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Acupuncture for Treating Anxiety Disorders - How It Works

Anxiety disorders are one of the most common mental health concerns in both the pediatric and adult population, with a prevalence of 5.7% in the US.1 These conditions are most frequently treated with pharmacotherapy and psychotherapy, yet alternative treatment methods with less side effects and high patient compliance are being explored in clinical research.

Acupuncture is one of the more popular non-conventional therapies used for anxiety disorders, as it has very few side effects and is safe for a broad spectrum of patients.2 This therapy has been used for centuries in Traditional East Asian medicine, and is now being extensively studied in Western medicine as the body of research continues to grow.

Acupuncture For Anxiety - How it Works

Acupuncture involves the application of thin metal needles into the skin, fascia, and muscles, accompanied by manual or electrical stimulation of the needles.3 Traditionally, acupuncture has been explained to work by stimulating the movement of Qi, or the body’s energy throughout the body. Contemporary research in anatomy and neurobiology of acupuncture is discovering how acupuncture works physiologically. Human and animal autopsies demonstrate that acupuncture points are more dense in free nerve endings, encapsulated cutaneous receptors, and connective tissue.3 They also have a higher number of myelinated nerves and autonomic nerve fibers compared to non-acupuncture points, which can result in both local and systemic effects.3 The stimulation of these densely innervated areas results in the release of neuro-peptides and neuro-transmitters, causing the following anxiolytic effects:

1. Stimulates the parasympathetic nervous system

Some acupuncture point locations have increased branches of somatic nerves. Acupuncture needle stimulation will send signals to the brain, which then project onto parasympathetic nerves.4 The systemic result of this includes a decrease in the “fight or flight” response, changes in heart rate, and alterations in anxiety levels.4 A randomized control trial examining acupuncture for anxiety in dental patients demonstrates that acupuncture decreases heart rate and anxiety scores compared to placebo.5 Another study measuring the brain’s electrical activity in response to acupuncture showed decreased activity in anxiety-associated brain regions compared to placebo.6

2. Alters serotonin and other neuroendocrine hormones

Changes in serotonin and neuroendocrine hormones are one of the leading theories to the mechanism behind anxiety.7 There appears to be a higher level of interaction between the hypothalamic-pituitary-adrenal axis in patients with anxiety disorders, along with increased adrenocorticotropic hormone (ACTH), cortisol, and serotonin.7,8 Acupuncture in patients with generalized anxiety disorder has been shown to lower anxiety scores, as well as plasma ACTH and platelet serotonin compared to placebo.8 In combination with anxiolytic medication, acupuncture lowers the side effects associated with the pharmacological treatment, and may be a useful combination therapy for anxiety.8

3. Analgesic effect

Acupuncture needles can stimulate mast cells in the local area to release endorphins and substance-p, which modulate pain.9 This could especially be useful in patients who have pain comorbidities associated with their anxiety. A study in women undergoing mastectomies demonstrated post-operative acupuncture to decrease pain and anxiety, compared to those patients undergoing the standard of care placebo.10 The authors conclude that acupuncture can be a beneficial addition to post-operative care in a hospital setting to manage pain, anxiety, and coping with stress following mastectomy.

Safety and Patient Tolerability

As anxiety is often a comorbidity to many illnesses, acupuncture can be used for a wide spectrum of conditions including anxiety associated with addiction recovery,11 pre- and post-surgical care,6,10 and during dental procedures.12 It is safe and generally well tolerated by patients, often being described as painless or a mild ache in the tissue where the needle is inserted. Various forms of needle stimulation can alter the sensation. For example, electro-acupuncture stimulation can also feel like light muscle contractions, or tingling. The use of needles may aggravate anxiety in some patients, so it is important to take patient preference into account. Acupuncture may include other therapies such as cupping, acupressure, or ear seeds. These can be used instead of needles particularly for the pediatric population.13 A recent pilot study in children with generalized anxiety disorder demonstrates that acupuncture is both well accepted, and reduces anxiety symptoms in a pediatric population.13

Limitations in Research

Despite the large breadth of research in the use of acupuncture for treating anxiety, there are limitations to developing gold standard protocols. A common limitation in acupuncture studies is the challenge of using a control group. Many studies utilizing sham acupuncture as a control may have skewed results due to the placebo effect of receiving any form of therapeutic care. An alternative to this may be the waitlist control method, as it has been shown to eliminate time and therapeutic care biases, as seen in the trial by Leung and colleages.13 A standardized type of control group is important when comparing acupuncture studies, and should be considered in the design of future trials.

Acupuncture for Treating Anxiety and Depression -

Dose

Since acupuncture is often practiced as an individualized form of treatment, an indicated “dose” is not standardized across all clinical trials. A recent literature review summarizes an optimal acupuncture “dose” recommendation, based on the most commonly used regimens in previous articles.14 For general anxiety treatments, three acupuncture points per session is most common, with each session being thirty minutes long, one to three times per week, for up to ten sessions.14 This recommendation is limited to the studies reviewed in the article, but gives a broad idea of what may be most commonly practiced.

Take Home Message

In general, acupuncture is a safe and effective treatment for anxiety, and has little to no side effects compared to pharmacologic treatment options. The mechanisms of action involve alterations in the neuroendocrine system, as well as stimulating the parasympathetic nervous system. Acupuncture also has pain modulating effects, leading to its use as a multi-targeted option for both anxiety and pain management in many conditions. It is well tolerated in a wide spectrum of patients, including the pediatric population, and can also be used in combination with anxiolytic drugs to lessen side effects. Although more research is warranted, the integration of acupuncture into standard care should be considered, as the current evidence demonstrates promising results.

(Acupuncture for Stress and Anxiety) Key Points:

  • Acupuncture is a safe and effective treatment for anxiety in the pediatric and adult population, with little side effects.
  • The mechanisms of action involve stimulating the parasympathetic nervous system, neuroendocrine system, and pain modulation.
  • The integration of acupuncture into standard of care should be considered as the body of research demonstrates promising results. 
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References

  1. Revicki DA, Travers K, Wyrwich KW, et al. Humanistic and economic burden of generalized anxiety disorder in North America and Europe. Journal of Affective Disorders. 2012;140(2):103-112.
  2. Amorim D, Amado J, Brito I, et al. Acupuncture and electroacupuncture for anxiety disorders: A systematic review of the clinical research. Complementary Therapies in Clinical Practice. 2018;31:31-37.
  3. Zhang Z-J, Wang X-M, McAlonan GM. Neural Acupuncture Unit: A New Concept for Interpreting Effects and Mechanisms of Acupuncture. Evidence-Based Complementary and Alternative Medicine. 2012;2012.
  4. Cheng KJ. Neurobiological Mechanisms of Acupuncture for Some Common Illnesses: A Clinician's Perspective. Journal of Acupuncture and Meridian Studies. 2014;7(3):105-114.
  5. Karst M, Winterhalter M, Münte S, et al. Auricular acupuncture for dental anxiety: a randomized controlled trial. Anesthesia and analgesia. 2007;104(2):295-300.
  6. Acar HV, Cuvaş Ö, Ceyhan A, Dikmen B. Acupuncture on Yintang Point Decreases Preoperative Anxiety. The Journal of Alternative and Complementary Medicine. 2013;19(5):42-424.
  7. Gerra G, Zaimovic A, Zambelli U, et al. Neuroendocrine Responses to Psychological Stress in Adolescents with Anxiety Disorder. Neuropsychobiology. 2000;42(2):82-92.
  8. Yuan Q, Li J-n, Liu B, Wu Z-f, Jin R. Effect of Jin-3-needling therapy on plasma corticosteroid, adrenocorticotrophic hormone and platelet 5-HT levels in patients with generalized anxiety disorder. Chinese Journal of Integrative Medicine. 2007;13(4):264-268.
  9. Zhang D, Ding G, Shen X, et al. Role of Mast Cells in Acupuncture Effect: A Pilot Study. Explore: The Journal of Science and Healing. 2008;4(3):170-177.
  10. Quinlan-Woodward J, Gode A, Dusek JA, Reinstein AS, Johnson JR, Sendelbach S. Assessing the Impact of Acupuncture on Pain, Nausea, Anxiety, and Coping in Women Undergoing a Mastectomy. Oncology nursing forum. 2016;43(6):725-732.
  11. Zeng L, Tao Y, Hou W, Zong L, Yu L. Electro-acupuncture improves psychiatric symptoms, anxiety and depression in methamphetamine addicts during abstinence: A randomized controlled trial. Medicine (Baltimore). 2018;97(34):e11905.
  12. Allan FK, Peckham E, Liu JA, 2018 #4}, et al. Acupuncture for anxiety in dental patients: Systematic review and meta-analysis. European Journal of Integrative Medicine. 2018;20:22-35.
  13. Leung B, Takeda W, Holec V. Pilot study of acupuncture to treat anxiety in children and adolescents. Journal of Paediatrics and Child Health. 2018;54(8):881-888.
  14. Errington-Evans N. Acupuncture for Anxiety. CNS Neuroscience & Therapeutics. 2012;18(4):277-284.