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Case Report

J Acupunct Meridian Stud 2024; 17(5): 172-177

Published online October 31, 2024 https://doi.org/10.51507/j.jams.2024.17.5.172

Copyright © Medical Association of Pharmacopuncture Institute.

Acupuncture for Panic Disorder with Agoraphobia: a Case Report

Yuto Matsuura*

Department of Acupuncture and Moxibustion, Tokyo Ariake University of Medical and Health Sciences, Tokyo, Japan

Correspondence to:Yuto Matsuura
Department of Acupuncture and Moxibustion, Tokyo Ariake University of Medical and Health Sciences, Tokyo, Japan
E-mail matsuuray@tau.ac.jp

Received: June 19, 2024; Revised: July 17, 2024; Accepted: October 2, 2024

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Importance: This report details a case of effectively managing severe panic attacks in a panic disorder (PD) patient with agoraphobia by acupuncture treatment.
Case presentation: A 38-year-old Japanese woman suffering from PD with agoraphobia presented at our acupuncture clinic with complaints of repeated panic attacks and anxiety. Initially starting to experience symptoms in her late teens, she avoided psychiatric consultation due to reluctance toward psychotropic medications. An unbiased psychiatrist used the Panic Disorder Severity Scale (PDSS) to assess her PD severity. The PDSS score decreased from 21 on the first to 12 points on the sixth visit. The patient experienced reduced frequency and severity of panic attacks, with restored confidence to go into public despite agoraphobia.
Conclusions and Relevance: This is the first report to demonstrate the effectiveness of acupuncture on PD with agoraphobia using PDSS, suggesting its potential as a nonpharmacological treatment for patients with PD and agoraphobia.

Keywords: Acupuncture, Agoraphobia, Case report, Panic disorder, Panic disorder severity scale

INTRODUCTION

Panic disorder (PD) is characterized by recurrent, unexpected panic attacks and ongoing concerns or maladaptive behavior regarding future attacks. Clinically, panic attacks manifest as autonomic nervous system dysregulation characterized by racing heartbeat, chest pain, sweating, shaking, dizziness, flushing, churning stomach, faintness, and breathlessness [1]. Besides these physical manifestations, PD often includes fear [1], encompassing the fear of collapsing, becoming mad, dying, and derealization (the sensation that the world is unreal). A common PD comorbidity is agoraphobia, which is characterized by an intense fear of situations when escape may be difficult or help is unavailable [2].

Although medication therapy remains the primary treatment for PD, many patients do not experience satisfactory results [3]. The National Institute for Health and Care Excellence (NICE) guidelines recommend cognitive behavioral therapy, including exposure therapy, as the first-line treatment for PD [4]. However, the accessibility of psychotherapy is limited among many patients with PD due to various barriers, including a scarcity of trained therapists, high treatment costs, and the societal shame and stigma associated with seeking psychological help [5]. Therefore, proposing and validating easily applicable and highly effective nonpharmacological therapies for patients with PD is urgently required. Furthermore, these advancements can significantly broaden treatment options and enhance patient outcomes.

Acupuncture is increasingly recognized as a promising alternative treatment in psychiatry, as evidenced by recent research trends and studies [6]. A previous randomized controlled trial (RCT) of treatment-resistant anxiety disorders demonstrated that a 10-week course of acupuncture can significantly alleviate anxiety symptoms, outperforming a control waitlist group [7]. Thus, acupuncture could represent an effective intervention for reducing anxiety symptoms in various anxiety disorders. However, this RCT primarily addressed chronic anxiety symptoms and included diverse anxiety disorders. Therefore, the specific effect of acupuncture on distinct symptoms unique to each anxiety disorder remains unclear.

PD is characterized by panic attacks significantly affecting the patient’s quality of life. Previous case reports suggested the effectiveness of cranial acupuncture in patients with PD and concurrent generalized anxiety, although with primarily subjective data [8]. Quantitative evaluations using psychiatric scales to measure the impact of acupuncture treatment on patients with PD are currently lacking. Our case report aimed to fill this gap by offering valuable insights into the application of acupuncture in a patient with PD comorbid with agoraphobia, an underexplored topic in the existing literature.

CASE PRESENTATION

1. History of presenting condition

A 38-year-old Japanese woman suffering from PD with agoraphobia presented at our hospital with complaints of repeated panic attacks and anxiety. She had no family history of mental illness and no history of substance use or abuse. Her psychiatric symptoms began in her late teens, initially manifesting as sudden anxiety attacks with physical symptoms, including palpitations, tachycardia, tachypnea, nausea, and dizziness. The symptoms intensified over time, with an emerging fear of dying, anticipatory anxiety, harm avoidance, and fear of being alone, which severely restricted her ability to go into public, impacting her daily life. However, she resisted to consult a psychiatrist because of an aversion to psychotropic medications. While she experienced slight improvement with anti-anxiety medication from her family physician, panic attacks continued. At the age of 36 years, she developed vertigo and was diagnosed with Meniere’s disease, exacerbating her panic symptoms. The patient’s vertigo improved with Meniere’s medication; however, panic persisted. At the age of 38 years, she opted to try acupuncture at our hospital after learning about acupuncture through the Nippon Hoso Kyokai (NHK) questionnaire. Before initiating acupuncture therapy, the patient’s acupuncturist at our hospital underscored the importance of psychiatric evaluation and recommended consultation with a psychiatrist. Following this advice, she underwent a psychiatric consultation and was formally diagnosed with PD. The psychiatrist, in collaboration with the patient, decided not to adjust medication and instead chose to monitor her progress solely on acupuncture.

2. Description of the patient

During her first visit, she complained of 3-4 panic attacks per week, accompanied by anticipatory anxiety, agoraphobia, and avoidance behavior. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) standard symptoms observed during her panic attacks included palpitations, tremors, difficulty in breathing, feelings of suffocation, abdominal discomfort, dizziness, chills, depersonalization, loss of control, fear of death, and abnormal sensations; however, sweating, chest pain, or dry mouth were not reported. She reported ringing in her left ear, vague anxiety, neck and shoulder pain, and diarrhea.

On physical examination, her height was 158 cm, and her weight was 46 kg. She had a blood pressure of 108/62 mmHg, pulse of 78 bpm, and normal neurological findings. A psychiatric assessment revealed scores of 21 on the Panic Disorder Severity Scale (PDSS), 25 on the Himorogi Self-Rating Anxiety Scale (HSAS), and 25 on the Himorogi Self-Rating Depression Scale (HSDS). Additionally, the patient exhibited no hallucinations, delusions, thought disorders, or suicidal tendencies. Her medications comprised sulpiride 150 mg/day, zolpidem tartrate 15 mg/day, alprazolam 1.2 mg/day, and betahistine mesilate 18 mg/day.

3. Acupuncture treatment

Japanese-style acupuncture was performed weekly by an acupuncturist with 8 years of clinical experience affiliated with the Acupuncture Center of Tokyo Ariake University. In Japanese acupuncture therapy, careful detection of individual patient’s acupoints by palpation and fine needling with a comfortable subjective sensation is crucial [9]. Thus, acupuncture treatment was performed according to the patient’s condition and physical findings.

Considering the patient’s fear of the prone position, all treatments were administered while the patient was lying on her left side. Specifically, Fig. 1 shows the used acupoints. The selected acupoints included the GV20, bilateral LR3, SP6, HT3, PC6, LI4, left ST36, and right SP9. These points were selected based on their documented efficacy in mood disorder clinical research and their potential to improve mood conditions [10]. Additional points on the left side (TE16, TE17, and GB12) were included to address the symptoms of dizziness and tinnitus. For neck pain, bilateral GB20 and GB21 were also added. Using disposable stainless needles (Seirin Co., Ltd.) 40 mm in length and 0.14 mm in diameter, a shallow insertion depth of 5-10 mm was employed to suit the patient’s sensitivity, with needles retained for 15 min without inducing de-qi. Furthermore, a 0.9-mm press-tack needle (Seirin Co., Ltd.) was applied to the bilateral PC6 for continuous acupoint stimulation, with the application period limited to 24 h.

Figure 1. Used acupoints. Red points were used for mood symptoms, blue points for neck pain, and green points for dizziness and tinnitus.

4. Outcome measures


1) Severity of PD

The PDSS, an interview-based assessment tool comprising seven items specifically designed to evaluate the severity of PD, was used to assess the patient’s PD severity [11]. Each item on the PDSS is rated on a 5-point Likert scale ranging from none (0) to extreme (4), measuring symptom severity. The symptoms include the frequency and distress of panic attacks, anticipatory anxiety, agoraphobic fear and avoidance, fear and avoidance of panic-related sensations, and panic-related impairment of work and social functioning. Each item is clearly defined and equipped with semi-structured interview guides and explicit anchor points [12]. A psychiatrist not involved in the acupuncture treatment evaluated the patient. In defining a clinically significant change, remission is categorized as a PDSS score of ≤ 5 for patients without agoraphobia and ≤ 7 for those with agoraphobia. Additionally, a clinically significant response is defined as a reduction by ≥ 40% on the PDSS score [13]. The validity of the Japanese version of PDSS was previously verified [14].

2) Anxiety and depressive symptoms

The HSAS was used to assess anxiety symptoms [15], whereas the HSDS was used to assess depression symptoms [16]. These self-evaluation criteria ensure the easy assessment of psychiatric symptoms, even outside psychiatric specialties, enabling the recording and evaluation of patient’s symptoms in a short time. The HSAS cut-off scores were 0-4 points for no problem, 5-9 points for very mild, 10-14 points for mild, 15-19 points for moderate, and 20-39 points for severe. The HSDS cut-off scores were 0-5 points for no problem, 6-13 points for very mild, 14-23 points for mild, 24-30 points for moderate, and 31-39 points for severe.

3) Physical symptoms

The Somatic Symptom Scale 8 (SSS-8), a brief self-report questionnaire utilized for assessing somatization due to stress responses, evaluates 8 symptoms on a scale from not at all (0) to very much (4) [17]. The SSS-8 includes such symptoms as stomach or bowel problems, back pain in the arms/legs/joints, headaches, chest pain/shortness of breath, dizziness, feeling tired/having low energy, and trouble sleeping. The Japanese version of the SSS-8 has adequate reliability and validity [17].

5. Clinical course

The patient received 6 acupuncture treatments weekly or biweekly over 48 days. The patient experienced positive changes in PD severity, anxiety and depression symptoms, and physical symptoms. This was reflected by a 43% decrease in the PDSS score, a 65% reduction in the HSAS score, a 96% decrease in the HSDS score, and a 76% reduction in the SSS-8 score.

The PDSS score during the first visit was 21 points. By the fourth visit, it decreased to 13 points and stabilized at 12 points by the sixth visit. The PDSS scores decreased by 43% at the sixth visit compared to baseline (Fig. 2A). The HSAS score during the first visit was 39 points. By the third visit, it decreased to 26 points and further improved to 14 points by the sixth visit. The HSDS score at the first visit was 25 points, which decreased to 10 points by the second visit and continued to improve, reaching 1 point by the sixth visit (Fig. 2B). The SSS-8 score during the first visit was 17 points, rising slightly to 21 points by the second visit. By the third visit, it decreased to 10 points and remained stable thereafter. By the sixth visit, the score was 4 points, indicating a significant reduction in the burden of physical symptoms (Fig. 2C).

Figure 2. Changes in the (A) Panic Disorder Severity Scale (PDSS), (B) Himorogi Self-Rating Depression Scale (HSDS) and Himorogi Self-Rating Anxiety Scale (HSAS), and (C) Somatic Symptom Scale-8 (SSS-8).

Encouraged by this progress, the patient discontinued medication after the fourth visit. Previously anxious about having no more medications, she gradually developed a fear of dependence. The acupuncturist strongly advised against self-discontinuation and recommended consultation with a psychiatrist. After the fifth visit, the physician discontinued medications. As her symptoms improved, her anticipatory anxiety and agoraphobia decreased, encouraging her to participate in outdoor activities. No adverse events were observed during the treatment period.

A point to note, after fourth visit, she discontinued her medication on her own. We advised her to consult her doctor if she wanted to discontinue, and she was officially discontinued medication after the fifth visit.

DISCUSSION

In this case, the patient with severe PD accompanied by agoraphobia underwent acupuncture treatment, providing significant improvements. Despite challenges in achieving improvement in agoraphobia [13], our patient experienced a 43% reduction in the PDSS score, indicating a clinically significant change. Therefore, acupuncture may be a promising treatment option for patients with PD when pharmacotherapy is problematic.

The positive effects of acupuncture on the symptoms might be explained by the mechanism of acupuncture stimulation. A review comparing autonomic changes in patients with PD and healthy controls showed that patients with PD had a higher short-term LF/HF ratio, indicating impaired sympathovagal balance [18]. Acupuncture treatment activates specific brain regions influenced by sympathetic and parasympathetic imbalances seen in various diseases and modulates neurotransmitters in these brain areas to reduce autonomic responses [19]. Additionally, acupuncture stimulation activates sensory nerve fibers transmitting signals through the spinal cord to various brain regions, facilitating complex information integration. This process involves a network of autonomic brain nuclei, including the insular cortex, prefrontal cortex, anterior cingulate cortex, amygdala, hypothalamus, periaqueductal gray, nucleus tractus solitarius, ventrolateral medulla, and nucleus ambiguus. Through these pathways, acupuncture modulates the autonomic nervous system, potentially alleviating PD-associated dysfunction [20]. In our case, the decrease in the SSS-8 score represented reduced somatization, which was caused by psychological problems. Thus, somatization-related autonomic symptoms might have been alleviated by acupuncture. Therefore, acupuncture may improve abnormalities in the autonomic nervous system in patients with PD.

A key strength of this case report is that the medication dose was not increased or changed during treatment, highlighting the effectiveness of acupuncture treatment. Additionally, it was evaluated using the PDSS, which comprehensively measures clinical symptoms of PD, including agoraphobia. To the best of our knowledge, we are the first to quantify the effects of acupuncture on PD using the specific PD severity assessment scale, the PDSS. Additionally, the PDSS was conducted by a psychiatrist who was not involved in the acupuncture treatment, minimizing subjective measurement bias. Future research with larger sample sizes is required to confirm the efficacy of acupuncture in PD with agoraphobia. Furthermore, including comparative trials with control groups would be beneficial for providing a more comprehensive assessment of the treatment effects. However, the limitation of this study was its short observation period. While short-term observations in this case indicated improvement with acupuncture, assessing the sustainability of these effects and the potential for symptom relapse requires long-term follow-up. Future studies should include detailed tracking of long-term outcomes after acupuncture treatment to evaluate the persistence of its effects and understand the recurrence rates.

A critical point is the patient’s decision to discontinue medication as symptoms improved. Such self-directed discontinuation may affect prognosis [21]. Medical professionals should supervise all changes in medications to ensure patient safety and the validity of treatment outcomes. This report emphasizes the importance of a collaborative approach between acupuncturists and physicians to manage treatment effectively and prevent potential risks associated with unsupervised alterations in medication regimens.

CONCLUSIONS

In conclusion, based on the positive outcomes observed, this case report suggests that acupuncture might represent a nonpharmacological treatment option for patients with severe PD and agoraphobia who are hesitant to receive psychiatric treatment.

FUNDING

None.

ETHICAL STATEMENT

Written informed consent was obtained from the patient following both written and verbal explanations regarding freedom to participate in the present study, withdrawal of consent, privacy protection, and publication of the findings of this case study. We referred to the CARE checklist when reporting the current study.

PREVIOUS PRESENTATIONS

This article was previously presented as a meeting abstract at the Japan Society of Acupuncture and Moxibustion Annual Scientific Meeting on May 25, 2024.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Fig 1.

Figure 1.Used acupoints. Red points were used for mood symptoms, blue points for neck pain, and green points for dizziness and tinnitus.
Journal of Acupuncture and Meridian Studies 2024; 17: 172-177https://doi.org/10.51507/j.jams.2024.17.5.172

Fig 2.

Figure 2.Changes in the (A) Panic Disorder Severity Scale (PDSS), (B) Himorogi Self-Rating Depression Scale (HSDS) and Himorogi Self-Rating Anxiety Scale (HSAS), and (C) Somatic Symptom Scale-8 (SSS-8).
Journal of Acupuncture and Meridian Studies 2024; 17: 172-177https://doi.org/10.51507/j.jams.2024.17.5.172

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