I. Etiology and pathology
1. Western medical etiology and pathology
Studies have shown that about 15% of the first-degree relatives of panic attack patients have the disease, which is 10 times higher than the general population. In contrast, the incidence of generalized anxiety in first-degree relatives does not increase. Therefore, it has been suggested that there may be a different pathogenesis for the two. The findings from monozygotic and dizygotic twins suggest that the role of genetic effects in the pathogenesis of panic attacks is more pronounced in patients with panic attacks than in those with generalized anxiety. In addition, research data show that increased lactate concentration, increased noradrenergic activity, and increased function of 5-HT in the blood of patients can induce anxiety disorders; in conclusion, it may be related to the regulatory state of multiple systems, encompassing structures such as the limbic system, thalamus, and frontal lobes; neurotransmitters in addition to NE and 5-HT are GABA, GABAa receptors coupled to benzene The neurochemical problem of coupling GABA, GABAa receptors and benzodiazepine receptors in addition to NE and 5-HT. There is a relationship between the occurrence of anxiety disorders and psychosocial factors, which is considered by some to be a precipitating effect, and similar effects on the induction of generalized anxiety and panic attacks.
2.TCM etiology and pathogenesis
According to Chinese medicine, the disease is caused by deficiency of qi and blood in the body, injury caused by the seven emotions of panic, deficiency of heart, spleen, liver and gallbladder, internal obstruction of phlegm, heat and blood stasis, and the heart, mind and soul being eroded.
The heart is deficient in Qi and the mind is not in charge; the gallbladder is deficient in decision making; or the heart and spleen are deficient in Qi and blood, and the mind is not nourished; or the Yin and blood are deficient, the Qi is stagnant, the fire hurts the Yin and interferes with the mind; or the phlegm is stagnant and fires, the phlegm-heat disturbs the mind, and the mind is not at peace; or the seven emotions are over-excited, the Qi is stagnant and blood is depressed, the heart and blood are stagnant, and the mind is not in charge. Therefore, the main etiology of this disease is the loss of internal organs or disturbance of the heart by phlegm-heat and blood stasis.
Clinical manifestations
1. Generalized anxiety disorder: It is the most common manifestation of anxiety disorder, accounting for 57% of anxiety disorders. Its main clinical characteristics are frequent or persistent anxiety, including nervousness, fear, excessive worry, etc., accompanied by symptoms of autonomic nervous system dysfunction, mainly manifested clinically by excessive sympathetic nervous system activity, such as dry mouth, sweating, palpitations, shortness of breath, gas congestion, urinary frequency, urinary urgency, etc., and motor symptoms, such as headache, slight tremor, restlessness, etc.
Sleep disorders are often characterized by difficulty in falling asleep, tossing and turning, lying in bed worrying, which may be accompanied by some unpleasant dream experiences; sometimes night terrors and nightmares occur. Patients wake up early in the morning with a groggy mind and no sense of freshness. Sometimes patients wake up with fear, but without a clear object of fear.
Patients with generalized anxiety often combine other symptoms at the same time, the most common being depression, fatigue, obsessive-compulsive symptoms, fear symptoms, depersonalization and other symptoms are not uncommon, although these symptoms are not the main clinical phase or secondary to anxiety.
2. Panic disorder: also known as acute anxiety attack. The disorder accounts for 41.3% of anxiety disorders and is not uncommon clinically. Patients often feel a sudden and inexplicable panic experience when there is no special fearful situation in daily life, and often accompanied by a sense of near death or loss of control, as well as severe symptoms of plant neurological disorders. Patients feel that death is imminent and use running, screaming and calling for help, accompanied by chest tightness, tachycardia, palpitations, dyspnea or hyperventilation, headache, dizziness, vertigo, numbness and abnormal sensation of the limbs, sweating, panic attacks, general shaking or general weakness and other vegetative symptoms. The onset and termination are usually rapid and can be sudden, usually lasting 5 to 20 minutes, rarely lasting an hour, but can be repeated soon. During the attack, there is always a clear consciousness and increased alertness, and after the attack, there are still palpitations and anticipatory anxiety, fearing that the next attack will be uncontrollable and that the person will become insane. Sixty percent of patients have avoidance behavior due to fear of not getting help during an attack, such as not daring to go out alone and not daring to go to crowded places, manifesting as place phobia. Some patients have only one attack in their lifetime, some often have recurrent attacks, the latter being more frequent.
Third, diagnosis and differential diagnosis】
1.Diagnostic points
(1) Western medicine diagnosis points
According to the above clinical manifestations of anxiety disorders, anxiety is the core symptom of the disease, panic disorder is sudden, and the diagnosis of typical patients is generally not difficult. It should be noted that the anxiety symptoms of anxiety disorders refer to the primary ones. Any anxiety secondary to physical illness and other psychiatric disorders such as delusions, depression, and obsessions cannot be diagnosed as anxiety disorder in clinical practice. Panic disorder requires at least three panic attacks within a month, or first attack followed by fear of reoccurrence of anxiety lasting for one month. And the duration of generalized anxiety disorder requires greater than or equal to 6 months.
(2) Key points of TCM diagnosis
The clinical manifestation of this disease is emotional tension, restlessness, easy to be frightened and good at fear, and other symptoms of emotional and mental disturbance. The first thing to do is to identify the deficiency and reality: deficient patients are weak and have a long duration of illness, with deficiency of qi and blood or deficiency of yin and blood as the main manifestations; real patients are mainly manifested by phlegm and heat or internal obstruction of stasis and blood, with more deficiency and less reality. Secondly, we can identify the location of the disease: the main location of the disease involves the heart, spleen, liver, gallbladder and other internal organs. In the heart, palpitations and insomnia; in the spleen, loss of appetite; in the gall bladder, timidity and anxiety; in the liver, impatience and talkativeness. Once again, the severity of the disease: long duration of the disease and the deficiency of positive energy is serious, and vice versa is light; the light is easy to treat, the heavy is difficult to cure.
2.Differential diagnosis
(1) Anxiety associated with somatic diseases.
Many clinical somatic diseases can be accompanied by anxiety symptoms, such as thyroid disease, heart disease, certain neurological diseases such as encephalitis, cerebrovascular disease, systemic lupus erythematosus and so on. Clinically, patients who are first diagnosed, older, without psychological stressors, and with good pre-morbid personality qualities should be alerted to whether anxiety is secondary to a somatic disease. The key points of differentiation include detailed medical history, physical examination, mental status examination and necessary laboratory tests to avoid misdiagnosis.
(2) Pharmacogenic anxiety.
Anxiety can occur during long-term use of certain drugs and during sudden discontinuation or withdrawal of drugs. For example, certain sympathomimetic drugs such as amphetamines, cocaine, caffeine, opioids, long-term use of hormones, sedative-hypnotics, antipsychotics, etc. This can be differentiated by the history of drug use.
(3) Anxiety associated with mental disorders.
Anxiety is often associated with many psychiatric disorders, such as schizophrenia, mood disorders, hypochondria, obsessive-compulsive disorder, phobias, post-traumatic stress disorder, etc. can often be accompanied by anxiety or panic attacks. If the patient is found to have anxiety symptoms during psychiatric examination, if schizophrenia symptoms are found, in principle, the diagnosis of anxiety disorders is excluded; depression and anxiety in mood disorders often have co-morbidity, and when the severity of depression and anxiety are not clearly distinguished in a primary and secondary manner, the diagnosis of depression should be considered first to avoid delaying the treatment of depression and causing serious adverse consequences such as suicide; when other neurological disorders are accompanied by anxiety, anxiety symptoms in When other neurological disorders are accompanied by anxiety, anxiety symptoms are often secondary or secondary to the clinical phase of these disorders.
IV. Treatment
1.Treatment principles
Chinese medicine has good efficacy in treating this disease. Since this disease is mostly a deficiency disease, treatment is generally based on supplementing the deficiency, and supplementing by expelling the evil. The deficiency is mainly to benefit the Qi, nourish the blood and nourish the Yin, in addition to the nimble and tranquilizing products; the actual evidence is mainly to clear the heat and phlegm, resolve the stasis and calm the alarm. In the treatment process, attention should be paid to both pharmacological and psychological treatment, and combined with other methods of comprehensive treatment.
2.Western medicine treatment
(1) Psychological behavior treatment
In general psychotherapy often uses explanation and encouragement to eliminate the patient’s doubts. Targeted psychotherapy is most commonly used for patients with anxiety disorders, such as cognitive therapy, behavioral therapy or cognitive-behavioral therapy. Because anxiety patients have certain personality characteristics such as dissatisfaction with reality, high expectations of life, thinking about everything in a bad way and always worrying about the bad ending, they are often in a state of high alertness and have some distorted cognition, which is one of the reasons for the persistence of the disease. At the same time, patients often have muscle tension caused by anxiety, cardiovascular system and digestive system symptoms caused by plant nerve dysfunction. Reinforcing the distorted perceptions makes the anxiety symptoms viciously worse. Therefore, the application of cognitive methods to change the patient’s distorted perception of the nature of the disease and timely behavioral therapy such as relaxation training and systematic desensitization to deal with anxiety-induced somatic symptoms can receive twice the effect with half the effort. Specific implementation methods are described in the chapter of psychotherapy.
(2) Drug treatment
Benzodiazepines: Benzodiazepines are the most commonly used anxiolytics in clinical practice, with strong anxiolytic effects, fast onset of action, safety, and few adverse drug interactions. Their pharmacological effects are anxiety relief, muscle relaxation, sedation, analgesia and hypnosis, and studies have shown that they have a potentiating effect on antidepressants. According to the length of half-life can be divided into long-range action drugs, medium-range action drugs and short-range action drugs. Long-acting drugs include diazepam, nitrazepam, clonazepam, etc.; medium-acting drugs include alprazolam, norethindrone, chlordiazepoxide, etc.; short-acting drugs include triazolam, etc. Generally speaking, short-range action drugs are used for episodic anxiety; medium- and long-range action drugs are used for persistent anxiety; short- and medium-range action drugs are generally used for those who have difficulty falling asleep, and medium- and long-range action drugs are used for those who are prone to awakening or early awakening. The clinical treatment of panic attacks is still better with intramuscular or oral lorazepam.
Treatment generally starts with a small dose, gradually increases to the best effective treatment amount, maintained for 2-6 weeks and then gradually reduces the amount of medication, the discontinuation process should not be shorter than 2 weeks to prevent the rebound of symptoms.
②Non-benzodiazepines: buspirone and tandospirone are more ideal, with the advantage that they are less likely to produce muscle relaxation and sedation-hypnotism.
③ β-adrenergic receptor blockers: the most commonly used for insulin. These drugs have good efficacy in reducing somatic symptoms such as palpitations, tachycardia, tremor, excessive sweating, shortness of breath or a feeling of suffocation caused by hypertension in patients with anxiety disorders, but they are not effective in reducing mental anxiety and preventing panic attacks. It is generally used clinically in combination with benzodiazepines. The usual dosage is 10mg~30mg/time, 3 times a day. Note that people with a history of asthma are prohibited.
(3) Combination medication: Since antidepressants such as tricyclic drugs (doxepin) and selective 5hydroxytryptamine reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, sertraline and other antidepressants have better effects on certain anxiety patients and are not addictive, the disadvantage is that the onset of action is slow, so the clinical use of benzodiazepines fast onset of action, in the early stage with tricyclic or SSRIS They are used in combination with tricyclic or SSRIS drugs in the early stage, and then benzodiazepines are gradually discontinued. Rarely are benzodiazepines used alone as a long-term treatment to prevent dependence and drug resistance. However, some patients taking SSRIS class can cause anxiety, such patients should not be used, if they must be used can also add a new generation of antipsychotics, such as small doses of quetiapine, olanzapine and so on.
3.Chinese medicine treatment
(1) Identification and treatment
① Heart and gallbladder Qi deficiency
Symptoms: palpitations and timidity, fearfulness, suspiciousness and apprehension, mental confusion, emotional restlessness, restlessness, sleeplessness and dreaminess, pale tongue, thin white fur, and a moving or deficient string pulse.
Treatment: Benefit Qi, nourish the heart, calm the mind.
Formula: Tranquilize the mind and calm the mind pills (“Medical Heart Enlightenment”) plus or minus Chen Fu Ling, Fu Shen, Yuan Zhi, Dang Shen, Sha Shen, Shi Calamus, Dragon’s tooth, Ling Magnet, Amber, roasted licorice, roasted astragalus. Heart and liver yin deficiency add maidenhair and wu wei zi; heart and liver fire add Huang Lian and gentian grass.
② Heart and spleen deficiency
Symptoms: palpitations, panic, insomnia, dizziness, lack of color, tiredness, loss of appetite, loose stools, pale tongue, thin white fur, weak pulse.
Treatment: Benefit Qi and nourish Blood, strengthen the spleen and calm the heart.
Radix: Ginseng, Atractylodes Macrocephala, Radix Astragali, Radix Angelicae Sinensis, Radix Glycyrrhiza Uralensis, Fu Shen, Radix Yuan Zhi, Radix Ziziphi, Radix Ziziphi, Red Date, Ginger.
③Yin deficiency internal heat
Symptoms: suspicious palpitations, little sleep and dreams, the desire to eat can not eat, the desire to sleep can not sleep, the desire to walk can not walk, bitter mouth and urine red, red tongue, slightly yellow coating and less fluid, thin pulse.
Treatment: Nourishing Yin and cooling Blood, clearing heat and tranquilizing the mind.
Prescription: Baihe Dihuang Tang (Jin Kui Yao) combined with Zhi Bai Dihuang Tang (Jin Jian of Medicine) plus or minus Baihe, Sheng Di, Zhi Mu, Huai Shan Yao, Fu Ling, fried jujube seeds, roasted licorice, Dan Pi, Red Peony, Huang Bai. For night sweats, add Wu Wei Zi and Calcined Oyster; for those who are easily frightened by sounds, add Vermilion.
④Phlegm-heat disturbing the heart
Symptoms: Disturbance of the heart, restlessness, sleep at night, anxious and talkative, dizziness and headache, dry mouth and bitterness, red tongue, yellow and greasy coating, slippery pulse.
Treatment: Clearing heat and eliminating phlegm, tranquilizing the mind and calming the spirit.
Huanglian Wenzhi Tang (Six Causes) plus or minus Huanglian, Fuxianxia, Chen Pi, Fu Ling, roasted licorice, Bile South Star, Citrus aurantium, bamboo rhizome, sour date palm, roasted Yuan Zhi, Tianzhu Huang, jiao Shanjian, gentian grass, jujube. Add raw rhubarb for dry stools; add white foxglove for short and red urine.
⑤ Internal obstruction of blood stasis
Symptoms: palpitations and palpitations, restless sleep at night; or sleeplessness at night, suspicious and irritable, chest tightness, sometimes headache and heartache like stabbing; or dark circles under the eyes, dark red tongue with petechiae on the sides; or petechiae on the tongue, purple lips, and astringent or tight pulse.
Treatment: To invigorate blood circulation and resolve blood stasis, and to promote blood circulation and calm the mind.
Treatment: Blood Mansions and Stasis Removal Soup (《Medical Forest Correction》) plus or minus peach kernel, safflower, angelica, Chuanxiong, raw earth, red peony, cow knee, Chai Hu, heliotrope shell, orris, salvia, raw dragon’s tooth, amber powder, licorice.
(2) Acupuncture treatment
(1) Body acupuncture: main points: Fengfu, Baihui, Tongli, Shenmen, Neiguan, etc. For phlegm depression, Lung Yu, He Gu, Li Gu, Tian Tu and Feng Long; for deficiency of Heart Blood, Heart Yu and Spleen Yu; for internal stasis of Blood, Blood Sea and Diaphragm Yu. Except for deficiency of heart blood, diarrhea is used in all cases. For restlessness, Yin Tang, Sun, Shui Gou; for anxiety, San Yin Jiao, Tai Chong; for insomnia, Shen Ting, Si Shen Cong, Yin Tang, San Yin Jiao, etc.
②ear acupuncture: brain point, subcortical, Shen Men, heart, etc. Acupuncture or compressing Wang Bu Liu Xing seeds.
③Electro-acupuncture treatment
Main acupuncture points: Shenmen, Sanyinjiao, Baihui, Fusanli, Dazhi. Choose 2 to 3 points each time.
Identify and match points: heart and gallbladder Qi deficiency with heart Yu and gallbladder Yu; heart and spleen deficiency with heart Yu and spleen Yu; yin deficiency and internal heat, heart and kidney disconnection with heart Yu, kidney Yu and Tai Xi; phlegm and heat with liver and gallbladder upheaval with liver Yu and Tai Chong. Once a day, 20-30 minutes each time.
(3) Qigong treatment
Relaxation gong. The first step is qi adjustment training: through limb tremors, static qi adjustment and limb lifting and opening and closing, adjusting the breathing to reach a fine and deep; the second step is relaxation training: through intention induction, the body is in a relaxed state; the third step is intention to guard the Dantian training: through intention to guard the Dantian and abdominal breathing, to achieve the purpose of concentrating the mind, gathering qi and tranquilizing the brain. The course of treatment is 6 weeks, once every other day, 15 minutes each time.
(4) Specialized prescriptions and medicines
(1) Concentration and relief soup: 30g each of dragon’s tooth and ling magnet, 15g each of jujube, farmer’s root and calamus, 24g of tulip, 12g of sweet pine, 9g each of helianthus bark and licorice, 3g each of amber and cinnabar, and evenly powdered and taken in three doses. It is used to treat anxiety disorders with obvious anxiety symptoms. It is often used in combination with acupuncture, mental and recreational therapy.
②Baihe An Shen Tang: 30g each of Baihui, Oyster, Dai Ochre and Nightshade, 15g each of Shengdi and Sour Jujube, 12g each of Zhi Mu and Bai Shao. 1 dose daily, decoction in water, morning and evening, 10 days for 1 course. In addition, take Sulezade 1~2mg/time or Nitrozade 5~10mg/time before bedtime, mainly for anxiety disorders.
Prevention, care and prognosis
This disease should pay attention to cultivate good living habits, maintain a good mental state, after the disappearance of symptoms should also adhere to the regulation of qi and blood, nourish the heart and brain, and regular review.
The prognosis is related to the quality of the individual, if treated properly, most of the patients will improve in a few weeks; in case of patients with special personality or frequent life events, the prognosis is poor.