TCM for Pregnancy Anxiety & Panic Disorder

Original title: Pregnancy Anxiety & Panic Disorder: Soothing Mammas with Traditional Chinese Medicine

Abstract

Mental health is a major issue worldwide but frequently overlooked during pregnancy. Specifically, many different factors cause prenatal anxiety and panic disorders now compounded by the COVID-19 pandemic. Treatments are often limited though research indicates these symptoms can have long-term negative side-effects for both mother and child. Only when quite severe are antenatal patients provided pharmaceuticals that can also predispose offspring to a lifetime of consequences. Scientific studies discussing harmful cognitive, behavioral, and long-term health impacts of maternal biochemistry and pharmaceutical drug-use are presented. Traditional Chinese medicine (TCM) research exists on infertility, miscarriage prevention, as well as postpartum care but not expressly for anxiety and panic disorder during pregnancy. Despite inadequate research in the United States, various TCM and complementary alternative medicine (CAM) interventions are offered as possible solutions to this compelling problem. The following is a call to action for more high-quality studies involving this area of reproductive psychiatry.

INTRODUCTION

Mental health is a chief global health concern, exacerbated by COVID-19. According to the Centers for Disease Control, mental illness is the primary cause of disability in the United States and a leading cause worldwide.[1, 2] Each year, roughly 1 in 5 US adults suffer mental disorders with anxiety and depression being most common.[2] Unfortunately, pregnant women also suffer from mental health issues and are oftentimes overlooked or given few options to quell symptoms.

METHODS

PubMed, Google Scholar and Pacific College of Health and Science databases were searched for randomized controlled trials regarding TCM efficacy treating antenatal anxiety and panic disorder. Unfortunately, results were limited. Some studies indicate the potential benefit of TCM for this issue, echoing that more quality research is needed.[3, 4, 5, 6] Therefore, a single case and potential solutions are explored here.

DISCUSSION

Anxiety evolved as a physiological survival response, creating strong emotions like fear to engage the sympathetic nervous system. Kidney adrenals release adrenaline (epinephrine) which elevates heart rate (HR), slows digestion, and redirects blood to muscles.[7] Our awareness then heightens to prepare us for fight or flight.[7] But unlike surviving a wild bear attack, modern humans mostly experience chronic low-level stressors revolving “around family, friends, health, money, or work.”[7] Conversely, unrelenting nervousness or overwhelming fears that interfere with daily life is called Generalized Anxiety Disorder (GAD). Additional symptoms are irritability, edginess, restlessness, trouble concentrating, excessive sweating, rapid heart rate, shortness of breath, insomnia, fatigue, shakiness, digestive upset, headaches, and changes in appetite.[7] “Other anxiety disorders include panic disorder, phobias, selective mutism, social anxiety…and separation anxiety.”[7] Many factors, especially physical and hormonal changes, leave women susceptible to mental health issues during the “Perinatal Period” which comprises pregnancy and the year thereafter.[8] Being anxious during pregnancy is common. However, unlike typical concerns about birth and motherhood, approximately “one in seven perinatal women experiences increased anxiety, depression, and distress.”[8] It is even greater amongst high-risk pregnancies.

Currently, the pandemic is exacerbating mental health problems but especially for women who have been disproportionately affected. Specifically, “there is a significant increase in antenatal depression and anxiety since the onset of COVID-19.”[9] Health concerns are magnified by social injustice, civil unrest, school closures and financial struggles with historic job losses not seen since the Great Depression;[10] all while more women are leaving the workforce than men to juggle childcare, eldercare, and housework.[9] Most pregnant women fear higher contagion vulnerability, increased virus severity, hospitalization, threat of preterm birth and possible fetal or newborn transmission.[8] Additional observed risks are premature membrane rupture, “(19% of cases), fetal distress (43% of cases), and late perinatal loss (stillbirth or neonatal death, 7% of cases).”[8] Other pandemic-related impacts involve social isolation, fear of obstetric visit exposure along with greater substance abuse and domestic violence.[9, 10] Recently, an Italian study linked COVID-19 infection to potassium deficiency that can increase heart arrhythmia and anxiety.[11] COVID-19 is obviously amplifying perinatal mental disturbances which already correlate to adverse outcomes.

Undoubtedly, mood disorders during pregnancy deeply impact both maternal and fetal health. A 2020 meta-analysis showed depression or anxiety can generate maternal hypertension, creating greater risks like preeclampsia and mortality while further implicating fetal neurodevelopment.[12] Such perinatal mental health problems can cause shorter gestation and low birth weight that adversely impact offspring.[13] Moreover, the Fetal Programming Hypothesis stipulates there are particularly sensitive brain development periods during pregnancy that predispose offspring to long-term cognitive, behavioral and emotional problems.[14] These include dyslexia, Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), autism, epilepsy, schizophrenia and others.[14] High maternal anxiety, especially between weeks 12-22, was proven more likely to “enhance the offspring’s susceptibility for developing childhood disorders;”[14] particularly, ADHD and anxiety, by disrupting the monoaminergic brain circuits, Hypothalamic Pituitary Adrenal (HPA) axis and limbic system. In addition, research shows maternal inflammatory cytokines are produced in response to anxiety and mental issues. These can infiltrate the placenta and possibly alter immunity, provoking atopic illnesses like skin disorders, asthma, wheezing, and allergies in progeny.[15]

Furthermore, high levels of prenatal stress and anxiety (PNS) are linked to higher concentrations of cortisol. This hormone crosses the placenta and produces numerous health consequences, particularly during late pregnancy. These include: “preterm birth, lower birth weight, obesity, metabolic dysfunction…shorter gestational age…infant respiratory and skin illnesses…larger systemic vascular resistance and lower artery elasticity.”[16] Child respiratory and digestive disorders are also associated with maternal transfer of unbalanced microbiota to offspring from PNS.[16] Correspondingly, pharmacological interventions can have similar negative outcomes.

In traditional Chinese medicine (TCM), pregnancy is the accumulation of qi (energy), blood and phlegm inside the uterus, an extraordinary organ.[17] The baby develops in utero, deriving from both the mother’s and father’s Jing Kidney essence.[17] Meanwhile, a pregnant woman’s body undergoes numerous systemic changes with increased caloric demands and diminished lung capacity.[18] The parathyroid enlarges for greater calcium requirements while urine output and kidney functions augment to meet larger maternal and fetal waste.[18] Moreover, massive hormonal shifts affect mood and can alter thyroid function while maternal heart rate increases to accommodate the 30-50 percent larger blood volume circulating to support fetal growth.[19] Clearly, several disorders can arise from such transformations.

Ancient TCM diagnostic theory identifies patterns of imbalance within the body’s zangfu organ systems.[20] Each organ corresponds to five elements that harmoniously create and control one another: fire, earth, metal, water, and wood.[20] Health is further viewed through the lens of yin and yang,[21] along with the smooth flow of qi and blood.[21] As with most diseases, the etiology of anxiety is highly variable and individualized from a TCM perspective. Sometimes, the root cause involves an excess such as phlegm (with or without heat/fire). Alternatively, the cause is deficiency (i.e., insufficient substances like qi, blood, and yin). Occasionally, both excess and deficiency are present. Although multiple organs can be involved, Heart (fire), Kidney (water) and Liver (wood) are the primary organs associated with anxiety or panic disorder; they are also deeply connected with the uterus.[17]

Remarkably, five spirits correspond with each organ and are controlled by the Heart (Emperor). Though Heart Shen is sometimes considered a spirit, it is more accurately interpreted as mind.[23] Emotions affect the mind and are housed in the blood, which is also governed by the Heart. Un-tempered emotions can become pathological, especially insulting the Heart-Mind.[23] “Heart blood provides the foundation for the activities of the spirit; when it is deficient, the spirit has no place to calmly reside…[leading] to irritability and insomnia.”[24] Likewise, Heart qi moves blood so qi deficiency creates weakness that prevents nourishment of the heart and other systems. This further causes irritability and mental problems.[25] Also, if Kidney and Heart are not communicating, this is associated with depleted Kidney yin that cannot cool heart fire and engenders wind;[26] thereby disturbing the mind.

Obviously, caution must be used during pregnancy. Some practitioners believe moxibustion is too moving and cupping is debatable with higher maternal blood clotting. Many herbs are contraindicated or utilized only with extreme caution. Forbidden points include LI 4, GB 21, UB 31, 32, 33, 34, 60, 67, SP 6, CV 1 as well as abdominal points. Some theories indicate Ghost Points, except H 7 and P 7, are too strong along with excessive auricular points.

During each trimester, K 9 (Guest House)[27] is needled at least once for a beautiful happy baby by esoterically separating offspring from their parents’ karmic baggage.[28] “Used for thousands of years to promote the health of the baby…this point [clears]…fetal and maternal toxins.”[28] It also generates blood, nourishes Kidney Yin, calms Shen for insomnia, anxiety, palpitations, and clears Heart phlegm fire. [27]

Diagnoses & Formulas

Liver Qi Stagnation: Xiao Yao San; with heat, Jia Wei Xiao Yao San.

Qi and Blood Stagnation: Gui Zhi Fu Ling Wan; add Huang Qi and Ren Shen to build qi, Fu Ling for dampness/phlegm.

Heart Qi and Blood Deficiency: Gui Pi Tang, Sheng Mai San, and/or Zhi Gan Cao Tang.

Phlegm Misting the Mind: Er Chen Tang; with heat/fire, Wen Dan Tang.

Others: Gan Mai Da Zao Tang, Suan Zao Ren Tang, An Shen Fang.

Generally, acupuncture treatments are based on corresponding diagnoses while the following calm Shen, tonify qi, yin and blood: Sympathetic, Shen Men, P 6, P 7, H 7, LV 3, Yin Tang, CV 17, GV 20 or 24, ST 36, K 3, K 9, UB 2; LI 11 or LV 2 for heat; SP 9 or ST 40 for phlegm-dampness. Contra-lateral needling reduces points.

Severe Case Example: Female, Age 38, BP 104/61; Second pregnancy.

TCM DX: Heart qi and blood deficiency, yin deficiency fire with phlegm.

Tongue: Pale, red tip, puffy, scallops, deep center crack, no front coat, thin yellow back coating.

Pulse: Rapid, slippery, wiry, thready in the back left position and weak bilateral front positions.

Treatment: Sedate Shen, tonify Heart qi and blood, nourish Kidney, subdue fire, clear phlegm.

Patient presents with severe anxiety, panic attacks, insomnia, and tachycardia, waking suddenly at 2 AM with HR 140 bpm daily. Initial onset and emergency room visit at 17 weeks pregnant, eleven days after abruptly stopping breastfeeding her toddler due to low supply. She closed her acupuncture and nutrition practice during the pandemic and is finishing her doctorate. Happily married, her husband’s job is stable and there is no specific reason for her anxiety. She eats healthily, exercises, and meditates. Interestingly, winds increase symptom severity; in TCM, wind is considered an evil environmental pathogenic qi that dries blood and yin while stirring phlegm.

Herbal Intervention: Gan Mai Da Zao Tang and Suan Zao Ren Tang 2-5 gm each during panic episodes; Zhi Gan Cao Tang 12 gm twice daily; Sheng Mai San and Wen Dan Tang each 6 gm; An Shen Fang 2 capfuls before bed.

Supplements: Prenatal, Vitamin D 5,000 mg, Omega-3 1280 mg, Probiotics, Magnesium 235 mg; B12 500 mcg.

Labs indicated low B12, suboptimal Vitamin D with history of deficiency. Potassium was low at the ER; otherwise, normal labs with unremarkable cardiac evaluation. Symptoms are likely due to pregnancy hormones and increased blood volume. A beta-blocker was prescribed to control tachycardia, but night panics persisted. She was prescribed alprazolam and escitalopram but refused them. Neurotransmitter and hormone labs indicated second stage adrenal fatigue with elevated morning cortisol, low GABA and serotonin. Therefore, she started 500 mg Ashwaghandha (adaptogen) along with bi-weekly complimentary alternative medicine (CAM) sessions: aromatherapy Epsom Salt baths, massage and acupuncture.

OUTCOME: The patient reported overall improvement during treatment course using alternating combinations of the aforementioned points. Manageable episodes occurred once or twice weekly; eight were severe. Her offspring was carried to 39 weeks without complications and APGAR score of 9/10.

Alternative Approaches

For millennia, acupuncture and herbs have been utilized across Asia including throughout pregnancy. Although investigations regarding safety and efficacy of herbal medicine during pregnancy are limited, research indicates the safety and advantages of implementing acupuncture. Studies show acupuncture reduces blood pressure to control preeclampsia and safely induces labor. Maternal health benefits extend through all three trimesters and postpartum, treating: “nausea, heartburn, constipation, headache/migraine, exhaustion, mood swings, hyperemesis gravidarum, edema, body aches…pains, hypertension, carpal tunnel syndrome, round ligament pain, leg cramps, hemorrhoids, sleep difficulties, breech position, healing [post-delivery], and postnatal depression/anxiety.”[28] Acupuncture clearly supports healthy pregnancies.

Scientific evidence shows acupuncture calms the nervous system and releases endorphins while balancing hormones;[28] thereby successfully treating anxiety and panic disorder. According to the article, “Acupuncture Effect and Central Autonomic Regulation…evidence through MRI scans of the hypothalamus show[s] acupuncture relaxes and modulates the sympathetic nervous system. The hypothalamus sits just above the pituitary gland and is considered the command center for hormonal production and regulation. When the body is balanced and relaxed…people feel good.”[28]

Many CAM treatments effectively reduce stress, panic and anxiety. For example, massages are soothing and beneficial during pregnancy. They improve hormone function and reduce stress hormones like catecholamines and cortisol. [29] Additional benefits include elevating oxytocin levels that reduce pain, relieve “sleeplessness and [enhance] feelings of wellbeing.”[29] Other self-care rituals comprise of bi-weekly magnesium Epsom Salt baths and aromatherapy. “Essential oils, after entering the body through the skin or the nose, evoke the sense of smell which…stimulates the limbic system of the brain where emotion and memory are processed. [Studies] report that essential oils enhance the body’s natural production of its own chemicals of sedation, stimulation, and relaxation.”[29] Similarly, Meditation, including Push-Squeeze-Muscle-Release techniques, Emotional Freedom Technique (EFT), and Yoga can promote sleep and decrease anxiety.[30]

Furthermore, exercising regularly releases endorphins to reduce stress hormones and helps control mood imbalances.[31] Healthy nutrition is also important; eating a plant-rich diet while limiting caffeine and sugar is beneficial. Although controversial, cannabis and CBD are possible treatments to explore along with Ashwaghandha (in small dosages). Used in India for thousands of years to promote vitality and healthy pregnancies, Ashwaghandha effectively reduces cortisol levels according to some studies.[32]

Biomedical Considerations

Functional Medicine Labs should be periodically measured to track progress, including: Microbiome Dysbiosis as well as Neurotransmitter and Cortisol Imbalances. Western labs can help identify underlying diagnoses: Complete Blood Count (CBC); Comprehensive Metabolic Panel (CMP), thyroid function, Vitamin D levels along with a cardiac evaluation.

Cognitive Behavioral Therapy (CBT) and Psychotherapy are the first course of non-invasive safe treatments. Otherwise, Eye Movement Therapy (EMDR), Virtual Reality Exposure Therapy (VRET) and Deep Brain Electrical Stimulation (DBS) are experimental treatments for mental disorders considered safe during pregnancy.[33]

Lastly, pharmaceutical medications are frequently used to treat severe mental health concerns during pregnancy. The most common medications used for panic and anxiety disorders are Benzodiazepines, Serotonin Reuptake Inhibitors (SSRIs), Serotonin-norepinephrine Reuptake Inhibitors (SNRIs), Tricyclic Antidepressants (TA), Monoamine Oxidase Inhibitors (MAOI), Beta-blockers, and Buspirone (Bu-Spar).[34]

Great caution is used with Benzodiazepines. They are highly addictive and usually only prescribed short-term while other medications take effect. As fast acting sedatives, they work in minutes to reduce anxiety, relax tension and induce calm. Benzodiazepines quickly cross the placenta. Those with Food and Drug Administration (FDA) classification D have potential risks to the fetus but might be necessary to control symptoms, including: alprazolam (Xanax), chlordiazepoxide (Librium), diazepam (Valium), clonazepam (Klonopin), and lorazepam (Ativan).[34] Newborn benzodiazepine toxicity is uncommon but high maternal doses typically result in preterm birth, low birth weight, neonatal respiratory distress, floppy baby syndrome and sedation.[35, 36] Neonatal withdrawal syndrome also occurs with seizures, tremors, melancholy, restlessness, irritability, and sleep disruptions.[35] Research suggests first trimester use poses the added risk of cleft lip and palate.[37] Notably, there are contraindicated FDA category X benzodiazepines considered too detrimental to the fetus.[37]

SSRIs like citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) prevent the mood regulation chemical, serotonin, from being reabsorbed by the brain’s nerve cells.[34] Mostly citalopram, escitalopram and sertraline are prescribed during pregnancy. A 2015 study claimed no defects were associated with sertraline or escitalopram but postulated a “marginal link between [citalopram] and neural tube defects.”[38] According to the literature, “paroxetine and fluoxetine have the strongest association with negative outcomes, significant malformations, PPHN [Persistent Pulmonary Hypertension of the Newborn] and PNAS [Peripheral Neonatal Abstinence Syndrome].”[39] A form of drug withdrawal, PNAS requires close observation in the hospital for up to a week with some symptoms persisting for months. PNAS “symptoms may include: blotchy skin coloring (mottling), diarrhea, excessive or high-pitched crying, excessive sucking, fever, hyperactive reflexes, increased muscle tone, irritability, poor feeding, rapid breathing, seizures, sleep problems, slow weight gain, stuffy nose…sneezing, sweating, trembling, [and] vomiting.”[40] This study also determined fluoxetine “was associated with ventricular septal defects, right ventricular outflow tract obstruction cardiac defects, and craniosynostosis.”[38] By comparison, “[paroxetine] was associated with anencephaly, atrial septal defects, right ventricular outflow tract obstruction cardiac defects, gastroschisis, and omphalocele.”[38] Likewise, SNRIs, TCAs, MAOIs and Buspirone are used for anxiety but not typically in pregnancy due to potential teratogenicity.

Beta-blockers are normally for heart issues or hypertension, though sometimes prescribed off-label to relieve anxiety by slowing cardiac rhythm and reducing norepinephrine sensitivity.[41] FDA Class C examples used during pregnancy are metoprolol (Toprol) and propranolol (Inderal); only atenolol (Tenormin) is class D with higher risk potential.[41] However, beta-blockers can reduce “placental perfusion, [cause] fetal and neonatal bradycardia, hypoglycemia,”[41] low birth weight and decreased neonatal respiratory rate. Clearly, these drugs should only be utilized when absolutely necessary.

RESULTS

Good obstetric care, daily prenatal vitamins, Omega-3 Fish Oil, probiotics, 1000 mg Vitamin D (5,000 mg for low levels), and 1,000 mg Vitamin C are standard recommendations during pregnancy and postpartum; an oral Magnesium dose (under 350 mg) helps anxiety and leg cramps. All patients need initial lab work-ups and vitals taken at each visit. TCM evaluation with tongue and pulse determines the differential diagnosis to customize acupuncture and formula recommendations. Treatment plans incorporate supplements, exercise, yoga, magnesium baths, aromatherapy, meditation, massage, acupuncture, nutrition, and herbs. Care should continue throughout pregnancy and at minimum three months thereafter.

Case severity determines treatment frequency, adjunct therapeutic interventions, and possible outcome. Mild cases have no impact upon offspring with an excellent prognosis and are treated once weekly for four weeks then 1-2 times monthly. Moderate cases have a good prognosis with little to no long-term ramifications. Treatments begin 2-3 sessions, eventually reducing to once weekly and possibly bi-monthly.Severe case prognosis is unknown, especially if the patient requires pharmaceutical interventions, with possible harmful impacts upon fetal development. Daily acupuncture begins for one week, continuing every other day for 6-8 weeks then reduced to 1-2 weekly sessions.

CONCLUSION

Many pregnant women cope with mental disorders like anxiety and panic alone because practitioners and researchers fear liability lawsuits as well as ethical concerns. Yet this is unacceptable when these mothers are suffering, and uncontrolled symptoms could adversely influence the physical, cognitive, emotional, and behavioral development of their offspring. Similarly, negative consequences are still possible with the use of pharmacologic treatments prescribed in difficult cases. Therefore, further investigation of TCM interventions is justified to serve this especially vulnerable population.

BIAS

The author was pregnant during this writing and inspired to investigate the ramifications and treatment options related to her personal experience with the subject. She intends to increase awareness of reproductive psychiatry and the need for studying viable CAM treatments.

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