26 Osteopathic Family Physician (2017) 26 - 34 Osteopathic Family Physician | Volume 9, No. 4 | July/August, 2017 REVIEW ARTICLE Osteopathic Approach to Anxiety Tim Blumer, DO1 & Janice Blumer, DO, FAAO2 1Samaritan Mental Health Family Center, Corvallis, Oregon 2Western University of Health Science - COMP- Northwest Keywords: Anxiety disorders are one of the most common psychiatric disorders presentng to the family physician. Anxiety disorders are both biologic and psychologic in origin. Anxiety is a Anxiety signal alertng the individual of ‘danger.’ This danger can be unknown, internal, confictual Behavioral Medicine and vague. The anxiety signal allows the individual to respond to, and resolve the ‘danger.’ This is to be diferentated from fear which is the emotonal response to a real or perceived Osteopathic Medicine imminent threat. These two states overlap but difer in that fear more ofen triggers the physiologic response of fght or fight. Anxiety disorders result when one or both of these Pediatrics systems are in a chronic ‘hyper reactve’ state for either biologic or psychologic reasons. Psychiatry This artcle reviews the criteria for anxiety disorders and the range of therapeutc interventons, pharmacologic and non-pharmacologic. INTRODUCTION Anxiety disorders are one of the most common psychiatric dis- Anxiety disorders often start in childhood and must be differenti- orders presenting to the family physician. Anxiety disorders are ated from normal childhood worries. Pediatricians and family phy- both biologic and psychologic in origin. Anxiety is a signal alerting sicians are familiar with the startle of infants and the fear of mon- the individual of ‘danger.’ This danger can be unknown, internal, sters in the toddler years. The preschool age child has fears about confictual and vague. The anxiety signal allows the individual to safety such as being kidnapped or worries about storms, thunder respond to, and resolve the ‘danger.’ This is to be differentiated and lightning. These worries may persist into the school age years from fear which is the emotional response to a real or perceived with the addition of worries related to school performance and so- imminent threat.1 These two states overlap but differ in that fear cial relationships and/or rejection. Fear of bodily harm and illness more often triggers the physiologic response of fght or fight. may arise during this time. Through the teenage years the main worry is about performance, both social and academic. Anxiety disorders result when one or both of these systems are in a chronic ‘hyper reactive’ state for either biologic or psychologic rea- Life time prevalence of any anxiety disorder in children and ado- sons. A brief example is making a presentation to your department lescents is between 15% and 32%, and the period prevalence (one at work. This situation is likely to trigger a small degree of anxiety year or six months) for any anxiety disorder ranges from 3.1% to in all individuals which allows the individual to take steps to make 18%.2,3 Children with anxiety disorders are at greater risk of devel- sure the presentation goes well such as checking the materials to oping substance abuse and conduct problems and have increased be presented for accuracy and clarity. Once the materials are re- use of long-term psychiatric and medical services and greater viewed the individual feels confdent and successfully completes overall functional impairment.3,4 the presentation. If the anxiety/fear systems are hyper reactive One in four adults have been found to have an anxiety disorder. the individual may experience a panic attack with a range of physi- A replication of the National comorbidity study by Kessler, et al. ologic responses such are rapid heart rate, hyperventilation, and found an 18.1% 12-month prevalence rate for any Diagnostic and light headedness to name a few. This physiologic response is clear- Statistical Manual of Mental Disorders IV (DSM IV) anxiety disor- ly inappropriate as this is not a life and death situation in which we der.5 need the fght and fight response for survival. In this situation the presentation may not occur possibly resulting in negative outcome for the individual. EVALUATION & DIAGNOSIS (CRITERIA) Anxiety disorders overlap but can be differentiated based on the CORRESPONDENCE: particular presentation of symptoms. Identifying and treating anx- Tim Blumer, DO | [email protected] iety disorders early can prevent long term morbidity. Mandates for improved mental health screening in the family practice medical home are based on the affordable care act.6 This includes screen- Copyright© 2017 by the American College of Osteopathic Family Physicians. All rights reserved. Print ISSN: 1877-573X ing for children, youth, and adults. Blumer, Blumer Osteopathic Approach to Anxiety 27 Use of validated rating scales in conjunction with the patient in- The problematic behaviors (drinking a soda rather than water or terview and examination can assist the busy clinician in evaluating driving one block to pick up a child rather than walking). And the for and following treatment of anxiety. Below are key features of developmental events or patterns of thinking that predisposed or the main anxiety disorders followed by abbreviated Diagnostic hold the behaviors causing the problem (developed earlier than and Statistical Manual of Mental Disorders-5 (DSM-5) criteria. many children and was teased, becoming overly self-conscious and Validated rating scales that may be used at no cost are referenced critical of self). under each diagnosis. See the DSM-5 for complete diagnostic cri- teria.1 The process of treatment is based on the cognitive formulation with the key goal of having the patient identify and change dys- functional thinking (cognitions). TREATMENT Treatment of the patient with an anxiety disorder is based on the PSYCHOEDUCATION evaluation and resultant biopsychosocial formulation for that pa- tient (part of the fve model approach to osteopathic patient cen- For the purpose of this article, psychoeducation refers to the di- tered care). This may range from parent guidance for the young dactic informing of patients and their relatives about the illness, 8 child with separation anxiety to aggressive pharmacologic inter- its treatment, and empowerment to handle the illness. Psycho- ventions with referral to a mental health specialist or child and education has been shown to be as effective as CBT for youth with 9 8 adolescent psychiatrist for evaluation and therapy. Osteopathic anxiety disorders. Goals for psychoeducation include; manipulative medicine should be considered as part of the overall • Ensuring patients and their family/relatives have a basic treatment plan for the patient. understanding of the illness and treatment In general, Cognitive Behavioral Therapy (CBT) is the treatment of • Empowering the patient and family/relatives to choice for all anxiety disorders, alone or in combination with medi- handle the illness cations and other interventions. • Helping the patient take on the role of the “expert” COGNITIVE BEHAVIORAL THERAPY: • Strengthen the role of family/relatives Although cognitive behavioral therapy is typically provided by a therapist for anxiety, depression, and other mental health disor- • Information to improve treatment compliance ders, the family practice physician can learn the underlying princi- • Relapse prevention pals and skills necessary to assist their patients achieve improved mental health. • Crisis management and prevention Cognitive behavioral therapy (CBT) was develop by Aaron Beck, • Support healthy choices MD, a psychoanalyst, in the early 1960s. CBT grew out of Dr. Beck’s research on the psychoanalytic theory of depression. His NUTRITION research, which Dr. Beck expected would validate the psychoana- lytic therapy of depression, ‘anger turned toward the self’, did just The osteopathic physician is skilled at communicating the im- the opposite. Rather, distorted thoughts and beliefs were the pri- portance of healthy nutrition for physical, mental and emotional mary feature of depression.7 Cognitive behavioral therapy as- health. There is considerable debate on the effect or usefulness of sumes that a patient's misconceptions and attitudes about the supplements in the treatment of mental health disorders. The sup- world and themselves precede and produce symptoms such as port for nutritional supplements is strongest for depressive dis- anxiety and depression. Therapy identifes habitual ways in which orders with more limited support for anxiety disorders. Because patients distort information (e.g., automatic thoughts) and teaches depression and anxiety are frequently comorbid it may be helpful patients to identify, evaluate, and respond to their dysfunctional to consider the complementary and alternative medicine (CAM) thoughts and beliefs, using a variety of techniques to change think- treatments for depression. The most support can be found for the ing, mood, and behavior. Cognitive therapy is a structured, goal-ori- B vitamins, Omega-3 Fatty Acids, and inositol.10 A review study by ented, problem-focused, and time-limited intervention. This active Shaheen Lakah, et al.11 found evidence for the use of herbal supple- approach involving principles of learning, help the patient develop ments containing extracts of passionfower or kava and combina- new and adaptive ways of behaving. Treatment also attempts to al- tions of L-lysine and L-arginine as treatments for anxiety symptoms ter behavior by systematically