Anxiety Overview, Part 2

An integrative approach to managing anxiety disorders

Printable Version 

Self-Care and Anxiety

Several self-care and professional care approaches can be beneficial for people with anxiety disorders. Some influence anxiety symptoms in general and are useful in addressing all the different subtypes of anxiety disorders. Conversely, others have been studied only for one subtype. For specific information related to PTSD, go to the “PTSD” overview. The emphasis in this overview is on self-care options, prevention, and complementary approaches. Conventional care approaches will be briefly mentioned, and more detailed reviews on medications for anxiety can be found elsewhere.1,2

Physical Activity

Exercise (and physical activity in general)

It is intuitive that exercise would help decrease anxiety; however, research has historically been somewhat limited. Most research focuses on effects on overall well-being or symptoms of anxiety, rather than exploring the effects of physical activity on specific populations who have a DSM-based diagnosis. A 2018 review of 15 studies (675 people) concluded that exercise programs are a viable anxiety treatment, noting that higher intensity regimens were more effective than lower intensity ones.3,4 In one study that found benefit for general well-being, exercise is most effective if it exceeds 12 minutes at a time for at least 12 weeks; maximal effects occur when a person exercises 40 minutes per session.5 A 2017 meta-analysis and a 2012 meta-review did recommend exercise as being well supported in general.6,7 A 2014 meta-analysis of eight studies of exercise for serious mental illness did not find a beneficial effect on anxiety.8 A 2014 systematic review concluded that exercise is effective as an adjunctive treatment, but not as effective as antidepressant medications.9,10

Of course, one of the advantages of physical activity in general is that it has numerous other health benefits as well. For general information on the benefits of physical activity and ways to incorporate it into a personal health plan, go to the “Physical Activity” overview.

Tai Chi

Tai chi has shown promise in recent studies, but studies to date have had methodological limitations, according to a 2014 review.11 That review found two randomized controlled trials (RCTs) and six nonrandomized trials indicating that tai chi was associated with a significant reduction in anxiety. Typically, study participants practiced two to four times a week (30 to 60 minutes per session) for 5 to 24 weeks. A 2015 review of 17 articles concluded that, for all the studies’ flaws, tai chi does have benefit and is quite safe.12

Qi Gong

Qi gong developed in China and has been used there for thousands of years. It focuses on concentration, relaxation, meditation, breathing regulation, body posture, and movement. A 2014 review found that there are at least two RCTs suggesting an immediate reduction in anxiety after participants did qi gong.13 A 2019 review noted a potential benefit, but indicated that more studies are needed.14

Yoga

The evidence for yoga as a solo therapy or as an adjunctive therapy for anxiety is sparse. A 2018 review looking at Hatha yoga (the type most commonly practiced in the United States) noted that the quality of current research did not allow firm conclusions to be drawn.15 This is in contrast to a 2014 review that concluded yoga can reduce anxiety symptoms.16 17

Surroundings

When supporting people with anxiety disorders, it is important to explore the role of external stressors. When exploring the influence of surroundings on anxiety, be sure to ask about work stress, vulnerability to crime, as well as safety at home. Not surprisingly, intimate partner violence is a risk factor for anxiety disorders.18 Be careful not to let external factors be the only focus, however; working with anxiety requires that people look within as well.

Media Fasts

A number of studies indicate that exposure to violence through the media can increase anxiety.19,20 Therefore, it might be helpful to suggest that a person with anxiety avoid the news for a set period of time to see if this is helpful. See the Media Fast handout.

Green Spaces

A 2018 cross-sectional study found that living in proximity to green spaces (natural outdoor environments) is protective against anxiety and depression.21 Other studies have come to similar conclusions.22 Even in the short-term, nature time can be helpful; a 2015 study found that a 15-minute walk in the park can lead to favorable changes in vital signs indicative of parasympathetic activation and decreased sympathetic nervous system activity.23

Personal Development

Personal Development includes anything a person can do to grow as an individual. Augmenting financial resources (including escaping from poverty) and furthering education can reduce to stress and anxiety. Exploring creative pursuits and doing volunteer work can reduce anxiety as well.24 Listening to music can also be helpful for a person with anxiety, though more research is needed to see how significant a benefit they have.25,26

Nutrition

Nutritional psychiatry is a rapidly growing field.27 Diet and anxiety symptoms are linked in many ways.28 There is research showing that people increase or decrease their food intake when anxious, and their choice of food may move away from usual meal-type foods toward high-fat, highly palatable snacks.28 Encourage people to pay attention to what they crave.

Animal studies indicate that diet-induced obesity can lead to anxiety-related behaviors in rats,29 but a link in humans has been less clear.30 Eating too many calories when younger may make a person more vulnerable to developing anxiety later in life.31 Eating a high fat diet for four months induces anxiety through a number of inflammatory and other biochemical means.32 Vegans report lower levels of stress and anxiety than people who eat animal products, as do vegetarians.33,34

A study done in Norway suggested that people whose dietary pattern consists mostly of fruits, whole grains, vegetables, and lean red meats are less likely to have either anxiety in general or an anxiety disorder.35 Conversely, a diet rich in processed meats, pizza, salty snacks, chocolates, sugars and sweets, soft drinks, margarine, French fries, beer, coffee, cake, and ice cream is associated with a significantly increased probability of anxiety. Foods with numerous pro-oxidant compounds seem to worsen anxiety symptoms.36

Nutrient levels may also play a role. People with anxiety tend to have lower levels of vitamin D in their blood.37 People with OCD may have various forms of B12 deficiency.38 In rats, vitamin E deficiency is associated with more anxiety-like behaviors.39 Certain amino acids need to be consumed in the diet to protect against anxiety, namely L-Tryptophan and L-Tyrosine, which are precursors to serotonin, dopamine and norepinephrine, as well as glutamate, which is used to create gamma-aminobutyric acid (GABA).40 Folate and B vitamins also are also needed in these biochemical pathways.

Caffeine, Alcohol, and Nicotine

Caffeine intake is associated with symptoms of anxiety and depression, and one option for people with anxiety is to discuss stopping caffeine for a few weeks to see if this is beneficial,41 noting that people vary genetically in terms of how caffeine affects them.42 Some research indicates that caffeine can have health benefits, including for mood.43 That said, overall the evidence seems to support avoiding alcohol and nicotine.6,44

Anti-Inflammatory Diet

Evidence indicates that there is a correlation in some study populations between the presence of neuropsychiatric illness and inflammation.45 It is thought that oxidative stress may contribute to the development of anxiety in some people, and imaging studies indicate that inflammation affects a number of anxiety-related brain regions.46 Eating an anti-inflammatory diet may prove helpful, and it will have many other health benefits as well. The Anti-Inflammatory Lifestyle handout has more information.

Glycemic Index and Load

Refined sugars and carbohydrates can cause sudden changes in insulin and glucose levels. Acute insulin and sugar variations have been linked to anxiety in some people.47 People who eat lower glycemic load foods have lower odds of having anxiety, so it is worth it for an anxious individual to try a low glycemic index/glycemic load diet for a few weeks to see if he or she notices a benefit.48 The Managing Dietary Carbohydrates for Better Health handout has additional information.

Probiotics

Probiotics for mental health—psychobiotics—have gotten increased research attention in recent years.49 A number of studies have found that supplementation with probiotics can help with psychological symptoms, such as anxiety.50 A trial of a probiotic supplement for a few weeks to see if it is beneficial is reasonable. The Promoting a Healthy Microbiome with Food and Probiotics tool has additional information.

Recharge

Sleep is essential for brain healing and function. People with anxiety have difficulties with sleep onset, maintenance, or efficiency. Recent research suggests a bidirectional link between sleep disorders and mood disorders, including anxiety.51 Sleep disturbance is known to exacerbate symptoms in most anxiety disorders.52 Furthermore, it is a hypothesized risk factor for the development and maintenance of mood and anxiety disorders;52 having a diagnosis of insomnia is associated with 3.2 times the odds of developing anxiety.53 Even relatively short periods of sleep deprivation significantly increase a person’s anxiety levels.53 Research and clinical practice have demonstrated that treatment of anxiety disorders significantly improves sleep.54 When a person has anxiety, always consider what can be done to make sleep better. It can also be helpful to focus on how to make vacations and other pauses (e.g. work breaks) as stress-reducing as possible. The “Recharge” overview has additional information.

Family, Friends, & Co-Workers

Relationships clearly influence anxiety levels for people. A 2017 review concluded that the link between anxiety disorders and relationships is bidirectional; having anxiety affects the quality of one’s relationships, and how one’s partner treats him or her can, of course, have a significant effect on anxiety level.55 Having anxiety and other mental health disorders increases risk of divorce.56 People with anxiety disorders tend to avoid social encounters, and encouraging shared medical visits and classes may be helpful.

Loneliness and social isolation are linked to multiple health problems, including anxiety. People who rate themselves as lonely tend to respond to stress more intensely, with higher levels of blood pressure and inflammation.57 A 2014 study found that people who were more isolated actually benefited more from short-term psychotherapy than others, while people with good support benefited more from long-term therapy.58

The effects of animal-assisted therapy (and having pets) on anxiety remains to be elucidated. Interactions with animals seems to have some positive effects, but it can also have its associated stresses (including the likelihood of ultimately having the animal die).59,60

Spirit & Soul

Depending on how a person experiences them (and it is important to be very respectful of variations in beliefs), religion and spirituality can have profound positive or negative effects on mental health. There is increasing research favorably linking healthy spirituality and religiosity with less anxiety. A large-scale review done in 2015 found that 147 different studies indicated a positive relationship between spirituality and anxiety, whereas only 33 found a negative effect.61 A 2015 meta-analysis of 23 studies found a significant effect of religious and spiritual interventions on general symptoms of anxiety.62 A review of 43 studies found that, specifically for Veterans, well-being is favorably linked to spirituality, and well-being was defined, in part, in terms of anxiety levels.63 One study found that framing treatment around religion and spirituality is often (though not always) the preferred approach for addressing anxiety in older adults.64 Meaning in life in general also has a significant inverse relationship with anxiety levels.61,65,66

Attunement to the existential aspect of patients’ stories may do much to help them work more successfully with anxiety symptoms.67 It is always worth asking if spiritual or religious issues (e.g., beliefs about death) are associated with anxiety symptoms. The “Spirit & Soul” overview has additional information.

Mind and Emotions

There is little doubt that invoking the mind’s power is essential for most people when it comes to working with anxiety disorders. Psychotherapy, relaxation practices, and other mind-body therapy all can be beneficial. The key is to successfully match the therapeutic approach to each specific individual.

Psychotherapy for Anxiety

A number of psychotherapies can be beneficial for people with anxiety disorders. Cognitive Behavioral Therapy (CBT) is a cornerstone of mental health care. In CBT, the clinician guides the patient in identifying and replacing negative patterns of thinking with more positive and realistic approaches. It includes behavior activation and education about the relationships between thoughts, behaviors, and emotions. CBT involves a limited number of sessions, typically 12. There are specific types of CBT for panic disorder, OCD, and PTSD.

A 2015 review of 19 fMRI studies found that CBT increases the prefrontal part of the brain’s control over the different subcortical structures that function differently in different anxiety disorders.68 CBT is helpful for people with health anxiety related to having a variety of chronic illnesses.69 It has been found just as effective as medication treatment for generalized anxiety disorder, and even more effective six months after the start of treatment.70 A large 2018 meta-analysis confirmed it has a large effect size for treating obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and acute stress; it has a small to moderate effect size for social anxiety disorder (SAD) and panic disorder.71 CBT is also effective for somatoform disorders and for medically unexplained physical symptoms.72

A systematic review of 21 studies found CBT is effective when administered via videoconferencing.73 A meta-analysis of 100 articles found a 51% remission rate for anxiety with CBT (with the number varying based on how “remission” was defined in each study).74

Other types of psychotherapy have also shown benefit. Examples of other approaches include emotion-focused therapy (mostly for GAD), exposure therapy (especially for OCD and PTSD), and group sessions of various types for SAD.75-77 A recent meta-analysis of 14 RCTs totaling 1,073 patients showed Psychodynamic Psychotherapy (PP) is as efficacious as other active treatments that have been studied for anxiety disorders.78 Limitations of PP include a longer length of treatment; however, longer lasting effects were also found.78 A 2017 review of 36 trials using Acceptance and Commitment Therapy (ACT) found that it outperformed being on a waitlist, as well as treatment as usual; effects were comparable to those of CBT.79 Of note, the dropout rate for psychotherapy for people with GAD is 17%, so it is important to support ongoing use of these helpful approaches.80

Positive Psychology

Positive psychology focuses on helping people build pleasant, engaged, and meaningful lives, in contrast to focusing on reducing negative states, such as anxiety, depression, and anger.81 This treatment approach helps people develop emotional resilience, rather than directly focusing on decreasing anxiety; it can be a useful adjunct when working with people with anxiety disorders.

Mind-Body Practices

Specific tools that go into more detail about several mind-body practices are featured in the Passport to Whole Health, Chapter 12.

Various states of relaxation elicit cardiorespiratory coherence, which in turn activates the parasympathetic nervous system and opposes the sympathetic nervous system, which tends to be more active in people with anxiety.82 Several approaches can decrease anxiety by eliciting the relaxation response. For additional details about each of the approaches listed below, check out the “Mind and Emotions” and “Mindful Awareness” overviews and tools.83-85

Biofeedback

Biofeedback uses various measurement tools to bring greater conscious awareness to what are normally unconscious bodily functions. There are several studies showing that use of biofeedback equipment can reduce anxiety. Heart rate variability biofeedback leads to a large reduction of stress and anxiety, according to a 2017 meta-analysis.86 Other studies have also found benefit.87,88 Refer to the “Biofeedback” tool.

Guided Imagery

Mental imagery has been demonstrated to elicit stronger emotions than other mind-body approaches. It has a role in eliciting a sense of calm in patients with anxiety.89 Guided Imagery shows promise for improving anxiety in critically ill patients, but more studies are needed.90 It also decreases anxiety in patients having hemodialysis and people who are about to have surgery.91,92

Hypnosis

A 2010 review concluded that hypnosis helps with both state anxiety (anxiety due to a specific situation, like taking a test) as well as anxiety disorders (longer-lived anxiety that recurs).93 It also seems to reduce anxiety for people who have cancer, are receiving wound care for burns, or about to have dental procedures.94-96

Meditation

The benefits of mindful awareness are beginning to be understood at a neurobiological level.83 A 2014 review concluded that meditation programs result in small to moderate reductions in “multiple negative dimensions of psychological stress.”97 There is still a lack of research on this topic, but a 2017 study of 57 people with GAD found that mindfulness meditation seems to improve occupational function and lead to more appropriate use of health care resources.98 In a 2010 meta-analysis, mindfulness was linked with improved anxiety symptoms.84 A 2012 review concluded, “The evidence suggests that both mindfulness-based stress reduction and mindfulness-based cognitive therapy have efficacy as adjunctive therapies for anxiety symptoms.”85

Progressive Muscle Relaxation

Progressive muscle relaxation decreases anxiety and improves quality of life in a number of different patient groups. Examples include people with acute schizophrenia,99 chronic lung disease patients,100 and people with hypertension.101

Breathing Exercises

Paced deep breathing is an effective way to elicit increased parasympathetic activity.102 It changes activity levels in different parts of the brain and alters EEG readings.103 Breathing retraining has been found to be an effective treatment alone and in conjunction with other treatments for decreasing anxiety and improving anxiety disorders.104

What we know about integrative health care has come to us thanks to the efforts, experiences, and collective wisdom of people from many cultures and backgrounds. We wish to acknowledge all the healers, researchers, patients, and peoples who have informed the content of this tool.

Author(s)

This overview was adapted for the Osher Center for Integrative Health at the University of Wisconsin-Madison by J. Adam Rindfleisch, MPhil, MD building on the original written by Mario Salguero, MD, PhD (2014, updated 2019).

This overview was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

Originally Created: 2014, Updated: 2019

References

  1. Strawn JR, Geracioti L, Rajdev N, Clemenza K, Levine A. Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy. Jul 2018;19(10):1057-1070. doi:10.1080/14656566.2018.1491966
  2. Bandelow B, Michaelis S, Wedekind D. Treatment of anxiety disorders. Dialogues in clinical neuroscience. Jun 2017;19(2):93-107.
  3. Aylett E, Small N, Bower P. Exercise in the treatment of clinical anxiety in general practice - a systematic review and meta-analysis. BMC Health Serv Res. Jul 16 2018;18(1):559. doi:10.1186/s12913-018-3313-5
  4. Bartley CA, Hay M, Bloch MH. Meta-analysis: aerobic exercise for the treatment of anxiety disorders. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2013;45:34-39. doi:10.1016/j.pnpbp.2013.04.016
  5. Moses J, Steptoe A, Mathews A, Edwards S. The effects of exercise training on mental well-being in the normal population: a controlled trial. Journal of psychosomatic research. 1989;33(1):47-61.
  6. Sarris J, Moylan S, Camfield DA, et al. Complementary medicine, exercise, meditation, diet, and lifestyle modification for anxiety disorders: a review of current evidence. Evidence-based complementary and alternative medicine : eCAM. 2012;2012:809653.
  7. Stubbs B, Vancampfort D, Rosenbaum S, et al. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Res. Mar 2017;249:102-108. doi:10.1016/j.psychres.2016.12.020
  8. Pearsall R, Smith DJ, Pelosi A, Geddes J. Exercise therapy in adults with serious mental illness: a systematic review and meta-analysis. BMC psychiatry. 2014;14(1):117. doi:10.1186/1471-244X-14-117
  9. Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety disorders: systematic review. British journal of sports medicine. Feb 2014;48(3):187-96. doi:10.1136/bjsports-2012-091287
  10. Ravindran AV, da Silva TL. Complementary and alternative therapies as add-on to pharmacotherapy for mood and anxiety disorders: A systematic review. Journal of affective disorders. 2013;150(3):707-719. doi:10.1186/1471-244X-14-117
  11. Wang F, Lee E, Wu T, et al. The effects of tai chi on depression, anxiety, and psychological well-being: a systematic review and meta-analysis. International Journal of Behavioral Medicine. 2014;21(4):605-617.
  12. Sharma M, Haider T. Tai chi as an alternative and complimentary therapy for anxiety: a systematic review. J Evid Based Complementary Altern Med. Apr 2015;20(2):143-53. doi:10.1177/2156587214561327
  13. Wang CW, Chan CH, Ho RT, Chan JS, Ng SM, Chan CL. Managing stress and anxiety through qigong exercise in healthy adults: a systematic review and meta-analysis of randomized controlled trials. BMC Complement Altern Med. 2014;14:8. doi:10.1186/1472-6882-14-8
  14. Chang PS, Knobf T, Oh B, Funk M. Physical and psychological health outcomes of Qigong exercise in older adults: A systematic review and meta-analysis. The American journal of Chinese medicine. 2019;47(2):301-322. doi:10.1142/s0192415x19500149
  15. Vollbehr NK, Bartels-Velthuis AA, Nauta MH, et al. Hatha yoga for acute, chronic and/or treatment-resistant mood and anxiety disorders: A systematic review and meta-analysis. PloS one. 2018;13(10):e0204925. doi:10.1371/journal.pone.0204925
  16. Skowronek I, Mounsey A, Handler L. Clinical inquiry: Can yoga reduce symptoms of anxiety and depression? Journal of Family Practice. 2014;63(7):398-407.
  17. Kirkwood G, Rampes H, Tuffrey V, Richardson J, Pilkington K. Yoga for anxiety: a systematic review of the research evidence. British journal of sports medicine. 2005;39(12):884-891.
  18. Ahmadzad-Asl M, Davoudi F, Zarei N, Mohammad-Sadeghi H, Rasoulian M. Domestic violence against women as a risk factor for depressive and anxiety disorders: findings from domestic violence household survey in Tehran, Iran. Archives of women's mental health. Oct 2016;19(5):861-9. doi:10.1007/s00737-016-0626-4
  19. Madan A, Mrug S, Wright RA. The effects of media violence on anxiety in late adolescence. Journal of Youth and Adolescence. 2014;43(1):116-126.
  20. Collimore KC, McCabe RE, Carleton RN, Asmundson GJ. Media exposure and dimensions of anxiety sensitivity: differential associations with PTSD symptom clusters. Journal of anxiety disorders. 2008;22(6):1021-1028.
  21. Gascon M, Sanchez-Benavides G, Dadvand P, et al. Long-term exposure to residential green and blue spaces and anxiety and depression in adults: A cross-sectional study. Environmental research. Apr 2018;162:231-239. doi:10.1016/j.envres.2018.01.012
  22. Beyer KM, Kaltenbach A, Szabo A, Bogar S, Nieto FJ, Malecki KM. Exposure to neighborhood green space and mental health: evidence from the survey of the health of Wisconsin. International journal of environmental research and public health. Mar 21 2014;11(3):3453-72. doi:10.3390/ijerph110303453
  23. Song C, Ikei H, Igarashi M, Takagaki M, Miyazaki Y. Physiological and psychological effects of a walk in urban parks in fall. International journal of environmental research and public health. Nov 9 2015;12(11):14216-28. doi:10.3390/ijerph121114216
  24. Thoreson A. Helping people, changing lives: 3 health benefits of volunteering. Mayo Clinic Health System. 2026. https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/3-health-benefits-of-volunteering
  25. Abbing A, Ponstein A, van Hooren S, de Sonneville L, Swaab H, Baars E. The effectiveness of art therapy for anxiety in adults: A systematic review of randomised and non-randomised controlled trials. PloS one. 2018;13(12):e0208716. doi:10.1371/journal.pone.0208716
  26. Wang S, Agius M. The use of Music Therapy in the treatment of Mental Illness and the enhancement of Societal Wellbeing. Psychiatria Danubina. Nov 2018;30(Suppl 7):595-600.
  27. Marx W, Moseley G, Berk M, Jacka F. Nutritional psychiatry: the present state of the evidence. Proc Nutr Soc. Nov 2017;76(4):427-436. doi:10.1017/s0029665117002026
  28. Murphy M, Mercer JG. Diet-regulated anxiety. International Journal of Endocrinology. 2013;2013doi:10.1155/2013/701967
  29. André C, Dinel A-L, Ferreira G, Layé S, Castanon N. Diet-induced obesity progressively alters cognition, anxiety-like behavior and lipopolysaccharide-induced depressive-like behavior: focus on brain indoleamine 2, 3-dioxygenase activation. Brain, behavior, and immunity. 2014;41:10-21. doi:10.1016/j.bbi.2014.03.012
  30. Eyres SL, Turner AI, Nowson CA, Torres SJ. Does diet-induced weight change effect anxiety in overweight and obese adults? Nutrition (Burbank, Los Angeles County, Calif). 2014;30(1):10-15.
  31. Baker KD, Loughman A, Spencer SJ, Reichelt AC. The impact of obesity and hypercaloric diet consumption on anxiety and emotional behavior across the lifespan. Neuroscience and biobehavioral reviews. Dec 2017;83:173-182. doi:10.1016/j.neubiorev.2017.10.014
  32. Dutheil S, Ota KT, Wohleb ES, Rasmussen K, Duman RS. High-fat diet induced anxiety and anhedonia: Impact on brain homeostasis and inflammation. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology. Jun 2016;41(7):1874-87. doi:10.1038/npp.2015.357
  33. Beezhold B, Radnitz C, Rinne A, DiMatteo J. Vegans report less stress and anxiety than omnivores. Nutritional neuroscience. Oct 2015;18(7):289-96. doi:10.1179/1476830514y.0000000164
  34. Beezhold BL, Johnston CS, Daigle DR. Vegetarian diets are associated with healthy mood states: a cross-sectional study in seventh day adventist adults. Nutrition journal. Jun 1 2010;9:26. doi:10.1186/1475-2891-9-26
  35. Jacka FN, Mykletun A, Berk M, Bjelland I, Tell GS. The association between habitual diet quality and the common mental disorders in community-dwelling adults: the Hordaland Health study. Psychosomatic medicine. 2011;73(6):483-490. doi:10.1097/PSY.0b013e318222831a
  36. Salim S, Asghar M, Chugh G, Taneja M, Xia Z, Saha K. Oxidative stress: a potential recipe for anxiety, hypertension and insulin resistance. Brain research. 2010;1359:178-185.
  37. Bicikova M, Duskova M, Vitku J, et al. Vitamin D in anxiety and affective disorders. Physiological research. 2015;64 Suppl 2:S101-3.
  38. Türksoy N, Bilici R, Yalçıner A, et al. Vitamin B12, folate, and homocysteine levels in patients with obsessive–compulsive disorder. Neuropsychiatric Disease and Treatment. 2014;10:1671-1675. doi:10.2147/NDT.S67668
  39. Terada Y, Okura Y, Kikusui T, Takenaka A. Dietary vitamin e deficiency increases anxiety-like behavior in juvenile and adult rats. Bioscience, Biotechnology, and Biochemistry. 2011;75(10):1894-1899.
  40. Fernstrom JD, Fernstrom MH. Tyrosine, phenylalanine, and catecholamine synthesis and function in the brain. The Journal of nutrition. Jun 2007;137(6 Suppl 1):1539S-1547S; discussion 1548S. doi:10.1093/jn/137.6.1539S
  41. Bruce MS, Lader M. Caffeine abstention in the management of anxiety disorders. Psychological medicine. 1989;19(1):211-214.
  42. Nehlig A. Interindividual differences in caffeine metabolism and factors driving caffeine consumption. Pharmacological reviews. Apr 2018;70(2):384-411. doi:10.1124/pr.117.014407
  43. Nehlig A. Effects of coffee/caffeine on brain health and disease: What should I tell my patients? Practical neurology. Apr 2016;16(2):89-95. doi:10.1136/practneurol-2015-001162
  44. Moylan S, Jacka FN, Pasco JA, Berk M. How cigarette smoking may increase the risk of anxiety symptoms and anxiety disorders: a critical review of biological pathways. Brain and Behavior. 2013;3(3):302-326. doi:10.1002/brb3.137
  45. Mitchell RH, Goldstein BI. Inflammation in children and adolescents with neuropsychiatric disorders: a systematic review. Journal of the American Academy of Child and Adolescent Psychiatry. 2014;53(3):274-296.
  46. Felger JC. Imaging the role of inflammation in mood and anxiety-related disorders. Current neuropharmacology. 2018;16(5):533-558. doi:10.2174/1570159x15666171123201142
  47. Penckofer S, Quinn L, Byrn M, Ferrans C, Miller M, Strange P. Does glycemic variability impact mood and quality of life? Diabetes Technology & Therapeutics. 2012;14(4):303-310. doi:10.1089/dia.2011.0191
  48. Haghighatdoost F, Azadbakht L, Keshteli AH, et al. Glycemic index, glycemic load, and common psychological disorders. Am J Clin Nutr. Jan 2016;103(1):201-9. doi:10.3945/ajcn.114.105445
  49. Rieder R, Wisniewski PJ, Alderman BL, Campbell SC. Microbes and mental health: A review. Brain, behavior, and immunity. Nov 2017;66:9-17. doi:10.1016/j.bbi.2017.01.016
  50. McKean J, Naug H, Nikbakht E, Amiet B, Colson N. Probiotics and subclinical psychological symptoms in healthy participants: A systematic review and meta-analysis. Journal of alternative and complementary medicine (New York, NY). Apr 2017;23(4):249-258. doi:10.1089/acm.2016.0023
  51. Alvaro PK, Roberts RM, Harris JK. A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep. 2013;36(7):1059-1068.
  52. Cox RC, Olatunji BO. A systematic review of sleep disturbance in anxiety and related disorders. J Anxiety Disord. Jan 2016;37:104-29. doi:10.1016/j.janxdis.2015.12.001
  53. Pires GN, Bezerra AG, Tufik S, Andersen ML. Effects of acute sleep deprivation on state anxiety levels: a systematic review and meta-analysis. Sleep medicine. Aug 2016;24:109-118. doi:10.1016/j.sleep.2016.07.019
  54. Ekor M, Adeyemi OS, Otuechere CA. Management of anxiety and sleep disorders: Role of complementary and alternative medicine and challenges of integration with conventional orthodox care. Chin J Integr Med. 2013;19(1):5-14.
  55. Kasalova P, Prasko J, Holubova M, et al. Anxiety disorders and marital satisfaction. Neuro endocrinology letters. Feb 2018;38(8):555-564.
  56. Kessler RC, Walters EE, Forthofer MS. The social consequences of psychiatric disorders, III: probability of marital stability. The American journal of psychiatry. Aug 1998;155(8):1092-6. doi:10.1176/ajp.155.8.1092
  57. Brown EG, Gallagher S, Creaven AM. Loneliness and acute stress reactivity: A systematic review of psychophysiological studies. Psychophysiology. May 2018;55(5):e13031. doi:10.1111/psyp.13031
  58. Lindfors O, Ojanen S, Jääskeläinen T, Knekt P. Social support as a predictor of the outcome of depressive and anxiety disorder in short-term and long-term psychotherapy. Psychiatry Research. 2014;216(1):44-51.
  59. Friedman E, Krause-Parello CA. Companion animals and human health: benefits, challenges, and the road ahead for human-animal interaction. Revue scientifique et technique (International Office of Epizootics). Apr 2018;37(1):71-82. doi:10.20506/rst.37.1.2741
  60. Crossman MK. Effects of interactions with animals on human psychological distress. J Clin Psychol. Jul 2017;73(7):761-784. doi:10.1002/jclp.22410
  61. Koenig HG. Religion, spirituality, and health: a review and update. Advances in mind-body medicine. Summer 2015;29(3):19-26.
  62. Goncalves JP, Lucchetti G, Menezes PR, Vallada H. Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials. Psychological medicine. Oct 2015;45(14):2937-49. doi:10.1017/s0033291715001166
  63. Smith-MacDonald L, Norris JM, Raffin-Bouchal S, Sinclair S. Spirituality and mental well-being in combat veterans: A systematic review. Military medicine. Nov 2017;182(11):e1920-e1940. doi:10.7205/milmed-d-17-00099
  64. Stanley MA, Bush AL, Camp ME, et al. Older adults’ preferences for religion/spirituality in treatment for anxiety and depression. Aging & mental health. 2011;15(3):334-343. doi:doi: 10.1080/13607863.2010.519326
  65. Weber SR, Pargament KI. The role of religion and spirituality in mental health. Curr Opin Psychiatry. Sep 2014;27(5):358-63. doi:10.1097/yco.0000000000000080
  66. Shiah YJ, Chang F, Chiang SK, Lin IM, Tam WC. Religion and health: anxiety, religiosity, meaning of life and mental health. Journal of religion and health. Feb 2015;54(1):35-45. doi:10.1007/s10943-013-9781-3
  67. Glas G. Anxiety, anxiety disorders, religion and spirituality. Southern medical journal. 2007;100(6):621-625.
  68. Brooks SJ, Stein DJ. A systematic review of the neural bases of psychotherapy for anxiety and related disorders. Dialogues in clinical neuroscience. Sep 2015;17(3):261-79.
  69. Petricone-Westwood D, Jones G, Mutsaers B, et al. A systematic review of interventions for health anxiety presentations across diverse chronic illnesses. Int J Behav Med. Feb 2019;26(1):3-16. doi:10.1007/s12529-018-9748-6
  70. Borza L. Cognitive-behavioral therapy for generalized anxiety. Dialogues in clinical neuroscience. Jun 2017;19(2):203-208.
  71. Carpenter JK, Andrews LA, Witcraft SM, Powers MB, Smits JAJ, Hofmann SG. Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depress Anxiety. Jun 2018;35(6):502-514. doi:10.1002/da.22728
  72. Liu J, Gill NS, Teodorczuk A, Li ZJ, Sun J. The efficacy of cognitive behavioural therapy in somatoform disorders and medically unexplained physical symptoms: A meta-analysis of randomized controlled trials. Journal of affective disorders. Feb 15 2019;245:98-112. doi:10.1016/j.jad.2018.10.114
  73. Berryhill MB, Halli-Tierney A, Culmer N, et al. Videoconferencing psychological therapy and anxiety: a systematic review. Fam Pract. Jan 25 2019;36(1):53-63. doi:10.1093/fampra/cmy072
  74. Springer KS, Levy HC, Tolin DF. Remission in CBT for adult anxiety disorders: A meta-analysis. Clinical psychology review. Apr 2018;61:1-8. doi:10.1016/j.cpr.2018.03.002
  75. Timulak L, McElvaney J, Keogh D, et al. Emotion-focused therapy for generalized anxiety disorder: An exploratory study. Psychotherapy (Chicago, Ill). Dec 2017;54(4):361-366. doi:10.1037/pst0000128
  76. Foa EB, McLean CP. The efficacy of exposure therapy for anxiety-related disorders and its underlying mechanisms: The case of OCD and PTSD. Annu Rev Clin Psychol. 2016;12:1-28. doi:10.1146/annurev-clinpsy-021815-093533
  77. Barkowski S, Schwartze D, Strauss B, Burlingame GM, Barth J, Rosendahl J. Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials. J Anxiety Disord. Apr 2016;39:44-64. doi:10.1016/j.janxdis.2016.02.005
  78. Keefe JR, McCarthy KS, Dinger U, Zilcha-Mano S, Barber JP. A meta-analytic review of psychodynamic therapies for anxiety disorders. Clinical psychology review. 2014;34(4):309-323.
  79. Twohig MP, Levin ME. Acceptance and commitment therapy as a treatment for anxiety and depression: A review. The Psychiatric clinics of North America. Dec 2017;40(4):751-770. doi:10.1016/j.psc.2017.08.009
  80. Gersh E, Hallford DJ, Rice SM, et al. Systematic review and meta-analysis of dropout rates in individual psychotherapy for generalized anxiety disorder. J Anxiety Disord. Dec 2017;52:25-33. doi:10.1016/j.janxdis.2017.10.001
  81. Duckworth AL, Steen TA, Seligman ME. Positive psychology in clinical practice. Annual Review of Clinical Psychology. 2005;1:629-651.
  82. Jerath R, Crawford MW. How does the body affect the mind? Role of cardiorespiratory coherence in the spectrum of emotions. Adv Mind Body Med. Fall 2015;29(4):4-16.
  83. Zeidan F, Martucci KT, Kraft RA, McHaffie JG, Coghill RC. Neural correlates of mindfulness meditation-related anxiety relief. Social Cognitive and Affective Neuroscience. 2014;9(6):751-759.
  84. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. Journal of consulting and clinical psychology. Apr 2010;78(2):169-183. doi:10.1037/a0018555
  85. Marchand WR. Mindfulness-based stress reduction, mindfulness-based cognitive therapy, and Zen meditation for depression, anxiety, pain, and psychological distress. Journal of psychiatric practice. Jul 2012;18(4):233-52. doi:10.1097/01.pra.0000416014.53215.86
  86. Goessl VC, Curtiss JE, Hofmann SG. The effect of heart rate variability biofeedback training on stress and anxiety: a meta-analysis. Psychological medicine. Nov 2017;47(15):2578-2586. doi:10.1017/s0033291717001003
  87. Bhat P. Efficacy of Alfa EEG wave biofeedback in the management of anxiety. Industrial psychiatry journal. 2010;19(2):111-114.
  88. Hampson M, Stoica T, Saksa J, et al. Real-time fMRI biofeedback targeting the orbitofrontal cortex for contamination anxiety. Journal of visualized experiments : JoVE. 2012;(59)
  89. Cooper K, Stollings S. Guided imagery for anxiety# 211. Journal of palliative medicine. 2010;13(5):606-607.
  90. Meghani N, Tracy MF, Hadidi NN, Lindquist R. Part II: The effects of aromatherapy and guided imagery for the symptom management of anxiety, pain, and insomnia in critically ill patients: An integrative review of current literature. Dimensions of critical care nursing : DCCN. Nov/Dec 2017;36(6):334-348. doi:10.1097/dcc.0000000000000272
  91. Beizaee Y, Rejeh N, Heravi-Karimooi M, Tadrisi SD, Griffiths P, Vaismoradi M. The effect of guided imagery on anxiety, depression and vital signs in patients on hemodialysis. Complement Ther Clin Pract. Nov 2018;33:184-190. doi:10.1016/j.ctcp.2018.10.008
  92. Felix M, Ferreira MBG, Oliveira LF, Barichello E, Pires PDS, Barbosa MH. Guided imagery relaxation therapy on preoperative anxiety: a randomized clinical trial. Rev Lat Am Enfermagem. Nov 29 2018;26:e3101. doi:10.1590/1518-8345.2850.3101
  93. Hammond DC. Hypnosis in the treatment of anxiety- and stress-related disorders. Expert review of neurotherapeutics. Feb 2010;10(2):263-73. doi:10.1586/ern.09.140
  94. Chen PY, Liu YM, Chen ML. The effect of hypnosis on anxiety in patients with cancer: A meta-analysis. Worldviews on evidence-based nursing / Sigma Theta Tau International, Honor Society of Nursing. Jun 2017;14(3):223-236. doi:10.1111/wvn.12215
  95. Provencal SC, Bond S, Rizkallah E, El-Baalbaki G. Hypnosis for burn wound care pain and anxiety: A systematic review and meta-analysis. Burns : journal of the International Society for Burn Injuries. Dec 2018;44(8):1870-1881. doi:10.1016/j.burns.2018.04.017
  96. Ramirez-Carrasco A, Butron-Tellez Giron C, Sanchez-Armass O, Pierdant-Perez M. Effectiveness of hypnosis in combination with conventional techniques of behavior management in anxiety/pain reduction during dental anesthetic infiltration. Pain Res Manag. 2017;2017:1434015. doi:10.1155/2017/1434015
  97. Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine. Mar 2014;174(3):357-68. doi:10.1001/jamainternmed.2013.13018
  98. Hoge EA, Guidos BM, Mete M, et al. Effects of mindfulness meditation on occupational functioning and health care utilization in individuals with anxiety. J Psychosom Res. Apr 2017;95:7-11. doi:10.1016/j.jpsychores.2017.01.011
  99. Chen WC, Chu H, Lu RB, et al. Efficacy of progressive muscle relaxation training in reducing anxiety in patients with acute schizophrenia. Journal of clinical nursing. 2009;18(15):2187-2196.
  100. Lolak S, Connors GL, Sheridan MJ, Wise TN. Effects of progressive muscle relaxation training on anxiety and depression in patients enrolled in an outpatient pulmonary rehabilitation program. Psychotherapy and psychosomatics. 2008;77(2):119-125.
  101. Pender NJ. Effects of progressive muscle relaxation training on anxiety and health locus of control among hypertensive adults. Research in nursing & health. 1985;8(1):67-72.
  102. Kromenacker BW, Sanova AA, Marcus FI, Allen JJB, Lane RD. Vagal mediation of low-frequency heart rate variability during slow yogic breathing. Psychosom Med. Jul/Aug 2018;80(6):581-587. doi:10.1097/psy.0000000000000603
  103. Zaccaro A, Piarulli A, Laurino M, et al. How breath-control can change your life: A systematic review on psycho-physiological correlates of slow breathing. Front Hum Neurosci. 2018;12:353. doi:10.3389/fnhum.2018.00353
  104. Jerath R, Crawford MW, Barnes VA, Harden K. Self-regulation of breathing as a primary treatment for anxiety. Applied psychophysiology and biofeedback. Jun 2015;40(2):107-15. doi:10.1007/s10484-015-9279-8

Keywords:
Mental health, anxiety, physical activity, nutrition, anxiety disorders, social life, spirituality, mind-body therapy, emotions 
Doc ID:
150641
Owned by:
Sara A. in Osher Center for Integrative Health
Created:
2025-05-12
Updated:
2026-06-04
Sites:
Osher Center for Integrative Health
Clean URL:
https://kb.wisc.edu/osher/anxiety-overview-part-2