How Do You Treat Panic Disorder in Your Practice?

According to World Health Organization estimates, 301 million people worldwide were living with anxiety disorders as of 2019.¹ Reports suggest an encouraging trend in the use of complementary and alternative medicine (CAM) therapies among these patients. This encompasses a wide variety of nonmainstream therapies. Acupuncture is one of the popular CAM modalities used across the globe to manage panic disorders.

In India, acupuncture is being practiced as an add-on therapy to yoga and naturopathy, one of the indigenous systems under the Ministry of Ayush, Government of India.² In our 125-bed inpatient setting at Sant Hirdaram Yoga and Nature Cure Medical College Hospital (in Bhopal, India), on average, we have visits of 5000 patients per year, among whom 8%–10% suffer from panic disorder.

We have an exclusive integrative mind–body medicine department, where we use a protocol that includes breathing techniques, therapeutic sun exposure, dietary modifications, and Traditional Chinese Medicine (TCM) to treat patients with panic disorders. In our clinical setup, the patient usually stays for 10 days and undergoes the integrative mind–body protocol.

Acupuncture

In TCM, panic disorder is classified as an emotional illness. Doctors frequently use the term palpitation, which can be brought on by the body's deficiencies, the seven emotions, pathologic alterations in the internal organs, and pathogenic disturbances of Phlegm and Blood Stasis. The Heart, Liver, Gall Bladder, Kidney, and Spleen are all directly associated with the illness. The clinical signs are complicated and intricately connected. This illness results from Spleen Deficiency and Liver Stagnation, which disturb the Heart with Phlegm–Heat.³

PC-6, TE-5 (to Open the Gates), HT-7 (to Quiet the Spirit and nourish the Heart Yin and Blood), LR-3 (to promote the free flow of Qi), LI-4 (to regulate Blood flow), KI-4 (to Clear the Fear or Phobia), GV-20, and Ex-2/M-HN-3 (Yintang; to Calm the Spirit) are the common acupuncture points we use in our practice, which are selected based on the work of Aung et al. on TCM and psychiatric disorders.⁴ Additional points are selected based on the patient's comorbidities and symptoms. These points are needled for 10 consecutive days, 30 minutes/day, with 1.5 t-sun stainless-steel needles. The treatment may also be repeated after 15–20 days, depending on the patient's needs.

Therapeutic Sun Exposure

Sun-avoidance habits significantly raise the risk of developing generalized anxiety disorder. Vitamin D deficiency has been linked to a variety of behavioral and mental illnesses, including anxiety. As a part of our protocol, we prescribe 20 minutes of direct sun exposure to the patients with minimal clothing between 10 am and 3 pm daily. The sun is thought to be the main source of vitamin D synthesis, a necessary neurosteroid hormone involved in brain development, neuroplasticity, and neuroimmunomodulation, all of which affect mood regulation indirectly.⁴

Diet Therapy

Diet therapy is an integral part of our protocol for panic disorders. We prescribe a naturopathic diet plan that provides 1000–1200 kcal daily. This includes:

• Breakfast—100 mL of herbal tea (≈ 80 kcal), followed by 200 mL of green juice (≈ 90.2 kcal)

• Lunch—60 g of multigrain roti, 100 g of vegetables, 100 g of salad, and 70 mL of curd (≈ 500 kcal)

• Evening—80 g of seasonal fruit (≈ 150 kcal)

• Dinner—200 g of mixed vegetable khichadi/daliya; 30 g of green chutney, and 100 mL of vegetable soup (≈ 450 kcal).

A diet with low calories, high protein, complex carbohydrates, low saturated fats, and fiber-rich foods balances serotonin, dopamine, and γ-aminobutyric acid (GABA) levels, which are the important neurotransmitters that help reduce anxiety. Consumption of tryptophan; vitamin D-, C-, and E-rich foods; omega-3– and omega-6–fatty-acid foods; selenium-rich foods; anti-inflammatory foods; and some phytochemicals, such as curcumin, quercetin, and resveratrol, have also been found helpful for reducing anxiety symptoms of. Patients are also advised to avoid high-fat diets, refined carbohydrates, artificial sweeteners, and high-glycemic foods, which are thought to aggravate the symptoms.⁵

Pranayama (Breathing Techniques)

Our protocol also includes selected breathing techniques such as bhastrika (bellows breath), kapalbhati (skull shining breath), bahya pranayama (external breathing), anulom-vilom (alternate nostril breathing), bhramari (honey bee breathing), and pranav pranayama (meditation of AUM with breathing). These breathing techniques are practiced by the patients for 20–25 minutes daily under supervision.

Practicing pranayama has been shown to increase self-control, boost mood, and reduce stress and anxiety. The solitary nucleus, thalamus, limbic regions, prefrontal cortex, and linkages between peripheral sensory organs are thought to be involved in the psychobiologic mechanism through which pranayama produces its effects. Furthermore, pranayama practice is postulated to induce parasympathetic dominance, which modulates the release of stress hormones and enhances GABA inhibition from the prefrontal cortex and insula to the amygdala, reducing its activity as well as the psychologic and physical symptoms of stress.⁶

Thus, a combined protocol of acupuncture, naturopathy, and yoga can be integrated effectively as a mind–body tool to manage panic disorders.

Deepika Singh, BNYS, MD,¹ Mamta Jagwani, BNYS, MD,¹

Gita Sharma, BNYS, MD,¹ Hemanshu Sharma, BNYS, MPH,²

Gulab Rai Tewani, BNYS,^3,4 and Pradeep M.K. Nair, BNYS, MSc, PhD⁴

¹Department of Acupuncture and Energy Medicine

²Department of Community Medicine

³Chief Medical Officer, and ⁴Department of Research

Sant Hirdaram Medical College of Naturopathy

and Yogic Sciences for Women

Bhopal

India

Address correspondence to:

Dr. Pradeep MK Nair

Professor & Head

Department of Research

Sant Hirdaram Medical College of Naturopathy & Yogic Sciences for Women

Lake Road, Sant Hirdaram Nagar

Bhopal 462020

India

E-mail: drpradeep18bnys@gmail.com

Panic Disorder is an anxiety disorder characterized by recurrent and unexpected panic attacks.¹ A panic attack is a sudden onset of intense fear or discomfort that reaches a peak within minutes and is accompanied by physical symptoms, such as a pounding or racing heart, sweating, dyspnea, weakness or dizziness, feeling hot or cold chills, tingling or numbness in the hands, chest pain or stomach pain. Panic attacks can be very frightening and can interfere with daily activities and quality of life.²

People with panic disorder often experience significant distress and disruption in their daily lives, as these patients may worry about having a panic attack at any time and may go to great lengths to avoid situations or activities that they associate with panic attacks. This can lead to social isolation, job loss, and other physical or mentally negative outcomes.³

Clinically, many practitioners choose acupoints targeted to calming the Mind, refreshing the Brain, and opening the Orifices, soothing the Liver, and strengthening the Spleen. These points may include:⁴

• (1)HT-7—Located on the wrist, this point is said to calm the Mind and reduce anxiety.
• (2)PC-6—Located on the inner forearm, this point helps regulate the Heart and reduces symptoms of anxiety or panic.
• (3)LR-3—Located on top of the foot, this point is said to help reduce stress and promote relaxation.
• (4)KI-6—Located on the inside of the ankle, this point regulates the nervous system and reduces anxiety.
• (5)CV-17—Located in the center of the chest, this point helps calm the mind and alleviate anxiety.
• (6)LU-1—Located on the chest, ∼1 cun below the collarbone and to the side of the breastbone, this point helps regulate breathing and reduces anxiety.

Illustrative Case

A 23-year-old female, Master's degree student, had a chief complaint of recurrent and unexpected panic attacks.

She presented to psychiatric specialists about the attacks, which had been occurring for the prior 5 months. The attacks were characterized by sudden-onset intense fear, palpitations, chest pain, shortness of breath, and a feeling of impending doom. The episodes lasted for ∼10 minutes and would often occur at random times, including during writing her final-year thesis, and study meetings, or even while she was relaxing at home. She reported that these episodes had a significant impact on her daily life, leading her to avoid certain situations for fear of having another panic attack. This patient had no significant medical history and was not taking any medications. She denied any history of substance abuse or poor mental conditions in her family. Her physical examination was unremarkable, and she appeared to be in good physical health.

This woman's psychiatric specialist evaluated her and diagnosed her with panic disorder, based on the Diagnostic and Statistical Manual of Mental Disorders, 5th ed.)⁵ criteria. She was started on a selective-serotonin reuptake inhibitor (SSRI) antidepressant and was given psychoeducation about panic disorder. In addition, her psychiatric specialist referred her for acupuncture treatments to address her symptoms and manage her panic attacks.

The acupuncture points selected were HT-7, PC-6, LR-3, and GV-20. Acupuncture was performed 2 times per week, for a total of 20 times with acupuncture needles 0.25 mm in diameter and 45 mm in length (Hansol, Korea). The patient reported a significant reduction in the frequency and severity of her panic attacks, with only a few mild episodes occurring occasionally. She also reported feeling more confident and in control of her symptoms. She underwent another evaluation and 20 more acupuncture sessions were added to her treatment, and the SSRI was gradually tapered off following the psychiatric specialist's supervision. At the end of the follow-up timeperiod, this patient reported complete resolution of her panic symptoms.

Conclusions

In this illustrative case, acupuncture was associated with reduced panic attacks for the patient, and the effect was persistent with the additional acupuncture treatments after the initial 20-acupuncture treatments intervention.

According to a systematic review and meta-analysis,⁶ acupuncture was relatively safer then control treatment, and the researchers suggested that acupuncture therapy aimed at reducing anxiety in patients had certain beneficial effects, compared to controls. However, in the future, more well-designed studies using standard manual acupuncture are needed to confirm the efficacy of acupuncture further for treating panic disorders and to explore its biologic mechanisms.

Address correspondence to:

Yun Jin Kim, PhD

School of Traditional Chinese Medicine

Xiamen University Malaysia

Jalan Sunsuria Bandar Sunsuria

Sepang, Selangor 43900

Malaysia

E-mail: yjkim@xmu.edu.my

Long-COVID syndrome (LCS) is defined as ongoing symptoms for more than 60 days post infection. Respiratory symptoms from COVID-19 triggered post-traumatic stress disorder (PTSD) in a patient who had developed it from a severe peanut allergy he had experienced as a child. This induced anxiety and panic attacks in the present day.

This 31-year old patient presented with LCS and PTSD related to the difficulty he had with breathing. Additional symptoms he had included chest pains, cold hands and feet, a cold sensation in his chest, nocturnal sweating, difficulty sleeping due to panic attacks that were worse when he reclined, a dry throat with difficulty swallowing, and tightness around his torso/diaphragm area.

He had contracted COVID-19 just over 2 months prior and had recovered fully. Five days after this recovery, this patient developed dyspnea, which triggered his feelings of panic. He was prescribed Zoloft^® for the anxiety but this made his panic episodes worse. One night, when eating out, he had a panic attack at dinner and was taken to an emergency room. The trigger was the difficulty breathing that stemmed from the severe peanut allergy that had constricted his throat when he was a child. He felt that he had to make a conscious effort to breathe, while experiencing crushing chest pain, and had a sensation of things getting “stuck in his throat.” He also had difficulty swallowing, which continually caused him to feel on the edge of a panic attack. His energy level was very low. Traditional Chinese Medicine (TCM) was used to diagnose and treat this patient.

TCM Diagnostics

Pulses

His pulse was overall slightly rapid, and the left side was tight with a deep Heart pulse. His right Lung pulse was not present at the superficial level. His Kidney pulses on both sides were rapid with force at the deep level. The volume of all his pulses were consistently good.

Diagnosis

Residual Blood Level Heat from his LCS caused Zhong Qi constriction in the Upper Jiao and his Lung Qi was not anchoring into the Kidneys, triggering a Shen disturbance.

TCM Treatments

TCM treatments were given once per week and involved use of the National Acupuncture Detoxification Association (NADA) auricular-acupuncture protocol¹ as well as some points being addressed bilaterally (bi) as follows:

• (1)Set 1—Ear NADA protocol modified: Liver; Kidney (K); Lungs; Shen Men; and Point Zero

• Set 2—Ren (R)-17, 12, and 6; PC-8 (left); LU-5 (bi); and K-6 and 7 (bi)

• (2)Set 1—Ear NADA protocol modified: Liver; Kidney, Lungs, Shen Men, and Point Zero

• Set 2—Ren-17, LU-5 (bi), KI-3 (bi), Ren-22, scalp Speech Area, and Du-23

• (3)Set 1—LI-4 (bi) and LR-3 (bi)

• Set 2—LU-5 (bi), Yin Tang, R-15, K-6 (bi), and SP-4 (bi)

• (4)Set 1—Ear NADA protocol modified: Liver; Kidney; Lungs; Shen Men; Point Zero; and LR-8 (bi)

• Set 2—SP-6 (bi); LU-7 (bi); Ren-23, 15, and 6; and Yin Tang

• (5)Set 1—Ear Shen Men, Point Zero, PC-6 (bi), and SP-4 (bi)

• Set 2—Ren-21, 12, and 6; ST-25 (bi); and ST-42 (bi).

Discussion

During the acupuncture treatments, this patient continued seeing a therapist as well as undergoing testing for lung capacity and signs of wheezing. It was determined that the wheezing was coming from his vocal cords, and he was prescribed speech therapy, which he did receive twice during his acupuncture treatments. It was also found that he had some postnasal drip that might have been irritating his throat.

The chief complaint of this patient was his intense anxiety and panic attacks. The initial 2 treatments focused on relieving his intense emotional response to difficulty with breathing by first calming his nervous system with the NADA protocol¹ to enable his body to be receptive to treatment at a deeper level. Because this patient had an emotional trigger from his childhood, the trigger was necessarily treated at a deeper level involving the Jue Yin level (Liver, Pericardium) of the 12 Primary Meridians, as well using the Ren and Yin Wei Mai of the 8 Extraordinary Meridians.²

Conclusions

While this patient will continue to work on resolving his emotional trigger, the acupuncture treatment reduced its associated symptoms and enabled him to disconnect from the fight-or-flight response the trigger evoked.

Complementary and alternative medicine (CAM) is being utilized more frequently form treating PTSD.³ Studies are evolving to the point where acupuncture theory is being matched with memory formation, attempting to develop a neuromodulatory treatment for PTSD.⁴ The most-effective point in the treatment in this case was PC-6, the point that connected to the Yin Wei Mai. There is an exciting opportunity to explore further and translate from Classical Chinese Medical language to biomedical language how acupuncture theory ties in with neuromodulation.

Address correspondence to:

Charis Wolf, DTCM, LAc, DiplAc

Seattle Institute of East Asian Medicine

and Middile Way Acupuncture Institute

226 S Orcas St

Seattle, WA 98108

USA

E-mail: Charis@chariswolfacupuncture.com

In Vietnamese Imperial Medicine, the proper functioning of the Shen depends not only on the brain, but also on each organ performing its function correctly.

Panic disorder can be related to specific organs, but it is preferable for the human system to work as a whole; it is the whole that organizes the functioning of the affected organs in any condition.

For this reason, in panic disorders, it is preferable to use a general formula that restores the balance of the patient and then, in the same session, strengthen the work of the Ren Mai. In doing so, I balance all the Yin and Yuan Qi of the body, thus restoring its organic balance.

To identify the patient's weaknesses, I perform the Tree of Life diagnosis as outlined below.

First

I identify, by interrogation of the patient, the basic component affected, and then treat that component.

• “Are you older than 21 years old?” JING. Treat with acupuncture and moxibustion at KI-3 and Ren-4.

• “Do you get tired?” QI. Treat with acupuncture and moxibustion at ST-36 and Ren-6

• “Do you get stressed?” SHEN. Treat with acupuncture and moxibustion at PC-7. Treat with acupuncture at Du-20.

• “Do you have cramps or thirst?” XUE/JIN YE. Treat with acupuncture and moxibustion at BL-20 and 21.

In all cases, 1 use superficial needling and ambiguous maneuvers until De Qi is achieved.

Second

In this case, 1 strengthen the work of the basic components by enhancing the functions of a wonderful vessel—the Ren Mai. I do it in the following way, by addressing specific Ren points:

• Ren-3: To anchor the center of gravity of the body and potentiate the Lower Jiao

• Ren-4: To potentiates all the Yuan Qi of the human system, restoring balance to the Middle Jiao

• Ren-7: To regulate the Upper Jiao.

Acupuncture

We use a copper steel needle, with a guide tube, 0.22 in diameter and 15-mm long. All points are punctured bilaterally, with the exception of the Ren points. The needle is applied to make a superficial puncture (≤ 1-fen deep). The needle is rotated to both sides until De Qi is achieved. We use moxibustion on all points (except Du 20) until the patient feels a burning sensation. It is important that the needling not become painful.

Illustrative Case

Let us look at the following example:

First

A 26-year-old male patient arrives for consultation spontaneously, referring symptoms to consistent with a panic disorder. I identify basic components affected by querying him. He reports that he has been experiencing panic episodes for 2 months (JING) and that he the problem has been getting worse in the last few weeks. He also reports having tiredness (QI) and that he is very stressed (SHEN).

Second

I activate the Ren Mai meridian through the Ren points 3, 4, 7, to balance the three Jiaos. The puncturing in all cases is superficial, as I am trying not to pierce his skin with the smallest and finest needles possible. This treatment is performed 2 times per week.

Results

Usually the patient remains silent, is very peaceful, or falls asleep after the technique is applied.

Warning

The abovementioned technique involves great energetic transference, so, during the treatment, a therapist may experience the following: yawning; tiredness; exhaustion; sleepiness; intermittent muscular discomfort; paresthesia; etc. This is avoided by doing Qi Gong exercises before entering the consultation, to raise the levels of Qi and Wei Qi.

It is important that, after the consultation is over, Qi Gong exercises are also performed to help release the toxic Qi that emerges from the patient during treatment.

Address correspondence to:

Felipe Abreu Márquez, MD

Universidad Estatal de Milagro

Urbanización Entre Ríos

Calle Sexta Manzana L1 Solar 14

Parroquia la Puntilla Samborondón

Province of Guayas, 092301

Ecuador

E-mail: hoathienecuador@gmail.com