The internet is full of supposedly “amazing,” “natural” cure-alls for anxiety. Unfortunately, a lot of these claims are over-hyped, and often not based on science! In this post, we’ll run through some of the lifestyle and dietary approaches to controlling anxiety, and review what the latest science says about each one.
Disclaimer: This post is not a recommendation or endorsement for any particular type of mental health treatment, either for anxiety disorders or otherwise. The only way to be sure you get effective treatment is to discuss your options with your personal doctor – and none of the complementary approaches described below should ever be used to replace what your doctor has prescribed or recommended. We have written this post for informational purposes only, and its goal is simply to inform our readers about the science behind some complementary approaches to alleviating anxiety, and what we currently know about how they might work.
What is Anxiety?
Anxiety disorders are a group of psychiatric disorders including social anxiety, generalized anxiety, panic disorder, PTSD, OCD, and phobias [1].
Common anxiety symptoms include inner turmoil, nervous behavior, and excessive rumination [2].
Flawed processing of threat is theorized to be the common underlying factor in contributing to anxiety disorders [3].
While it is certainly helpful to experience fear and vigilance in response to an actual threat, someone with anxiety will interpret non-threatening signals as threatening, thus maintaining an unnecessarily high state of worry and arousal [4].
Underlying this exaggerated fear response is a network of brain structures that function improperly in response to stimuli. The amygdala, which controls fight-or-flight threat response, is often overactive [5].
On the contrary, the prefrontal cortex, which inhibits the fear-generation of the amygdala, is underactive [6].
Impaired activity of the hippocampus, striatum, anterior cingulate cortex, and insula can also be involved in anxiety [7].
These neural “malfunctions” can be accompanied by disturbances in neurotransmitters (serotonin, norepinephrine, dopamine, GABA), neurotrophic factors (nerve growth factor, BDNF), the HPA axis, immune function, heart rate variability, and cognitive function [8].
Now that we know what we’re up against, here are some tools you can use to overcome anxiety.
Anxiety: Why Take A “Complementary” Approach?
While there are many pharmaceutical drugs that have been developed which can treat anxiety relatively safely and effectively, it is unfortunately also the case that these can often have negative side-effects in some people [9].
For these reasons, there’s a lot of people out there who are skeptical about jumping right into using medical drugs to control their anxiety, and who are curious about complementary approaches that might be more “natural”, or which don’t rely on psychiatric medications [10].
However, before we begin we want to stress that this post is not an endorsement for- or against any particular mode of treatment! Nor are the strategies outlined in this post intended to be used as a replacement for conventional medical care in any way.
If you are ever diagnosed with a mental health condition of any kind, the only way to decide what the best treatment for your specific case might be is to discuss it with your doctor. Only a fully-qualified medical professional fully understands all the different advantages and drawbacks associated with the many different possible modes of treatment – and they will work with you to come up with the safest and most effective approach for your individual needs.
With that in mind, in the rest of this post we’ll discuss some of the many non-drug-based treatments for anxiety and other related mood symptoms, and what science currently says about them.
Complementary Behavioral and Lifestyle Strategies
Possibly Effective
1) Cognitive-Behavioral Therapy (CBT)
CBT is one of the most widely-used evidence-based strategies for reducing anxiety [9].
People who do CBT aim to develop coping strategies to solve current problems and modify unhelpful cognitive patterns (thoughts, beliefs, and attitudes), behaviors, and emotions [11].
CBT is traditionally delivered in-person by therapists, but is also sometimes administered over the internet with or without therapist involvement (also known as “self-guided” forms of therapy).
In the treatment of anxiety, some studies have reported that internet-based CBT can be as effective as face-to-face CBT [12], although this is not always the case [9].
Because therapist involvement is not always feasible (or even preferred) for some people, self-guided CBT can also be used. Self-guided internet-based CBT reportedly reduced general anxiety, social anxiety, fear of public speaking, and depression in studies of 235, 81, and 127 people [13, 14, 15].
Mechanism
CBT has been claimed to reduce cognitive reappraisal frequency, subtle avoidance, cognitive distortions, safety behaviors, and rumination [16].
On a biological level, these changes may be due to CBT reducing activity in the amygdala and hippocampus – brain areas which are involved in emotional processing – and increasing activity in the prefrontal cortex and anterior cingulate cortex – which perform cognitive processing [17].
How to Implement
MoodGYM is a freely available and moderately effective online cognitive behavioral therapy program for anxiety [18].
Limitations
Self-guided CBT is often not as effective as in-person CBT, but at least one meta-analysis has concluded that self-guided CBT can still have at least some positive effect on anxiety [9].
According to some researchers, one of the biggest challenges of self-guided CBT is low participant adherence to the protocol [19]. Therefore, individuals who want to perform self-guided CBT should consider their commitment to the program before starting.
2) Mindfulness Meditation
The practice known as “mindfulness” is simply paying full attention to what’s happening in the present moment [20]. It can be performed throughout the day by being “in-tune” to what you are experiencing, although it is often developed through meditation techniques as well.
Meditation is a type of mental training that aims to improve attentional and emotional control [21].
Meditation can be “attention-focused” (such as “transcendental meditation” and “mantra meditation”) or “awareness-focused” (as in “mindfulness meditation”) [22]. These three types are the most-studied forms of meditation for anxiety. However, some have reported that mindfulness meditation may be the only form of meditation that reliably improves anxiety [23].
The goal of mindfulness meditation is detached self-observation. Think of it as becoming a “witness” rather than a “judge” of events that happen about you (sounds, inner thoughts, etc.).
During mindfulness meditation, a person is typically instructed to concentrate on one main object (usually their breath) in order to stabilize their attention, and then expand their awareness “outward” towards bodily sensations, thoughts, memories, emotions, perceptions, intuitions, etc. This “expansion” happens gradually over a number of meditation sessions as the person gains more practice and experience with the technique [22].
According to one study, one single twenty-minute session of mindfulness meditation was reported to reduced anxiety in 15 healthy subjects [24].
Additionally, mindfulness-based stress reduction was reported to decrease social anxiety with the same effectiveness as CBT in a study of 108 participants [16].
A systematic review of scientific literature recently concluded that mindfulness-based cognitive therapy is an effective approach for reducing anxiety [25].
Mechanism
Mindfulness meditation has been reported to lead to improvements in attention and emotion self-control [26] – both of which are important factors when it comes to promoting a healthy, positive mood.
A region of the brain called the anterior cingulate cortex is believed to control executive attention to resolve emotions [27]. Relatedly, reduced activity in this brain region has been associated with generally higher levels of anxiety [28].
However, experienced meditators have been reported to have greater anterior cingulate cortex activity [29], and meditation therapy improves anterior cingulate cortex activation [30]. Therefore, this may be one of the mechanisms by which practicing meditation leads to anxiety relief over time.
According to other studies, increased dorsolateral prefrontal cortex activation follows from practicing a mindfulness-based stress reduction program in people with social anxiety [31]. The dorsolateral prefrontal cortex is believed to be centrally involved in working memory, cognitive flexibility, and planning [32].
According to one study of a mindfulness-based stress reduction program, participants were reported to show lowered amygdala activation, ventrolateral prefrontal cortex activation, and increased functional connectivity between the amygdala and prefrontal cortex regions [33]. These changes have been proposed to be responsible for some of the associations with decreased anxiety symptoms.
Heightened amygdala activation is frequently reported by studies on multiple different forms of anxiety [5], although ventrolateral prefrontal cortex activation is associated with social anxiety, specifically [34].
It has also been reported that people who meditate may have increased GABA levels, and reduced levels of cortisol and norepinephrine, which may further contribute to some of the effects observed in mindfulness meditation studies [35, 36].
How to Implement
Guidelines for meditation are readily available through many websites and consumer apps.
3) Applied Relaxation
“Applied relaxation” is the name for a technique used to develop relaxation skills through diaphragmatic breathing and progressive muscle relaxation. These techniques are typically applied in response to early signs of anxiety [37].
According to a handful of studies, applied relaxation techniques have been reported to reduce general anxiety, excessive worry, and tension in studies of 41, 26, and 18 adults with general anxiety [38, 39, 37]. In some cases, these improvements were reported to be maintained for up to one year after initial treatment.
Mechanism
According to one case study, those who practiced applied relaxation became more accepting, mindful, and non-judgmental of their perceptions and thoughts [40]. The development of these characteristics was associated with lower anxiety.
There is also some evidence that applied relaxation improves anxiety by reducing muscle tension [41]. However, more research is needed to fully support this claim.
How to Implement
Computer-delivered applied relaxation was reported to be as effective as therapist-guided applied relaxation in reducing emotional stress and improving relaxation, as reported by a study of 60 adults [42].
Insufficient Evidence
4) Yoga
Yoga is a form of exercise that involves physical poses, breath control, and meditation [43].
A large body of evidence supports the benefits of yoga in reducing anxiety [44].
For example, practicing yoga was reported to improve mood, quality of life, and anxiety compared to a walking group in a study of 34 participants [45].
According to one study, yoga practice reportedly reduced anxiety in 300 individuals [46].
One study reports that participation in a 2-month yoga class reduced self-perceived anxiety levels in 65 women suffering from anxiety disorders [47].
Among 20 patients with hypertension, yoga was reported to reduce blood pressure, alleviate stress, and reduce anxiety and other negative emotions [48].
In 238 individuals with hypertension, hatha yoga was associated with decreased heart rate, blood pressure, anxiety, and perceived stress [49].
A type of yoga called Iyengar yoga was reported to reduce blood pressure, anxiety, and perceived stress in 20 women with restless-leg syndrome, as well as improved their overall mood and sleep quality [50].
A yoga program called trauma-sensitive yoga has been associated with reduced symptoms of PTSD, depression, and anxiety in women with PTSD stemming from intimate-partner violence [51].
A group yoga therapy program reportedly lowered anxiety and stress in patients with PTSD [52].
Mechanism
Although the precise biological mechanisms behind yoga’s effects are not yet fully known, some early evidence provides some clues.
Some researchers have proposed that yoga may reduce anxiety by improving HPA-axis function and increasing GABA. Yoga was also reported to reduce levels of salivary cortisol, which was accompanied by reduced depression, anxiety, and perceived stress, in several studies in 56, 59, and 46 individuals [53, 54, 55].
According to one study, just a single yoga session was reported to increase GABA among 8 yoga participants [56].
5) Exercise
Many studies provide evidence for the potential benefits of regular exercise. For example, people who exercise regularly are reported to experience lower levels of neuroticism, anxiety, and depression [57].
Conversely, lack of regular physical activity has been associated with an increased risk of anxiety [58].
Aerobic exercise has been proposed to be effective for a variety of anxiety disorders [59], including generalized anxiety, panic, and PTSD [60].
Some studies provide evidence that some of the potential benefits of exercise aren’t just limited to people with specific mental health conditions; for example, exercise has also been reported to reduce anxiety in people without a diagnosed anxiety disorder [61, 62].
According to one study, just a single session of aerobic exercise was reported to reduce anxiety sensitivity in a randomized controlled trial (RCT) of 21 adults [63].
Similarly, exercising on a treadmill for 20 minutes at 70% of maximum heart rate just 3 times per week was reported to lead to reduced anxiety sensitivity in 19 healthy adults [64].
In another study of 24 women, substantial decreases in anxiety were reported following 20 minutes of aerobic exercise at roughly 90% maximal heart rate [65].
Both aerobic exercise and resistance training have been reported to reduce anxiety sensitivity – however, only aerobic training lowered the anxiety-related sensations after inhalation of carbon dioxide (a common task for inducing anxiety in research studies) in a 77-person study [66].
One study reports that high-intensity interval training (HIIT) helped alleviate anxiety symptoms in 20 schizophrenic patients [67].
Mechanism
Although exercise promotes inflammation in the short-term, regular exercise has been reported to result in long-term anti-inflammatory and antioxidant effects in the brain [68].
Because neuronal inflammation and oxidative stress are key factors that can sometimes contribute to anxiety [69], the anti-anxiety effects of exercise are believed to be due (at least in part) to exercise’s protective effects on inflammation and oxidative stress.
Exercise has also been reported to increase levels of serotonin, dopamine, and norepinephrine, as well as endorphins, throughout the brain [70, 71], which may further account for some of its potential effects.
According to one study, aerobic exercise reportedly led to increased BDNF levels in 12 panic disorder patients compared to 12 control patients [72].
People with chronic anxiety are often reported to have an overactive HPA axis (one of the major stress-related systems in the brain). Regular exercise has been linked to reduced HPA-axis reactivity in studies of both humans and animals [73, 74].
Aerobic exercise was reported to increase heart rate variability among individuals with chronic heart failure [75], and among 43 anxiety patients with low heart rate variability [76].
6) Heart Rate Variability Biofeedback Training
Heart rate variability measures how much and how often your heart rate deviates from your normal “baseline” heart rate.
A higher heart rate variability (more inconsistent, e.g. varying between 50 to 75 bpm while at rest) is believed to be desirable, as it may indicate a dominance of the “rest-and-digest” (parasympathetic) nervous system.
In contrast, lower heart rate variability (e.g. staying between 65 and 70 bpm, like a metronome) indicates a dominance of the “fight-or-flight” (sympathetic) nervous system, which has been linked to generally increased levels of stress and inflammation [77].
Some studies have linked higher heart rate variability to better overall health [78], as well as better emotional control [79].
In contrast, many forms of anxiety have been associated with low heart rate variability [80].
“Heart rate variability biofeedback training” is a technique that involves breathing for a period of time (suggested 20 minutes twice per day) at the frequency at which maximum heart rate variability is generated voluntarily for each individual. Usually, this is between 4.5 and 6.5 breaths per minute [81]. This breathing frequency is termed “resonance” breathing.
According to a handful of studies, heart rate variability biofeedback training was reported to reduce anxiety in studies of 26, 30, and 48 people [82, 83, 84].
Similarly, a recent meta-analysis concluded that heart rate variability biofeedback training may considerably reduce overall levels of anxiety and perceived stress [85].
Mechanism
It is believed that some of the brain regions involved in regulating heart rate variability are the amygdala and medial prefrontal cortex, which are also believed to be responsible for perceptions of threat and safety [86].
This type of training also involves slow diaphragmatic breathing, which may stimulate the vagus nerve (the nerve that connects the gut to the brain). Vagal pathways to the brain affect brain regions believed to be involved in regulating mood (such as the locus coeruleus, insula, hippocampus, and amygdala) [87].
Heart rate variability has also been linked to the functioning of the body’s inflammatory response [88]. For example, increasing the heart rate variability was reported to reduce inflammation in studies of 45 and 11 people [89, 90]. Inflammation is also often elevated in people with anxiety disorders [91, 92], and so this mechanism may be part of the explanation for why heart rate variability has been associated with anxiety levels.
How to Implement
Use a biofeedback device to find your resonance breathing frequency (which is relatively constant) and spend 10-20 minutes per day breathing at this frequency.
One way to receive biofeedback on your heart rate is by using a heart rate monitor (chest strap or finger sensor) which syncs to a smartphone app.
The iThlete biofeedback app has been validated for accuracy [93]. Other common apps include Bioforce, HeartRate+, and Sweet Beat/DailyBeat, although these apps have not yet been scientifically validated.
The app HRV4Training does not require a heart rate monitor, and has been validated [94].
Limitations
Biofeedback training requires equipment that may be costly.
7) Cognitive Bias Modification
While cognitive-behavioral therapy (CBT) teaches people to deal with thoughts as they arise, cognitive bias modification targets thoughts earlier in the cognitive process. Biases toward a threat that have been reported as common in individuals with anxiety issues include:
- “Attention” biases: preferentially paying attention to threatening information.
- “Interpretation” biases: comprehending emotionally ambiguous information as threatening rather than neutral.
- “Memory” biases: storing and/or retrieving threatening information more often than neutral- or positive information [95].
Cognitive bias modification is the practice of “re-training” the above biases using computerized tasks. According to some early studies, cognitive bias modification may lower anxious behavior at clinically-relevant levels [96].
Cognitive bias modification may even be more effective than CBT in some cases. For example, during one year following an intervention, cognitive bias modification was reported to bring about a greater decrease in negative automatic thoughts compared to CBT and (non-treated) control groups, according to a 240-person study [97].
However, another randomized controlled trial (RCT) of 133 participants reported that internet-based attention bias modification combined with internet-based CBT did not improve social anxiety more than internet-based CBT alone – so the evidence is a bit mixed, and more research will be needed [98].
Mechanism
Although the mechanisms behind this technique have not been extensively studied, one preliminary study (using electrode brain monitoring) suggests that cognitive bias modification may act by improving the “top-down” cognitive processes that control emotions (specifically, via the prefrontal cortex) [99].
How to Implement
Cognitive bias modification is a relatively new technique and has not yet been shown effective in self-guided settings. Therefore, until more research is done, it is best performed under the direction of a therapist trained in administering this technique.
8) Gut Microbiome
Although this is a very recent line of research, some early evidence suggests a strong connection between gut microbiota and brain function [100].
It has also been reported that people who have inflammatory diseases of the gut frequently also have anxiety issues [101], and vice versa: those with anxiety have higher rates of gastrointestinal (GI) disorders [102]. In fact, GI disorders are the second-most commonly-occurring health condition in individuals with anxiety, second only to migraines [102].
Relatedly, some studies have reported that when inflammatory / GI diseases are resolved, anxiety often subsides as well, thus further reinforcing a potential link between these two types of conditions [103].
According to one study in mice, consumption of 50% lean beef (compared to normal mouse food) improved the diversity of fecal bacteria, and was also reported to reduce anxiety-like behaviors [104].
In a population-based study, 5,286 individuals took a food sensitivity blood test, and were asked to make dietary changes based on foods that caused an elevated antibody response. Among those who both reported psychological issues and followed the dietary recommendations, 40% showed psychological improvement [105].
9) Sunlight / Natural Light Exposure
Interestingly, some studies have reported that anxiety issues appear to follow a strong seasonal pattern – specifically, people with anxiety report worse symptoms in winter compared to any other time of year [106].
Individuals exposed to UVA radiation (the wavelength of natural sunlight) showed elevated serotonin levels and reported feeling less nervous compared to those who did not receive UVA radiation, according to one 53-person study [107].
Interestingly, the first enzyme involved in serotonin production – tryptophan hydroxylase – is found in human skin. Some researchers have suggested that sunlight may help activate this enzyme, thus increasing its activity and ultimately raising serotonin levels in the brain [108].
Bright light exposure has also been reported to stimulate neurogenesis (the growth and development of new neurons) in the adult rat brain, which may, in turn, contribute to reduced anxiety and depression [109].
10) Sauna Use
Far-infrared sauna use reportedly lowered anxiety in a pilot study of 10 patients with chronic fatigue syndrome [110].
Far-infrared sauna therapy combined with exercise was reported to improve emotional and psychological status in 45 patients with fibromyalgia [111].
While these early results are promising, the small sample size – as well as the fact that these studies were done in populations with specific medical conditions – means that more research will be needed before we can know for sure whether similar effects might be seen in healthy human users as well.
Takeaway
Anxiety disorders are a group of mental illnesses that cause a disproportionate fear response to non-threatening signals. People with anxiety disorders typically have irregular levels of many neurotransmitters.
Many psychological techniques and lifestyle changes have been found to decrease anxiety in clinical settings. The best-known and best-studied of these is cognitive behavioral therapy, or CBT, which is best undergone under the care of a psychologist or trained counselor. Various types of meditation may also help.
Other strategies, including yoga, exercise, natural light, and modifying the gut flora, are currently under investigation.
