Anxiety Non-pharmacologic Management

1. See Also
   1. Anxiety Pharmacologic Management
   2. Anxiety Disorder
   3. Anxiety Secondary Cause
   4. Anxiety Symptoms
   5. Generalized Anxiety Disorder
   6. Obsessive Compulsive Disorder
   7. Body Dysmorphic Disorder
   8. Panic Disorder
   9. Social Anxiety Disorder (Social Phobia)
   10. Acute Stress Disorder
   11. Post-Traumatic Stress Disorder
   12. Excessive Worry
   13. Anxiety Non-pharmacologic Management
2. Management: General
   1. Offer Reassurance
      1. Not a serious physical disease
      2. Not insanity
      3. Not a sign of weakness or failure
      4. Not childishness or overdependency
      5. Not life-threatening
   2. Encourage Acceptance of anxiety as a life-long problem
      1. Innate response with years of reinforcement
      2. Complete calm always is unrealistic goal
   3. Set Goals for Therapy
      1. Decrease level of anxiety and maintain at low level
      2. Modulate future symptom responses
      3. Increase functioning
3. Management: Lifestyle Modification
   1. Daily Physical Exercise (e.g. Walking, Tennis, Aerobics, Bicycling)
      1. Likely effective, although less than with Major Depression, and with inadequate evidence to date
      2. Jayakody (2014) Br J Sports Med 48(3): 187-96 [PubMed]
      3. Stonerock (2015) Ann Behav Med 49(4): 542-6 [PubMed]
   2. Improve sleep quality
      1. Establish good Sleep Hygiene
   3. Consider new hobbies
   4. Avoid harmful intakes (See Anxiety Secondary Causes)
      1. Avoid Alcohol use
      2. Avoid Tobacco use
      3. Avoid Caffeine
      4. Avoid Substance Abuse
4. Management: Psychotherapy
   1. Background
      1. Optimal effects are after 8 weeks of weekly sessions
      2. As effective as medication for the treatment of Generalized Anxiety Disorder and Panic Disorder
   2. Goals
      1. Increase self confidence
      2. Increase self control
      3. Promote emotional growth
   3. Specific areas of education
      1. Teach coping skills and Conflict Resolution
      2. Encourage patient to express themselves
   4. Practice goal directed behavior
      1. Redirect energy and creativity
      2. Identify a new source of fulfillment
   5. Cognitive Behavioral Therapy
      1. Systematic Desensitization with exposure therapy (most effective single measure)
      2. Recognize, Reexamine and replace anxious thoughts
5. Management: Mindfulness and relaxation
   1. See Relaxation Training
   2. Mindfulness-based Interventions (including stress reduction)
      1. Appears effective, but variable benefit in studies to date
      2. Goldberg (2018) Clin Psychol Rev 59:52-60 [PubMed]
      3. Khoury (2013) Clin Psychol Rev 33(6): 763-71 [PubMed]
   3. Progressive Muscle Relaxation
   4. Relaxation Training
      1. Meditation
      2. Yoga
         1. Likely offers benefit, but effects appear small, adjunctive
         2. Hoffman (2016) J Evid Based Med 9(3):116-24 [PubMed]
      3. Self-Hypnosis
      4. Tai Chi
         1. Effective in older adults with anxiety (symptom control with less relapse)
         2. Song (2014) J Physiol Pathophysiol Pharmacol 6(1): 55-60 [PubMed]
   5. Biofeedback
   6. Breathing retraining (arousal reduction)
      1. Take a deep breath
      2. Let breath out through pursed lips
6. Management: Measures to Avoid
   1. Virtual Reality Exposure Therapy does not appear effective and should not be used as therapy for GAD
      1. Hungenberg (2021) Am Fam Physician 104(6): 638-40 [PubMed]
      2. Wechsler (2019) Front Psychol 10: 1758 +PMID: 31551840 [PubMed]
7. References
   1. Saeed (2019) Am Fam Physician 99(10): 620-7 [PubMed]