Dealing with anxiety: Some tips from Traditional Chinese Medicine

by Dr John McDonald, PhD

Anxiety can be very uncomfortable, even excruciating and paralysing, but Traditional Chinese Medicine has developed some strategies which might help.

The Yellow Emperor’s Classic of Internal Medicine was a Chinese medical classic written more than two thousand years ago. This classic introduced the theory of Five Elements – Wood, Fire, Earth, Metal and Water. The Five Elements harmonise with each other through the Generating cycle (Sheng cycle) and the Constraining cycle (Ke cycle).

Wood generates Fire, Fire generates Earth, Earth generates Metal, Metal generates Water, Water generates Wood.

Wood constrains Earth, Earth constrains Water, Water constrains Fire, Fire constrains Metal, Metal constrains Wood.

The Yellow Emperor’s Classic also associated a particular emotion with each element – Anger with Wood, Joy with Fire, Reflection with Earth, Grief with Metal and Fear with Water. The Generating and Constraining relationships could also be applied to the emotions.

Anger generates Joy, Joy generates Reflection, Reflection generates Grief, Grief generates Fear, Fear generates Anger.

Anger constrains Reflection, Reflection constrains Fear, Fear constrains Joy, Joy constrains Grief, Grief constrains Anger.

The Five Element relationships between the emotions was used as the basis for a therapy by 12th Century Chinese doctor, Zhang Congzheng. By creating specific emotions, he reasoned that this could generate or constrain other emotions. Among his case histories he recounts stories of making an emperor laugh with a comedy performance to break through excessive grief, and provoking anger to break through excessive reflection. According to Zhang, the Constraining emotion should be used to produce a short-term effect but for long term resolution, the Generating emotion should be the focus.

So how can this be applied to dealing with anxiety? There are several strategies suggested by this model.

Reflection constrains fear

Fear is not just a feeling. It is whole body experience. When we experience fear, a physiological alarm goes off. Our breathing changes, our heart beats faster and a surge of adrenalin prepares us for fight or flight. But are we reacting to a real danger, or is it just a perception of danger? Let’s take a scenario of running late for work on a train. We become anxious and our breathing and heart rate change. So how big a danger are we really facing here? Let us reflect for a moment. Are we about to die? No. Suffer serious injury? No. Will our boss physically attack us when we arrive late to work? Probably not. Will our boss be verbally abusive and humiliate us in front of the other staff? Probably not. Will we be fired on the spot? Very unlikely. We arrive at work to find that the boss has not yet arrived. His train was delayed too. Then we wonder why we agonised through that entire train journey over a threat which was not real. Reflection can be useful to assess just how much danger we are really in at any given moment.

Joy constrains grief, which generates fear

Laughter helps to move us out of grief, even if only temporarily. These days comedy is not hard to find and by choosing to watch comedy rather than horror or drama, we can constrain grief, which in turn will then not generate fear. A good sense of humour and a hearty laugh can help to move us out of anxiety.

Grief generates fear

When fear is a longstanding issue for us, Zhang recommended that we focus on dealing with our sense of loss. Fear is generated by what we fear to lose. When we have nothing to lose we have nothing to fear. This is a process which could take a long time, but there is no rush.

Create tranquility – breathe

The opposite of fear is tranquillity. When we are tranquil and serene, anxiety simply does not arise. The opposite of “fight or flight” is “rest and digest”. When the sympathetic nervous system is triggered this creates the adrenal rush of “fight or flight”. The parasympathetic nervous system, when activated, inhibits the sympathetic nervous system and switches off the alarm – the emergency is past; everything is fine. This is called the “rest and digest” state. So how do we switch off the alarm? The key is to deliberately change our breathing. When our breath is rapid and shallow, our body will believe we are in danger, even if the emergency is running late for work, as opposed to being in fear of our lives. Our sympathetic nervous system cannot tell the difference between real danger and anxiety. The way to switch off the alarm is to breathe like we are perfectly safe – slowly and deeply. This could be meditation, yoga or Tai Ji Quan but it does not need to be. We can also achieve the same result by singing or physical activity (dancing, walking, swimming, exercise) as they all change our breathing. Physical activity also helps by burning off the arenalin that our body helpfully provided us with to help us outrun whatever was chasing us.

REFLECT    LAUGH    BREATHE

Acupuncture clinical trials exceed 9,000

The number of clinical trials investigating acupuncture’s effectiveness and efficacy have now surpassed 9,000 in the Cochrane Register of Clinical Trials. This compares favourably with the number of trials for other Allied Health professions such as physiotherapy and chiropractic, but is unsurprisingly exceeded by nursing research.

Allied Health Cochrane trials Jan 2018

There are also now 115 Cochrane systematic reviews which include acupuncture among other interventions, of which 45 are dedicated solely to acupuncture. There are also an additional 381 systematic reviews on acupuncture published by other reviewers.

Cochrane reviews Jan 2018

Acupuncture: the evidence

The Acupuncture Evidence Project: New review finds mounting evidence

In a new review of acupuncture research, Australian researchers have found that the quality of evidence and the number of conditions for which acupuncture has been shown to be effective has increased significantly since the last major review published by the US Veterans Affairs Department in 2014.

In a project funded by the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA), researcher Dr John McDonald PhD and Stephen Janz reviewed all the systematic reviews of acupuncture published between March 2013, the cut-off date for the US Veterans Affairs ‘Evidence Map of Acupuncture’, and September 2016. A total of 136 systematic reviews, including 27 Cochrane systematic reviews, were included in this review, along with three network meta-analyses, nine reviews of reviews and 20 other reviews. In total over 8,000 randomised controlled trials of acupuncture have now been published and over 1,000 of these were included in the systematic reviews examined. In all, 122 conditions were reviewed.

In the Evidence Map of Acupuncture only three conditions reached the highest level of evidence – ‘Evidence of Positive Effect’. However, that number has risen to eight conditions in the new review: allergic rhinitis; chronic low back pain; migraine prevention; chronic tension-type headache; knee osteoarthritis; post-operative nausea and vomiting; post-operative pain; and chemotherapy-induced nausea and vomiting (CINV).

A further 38 conditions are now graded as ‘Evidence of Potential Positive Effect’ compared to 20 conditions in the 2014 Evidence Map. There was either low quality evidence or conflicting evidence for 71 more conditions categorised as ‘Unclear/ Insufficient evidence’. Only five conditions were found to have ‘No evidence of effect’. In total positive results were found at various levels of evidence for 117 conditions. It is clear that the research effort in acupuncture is accelerating and that many new conditions are now being studied for the first time. The other emerging trend is that researchers are becoming more specific in their research focus. What was once reviewed as just ‘cancer adverse effects’ has now been separated into a dozen different conditions including cancer pain, cancer-related insomnia, cancer-related fatigue, chemotherapy-induced nausea and vomiting.

Where studies on safety or cost-effectiveness of acupuncture were available, these results have been included in the review. Overall, acupuncture was found to safe in the hands of well-trained practitioners, and acupuncture was specifically shown to be safe in treatment of low back pain, migraine, osteoarthritis of the knee, depression, allergic rhinitis, prostatitis pain/chronic pelvic pain syndrome, ambulatory anaesthesia, Alzheimer’s disease and cancer-related psychological symptoms. Studies also showed acupuncture to be cost-effective for low back pain, migraine, headache, chronic pain, neck pain, post-operative nausea and vomiting, osteoarthritis, allergic rhinitis, depression, dysmenorrhoea, ambulatory anaesthesia.

Acupuncture is now recommended by many clinical practice guidelines. By November 2018, 4,552 recommendations for acupuncture were identified for over 300 conditions from multiple international groups and over 30 countries. Examples include:

  • Non-invasive Treatments for Acute, Sub-acute and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians 2017
  • Acute Pain Management: Scientific Evidence published by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine in 2015
  • Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace published by The University of New South Wales in 2013
  • Consensus Guidelines for the Management of Postoperative Nausea and Vomiting published in USA by the Society for Ambulatory Anesthesia in 2014
  • Clinical Practice Guidelines For Allergic Rhinitis published by the Otolaryngology Head Neck Surgery Foundation’s in 2015
  • The National Institute for Health and Care Excellence (NICE), UK for migraine and tension type headache in 2012
  • Guideline for the Management of Chronic Pain published by The Scottish Intercollegiate Guidelines Network in 2013
  • Clinical Practice Guidelines for Breast Cancer Treatment published by The National German Gynaecologic Oncology Association’s (Arbeitsgemeinschaft Gynakologische Onkologie) in 2015.

This review reflects the current state of evidence from research, but is not a definition of acupuncture’s scope of practice. When research attempts to validate traditional medical practices which have a history of over two millennia, it takes a great deal of time, research effort and funding to fully explore acupuncture’s scope of practice as it is described anecdotally in the historical literature, which includes thousands of clinical acupuncture books dating from the pre-Christian era to the present day.

What is clear is that the evidence for the effectiveness, safety and cost-effectiveness of acupuncture is growing rapidly.

The Acupuncture Evidence Project by Dr John McDonald, PhD and Stephen Janz was commissioned and funded by the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA).

A plain language summary https://www.acupuncture.org.au/wp-content/uploads/2017/04/Acupuncture-Evidence_plain-English-Web-version_17_Feb.pdf and the full document (81 pages) https://www.acupuncture.org.au/wp-content/uploads/2017/11/28-NOV-The-Acupuncture-Evidence-Project_Mcdonald-and-Janz_-REISSUED_28_Nov.pdf is available from the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA): http://www.acupuncture.org.au.

McDonald J, Janz S. The Acupuncture Evidence Project: A Comparative Literature Review (Revised edition). Brisbane: Australian Acupuncture and Chinese Medicine Association Ltd; 2017.

Acupuncture alleviates symptoms of allergic rhinitis (hay fever) by creating lasting modulation of the immune system

The full results of our study have now been published in the Annals of Allergy, Asthma and Immunology and Australian Doctor has also reported on our paper.

The purpose of the study, which was conducted at Southport Acupuncture Clinic, Queensland Allergy Services Allergy and Griffith University, was to investigate how the immune system changes in response to acupuncture when treating allergic rhinitis.

The study was funded by the National Health and Medical Research Council and all acupuncture needles for the study were generously donated by Helio Supply Company (Sydney).

I would like to thank all of the 151 allergic and 20 non-allergic volunteers who participated in the study, and all of the research team. Prof Allan Cripps (Pro-Vice-Chancellor Health at Griffith University), Prof Pete Smith (Allergy Specialist and Griffith Professor) and Prof Charlie Xue (Head of Health Sciences at RMIT) were my three supervisors and Associate Professor Caroline Smith (Western Sydney University) and Associate Professor Brenda Golianu (Stanford University) completed our team. I have been most fortunate to have the opportunity, as a first-time researcher, to work with such a wonderful team of people, and to be able to investigate how acupuncture works, a question which has always fascinated me. This study formed the basis of my thesis for Doctor of Philosophy which was awarded on 16th April 2015.

So what did we learn from this study? Firstly, we did see clear evidence that the immune system changes in response to acupuncture and that symptoms continued to improve four weeks after the treatment ceased. In other studies, this improvement has been shown to last for 3 months, and but even at 6 months, although symptoms were starting to deteriorate slightly, they were still much better than before treatment. In clinical practice, a “top up” short course of treatment is therefore recommended if symptoms begin to recur after 3 months.

The symptoms which improved most were nasal congestion, runny nose, sneezing, nasal itch, eye itch and unrefreshed sleep. Post-nasal drip and sinus pain did not improve.

Based on the observation from past studies that all of the studies which used less than 12 treatments and treated less than twice weekly had produced poor or mixed results, whereas all of the studies providing 12 treatments or more, at least twice weekly had been very successful, our study treated twice weekly for 8 weeks. A previous study at RMIT in Melbourne by Prof Charlie Xue and colleagues used twice weekly treatments for 8 weeks rather than 6 weeks so we decided to use the same regimen.

Of those who received real acupuncture in the study, 86.1% of participants showed significant improvements in symptoms and quality of life. Other studies have reported responder rates between 84.6% and 95.8%. Acupuncture treatment has been shown to be very safe with total minor adverse events rate in this study (such as transitory pain on needle insertion or slight bruising) of 3%. Other studies have reported adverse events rates from 0.15% to 4.2%.

In April 2015, the American Academy of Otolaryngology Head and Neck Surgery Foundation updated their Clinical Practice Guidelines for allergic rhinitis in which they recommended acupuncture as a treatment option for patients preferring a non-pharmacologic therapy.

A study in Germany found acupuncture is also cost-effective as a treatment for allergic rhinitis (Witt et al, 2009).

So, in a nutshell, acupuncture is a safe, effective and cost-effective treatment for allergic rhinitis which produces lasting changes in the immune system and hence improvements in symptoms and quality of life.

Dr John McDonald, PhD

McDonald, J.L., Cripps, A.W., Smith, P.K., Smith, C.A., Xue, C.C. & Golianu, B. (2016) Effect of acupuncture on house dust mite specific IgE, substance P, and symptoms in persistent allergic rhinitis Annals of Allergy, Asthma & Immunology (116),6: 497–505

http://dx.doi.org/10.1016/j.anai.2016.04.002

McDonald, J.L., Cripps, A.W., Smith, P.K., Smith, C.A., Xue, C.C. & Golianu, B. (2013) The Anti-inflammatory Effects of Acupuncture and Their Relevance to Allergic Rhinitis: A Narrative Review and Proposed Model. Evidence-Based Complementary and Alternative Medicine, Vol 2013, Article ID 591796.

http://www.hindawi.com/journals/ecam/2013/591796/

McDonald, J.L., Cripps, A.W., Smith, P.K. (2015) Mediators, Receptors and Signalling Pathways in the Anti-Inflammatory and Antihyperalgesic Effects of Acupuncture. Evidence-Based Complementary and Alternative Medicine, Vol 2015, Article ID 975632.

http://www.hindawi.com/journals/ecam/2015/975632/

Acupuncture and the “Opioid Epidemic”

The Centres for Disease Control (CDC) in the USA recently called for submissions on their draft revised prescribing guidelines for opioid medications. This was in response to what has been described by the Journal of the American Medical Association as “The Opioid Epidemic” with prescribed opioid medications accounting for more deaths in the US than any illegal drug. The Acupuncture Now Foundation joined with the American Society of Acupuncturists to form the Joint Acupuncture Opioid Task Force which lodged a submission in the CDC process. The main points in the submission were:

  1. Acupuncture is an effective, safe and cost-effective treatment for various types of pain. Acupuncture should be recommended for the treatment of pain before opiates are prescribed.
  1. Acupuncture analgesic mechanisms have been extensively researched and include the production and release of endogenous opioids.
  1. Acupuncture is effective for the treatment of chronic pain involving adverse neuroplasticity.
  1. Acupuncture is a useful adjunctive therapy in opiate dependency and rehabilitation.

The full text of the submission can be found at:

https://acupuncturenowfoundation.org/opioid-epidemic-campaign

Two White Papers regarding the potential role of acupuncture in the opioid crisis have recently been sent to the FDA (Food and Drug Administration) in the US. One was written for the Acupuncture Now Foundation (ANF) by Matthew Bauer and John McDonald, and the second White Paper was a collaboration between ANF and several acupuncture organisations including the American Society of Acupuncturists.

ANF White paper on Acupuncture’s role in solving the opioid epidemic

The second White Paper has recently been published in the Journal of Integrative Medicine.

The potential role of acupuncture in the opioid crisis

The original version can also be downloaded free from the American Society of Acupuncturists website