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Table of Contents
GUIDELINE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 280-286

International clinical practice guideline of chinese medicine anxiety


3rd Hospital Affiliated to Beijing University of Chinese Medicine, Beijing,100029, China

Date of Submission10-Jan-2021
Date of Acceptance10-Feb-2021
Date of Web Publication24-May-2021

Correspondence Address:
Prof. Qi-Sheng Tang
3rd Hospital Affiliated to Beijing University of Chinese Medicine, Beijing,100029
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wjtcm.wjtcm_29_21

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How to cite this article:
Tang QS. International clinical practice guideline of chinese medicine anxiety. World J Tradit Chin Med 2021;7:280-6

How to cite this URL:
Tang QS. International clinical practice guideline of chinese medicine anxiety. World J Tradit Chin Med [serial online] 2021 [cited 2021 Jun 16];7:280-6. Available from: https://www.wjtcm.net/text.asp?2021/7/2/280/316606




  Foreword Top


Patent issues may be existed in this guideline, and the World Federation of Chinese Medicine Societies (WFCMS) declared that they are not responsible for identifying these patents.

International Clinical Practice Guideline of Chinese Medicine-Anxiety is based on the Guidelines for Diagnosis and Treatment of Common Internal Diseases in Chinese Medicine-Anxiety (Standard No. ZYYXH/T 132-2008) published by the China Association of Chinese Medicine in 2008. Combined with clinical study evidence at home and abroad in recent years, as well as evidence grading and opinion recommendation, after expert discussion, this guideline was formed.

The main drafting committee of this guideline: The Third Affiliated Hospital of Beijing University of Chinese Medicine.

The drafting committee of this guideline: Xuanwu Hospital of Capital Medical University, American Institute of Health in Traditional Chinese Medicine, College and Association of Acupuncturists of Alberta Canada, Kumamoto Kampo Institute of Japan, Queen Mary University of London, et al.

The main drafters of this guideline: Qi-Sheng Tang, Miao Qu, Wen-Jun Sun.

The drafters and review experts of this guideline: Chang-Qing Yang, Wang-Lin Boxin, Ji-En Zhao, Ping Wang, et al.

Based on the previous version, this guideline structurally adds a foreword, introduction, scope, normative references, terms and definitions, and the corresponding content of the English version; in terms of content, it updates the diagnostic criteria of Western medicine and the diagnostic criteria of Chinese medicine and adds evidence grading and level recommendation for the intervention programs.

This guideline is drafted according to the Measures of International Standard of WFCMS and Guideline Setting and Publishing Work Norms (SCM 0001-2009) by WFCMS.

This guideline is published by the WFCMS.

All rights are reserved.


  Introduction Top


At present, there is still a lack of international standards and guidelines for prevention and treatment of anxiety in Chinese medicine, which makes the study on the treatment of anxiety in Chinese medicine lack of international influence and lack of unity and recognition. Therefore, based on the previous version, this guideline intends to integrate and absorb the study results and successful experience of the prevention and treatment of anxiety in Chinese medicine at home and abroad and draw on the evidence-based medicine method to grade and recommend modern clinical study literature and ancient documents on anxiety, so as to draft a clinical practice guideline of Chinese medicine in the prevention and treatment of anxiety. This guideline plays an important role in normalizing the use of Chinese medicine methods and improving clinical efficacy in treating anxiety.

Literature retrieval, a Delphi method questionnaire survey, expert interviews, and conference discussion were used for formulation of this guideline. At first, a guideline drafting group was set up to form a list of initial issues, draft key issues, and outcomes in the participants, interventions, comparisons, and outcomes format, and develop a work plan. Retrieval strategies were based on the key issues and outcomes, and the literature retrieval covered Chinese literature (including modern literature and ancient documents), English literature, and existing relevant international guidelines. According to the grading suggestion of traditional medical evidence and the grading suggestion of the ancient document evidence on Chinese medicine, quality evaluation and evidence grading of the literature were carried out. The Delphi method was used to obtain clinical experts' consensus on the guideline, and the final guideline was formed after the expert discussion.

This guideline mainly provides the prevention, healthcare, diagnosis, and treatment recommendations of Chinese medicine for anxiety. It recommends the diagnosis and treatment of anxiety in Chinese medicine with evidence-based medical evidence; guides standard use of Chinese medicine and clinical practice for clinicians, nurses, and patients; and improves awareness of patients and their families about prevention and treatment knowledge of anxiety in Chinese medicine.


  International Clinical Practice Guideline of Chinese Medicine Anxiety Top


1. Scope

This guideline specifies terms and definitions, clinical manifestations, syndrome differentiation, medication, and other therapies for anxiety.

This guideline is applicable to the prevention and treatment of Chinese medicine for anxiety such as generalized anxiety and panic disorder. It applies to neurologists, psychiatrists, Chinese medicine practitioners, nurses, and patients as a reference.

2. Normative references

Contents of the following reference documents constitute indispensable clauses of this guideline through normative citing. For dated reference documents, only the dated version applies. For undated reference documents, the latest version (including any amendments) applies.

  • ZYYXH/T 132-2008, Guidelines for Diagnosis and Treatment of Common Internal Diseases in Chinese Medicine – Anxiety
  • World Health Organization. ICD-10 Classification of Mental and Behavioural Disorders Diagnostic Criteria for Research. Geneva: World Health Organization: 1993
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington: American Psychiatric Association; 2013.


3. Terms and definitions

The following terms and definitions apply for this guideline.

3.1. Anxiety

Anxiety is characterized by extensive and persistent anxiety or recurrent episodes of panic disorder, often accompanied by autonomic disorders and motor disorders.

Note 1: Clinically, it is divided into two main forms – generalized anxiety and panic disorder.

Note 2: According to clinical manifestations and characteristics, the disease can be attributed to the category of mental diseases. Anxiety is equivalent to “depression,” “fright palpitation,” “severe palpitation,” “insomnia,” “amnesia,” “lily disease,” “kidney amassment,” and “lantern disease” in Chinese medicine.

4. Clinical manifestations

4.1 Generalized anxiety

4.1.1 Psychogenic anxiety

Psychogenic anxiety is the core symptom of anxiety. It is characterized by fear and nervousness without clear objects and specific content or excessive worry or annoyance about certain problems in real life. The patient knows that this is a subjective concern, but it cannot be controlled.

4.1.2 Somatic anxiety

Somatic anxiety is mainly the manifestation of autonomic nerve hyperactivity. Its symptoms involve multiple systems, which is often the initial chief complaint of the patient, such as dry mouth, upper abdominal discomfort, nausea, swallowing obstruction, borborygmus, abdominal pain, abdominal distension, diarrhea, dyspnea or tachypnea, dizziness, palpitation, chest discomfort, tachycardia, frequent urination, urgent urination, impotence, premature ejaculation, sexual hypoactivity, irregular menstruation, excessive sweating, and facial flushing or paleness.

4.1.3 Psychological alertness

It can be characterized by irritability, decreased concentration, and sensitivity to noise. Because of the inability to concentrate, the patient is often accompanied by memory loss.

4.1.4 Motor restlessness

Motor restlessness is related to muscle tension. It can manifest as restlessness, trembling, inability to relax, as well as pain in the head (usually bilateral, with forehead or occiput), shoulders, and back.

4.1.5 Sleep disorder

It manifests as difficult to fall asleep and easy to wake up after falling asleep. The patient often complains of nightmares and night terrors, which appear to wake up suddenly and often feel extreme fear.

4.2 Panic disorder

4.2.1 Typical manifestations of attack

Often, the patient suddenly has a strong fear in his/her daily activities, as if he/she is about to die (a sense of death) or is about to lose his/her sense of reason (out of control), making the patient intolerable. At the same time, the patient feels palpitation, chest tightness, chest pain, shortness of breath, and a choking sensation in the throat, so he/she screams, calls for help, or runs out of the room. Some are accompanied by significant autonomic symptoms such as hyperventilation, dizziness, excessive sweating, facial flushing or paleness, tremors, numbness of hands and feet, and gastrointestinal discomfort, as well as painful experiences, such as depersonalization and derealization.

4.2.2 Panic attack characteristics

The attack is not limited to any particular situation or a certain type of environment. It is a sudden attack that peaks within 10 min, generally no more than 1 h. Consciousness is clear at the time of the attack, and the course of attack can be recalled afterward. Although this attack lasts for a short time, soon it can be repeated again.

  1. Anticipatory anxiety: Most patients are nervous during the intermittent period due to fear of recurrence, and some symptoms of autonomic nerve hyperactivity may occur
  2. Help-seeking and avoidance behavior: The strong fear during a panic attack makes the patient intolerable and often urges help. During the intermittent period, most patients are worried about not getting help during an attack. Therefore, they voluntarily avoid some activities, such as not wanting to go out alone, not wanting to go to a crowded place, or not traveling by bus. They need to be accompanied when they go out.


4.3 Physical–chemical examination

So far, no specific physical and chemical indicators have been found for anxiety. Clinically, anxiety assessment scales are used to evaluate the severity of anxiety, including the self-rating scale and examiner-rating scale, such as Zung Self-Rating Anxiety Scale, Hamilton Anxiety Scale, and Generalized Anxiety Disorder Scale.

5. Syndrome differentiation

5.1 Syndrome of liver depression transforming into fire

Restlessness, depression and dysphoria, chest and hypochondriac distending pain, oppression in stomach with belching, no appetite, irregular stool, impatience and irritability, bitter taste in mouth, dry mouth, headache, red eyes, tinnitus, gastric upset and acid regurgitation, constipation, red tongue, yellow coating, stringy pulse or stringy and rapid pulse.

5.2 Syndrome of internal blockade of static blood

Palpitation or severe palpitation, restless sleep at night, insomnia, excessive suspicion and dysphoria, chest tightness, headache and stabbing pain in the chest from time to time, dark red tongue with ecchymosis on the edge or petechiae on the surface, dark purple lips or dark eyes, hesitant pulse or stringy and tight pulse.

5.3 Syndrome of phlegm-fire disturbing heart

Panic and restless, upset and distraction, irritability and excessive talk, fright during sleeping, dizzy and headache, bitter taste in mouth, dry mouth, red tongue with yellow and greasy coating, slippery and rapid pulse.

5.4 Syndrome of deficiency of both heart and spleen

Palpitation and dizziness, fear and fright, insomnia and dreaminess, lusterless complexion, fatigue, lack of appetite, pale tongue, thin coating, thready and weak pulse.

5.5 Syndrome of qi deficiency of heart and gallbladder

Palpitation and timidity, fear and fright, trance, restlessness, fidget, insomnia and dreaminess, excessive suspicion and consideration, pale tongue, thin and white fur or normal coating, deep pulse or feeble and stringy pulse.

5.6 Syndrome of disharmony between heart and kidney

Depressed mood, sentimentality, dysphoria and insomnia, palpitation and restlessness, amnesia, dizziness and tinnitus, soreness and weakness of the waist and knees, feverishness in palms and soles, dry mouth with less fluid, or night sweating, red tongue, thin coating, thready pulse or thready and rapid pulse.

5.7 Syndrome of kidney deficiency and liver depression

Depressed mood, lassitude and fatigue, lags in response, dysphoria and irritability, soreness and weakness of waist and knees, shortness of breath and chest oppression, frequent signing, amnesia, insomnia and dreaminess, pale or dark tongue, white coating, deep and thready pulse, or deep and stringy pulse.

6. Medication

6.1 Basic therapeutic principles

This disease belongs to radical deficiency and symptomatic excess, which is a syndrome of intermingled deficiency and excess. The radical deficiency is mainly deficiency of kidney essence, deficiency of both heart and spleen, and qi deficiency of heart and gallbladder. The symptomatic excess is mainly liver depression and qi stagnation, turbid phlegm, and blood stasis. It is necessary to pay attention to distinguishing yin, yang, deficiency, and excess and to keep an eye on the law of taking both deficiency and excess into account. Excess syndromes need to be treated by regulating qi and resolving stagnation or accompanied by activating blood circulation, clearing heat, dissipating phlegm, and eliminating dampness; deficiency syndromes need to be treated by nourishing heart, invigorating spleen, nourishing liver, and supplementing kidney.

6.2 Syndrome of liver depression transforming into fire

Therapeutic methods

Clearing liver fire, as well as regulating qi and facilitating the middle.

Prescription

Modified Danzhi Xiaoyao Power (Evidence level: I; highly recommend). Danpi (Cortex Moutan Radicis) 15 g, Zhizi (Fructus Gardeniae) 15 g, Shengdi (Radix Rehmanniae Recens) 15 g, Huangqin (Radix Scutellariae) 10 g, Chaihu (Radix Bupleuri) 12 g, Xiangfu (Rhizoma Cyperi) 12 g, Zhiqiao (Fructus Aurantii) 10 g, Chenpi (Pericarpium Citri Reticulatae) 10 g, Chuanxiong (Rhizoma Ligustici Chuanxiong) 15 g, Baishao (Radix Paeoniae Alba) 12 g, Fuling (Poria) 20 g, Baizhu (Rhizoma Atractylodis Macrocephalae) 15 g, Danggui (Radix Angelicae Sinensis) 12 g, and Zhigancao (Radix Glycyrrhizae Preparata) 6 g are included.

Modified

If combined with severe thermal potential, bitter taste in mouth, and constipation, Longdancao (Radix Gentianae) 9 g and Dahuang (Radix et Rhizoma Rhei, decocted later) 6 g are added for purging heat and catharsis. If combined with liver fire invading stomach, hypochondriac pain, bitter taste in mouth, gastric upset and acid regurgitation, as well as belching and vomiting, Huanglian (Rhizoma Coptidis) 6 g and Wuzhuyu (Fructus Evodiae) 9 g are added. If combined with liver fire flaring up, headache, red eyes, and tinnitus, Juhua (Flos Chrysanthemi) 10 g, Gouteng (Ramulus Uncariae Cum Uncis, decocted later) 10 g, and Cijili (Fructus Tribuli) 12 g are added.

6.3 Syndrome of internal blockade of static blood

Therapeutic methods

Activating blood circulation and resolving stasis, as well as regulating qi and dredging collaterals.

Prescription

Modified Xuefu Zhuyu Decoction (Evidence level: I; highly recommend). Taoren (Semen Persicae) 12 g, Honghua (Flos Carthami) 9 g, Danggui (Radix Angelicae Sinensis) 10 g, Shengdi (Radix Rehmanniae Recens) 15 g, Chuanxiong (Rhizoma Ligustici Chuanxiong) 5 g, Chishao (Radix Paeoniae Rubra) 15 g, Niuxi (Radix Achyranthis Bidentatae) 10 g, Jiegeng (Radix Platycodonis) 5 g, Chaihu (Radix Bupleuri) 3 g, Zhiqiao (Fructus Aurantii) 6 g, Gancao (Radix Glycyrrhizae) 3 g, Dangshen (Radix Salviae Miltiorrhizae) 30 g, Shenglongchi (Dens Draconis) 30 g, and Hupofen (Succinum) 6 g are included.

Modified

If combined with a cool sensation outside the body, hidrosis, and aversion to wind, Fangfeng (Radix Saposhnikoviae) 10 g, Maidong (Radix Ophiopogonis) 10 g, Wuweizi (Fructus Schisandrae Chinensis) 10 g, and Yuanshen (Radix Scrophulariae) 20 g are added. If combined with obvious distending pain, Xiangfu (Rhizoma Cyperi) 12 g, Qingpi (Pericarpium Citri Reticulatae Viride) 9 g, and Yujin (Radix Curcumae) 12 g are added. If combined with poor appetite and stomach distension, Jiaosanxian (Jiaomaiya, fried Fructus Hordei Germinatus; Jiaoshanzha, fried Fructus Crataegi; and Jiaoshenqu, fried Massa Medicata Fermentata) 12 g of each and Chenpi (Pericarpium Citri Reticulatae) 10 g are added. If combined with cold manifestations, Wuyao (Radix Linderae) 9 g and Muxiang (Radix Aucklandiae) 12 g are added. If combined with heat manifestations, Danpi (Cortex Moutan Radicis) 10 g and Zhizi (Fructus Gardeniae) 12 g are added.

6.4 Syndrome of phlegm-fire disturbing heart

Therapeutic methods

Clearing heat and clearing phlegm, as well as calming heart for tranquillization.

Prescription

Modified Huanglian Wendan Decoction (Evidence level: I; highly recommend). Huanglian (Rhizoma Coptidis) 10 g, Fabanxia (Rhizoma Pinelliae Preparatum) 15 g, Chenpi (Pericarpium Citri Reticulatae) 6 g, Fuling (Poria) 15 g, Zhigancao (Radix Glycyrrhizae Preparata) 6 g, Dannanxing (Rhizoma Arisaematis Cum Bile) 10 g, Zhishi (Fructus Aurantii Immaturus) 10 g, Zhuru (Caulis Bambusae in Taenia) 10 g, Dazao (Fructus Jujubae) 10 pieces, Suanzaoren (Semen Ziziphi Spinosae) 15 g, Zhiyuanzhi (Radix Polygalae Praeparata) 10 g, Jiaoshanzhi (Fructus Gardeniae Praeparatus) 10 g, Longdancao (Radix Gentianae) 10 g, Shenglongchi (Dens Draconis, decocted first) 15 g and Qingmengshi (Lapis Chloriti, decocted first) 30 g are included.

Modified

If combined with exuberant excess fire and dysphoria, Huanglian (Rhizoma Coptidis) 15 g can be added to support clearing fire and calming heart. If combined with phlegm exuberance, Zhebei (Bulbus Fritillariae Thunbergii) 20 g and Shichangpu (Rhizoma Acori Tatarinowii) 30 g are added. If long-time heat causes damage to both qi and yin, Wuweizi (Fructus Schisandrae Chinensis) 10 g and Huangjing (Rhizoma Polygonati) 10 g are added.

Syndrome of deficiency of both heart and spleen

Therapeutic methods

Nourishing blood and invigorating spleen, as well as calming heart and relieving anxiety.

Prescription

Modified Guipi Decoction (Evidence level: I; highly recommend). Dangshen (Radix Salviae Miltiorrhizae) 15 g, Fushen (Sclerotium Poriae Pararadicis) 10 g, Baizhu (Rhizoma Atractylodis Macrocephalae) 10 g, Gancao (Radix Glycyrrhizae) 6 g, Huangqi (Radix Astragali seu Hedysari) 10 g, Danggui (Radix Angelicae Sinensis) 12 g, Longyanrou (Arillus Longan) 15 g, Suanzaoren (Semen Ziziphi Spinosae) 15 g, Yuanzhi (Radix Polygalae) 10 g, Muxiang (Radix Aucklandiae) 9 g, Dazao (Fructus Jujubae) 5 pieces, and Shengjiang (Rhizoma Zingiberis Recens) 3 pieces are included.

Modified

If combined with obvious symptoms of heart yin deficiency such as palpitation, insomnia, and red tongue with less coating, Baihe (Bulbus Lilii) 15 g, Baiziren (Semen Platycladi) 12 g, and Zhishouwu (Radix Polygoni Multiflori Praeparata) 12 g are added for nourishing heart for tranquillization. If combined with anorexia and eating less, abdominal distension after eating, shortage of qi, and laziness to speak, so Dangshen (Radix Salviae Miltiorrhizae) is heavily used at 20 g, and Sharen (Fructus Amomi Villosi, decocted later) 6 g, and Chenpi (Pericarpium Citri Reticulatae) 15 g.

6.6 Syndrome of Qi deficiency of heart and gallbladder

Therapeutic methods

Suppressing fright and calming the mind, as well as calming heart for tranquillization.

Prescription

Modified Anshen Dingzhi Pills (Evidence level: I; highly recommend). Renshen (Radix Ginseng) 9 g, Fuling (Poria) 12 g, Fushen (Sclerotium Poriae Pararadicis) 12 g, Yuanzhi (Radix Polygalae) 10 g, Shichangpu (Rhizoma Acori Tatarinowii) 9 g, Longchi (Dens Draconis) 30 g, Danggui (Radix Angelicae Sinensis) 12 g, Baishao (Radix Paeoniae Alba) 12 g, and Baizhu (Rhizoma Atractylodis Macrocephalae) 12 g are included.

Modified

If combined with dysphoria and insomnia, Suanzaoren (Semen Ziziphi Spinosae) 20 g and Cishi (Magnetitum, decocted first) 30 g are added. If combined with fright and timidity, Zhenzhumu (Concha Margaritifera, decocted first) 30 g, Longgu (Os Draconis, decocted first) 30 g, and Muli (Concha Ostreae, decocted first) 30 g are added.

6.7 Syndrome of disharmony between heart and kidney

Therapeutic methods

Nourishing yin and clearing heart, as well as nourishing brain for tranquillization.

Prescription

Modified Jiaotai Pills (Evidence level: I; highly recommend). Huanglian (Rhizoma Coptidis) 10 g, Rougui (Cortex Cinnamomi) 5 g, Dengxincao (Medulla Junci) 10 g, Zhimu (Rhizoma Anemarrhenae) 10 g, Huangbai (Cortex Phellodendri) 10 g, and Shengdi (Radix Rehmanniae Recens) 20 g are included.

Modified

If combined with severe deficient fever, low fever, and feverishness in palms and soles, Baiwei (Radix Cynanchi Atrati) 10 g and Maidong (Radix Ophiopogonis) 10 g are added for clearing deficient heat. If combined with insomnia, Hehuanpi (Leguminosae) 15 g and Suanzaoren (Semen Ziziphi Spinosae) 15 g are added.

6.8 Syndrome of kidney deficiency and liver depression

Therapeutic methods[11]

Benefiting kidney and regulating qi, as well as resolving depression for tranquillization.

Prescription

Modified Jieyou Anlv Formula (Evidence level: I; highly recommend). Zhizi (Fructus Gardeniae) 10 g, Dengxincao (Medulla Junci) 10 g, Yujin (Radix Curcumae) 30 g, Ciwujia (Radix et Caulis Acanthopanacis Senticosi) 30 g, Guanyejinsitao (Herba Hyperici Perforati) 10 g, Shanyurou (Fructus Corni) 15 g, Zishiying (Fluoritum) 20 g Zhishi (Fructus Aurantii Immaturus) 15 g, and Tianma (Gastrodia elata BI.) 20 g are included.

Modified

If it tends to be liver depression, Foshou (Fructus Citri Sarcodactylis) 15 g and Meiguihua (Flos Rosae Rugosae) 10 g are added. If it tends to be yang deficiency, vital gate fire should be warmed and nourished, Bajitian (Radix Morindae Officinalis) 15 g and Gouqizi (Fructus Lycii) 12 g are added for supplementing kidney origin, and Duzhong (Cortex Eucommiae) 9 g and Tusizi (Semen Cuscutae) 12 g are added for supplementing kidney essence. If it tends to be yin deficiency, and kidney yin should be nourished, Shudi (Radix Rehmanniae Preparata) 12 g and Huangjing (Rhizoma Polygonati) 10 g are added. If combined with insomnia and dysphoria, Cishi (Magnetitum, decocted first) 30 g is added for tranquillization.

7. Other therapies

7.1 Acupuncture

Fengfu (GV16), Baihui (GV20), Shenmen (TF4), Tongli (HT5), and Neiguan (PC6) are selected as main acupoints. Taichong (LR3) and Hegu (LI4) are added for the syndrome of liver depression transforming into fire. Xuehai (SP10) and Geshu (BL17) are added for the syndrome of internal blockade of static blood. Fenglong (ST40) and Yinlingquan (SP9) are added for the syndrome of phlegm-fire disturbing heart. Xinshu (BL15) and Pishu (BL20) are added for the syndrome of deficiency of both heart and spleen. Xinshu (BL15) and Danshu (BL19) are added for the syndrome of qi deficiency of heart and gallbladder. Xinshu (BL15), Shenshu (BL23), and Taixi (KI3) are added for the syndrome of disharmony between heart and kidney. Shenshu (BL23) and Taixi (KI3) are added for the syndrome of kidney deficiency and liver depression. The reinforcing-reducing method by lifting–thrusting and twirling as well as the even reinforcing-reducing method are applied. Retain the needles for 30–60 min and manipulate them every 10 min, 1 time every other day, and 10 times as a course of treatment (Evidence level: I; highly recommend).

7.2 Psychotherapy

7.2.1 Cognitive-behavioral therapy

In the cognitive-behavioral therapy, behavioral correction techniques are used to change patients' unreasonable cognitive perceptions, thereby curing the disease.

First, establish a good doctor–patient relationship with the patients, understand their psychological problems and related causes, and let them understand the nature of anxiety, the essence of panic, the cognitive bias of invasive thoughts, and the vicious circle between catastrophizing thoughts of panic and panic reaction by explaining and asking questions, so as to make them understand the mechanism of psychotherapy and increase their hope and confidence in healing.

Second, help the patients reconstruct new correct cognition, including identifying automatic ideas, identifying cognitive errors, authenticity testing, as well as attention and monitoring of anxiety levels.

Finally, assign homework. Homework allows them to practice new behaviors and help them establish new conditioned reflex (Evidence level: I; highly recommend).

7.2.2 Analytical psychotherapy


  7.2.2.1Develop plan Top


Learn more about the medical history, determine treatment goals, and develop a treatment plan.


  7.2.2.2Analyze psychological problems Top


It is necessary to point out psychological problems of patients' anxiety and fear, analyze psychological conflicts hidden behind symptoms, analyze and explain to them in plain language, carefully remind them the problems ignored, help them recognize the influence of psychological conflicts in the subconscious on anxiety and fear symptoms and the root of the current symptoms, inspire the patients to explore themselves, to eliminate inappropriate emotions and behavior patterns, and prompt them to face life with more realistic and mature attitudes and behaviors. Finally, eliminate symptoms and achieve longer lasting efficacy (Evidence level: I; week recommend).

7.2.3 Morita therapy


  7.2.3.1 Inpatient treatment Top


It can be divided into four phases:

The first phase is the absolute bed rest period, which allows the patients to be almost absolute bed rest, except for eating, urination, and defecation, making the patients feel troubled and his physical and mental fatigue adjusted.

The second phase is the light work period, during which the bed rest time is reduced, and the air and sunlight are received outdoors during the day to promote spontaneous activities of their mind and body.

The third period is the heavy work period, during which the patients can freely choose various heavy physical labor and guide them to develop stamina on work unconsciously.

The fourth phase is the social rehabilitation period, during which the patients' external change training is performed, making the patients have insight into their own normality and fundamentally promote their natural healing power (Evidence level: I; highly recommend).


  7.2.3.2 Outpatient treatment Top


Let the patients naturally accept anxiety and fear, taking what they should do as a real purpose and a guideline of behavior. Inspire the patients to “start from now,” “make real life full of energy,” and “live like a healthy person to become healthy.” Guide the patients to strive to carry forward strengths of their character, avoid shortcomings, gradually cultivate their character, and guide patients in life. Change actions of the patients to promote recovery of anxiety and fear (Evidence level: I; weak recommend).

7.2.4 Supportive psychotherapy

For patients with short course of disease or unsuitable for other psychotherapy, supportive psychotherapy can be used alone. First, establish a good relationship with the patients to gain the trust from the patients. Second, give scientific analysis and explanation on the patients' condition and the cause of the disease, give the patients comfort, encouragement, and appropriate assurance, strengthen the patients' confidence in overcoming anxiety and fear, encourage them to be active to participate in some social activities, cultivate their strong interest in beneficial things and open personality, exercise their will, and support the patients to adapt to the real environment (Evidence level: I; weak recommend).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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