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 Routines (sleep, meals, Progressive relaxation/Body scan exercise, regular Meditation practices activities) Positive self-talk Biofeedback Self- Mind-body Journaling regulation techniques Autogenics practices Humor Clinical Hypnosis
Taking a break Guided imagery Talking to someone you trust Yoga, Tai Chi, others 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
Anxious mind Logical mind
Wise mind
PSYCHOTHERAPY
¡ Psychodynamic therapies
¡ Psychiatrists ¡ Parent-Child Interaction Therapy (PCIT) ¡ Psychologists (PhD, PsyD) ¡ Play therapy ¡ Marriage and Family Therapists (MFT) ¡ Group therapy ¡ Social workers ¡ Family therapy
¡ LPCCs ¡ CBT and DBT ¡ 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 PSYCHOTHERAPY: The Common Factors
Alliance: the bond, agreement about the goals and the tasks (of therapy) Empathy: identifying with the other by adopting his or her perspective Expectations: through explanation of the patient’s disorder, presenting the rationale for the treatment, and participating in the therapeutic actions. Cultural adaptation: the explanation given for the patient’s distress and the therapy actions must be acceptable to the patient. ‘Clinician’ effects: does is matter who the clinician is? Treatment Differences: when empathy, structure and alliance are there, it doesn’t matter what the modality is (maybe). Adherence and competence: adherence to the protocol and competence is not significantly related to outcome. PSYCHOTHERAPY: The Common Factors Larger effect sizes: Smaller effect sizes: Alliance/Rapport Treatment differences
Empathy Adherence and competence
Expectations
Cultural adaptation
Clinician effects EXPECTATIONS
¡ “In medicine, expectations can be induced verbally and then physiochemical agents or procedures can be administered or not, making the two components (creation of expectations and the treatment) independent… ¡ …In psychotherapy, creating the expectations, through explanation of the patient’s disorder, presenting the rationale for the treatment, and participating in the therapeutic actions, is part of therapy.” World Psychiatry 2015;14:270–277 ¡ In clinical care (and formal MBM), context creates an opportunity for a focused state of concentration, during which shifts in awareness, mindset, and biological functions are possible. THERAPIST EFFECTS
¡ “Studies have shown that effective therapists (vis-a-vis less effective therapists) are able to form stronger alliances across a range of patients, have a greater level of facilitative interpersonal skills, express more professional self-doubt, and engage in more time outside of the actual therapy practicing various therapy skills.”
World Psychiatry 2015;14:270–277 TREATMENT DIFFERENCES
¡ When empathy, structure and alliance are there, it doesn’t matter what the modality is.
¡ “All therapies with structure, given by empathic and caring therapists, and which facilitate the patient’s engagement in behaviors that are salubrious, will have approximately equal effects.” World Psychiatry 2015;14:270–277 PSYCHOTHERAPY - HELPFUL QUESTIONS TO CONSIDER
¡ Are there major disruptions in relationships with key parent figures? ¡ Does the family history suggest a strong biological component? ¡ Individual/family experiences? ¡ Does the family have a particular preference? ¡ Insurance/access limitations? ¡ Remind the child/teen/parent that the relationship is key ¡ Allow 4-6 sessions before considering a change ¡ It’s ok to tell the therapist you’re not comfortable about something ANXIETY - REVIEW
¡ Consider routinely asking: what are your go-to coping tools? (primary prev) ¡ Anxiety as super-power ¡ Assessment: how prevalent? how functionally impairing? 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 – MILD, MODERATE, OR SEVERE?
¡ Lifestyle (sleep, physical activity, schedule management, parent modeling, spiritual) ¡ Psycho-education ¡ Family, genetics and the environment ¡ Mind-body (journaling, relaxation strategies, formal tools) ¡ Supplements/botanicals/pharmaceuticals ¡ Talk therapy ¡ Other systems (TMC, Ayurveda, Homeopathy)