GB 8, 18, KD 6, SP 6, An Mian, Yin Tang
Shen Qi Over-sensitivity
RN 4, 12, 17, DU 11, Back Shu (inner/outer)

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Treating the Zang Fu Pattern: Guidelines and Formula
Heart Yin Xu, empty heat, Shen Qi Irritable
HT 6, 3, LI 11, KD 6
Tian Wang Bu Xin Dan
Phlegm heat misting HT, Shen Qi Irritable
HT 6, GB 34, ST 40
Wen Dang Tang
Spleen/Stomach Qi Xu, Shen Qi Weakness
DU 20, Yin Tang, ST 36
Bu Zhong Yi Qi Tang
Qi & Blood Xu, Shen Qi Weakness (Exhaustion)
LI 10, ST 36, DU 20, RN 6, 17
Shi Quan Da Bu Tang
Plegm Turbidity, Qi Stagnation, Shen Qi Cloudiness
Si Shen Cong, ST 40, RN 12, SP 6
Er Chen Tang
KD Qi Xu, Shen Qi Cloudiness and Weakness
DU 20, RN 4, 6, KD 3
Jin Gu Shen Qi Wan
KD Yin Xu, empty heat, Shen Qi Irritable
KD 2, 3, 6, SP 6, Yin Tang
Zhi Bai Di Huang Wan
LV Qi Stagnation, Shen Qi Inflexible
LV 3, 13, SJ 6, LI 4
Chai Hu Shu Gan San
LV Heat, Shen Irritable
LV 2, 3, 5, SP 6, LI 11
Jia Wei Xiao Yao San
LV Fire Burning, Shen Qi Irritable w/ Shen Qi Confusion
LV 1, 2, 5, SP 6, ST 44, LI 1, 11
Huan Lian Jie Du Tang

Psychosomatic Conditions
Psychosomatic reactions
Regulate Shen as the key to resolving issue
Psychosomatic disorders
More Shen than body treatment, but we can do both
Psychosomatic diseases
Shen and body treatment, both are needed to resolve

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BENZODIAZEPINES
Alprazolam (Xanax) panic, generalized anxiety, phobias, social anxiety, OCD
Clonazepam (Klonopin) panic, generalized anxiety, phobias, social anxiety
Diazepam (Valium) generalized anxiety, panic, phobias
BENZODIAZEPINES
Lorazepam (Ativan) generalized anxiety, panic, phobias
Oxazepam (Serax) generalized anxiety, phobias
Chlordiazepoxide (Librium) generalized anxiety, phobias
BETA BLOCKERS
Ropranolol (Inderal) social anxiety
Atenolol (Tenormin) social anxiety
TRICYCLIC ANTIDEPRESSANTS
Imipramine (Tofranil) panic, depression, generalized anxiety, PTSD
Desipramine (Norpramin, Pertofrane and others) panic, generalized anxiety, depression, PTSD
Nortriptyline (Aventyl or Pamelor) panic, generalized anxiety, depression, PTSD
TRICYCLIC ANTIDEPRESSANTS
Amitriptyline (Elavil) panic, generalized anxiety, depression, PTSD
Doxepin (Sinequan or Adapin) panic, depression
Clomipramine (Anafranil) panic, OCD, depression
OTHER ANTIDEPRESSANTS
Trazodone (Desyrel) depression, generalized anxiety
MONOAMINE OXIDASE INHIBITORS (MAOIs)
Phenelzine (Nardil) panic, OCD, social anxiety, depression, generalized anxiety, PTSD
Tranylcypromine (Parnate) panic, OCD, depression, generalized anxiety, PTSD
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
Fluoxetine (Prozac) OCD, depression, panic, social anxiety, PTSD, generalized anxiety
Fluvoxamine (Luvox) OCD, depression, panic, social anxiety, PTSD, generalized anxiety
Sertraline (Zoloft) OCD, depression, panic, social anxiety, PTSD, generalized anxiety
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
Paroxetine (Paxil) OCD, depression, panic, social anxiety, PTSD, generalized anxiety
Escitalopram oxalate (Lexapro) OCD, panic, depression, generalized anxiety, social anxiety
Citalopram (Celexa) depression, OCD, panic, PTSD, generalized anxiety
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)
Venlafaxine (Effexor) panic, OCD, depression, social anxiety, generalized anxiety
Venlafaxine XR (Effexor XR) panic, OCD, depression, social anxiety, generalized anxiety
Duloxetine (Cymbalta) generalized anxiety, social anxiety, panic, OCD
MILD TRANQUILIZER
Buspirone (BuSpar) generalized anxiety, OCD, panic
ANTICONVULSANTS
Valproate (Depakote) panic
Pregabalin (Lyrica) generalized anxiety disorder
Gabapentin (Neurontin) generalized anxiety, social anxiety
OTHER ATYPICAL ANTI-PSYCHOTICS
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega)

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Common side-effects of benzodiazepines or tranquilizers
Drowsiness
Lack of energy
Clumsiness
Slow reflexes
Slurred Speech
Confusion and Disorientation
Depression
Dizziness, lightheadedness
Impaired thinking and judgement
Memory loss, forgetfullness
Nausea, stomach upset
Blurred or double vision

Paradoxical effects of anti-anxiety drugs

Mania
Hostility and rage
Aggressive or impulsive behavior
Hallucinations and confusion
Anti-anxiety drug dependence and withdrawal
Increased anxiety
Insomnia
Pounding Heart
Sweating
Shaking and trembling

Cautions and Failures

Problematic relationship with patients
Improper TCM treatment strategy
Didn’t check laws and regulation
No improvement in knowledge, skills

Misdiagnosis in TCM
Wrong treatment with acupuncture or herbs
Patient gets worse

Communication with Psychotic Patients

Wait for patient to stabilize (listen)
Once stable, then permissible to treat patient
Never argue with patients
Exercise proper boundaries

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Anxiety Diagnostic Supplement

DSM-V (American Psychiatric Association, 2013) classes and incidence of anxiety disorders include
12 month prevalence estimates and Lifetime morbid risk assessment (12month prevalence /LMR) for:
Specific phobias (SP) (12.1/18.4%) (15.6% lifetime prevalence)
Social anxiety disorder (SAD) (social phobia) (7.4/13.0%) (10.7% lifetime prevalence)
Agoraphobia (AG) (1.7/3.7%) (2.5% lifetime prevalence)
Panic disorder (PD) (2.4/6.8%)
Generalized anxiety disorder (GAD) (2.0/9.0%)
Separation anxiety disorder (SepAD) (1.2/8.7%)
Selective mutism (SM) (point prevalence – est. between 0.02% and 0.3%)

Related or Accompanying Disorders: 12 month prevalence/ Lifetime Morbidity risk

Depression disorders: major depression (16.6/29.9%)
Obsessive compulsive disorder (1.2/2.7%) (2.3% lifetime prevalence)
Trauma or stress based disorders (including PTSD) (3.7/10.1%)
Bipolar disorder (mood disorder) (1.8/4.1%)

Data are based on the US National Comorbidity Survey Replication and the Adolescent Supplement to
that survey with over 70% response rate among people aged 13 and over during 2001-2004. (3)
Other Etiological factors and Comorbidities:
Substance/medication induced anxiety (stimulants and other toxins)
Anxiety due to another medical condition (e.g. balance dysfunction)
Other or unspecified anxiety disorders
Eating disorders (bulimia, anorexia nervosa, overeating; impulse control disorders)
Hypochondria
Sleep disorders
Pain disorders

Anxiety disorder pathogenesis arises from complex, intricate interactions between psychological
influences, environmental factors, biological and epigenetic mechanisms. However, there is converging
evidence pointing to the key role of adverse experiences affecting anxiety, especially during the
sensitive development stages of childhood (ie. violence, sexual abuse, loss, or death of family member)
Childhood trauma increases risk of PD, SAD, and GAD by two- or four-fold in later life

Hypothalmus Pituitary Adrenal Axis (HPA impairment)

Hypothalmic role in stress response: Corticotropin-Releasing Hormone - acts on the pituitary gland to
release Adrenocorticotropic hormone ACTH, which promotes adrenal cortical hormone secretion
Hyperreactivity of the HPA axis has been associated with maltreatment in early life
HPA impairment leads to a wide range of behavior disruptions and impaired coping in later life

Neurobiology –
Parabrachial Nucleus Malfunction
Ascending reticular activation system
Related Nuclei connection from RAS

Amygdala Malfunction (Phineas Gage, 1860)

Emotional Learning and Memory Modulation

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Basolateral Amygdala implicated in generating feelings of anxiety
Fear processing circuit comprised of amygdala, hippocampus, and prefrontal cortex
Neurotransmitters -
Nor-adrenaline (nor-epinephrine, NA): attending and response function
Fight or Flight Autonomic Nervous System Response, hyper arousal or acute stress response
Serotonin (5-hydroxytryptamine, 5-HT)
Control of appetite, mood, and anger
GABA (Gamma-Aminobutyric acid)
Inhibiting neurotransmitter, reduces CNS activity
Implicated in low level anxiety

80% of PD patients report at least one triggering life event prior to experiencing their first panic attack
The higher the number of adverse events the greater increased GAD risk; with threefold increased risk
for disorder onset after the first major negative event.

Gender/age/genetic factors (family/twin studies show four- to sixfold increased odds, women: twofold)
Early ago-of-onset (AOO); Resilience-promoting characteristics: trait personality and coping skills
Social support networks protective against mental emotional disorders
Stress inoculation confers blunted cortisol responses to standardized stress protocols

References

1 Crocq, MA. (2015). A history of anxiety: from Hippocrates to DSM. Dialogues Clin Neurosci. 17(3),
319-25. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610616/

2 Dean, E. (2016). Anxiety. Nurs Stand. 30(46), 15. Retrieved from:

https://www.ncbi.nlm.nih.gov/pubmed/27406490

3 Kessler, R., Petukhova, M., Sampson, N., Zaslavsky, A., & Wittchen, H. (2012). Twelve‐month and
lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States.
Int J Methods Psychiatr Res 21, 169–184.

4 Schiele, M. Domschke, K. (2018). Epigenetics at the crossroads between genes, environment and
resilience in anxiety disorders. Genes Brain Behav. 17(3), e12423. Retrieved from:
https://www.ncbi.nlm.nih.gov/pubmed/28873274

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