Massage Therapy for Chronic Stress and Anxiety

Massage alters EEG activity, increases parasympathetic activity and decreases cortisol levels

Massage is widely used in all cultures to evoke feelings of deep relaxation and reduced anxiety. The anxiety reducing and mood enhancing benefits of massage are probably related to changes in EEG activity, decreased levels of cortisol and increased activity of the parasympathetic nervous system, which acts automatically to calm the body and brain during stress. Numerous studies show that moderate pressure massage is more effective than light pressure massage for reducing pain associated with different medical problems including fibromyalgia and rheumatoid arthritis. Moderate pressure massage also improves attention and enhances the body’s immune response by increasing the activity of natural killer cells. Functional brain imaging studies show that changes take place in many areas of the brain involved in regulating emotions and stress response including the amygdala and the hypothalamus. For an excellent review on the research evidence for massage therapy see “Massage Therapy Research Review” by Field (Field 2014).

Challenges to designing studies on massage

It is difficult to examine the beneficial effects of massage therapy using contemporary research methods because it is impossible to design a double-blind study in which the person receiving massage therapy is ‘blinded’ to treatment. Also, the physical and psychological benefits of massage are difficult to quantify in controlled trials. Findings of many studies are limited by the absence of a sham control group i.e., a group treated by someone who poses as a massage therapist but has no training. The situation is further complicated by the fact that few massage therapists are trained in research methods or work in institutional settings where sham-controlled trials can be conducted.

Massage is widely used for anxiety and has a strong record of success

In spite of the paucity of published research evidence, regular massage is a widely used technique in many cultures to treat chronic stress and anxiety and deserves serious consideration. Consistent anecdotal evidence, a long history of widespread use of massage for stress reduction, and positive findings of open trials support the view that regular massage therapy reduces the severity of chronic moderate anxiety in general, and specifically when anxiety is related to test-taking or problem-solving, work stress or the anticipation of invasive medical procedures.

In my own clinical experience working with patients who complain of chronic stress, test-taking stress and generalized anxiety, regular massage therapy effectively reduces anxiety, improves emotional resilience and enhances feelings of general well-being in anxious patients.

Few safety issues

Massage is safe when done by a trained therapist, seldom resulting in injuries. However, individuals who have chronic pain disorders or other medical conditions that involve the musculoskeletal system should consult with their physician before receiving regular massage therapy.

Regular Physical Activity Improves Anxiety

Psychological and physiological mechanisms are involved

The relationship between physical activity and anxiety is multi-factorial. Many hypotheses have been proposed to explain the anxiety reducing benefits of regular exercise. Psychological theories include distraction, enhanced self-efficacy, mastery and psychological benefits of regular social interaction. Physiological mechanisms include beneficial effects of regular exercise on the levels of several neurotransmitters that affect anxiety including serotonin, norepinephrine, dopamine and the endorphins.

Regular exercise alleviates chronic anxiety and may reduce the frequency and severity of panic attacks

Individuals who report chronic anxiety frequently engage in strenuous physical activity in efforts to alleviate their symptoms. Open studies suggest that both aerobic exercise and strength training improve anxiety when done on a regular basis (Paluska 2000). The beneficial effects of exercise are similar to those of meditation and regular relaxation. Acute onset anxiety generally responds better to exercise than long-standing symptoms of anxiety.

A work-out program consisting of at least 20 to 30 minutes of daily exercise can significantly reduce symptoms of generalized anxiety. Findings of a prospective 10 week study of exercise in individuals prone to panic attacks show that regular walking or jogging (4 miles three times a week) reduces the severity and frequency of panic attacks (Stevinson 1999).

Most studies on the effects of physical activity on anxiety have been done in healthy adults. Although some studies have been done in children, adolescents and the elderly more studies need to be done to determine the kind, intensity, frequency and duration of physical activity that are most effective in reducing anxiety in these age groups.

In my own 20+ year clinical practice I have observed that chronically anxious patients who follow a regular exercise program usually pay more attention to their health in general, and tend to respond more rapidly to both prescription medications and integrative treatments compared to patients who are not physically active.

Safety issues

Individuals in good health can engage in vigorous exercise with few limitations. However, individuals with heart disease, chronic pain, or other serious medical problems should consult with their physician before starting an exercise program.

To read more

To find out more about non-medication treatments for anxiety read my short e-book “Anxiety: The Integrative Mental Health Solution.”

Inositol: a promising treatment of panic disorder

Inositol: a promising treatment of panic disorder

Inositol has been the focus of renewed research interest because it is a necessary building block of phosphatidyl-inositol, a molecule in the brain that plays a central role in the functioning of receptors that bind with several neurotransmitters including serotonin, norepinephrine and others. Research findings support that inositol taken in doses up to 20 grams per day reduces the severity and frequency of panic attacks by interfering with a molecule called m-CPP. The potential role of inositol as a treatment of panic disorder is important in view of the fact that currently available prescription medications are effective in only two thirds of patients who report panic attacks, have adverse effects and may lead to dependence (e.g. benzodiazepines).

A one month double-blind placebo controlled study enrolling 20 patients concluded that inositol (up to 18g/day) and fluvoxamine (up to 150 milligrams per day) were equally effective in reducing the frequency of panic attacks (Palatnik 2001). The average number of weekly panic attacks in the group taking inositol decreased by 4, compared to an average decrease by 2 in the group treated with fluvoxamine.

Emerging research findings for inositol as a treatment of other anxiety disorders

Findings of several small double-blind placebo-controlled studies show that large doses of inositol improve different anxiety conditions that respond to serotonin reuptake inhibitors (SSRIs), including for example panic attacks, agoraphobia, and symptoms of obsessive-compulsive disorder. A 4-week double-blind crossover study concluded that inositol taken at a dose of 12 grams per day and imipramine, a prescription medication, are equally effective in reducing the frequency and severity of panic attacks and agoraphobia. Two small double-blind studies have been done on inositol for symptoms of obsessive-compulsive disorder (OCD). In one study patients taking inositol 18 grams per day showed significantly greater improvement compared to patients taking a placebo. In another small study, patients taking inositol 18 grams per day plus a placebo or a SSRI medication reported equivalent responses.

Small study sizes limit significance of findings

Although many studies report beneficial effects of inositol on panic disorder and other anxiety disorders, the significance of findings is limited by the small number of studies completed and the small size of studies. Large prospective placebo-controlled studies are needed to confirm the above findings and to clarify the most effective and appropriate dosing strategies of inositol for panic disorder, agoraphobia and obsessive-compulsive disorder.

Few adverse effects

Some individuals who take inositol report mild transient side effects. Serious adverse effects have not been reported at doses of inositol that are effective against panic attacks.

To learn more about natural supplements and other non-pharmacologic treatments of anxiety check out my book “Anxiety: The Integrative Mental Health Solution.” In

The amino acid 5-HTP is a natural, safe and effective treatment of anxiety

The brain needs L-tryptophan and 5-hydroxytryptophan (5-HTP) to manufacture serotonin

L-tryptophan and 5-HTP are widely used alternative treatments of generalized anxiety. Both amino acids are essential for manufacture of serotonin in the brain. Serotonin is a neurotransmitter that plays a central role in the regulation of mood and anxiety. Greater research evidence supporting the use of 5-HTP for anxiety, together with smaller effective doses and increased CNS availability generally make 5-HTP the preferred choice over L-tryptophan.

5-HTP reduces the severity of generalized anxiety  

More research has been done on 5-HTP than l-tryptophan. In a double-blind study, 58% of generally anxious patients (79 total subjects) randomized to L-tryptophan 3 grams per day reported significantly greater reduction in baseline anxiety compared to individuals who received a placebo. Both animal studies and human clinical trials show that 5-HTP has anti-anxiety effects. There is some evidence that 5-HTP may inhibit panic attacks induced by carbon dioxide.

Uses of 5-HTP in integrative psychiatry

In the rapidly growing field of integrative psychiatry prescription medications and natural supplements are often used in combination to improve treatment response and reduce side effects when medications are taken alone. 5-HTP is an example of a natural supplement that may be safely combined with a prescription anti-anxiety medication with little risk of adverse effects. In one study patients randomized to 5-HTP in combination with carbidoba (a drug that inhibits the enzyme that breaks down 5-HTP in the peripheral blood supply, thus increasing the amount of 5-HTP that enters the brain) reported reductions in anxiety comparable to patients treated with an anti-anxiety medication. In contrast, patients who received a placebo did not improve.

Starting 5-HTP at a low dose reduces the risk of side effects

Some individuals who take 5-HTP report daytime fatigue or sleepiness. There have been infrequent reports of mild serotonin syndrome, a condition caused by excessive brain serotonin associated with insomnia, agitation and nervousness. The risk of serotonin syndrome and other adverse effects is minimized when 5-HTP is started at low doses such as 25 milligrams per day and gradually increased over several weeks to a daily regimen that is well tolerated and produces beneficial anti-anxiety effects.

In over 20 years of experience as an integrative psychiatrist I have found that 5-HTP 50 milligrams to 100 milligrams taken three times a day is a safe and effective approach for chronic generalized anxiety that is well tolerated without excessive daytime sedation. 5-HTP may be taken alone or in combination with anti-anxiety medications.

Taking 5-HTP at bedtime improves sleep and reduces daytime anxiety

Gradually increasing a bedtime dose of 5-HTP from 50 milligrams to 200 to 300 milligrams over a period of 2 to 3 weeks often improves the quality of sleep in chronically anxious patients who complain of insomnia while also reducing the severity of daytime anxiety.

Finding a quality brand of 5-HTP

When considering taking 5-HTP or any natural supplement it is important to find a quality brand known to be both effective and safe. I do not recommend particular brands to my patients. However my website includes links to web resources that will help you identify quality brands.

Conventional Treatments of Anxiety Disorders: Benefits and Limitations

In this post I review the benefits and limitations of conventional treatments of anxiety disorders. Future posts in this series will discuss complementary and alternative approaches used to treat different anxiety disorders. 

Conventional treatments of anxiety

Cognitive-behavioral therapy (CBT), supportive psychotherapy, and psychopharmacology are widely used conventional treatments of anxiety. Double-blind studies have established the efficacy of prescription medications such as benzodiazepines and serotonin-selective reuptake inhibitors (SSRIs) in the short-term treatment of recurring panic attacks and generalized anxiety. Certain prescription drugs are effective treatments of social phobia, however there are no effective psychopharmacological treatments of specific phobias such as arachnophobia (i.e., ‘fear of spiders,), fear of flying or others. Behavioral therapies including graded exposure and flooding are beneficial in social anxiety and performance anxiety. The conventional treatment approaches of obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) rely on both psychotherapy and medications.

Limitations of conventional treatments

Conventional treatments of anxiety are often beneficial but also have significant limitations. A meta-analysis of high-quality studies concluded that the efficacy of conventional treatments varies widely depending on the core symptom being treated. Panic attacks tend to improve and remain improved in response to medications like lorazepam and clonazepam, but patients who use these medications or other benzodiazepines chronically to control panic symptoms are at significant risk of dependence and withdrawal. Most individuals with generalized anxiety initially have positive responses to conventional treatments but remain symptomatic over the long-term. Phobias, obsessions and compulsions, and symptoms of post-traumatic stress are often poorly responsive to conventional Western treatments. This is complicated by the fact that many patients who experience chronic anxiety are too impaired to seek treatment and frequently have other mental health problems such as depressed mood, sleep disturbances and substance abuse.

Inter-individual differences and no standard care model

In general, anxiety is difficult to treat because of significant inter-individual differences in the type and severity of symptoms and incomplete understanding of medical, psychological, social and cultural factors that cause or exacerbate anxiety symptoms. Finally, standards of care for the acutely or chronically anxious patient are difficult to achieve because of differences in training, experience and skill of conventionally trained mental health professionals.

To learn more about complementary and alternative treatments of anxiety check out my e-book, “Anxiety: The Integrative Mental Health Solution.” 

Preliminary findings on choline for bipolar disorder

Choline for bipolar disorder

This post is the 4th in a series on bipolar disorder. Previous posts briefly reviewed conventional pharmacologic treatments, uses of select amino acids and omega-3 fatty acids and a proprietary nutrient formula. This post reviews research findings of studies on the B vitamine choline in the treatment of bipolar disorder. 

Findings on choline and phosphatidylcholine in bipolar disorder 

Choline is a naturally occurring B vitamin necessary for the biosynthesis of the neurotransmitter acetylcholine (Ach). It has been postulated that abnormal low brain levels of acetylcholine cause some cases of mania. Findings of a small placebo-controlled trial suggest that phosphatidylcholine (15 g to 30 g/day) may reduce the severity of mania and depressed mood in bipolar patients. Case reports and case series suggest that choline reduces the severity of mania. 

In a small case study of treatment-refractory, rapid-cycling bipolar patients who were taking lithium, four out of six patients responded to the addition of 2000–7200 mg/day of free choline. It should be noted that two non-responders were also taking high doses of thyroid medication at the same time. Clinical improvement correlated with higher levels of choline in a part of the brain called the basal ganglia as measured using magnetic resonance imaging (MRI). The effect of choline on depressive symptoms in these patients was inconsistent. 

Case reports, open trials and one small double-blind study suggest that supplementation with phosphatidylcholine 15 g to 30 g/day reduces the severity of both mania and depressed mood in bipolar patients, and that symptoms recur when phosphatidylcholine is discontinued.

Choline and phosphatidylcholine are safe and generally well tolerated when taken at doses used to treat bipolar disorder.

Because of the limited number of studies and small study size, findings on choline and phosphatidylcholine in the treatment of bipolar disorder should be regarded as preliminary. 

To learn more about non-pharmacologic treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution” by Dr. Lake 

Select amino acids and Omega3s are beneficial and safe treatments of bipolar disorder

Integrative Management of Bipolar Disorder: Amino Acids and Omega-3s

This is the second post in a series on integrative management of bipolar disorder. Previous post reviewed conventional psychiatric management of bipolar disorder. The focus of this post is on amino acids and omega-3 essential fatty acids. Future posts will provide concise reviews of evidence for a range of non-pharmacologic treatments of this disorder. 

Amino acids have beneficial effects on depressed mood, anxiety and insomnia in bipolar patients.

Taking the amino acid L-tryptophan 2–3 gm/day or 5-hydroxytryptophan (5-HTP) 25 to 100 mg up to three times a day may have beneficial effects on anxiety associated with mania. L-tryptophan 2 gm can be safely added to mood stabilizers such as lithium and valproic acid at bedtime improving sleep quality in agitated manic patients. Doses of L-tryptophan as high as 15 gm may be required when insomnia is severe (although individuals who take doses this high should be closely monitored by a psychiatrist, and this dosage may be restricted in some countries). Research findings suggest that when added to sedating antidepressants (such as trazodone) taken at bedtime L-tryptophan 2 gm may accelerate antidepressant response and improve sleep quality. Serious adverse effects have not been reported using this protocol. The amino acid L-theanine, a natural constituent of green tea, reduces anxiety by increasing alpha activity and increasing synthesis of the inhibitory neurotransmitter GABA. Noticeable anxiety reduction is generally achieved within 30 to 40 minutes and effective doses range between 200 mg and 800 mg/day. There are no contraindications to taking L-theanine in combination with mood stabilizers. 

Omega-3 fatty acids are beneficial in the depressive phase but do not lessen symptoms of mania.

Countries where there is high fish consumption have relatively lower prevalence rates of bipolar disorder. In a systematic review of controlled trials on omega-3 fatty acids in bipolar disorder only one study was identified in which omega-3s were used adjunctively with a mood stabilizer. The combined treatment protocol resulted in a differential beneficial effect on depressive but not manic symptoms. The reviewers cautioned that any conclusions about the efficacy of omega-3 fatty acids in bipolar disorder must await larger controlled studies of improved methodological quality. Large doses of omega-3 fatty acids may be more effective in the depressive phase of the illness.

Some studies suggest that the omega-3 essential fatty acid ecosapentanoic acid (EPA) at doses between 1 and 4 gm/day may have enhance the effectiveness of atypical antipsychotics used to treat acute mania, however, one placebo-controlled trial failed to confirm an adjuvant effect. The appropriate management of a severely depressed bipolar patient might include a mood stabilizer, an antidepressant and omega-3 fatty acids. 

There are few safety issues.

Rare cases of increased bleeding times, but not increased risk of bleeding, have been reported in patients taking aspirin or anti-coagulants together with omega-3s.

To learn more about non-pharmacologic treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake MD.

Meditation and Mind-body practices for Treating ADHD

Non-pharmacologic treatments of ADHD

This is the 10th post in a series on complementary and alternative therapies for ADHD. This post comments on research highlights from studies on meditation and mind-body practices as treatments of ADHD. Previous posts briefly reviewed the evidence for a variety of non-pharmacologic treatments including herbals, EEG biofeedback, omega-3 fatty acids, dietary modification, acupuncture and others.

Study design problems and small study sizes make most findings inconclusive

In a systematic review of studies on meditation and mind-body practices (eg, yoga, tai-chi, qigong) as treatments of ADHD only four studies including a total of 83 participants met inclusion criteria for methodological rigor and size. Two studies evaluated mantra meditation and two studies compared yoga with conventional drugs, relaxation training, non-specific exercise or treatment as usual (i.e. stimulant medications and cognitive therapy). The authors reported that study design problems resulted in a high risk of bias in all studies and identified only one study that met criteria for formal analysis. In that small study (15 chlldren) the teacher rating ADHD scale failed to show significant outcome differences between the meditation group and the drug therapy group. The authors commented that small sample sizes of a few well designed studies and high risk of bias render current findings on meditation and mind-body techniques in the treatment of ADHD inconclusive.

Regular yoga practice may have an additive effect over medication alone

In a small pilot study ADHD children randomized to yoga experienced greater improvement over time compared to children who exercised. Children who continued on stimulants while practicing yoga experienced the greatest improvements. Two small controlled studies suggest that yoga and regular massage therapy may reduce the severity of ADHD symptoms.

Large well-designed studies are needed

Larger and better designed studies are needed to confirm beneficial effects of meditation and mind-body practices in individuals diagnosed with ADHD. To learn more about non-pharmacologic approaches to ADHD read my e-book ‘ADHD: The Integrative Mental Health Solution.”

The Effects of Dietary Modification on ADHD: A Concise Review

Inconsistent findings on food colorings and positive findings on highly restrictive diets

Many studies have investigated the effects of changes in diet on symptoms of ADHD. Research findings support that artificial food colorings do not contribute to ADHD however excluding food additives, sugar and certain food groups may reduce symptoms of hyperactivity in some cases.

Early studies on a restrictive diet that eliminates all processed foods reported promising findings in children with ADHD; however, a review of controlled studies failed to support these findings. Early studies suggested that artificial food colorings were associated with ADHD however a meta-analysis failed to confirm this. The oligoantigenic diet (OAD) is a highly restrictive multiple elimination diet that excludes food colorings and additives, in addition to dairy products, sugar, wheat, corn, citrus, eggs, soy, yeast, nuts and chocolate. Oligoantigenic diets permit a limited number of hypoallergenic foods, like lamb, chicken, potatoes, rice, banana, apple, cabbage, broccoli, Brussels sprouts, carrots, peas, pears and cucumber, as well as salt, pepper, calcium, and some vitamins. Studies involve several phases and require many weeks to complete. During phase I, which typically lasts 4 weeks, specific food items are withheld from the diet and the patient is monitored using standardised symptom rating scales. In cases where symptoms improve during the initial treatment phase, specific foods are gradually re-introduced in phase II. A third phase follows a placebo-controlled crossover design in which the patient is randomized to a food item that initially caused symptoms or an acceptable placebo for 1 week, followed by a washout period, and subsequently exposed to either placebo or a specific food item or additive for an additional week. Several studies on the OAD regimen reported significant reductions in hyperactivity in children diagnosed with ADHD when specific food items were eliminated from the diet using the above protocol. In all of these studies behavioral symptoms improved during the elimination and placebo phases and recurred when children were subsequently challenged with the eliminated food item following a blinded protocol. A recent meta-analysis of studies on restrictive diets in childhood ADHD including 14 open studies and six controlled trials concluded that roughly 1/3 of hyperactive children may benefit from some form of an elimination diet.

Large well-designed studies are needed to confirm benefits of dietary modification

Although these results are promising they cannot be used to develop general ADHD treatment protocols because of study design flaws, including heterogeneity of patient populations, absence of standardized outcome measures, high drop-out rates and, in some studies, non-blinded researchers. In the face of these promising findings the American Academy of Pediatrics does not endorse elimination diets because of inconsistent findings of efficacy and concerns that highly restrictive diets do not provide balanced nutrition. Parents who are considering restrictive diets should consult with a nutritionist and highly restrictive diets should not be continued longer than two weeks in the absence of noticeable improvements in ADHD symptoms.

To learn more about the role of nutrition and other non-pharmacologic treatments of ADHD read my e-book “Attention-Deficit Hyperactivity Disorder: The Integrative Mental Health Solution.”

Non-medication Therapies are Widely Used to Treat ADHD but Research Findings are Inconsistent

Many individuals diagnosed with ADHD use CAM therapies

Many individuals diagnosed with ADHD use alternative therapies alone or together with stimulants or other prescription medications. Growing concerns about inappropriate prescribing or over-prescribing by physicians of stimulant medications and incomplete understanding of risks associated with their long-term use have led to increasing acceptance of many complementary and alternative (CAM) therapies.

Surveys suggest that between 12 and 68% of children diagnosed with ADHD use CAM therapies largely out of parental concerns over safety of prescription medications. Over half of parents of children diagnosed with ADHD treat their children’s symptoms using one or more CAM therapies, including vitamins, dietary changes and expressive therapies, but few disclose this to their child’s pediatrician. However, when any herbal product or other natural supplement is used to treat ADHD it is regarded as the primary treatment over 80% of the time.

Uneven research findings support CAM treatments of ADHD

Most CAM therapies for ADHD are supported by limited research findings. However, a systematic review of clinical trials on herbal and nutritional interventions for ADHD found good support for zinc, iron, Pinus marinus (French maritime pine bark), and a Chinese herbal formula (Ningdong); and inconsistent findings for omega-3s, and l-acetyl carnitine. Limited findings from clinical trials on Bacopa monniera (brahmi) and Piper methysticum (kava) call for more research on these two herbals. The most appropriate CAM and integrative treatment strategies for ADHD depend on the subtype of ADHD that is being addressed, symptom severity, previous treatment outcomes using conventional pharmacologic treatments or CAM therapies, side effects, co-occurring psychiatric or medical problems, patient preferences, the availability of qualified CAM practitioners and access to reputable brands of specific natural supplements.

Future blog posts in this series will review the evidence for widely used CAM therapies used to treat ADHD. A concise review of non-pharmacologic CAM therapies used to treat symptoms of ADHD can be found in my e-book ‘Attention-deficit Hyperactivity Disorder: The Integrative Mental Health Solution.”