Managing COVID-19 Anxiety Without Benzodiazepines

Globally hundreds of millions of people are experiencing high levels of stress and anxiety in the face of the COVID-19 pandemic. Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan) are being widely prescribed by doctors to help people manage their symptoms, and there has been an increase in the illicit market for benzodiazepines.

While benzodiazepines are often helpful for the short-term management of anxiety, they have limited overall efficacy and potentially serious safety consequences. In part 1, I talked about and risks of chronic benzodiazepine use. In part 2, I reviewed the evidence for Kava and l-theanine, two natural supplements widely used to treat anxiety. In this post, I briefly review the evidence for anxiety- and stress-reducing benefits of relaxation techniques, guided imagery, meditation—including mindfulness-based stress reduction (MBSR)—and yoga. Please note that links to some references are provided in the text of the post while others are listed in the references below.

Relaxation

Simple relaxation techniques such as sustained deep breathing, progressive muscle relaxation, guided imagery, and systematic desensitization are widely used to self-treat symptoms of anxiety. The physiological mechanisms underlying anxiety-reducing effects of relaxation and guided imagery have been established by decades of research. For example, anxiety is often associated with muscle tension and is reduced by behaviors or thoughts that diminish tension and arousal. Regular relaxation is known to be an effective treatment of generalized anxiety, social anxiety, and phobias such as fear of flying and fear of heights (Titlebaum 1988). Applied relaxation (AR) is a technique that emphasizes the application of anxiety-reducing coping strategies in daily life with the goal of helping individuals with generalized anxiety and panic disorder to relax rapidly when confronted with anxiety-provoking situations by recognizing warning signs of anxiety and ‘applying relaxation’ techniques when in stressful situations to enhance coping (Hayes-Skelton 2013).

Guided imagery

In guided imagery, the individual focuses on calming mental imagery directed at reducing specific anxiety symptoms. Guided imagery enhances the immune system and one's general well-being (Achterberg 1985). When practiced on a regular basis, mental imagery effectively reduces symptoms of generalized anxiety, panic, and traumatic memories (Zahourek 1998; Achterberg, Dossey & Kolkmeier 1994).

In a 5-month study individuals with generalized anxiety enrolled in a relaxation group reported reductions in the severity of anxiety equivalent to changes reported in a group taking antidepressants while engaging in regular relaxation ((Bernal 1995). In another study, anxious adults randomized to a relaxation group and a cognitive therapy group experienced comparable reductions in anxiety (Ost & Breitholtz 2000). An open trial enrolling 60 women with anxiety and depressed mood in the first month following childbirth, found that a combined regimen of relaxation and guided imagery is more effective than either approach alone (Rees 1995). In one study, 60 women reporting anxiety and postpartum depressed mood experienced significant reductions in both anxiety and depressed mood using a combined relaxation-guided imagery approach during the first four weeks after childbirth.

Yoga

Research studies and anecdotal evidence suggest that the regular practice of yoga is beneficial for women who experience symptoms of generalized anxiety, stress, and depressed mood (Shohani et al 2018). The regular practice of specific yogic postures or breathing techniques may cause changes in neurotransmitter activity that manifest as a state of alert calmness. Training in a particular style of yoga called Sudarshan kriya yoga involves a specialized breathing technique that decreases serum cortisol, the major stress hormone in humans (Gangadhar et al 2000).

Individuals diagnosed with any anxiety disorder improve significantly when they combine a daily yoga practice with relaxation and mindfulness training (Miller & Fletcher 1995). Research studies show that regular yoga practice reduces the level of anxiety in individuals with high blood pressure and epilepsy and reduces test anxiety in students (Chaudhary et al 1988; Panjwani 1995; Malathi 1999). Limited research findings suggest that regular yoga practice may reduce the need for prescription medications in individuals who struggle with generalized anxiety (Chaudhary et al 1988).

Meditation

Different styles of meditation are widely used in the U.S. and other countries as a contemplative practice, to maintain optimal psychological and spiritual wellbeing, enhance attention, improve one’s capacity for emotional self-regulation, and manage symptoms of stress and anxiety (Burke 2017).

Meditation has been extensively studied as a treatment of anxiety. Beneficial physiological effects of meditation include decreased oxygen consumption, respiratory rate, and blood pressure, as well as long-term beneficial changes in brain electrical activity that result in increased calmness (Delmonte 1985). Mindfulness-based stress reduction (MBSR) is an integrative approach pioneered by Kabat-Zinn that has been validated as highly effective for reducing the physical and mental symptoms of cancer, cardiovascular disease, chronic pain, depression, and anxiety disorders in adults and children (Gotink 2015). The approach incorporates elements of Asian meditation practices and Western psychology. Research findings show that the regular practice of mindfulness meditation, in which the individual practices detached self-observation, significantly reduces generalized anxiety and other anxiety symptoms (Kabat-Zinn 1992). It has been suggested that regular mindfulness training helps individuals to improve their capacity for self-awareness, resulting in more effective coping strategies when stressful situations cannot be avoided (Epstein 1999). In one study, almost 100% of individuals who started a 10-week MBSR training program reported significantly decreased physical and emotional distress, improved quality of life, a greater sense of general well-being, increased optimism, and increased feelings of control (Abbey 2004).

Anxiety Essential Reads

Helping Children with Performance Anxiety

How I Quickly Stopped a Panic Attack

Bottom line

The COVID-19 pandemic has resulted in a surge in benzodiazepine use for the management of stress and anxiety. Although benzodiazepines can be helpful for the short-term management of stress and anxiety, they have limited efficacy when used for long periods of time and are associated with significant risks. Research findings confirm that the regular practice of relaxation, guided imagery, meditation and yoga provide effective strategies for reducing symptoms of stress and anxiety while avoiding the risks associated with benzodiazepines.