Convergent Points Volume 3 Issue 2

Generalized Anxiety Disorder and Related Conditions Treated with Acupuncture, A Case Report

By Bonnie Sweetland, DAOM, LAc

Introduction

Biomedical Perspective

Mental health issues include, but are not limited to, generalized anxiety disorder (GAD), panic disorder (PD), depression, and premenstrual dysphoric disorder (PMDD), each with distinct yet often overlapping features. These prevalent diagnoses, occurring singly or as comorbidities, can severely impair one's ability to carry out major life activities (Halbreich, 1995).

Individuals navigating GAD often face persistent fear, restlessness, and heightened physiological responses like increased heart rate and muscle tension, alongside related manifestations such as insomnia, nightmares, and disturbing thoughts (Chou et al., 2020). Similarly, PD brings recurring panic attacks, contributing to social impairment and exacerbating the overall symptom burden. Depression, a pervasive mental health condition, introduces persistent low mood, loss of interest or pleasure, and disruptions in sleep patterns (American Psychiatric Association, 2013). PMDD, classified as a depressive disorder in the DSM-5, involves cyclic psychological, cognitive, and somatic symptoms, leading to functional impairment within the late luteal phase of the menstrual cycle (Epperson et al., 2012; Rapkin & Winer, 2009). PMDD is frequently associated with anxiety and depressive disorder and encompasses emotional symptoms such as irritability and mood swings, extending its impact to the physical realm with symptoms like insomnia and fatigue (Adewuya et al., 2008; Pearlstein & Steiner, 2008).

The prevalence of these mental health diagnoses is considerable, with about 31% of individuals experiencing an anxiety disorder at some point in their lives, 3-8% of women of reproductive age experiencing mild to severe PMDD (Harvard Medical School, 2007; Borenstein et al., 2003), and an estimated 8.3% of all adults in the U.S. reporting at least one major depressive episode (National Institute of Mental Health, n.d.). This statistic underscores the widespread impact of such conditions on the global population. Moreover, the economic burden linked to these multifaceted mental health conditions, encompassing healthcare costs and reduced productivity, underscores the need for comprehensive and effective interventions (Ivandic et al., 2017).

First-line treatments for GAD, depression, PMDD, and panic attacks typically involve selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), with benzodiazepines/buspirone following suit. These pharmaceutical options carry significant safety risks that warrant a consideration of alternative therapies. Despite the widespread use of SSRIs and SNRIs, they are associated with various side effects, including weight gain, sexual dysfunction, insomnia, and gastrointestinal disturbances, which can impact patient adherence and quality of life (Serretti & Chiesa, 2011). Additionally, long-term use of SSRIs and SNRIs has been linked to withdrawal symptoms, sometimes referred to as antidepressant discontinuation syndrome, which includes dizziness, headaches, and flu-like symptoms, making it difficult for patients to discontinue use (Fava et al., 2018). Recent studies suggest that SSRIs may be associated with an increased risk of suicidal ideation in specific populations, particularly in young adults and adolescents (Bridge et al., 2007).

Benzodiazepines, while effective in reducing anxiety, carry a high risk of dependence and tolerance, leading to potential misuse and addiction (Baldwin et al., 2013). Long-term use of benzodiazepines is also associated with cognitive impairment, psychomotor slowing, and an increased risk of falls, particularly in older adults (Barker et al., 2004). Buspirone, though often considered safer than benzodiazepines due to its lower potential for dependence, may still cause side effects such as dizziness, nausea, and headaches, limiting its tolerability (Rickels et al., 1993). These risks highlight the need for alternative therapies, such as acupuncture and other non-pharmacological approaches, that can offer symptom relief without the burden of these adverse effects.

Psychotherapy, including cognitive behavioral therapy (CBT) or dialectical behavior therapy, may also be recommended to identify and address unhealthy beliefs and behaviors and foster healthier coping skills (Mayo Clinic, n.d.).

Traditional Chinese Medicine (TCM) Perspective

In TCM, addressing multifaceted mental health conditions like GAD, PMDD, depression, panic, and insomnia requires a nuanced understanding of various pattern diagnoses. Commonly encountered patterns often implicate the Liver, Heart, or both (Bayley et al., 2018). Symptoms tend to worsen when compounded by pathologies like heat or blood deficiency. Heat disturbs the shen and hun, while blood deficiency fails to stabilize and ground, contributing to symptom aggravation. Prolonged qi constraint obstructs the smooth flow of qi in the body and can hinder fluid movement, leading to the formation of phlegm. The pathology of Liver qi constraint leads to a predictable cascade of consequences (Figure 1).

Figure 1: Pathological relationships of Liver qi constraint (Maclean et al., 2018)

Accurate determination of presenting patterns is crucial for effective TCM treatment, as various patterns, such as Spleen qi deficiency and Liver overacting on the Spleen and Stomach, may contribute to emotional turbulence, insomnia, and nightmares, aligning with anxiety and PMDD (Pacific College of Oriental Medicine, 2014).

Current research provides a growing body of evidence supporting the efficacy of acupuncture, particularly in the management of anxiety, depression, and insomnia (Pilkington, 2010; Choi et al., 2014). Meta-analyses and systematic reviews consistently report positive clinical outcomes. Acupuncture is thought to regulate the nervous system, promoting emotional well-being and a calming effect (Chen et al., 2022). The theoretical framework is supported by clinical findings and modern neuroscience, which support acupuncture's role in memory consolidation and reconsolidation processes. Specifically, studies suggest that acupuncture may (a) balance sympathetic and parasympathetic nervous system activity, (b) reduce limbic system activation to induce calm, and (c) modify functional connectivity in key cortical regions, including the default-mode network (Assouline et al., 2022). Additionally, emerging research highlights acupuncture's potential to alleviate both emotional and physical symptoms in patients with PMDD (Gao et al., 2020).

This case report aims to explore the methods used, the challenges encountered during treatment, and the outcomes achieved in addressing the complex mental health symptoms experienced by one patient.

Case Description

This case report focuses on a 37-year-old female presenting with severe symptoms of generalized anxiety disorder (GAD), depression, and premenstrual dysphoric disorder (PMDD), with insomnia, nightmares, and panic attacks persisting for the preceding seven months. These symptoms significantly impacted her daily life. Heightened anxiety and panic attacks were particularly pronounced following stressful situations at work. During the premenstrual phase, PMDD symptoms intensified for about three days each month, occasionally leading to suicidal ideation. The patient had no prior diagnoses or significant health issues before the onset of this illness.

During the initial consultation, the patient appeared calm and articulate. However, psychological assessments, including validated scales (GAD-7, PHQ-SADS), confirmed the severity of her symptoms, indicating a significant impairment in mental health and quality of life (Bair et al., 2016). The GAD-7 is a widely used self-report measure to assess the severity of generalized anxiety disorder (GAD), and it categorizes scores into four severity levels: minimal (0-4), mild (5-9), moderate (10-14), and severe (15-21). The patient's initial score of 19 suggests that she was experiencing significant anxiety symptoms that may have impacted her daily functioning, including difficulty in controlling worry, restlessness, fatigue, trouble concentrating, irritability, muscle tension, and sleep disturbances. Such a score typically warrants clinical attention and therapeutic interventions (Spitzer et al., 2006).

The PHQ-9 is another widely used tool to assess the severity of depressive symptoms, with scores categorized into minimal (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27) depression. The patient’s initial score of 17 suggests that she was experiencing significant depressive symptoms, which may have included persistent sadness, loss of interest or pleasure in activities, fatigue, feelings of worthlessness, trouble concentrating, changes in appetite, and sleep disturbances. This level of severity typically warrants active treatment, such as psychotherapy, medication, or a combination of both, to prevent further deterioration of mental health and improve functioning (Kroenke et al., 2001).

The patient reported that her symptoms had substantial adverse effects on her daily functioning, including social interactions, work performance, and overall well-being. As an anesthesiologist in a hospital emergency room, she described high stress levels, exacerbated by the effects of violence and challenging interactions with colleagues. She reported taking extra time off work to go camping in the wilderness, which was the only thing that helped relieve her symptoms.

The patient underwent biomedical assessments with her primary care provider (PCP) to rule out organic causes. No abnormalities were revealed in routine blood tests, hormonal profiles, or imaging studies. She had not previously undergone psychiatric evaluation or treatment, expressing a preference for exploring complementary and alternative approaches before considering conventional medications. Traditional Chinese medicine (TCM) interventions, such as acupuncture and Chinese herbal medicine, were recommended and discussed as potential therapeutic options. Because of the patient’s preferences, following consultation with her PCP, acupuncture was the first treatment approach for her mental health symptoms.

TCM Diagnosis

Tongue evaluation showed thin, pale edges with a scalloped border in the anterior third, a red tip, and a thin yellow coat. Pulse assessment indicated a slightly rapid, thin-wiry pulse in the left central position (guan), with deep and weak qualities noted in other positions.

The TCM diagnosis comprised four interrelated patterns of disharmony, contributing to the patient's symptoms of depression, anxiety, insomnia, and emotional turbulence.

The first pattern identified was Liver qi constraint with heat, characterized by a rapid, wiry pulse detected in the left guan, along with symptoms of anger, agitation, depression, and mood swings. The slightly yellow coat on the tongue could have indicated heat in the Liver meridian.

The second pattern involved Heart qi constraint with heat harassing, characterized by a red tip of the tongue, a rapid pulse, and a yellow coating on the tongue. The patient experienced exacerbated anxiety and agitation, particularly in the evening or during times of stress, leading to insomnia.

Furthermore, Spleen qi deficiency was identified as another contributing factor to the patient's condition. This pattern was characterized by a marked lack of appetite, poor digestion, scallops on the front third of the tongue, and worry with unproductive circular thought processes.

Additionally, the diagnosis highlighted Liver blood deficiency, characterized by pale tongue edges and a low pulse amplitude, which was weak overall. Her PMDD exacerbated the Liver blood deficiency.

During the initial interview, the patient expressed feelings of detachment from herself and a loss of meaning in her life. She attributed this to her family's austerity and ideological inflexibility, which she felt had negatively impacted her ability to connect with her spirituality. She described feeling "adrift" and disconnected from her sense of purpose. Although these subjective experiences couldn't be quantified, they informed the decision to include the upper Kidney points in the treatment.

The treatment principles based on the TCM diagnosis were: regulate Liver qi, clear heat, calm shen and hun, tonify Spleen and Stomach, nourish blood, and restore spirit (Bayley et al., 2018).

Treatment

Acupuncture served as the primary intervention, initially scheduled twice weekly and later reduced to once weekly as symptoms improved. Treatment plans were adjusted based on the patient's evolving condition.

Acupuncture points were selected from different styles, including TCM, a variation of the auricular protocol from the National Acupuncture Detoxification Association (NADA), and upper Kidney channel points for their "spirit of the point" functions in Five Element acupuncture (see Table 2.) (Jarrett, 1998; Black, 2002).

Techniques and Methods

As tonification, reduction, and neutral stimulation methods can vary significantly within TCM applications, the specific methods used in this case will be defined for clarity.

Tonification involved slow needle insertion in the direction of channel flow as the patient exhaled. The needle was rotated rapidly and forcefully clockwise. On removal, it was swiftly extracted, and the insertion site was covered.

The reducing method entailed rapid needle insertion against the direction of channel flow while the patient inhaled. The needle was swiftly rotated counterclockwise. Withdrawal was conducted slowly, leaving the insertion site uncovered.

Neutral technique involved tapping the needle perpendicular to the body's surface, inserting it to the required depth, and refraining from rotation.

Deqi, the sensation signaling the arrival of qi at the acupuncture point, was elicited using both the tonification and reducing methods outlined earlier. The patient may interpret this sensation as a heavy, achy feeling, or the practitioner may interpret it as the needle's response to stimulation.

Treatment Record

The core point prescription used in each session is detailed below.

Table 1: Core point prescriptions

(Maclean et al., 2018; Deadman et al., 2001)

In addition to the core point prescription listed above, additional points and point combinations were added to enhance therapeutic value (e.g., entry/exit blocks, spirit of the points, and extra points to address acute concerns). These are listed below for each treatment session.

Table 2: Additional acupoints and spirit of the point functions

(Maclean et al., 2018; Deadman et al., 2001)

Outcomes and Discussion

One of the strengths of this case report was the use of validated instruments: the GAD-7, a widely accepted measure of anxiety, and the PHQ-SADS, which screens for somatic, anxiety, and depressive symptoms. Below is a comparison of the patient’s scores before and after treatment.

Figure 2. GAD-7 and PHQ-SADS Scores Before and After Acupuncture

As promising as the outcome of this case may be, it is important to acknowledge several limitations. First, the patient's symptoms of GAD and PMDD had only developed within the past seven months, raising the possibility that spontaneous remission could have occurred without treatment. Additionally, the application of multiple acupuncture modalities—TCM point prescriptions, the NADA protocol, and the Five Element concept of the spirit of the points—makes it difficult to determine which specific modality was most effective or whether the combination of all three was necessary for the observed improvements. The uniqueness of this case lies in the rapid and profound reduction of symptoms, potentially attributable to the integration of these acupuncture approaches. While existing literature supports the moderate benefits of acupuncture for conditions such as GAD and PMDD, research on the use of spirit of the points in these contexts remains limited (Jang et al., 2014; Yang et al., 2021).

Despite these limitations, the case provides a compelling illustration of acupuncture's potential effectiveness, particularly when a combination of TCM, NADA, and spirit of the points modalities is utilized to address GAD and its associated mental health symptoms. Notably, a follow-up assessment conducted three years post-treatment (with no additional interventions) revealed that the patient continued to do well, reporting a GAD-7 score of 3 and a PHQ-9 score of 3. The patient also described the acupuncture treatments as life-changing, further reinforcing the long-term benefits observed in this case.

Conclusion

In conclusion, this case report highlights a positive outcome of acupuncture in treating mental health conditions such as GAD and PMDD, suggesting its potential as a complementary treatment option. Acupuncture's holistic approach addresses the multifaceted nature of mental health disorders by considering the interplay of various patterns and symptoms. However, while the results in this case are promising, they cannot be generalized to a broader population. Further research, including larger studies and clinical trials, is necessary to validate the therapeutic effectiveness of acupuncture across diverse patient populations. Understanding the mechanisms behind these outcomes and refining treatment protocols will be critical in determining acupuncture's broader applicability in mental health care.

Informed Consent and Safety

The patient provided written informed consent for the publication of this case report, and a copy is on file with the author. There were minimal safety concerns during treatment, and no adverse events were reported.

References