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NCCIH Clinical Digest

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Mind and Body Approaches for Stress:
What the Science Says

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January 2016
Clinical Guidelines, Scientific Literature, Info for Patients: 

Mind and Body Approaches

Relaxation Techniques

Relaxation techniques may be helpful in managing a variety of stress-related health conditions, including anxiety associated with ongoing health problems and in those who are having medical procedures. Evidence suggests that relaxation techniques may also provide some benefit on symptoms of post-traumatic stress disorder (PTSD), and may help reduce occupational stress in health care workers. For some of these conditions, relaxation techniques are used as an adjunct to other forms of treatment.

The Evidence Base

  • The evidence base on efficacy of relaxation techniques for stress consists of several systematic reviews and meta-analyses as well as 2010 clinical practice guidelines from the Department of Veterans Affairs and Department of Defense on the management of post-traumatic stress.

Efficacy

  • Anxiety. Studies have shown relaxation techniques may produce modest, short-term reduction of anxiety in people with ongoing health problems such as heart disease or inflammatory bowel disease, and in those who are having medical procedures such as breast biopsies or dental treatment. Relaxation techniques have also been shown to be useful for older adults with anxiety.
    • A 2009 review of five randomized trials and two meta-analyses, in more than 2,700 cardiac patients, found small but significant reductions in anxiety in this patient population with greater effects expected from more intensive training. The review recommended considering inclusion of relaxation techniques in cardiac rehabilitation programs.
    • A 2012 randomized controlled trial in 39 patients with inflammatory bowel disease found that those receiving relaxation training intervention showed statistically significant improvement in anxiety levels, quality of life and mood, and stress and pain, compared to the control.
    • A 2006 randomized trial in 236 women undergoing large core needle breast biopsies assessed the effects of self-hypnotic relaxation on anxiety and pain compared to standard treatment or empathic attention. The study found that women’s anxiety increased significantly in the standard group, did not change in the empathic group, and decreased significantly in the relaxation group. Pain increased significantly in all three groups.
    • A 2008 randomized controlled trial of 90 patients examined the effects of a brief relaxation method on dental anxiety compared to music distraction and to a control. Both treatment groups significantly reduced dental anxiety, but the brief relaxation intervention was significantly superior to music distraction. Patients in the control group did not exhibit a significant change in their anxiety level.
  • Occupational stress in health care workers. A 2015 Cochrane review of 17 studies evaluating occupational stress in health care workers found low- to moderate-quality evidence that both mental and physical relaxation led to a reduction of 23 percent in stress levels compared to no intervention.
  • Stress-related headaches. There is conflicting evidence on the effectiveness of biofeedback and relaxation training for tension-type headaches.
    • The efficacy of biofeedback has been evaluated in numerous studies for tension headaches, with positive results. However, a 2009 systematic review of 11 randomized controlled trials concluded that there is conflicting evidence on the effectiveness of biofeedback compared with placebo to prophylactic drugs or any other treatment. A 2008 meta-analysis of 53 studies suggests that relaxation training is less effective than biofeedback.
  • High blood pressure. Relaxation techniques have shown modest, short-term reductions in blood pressure; however many of these studies were of poor quality.
    • A 2009 Cochrane systematic review of 25 randomized controlled trials involving 1,198 participants found that overall, relaxation techniques resulted in small average reductions in blood pressure, but many trials were not well designed and had inconsistent results. The reviewers concluded that the evidence of causal association between relaxation and the reduction of blood pressure is weak.
  • PTSD. Relaxation techniques may provide some benefit on symptoms of PTSD, including sleep disturbance, anger, pain, and hyper-arousal.
    • Clinical practice guidelines issued in 2010 by the Department of Veterans Affairs and Department of Defense on the management of post-traumatic stress recommend that relaxation techniques be considered as a component of treatment approaches for acute stress disorder or PTSD in alleviating symptoms associated with physiological hyper-reactivity. The guidelines also state that complementary health approaches that facilitate a relaxation response (e.g., mindfulness, yoga, acupuncture, massage, and others) may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques.
    • These guidelines also suggest relaxation techniques may be helpful, as adjunct treatment, for specific symptoms including sleep disturbance; irritability, severe agitation, or anger; pain; and hyper-arousal.

Safety

  • Relaxation techniques are generally considered safe for healthy people. However, occasionally, people report unpleasant experiences such as increased anxiety, intrusive thoughts, or fear of losing control.
  • There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.

Yoga, Tai Chi, and Qi Gong

A range of research has examined the relationship between exercise and depression. Results from a much smaller body of research suggest that exercise may also affect stress and anxiety symptoms. Even less certain is the role of yoga, tai chi, and qi gong—for these and other psychological factors.

The Evidence Base

  • The evidence base on efficacy of yoga, tai chi, and qi gong for stress, anxiety, and depression consist of several randomized, nonrandomized, and observational studies, systematic reviews and meta-analyses.

Efficacy

  • A 2014 systematic review of 17 studies examining the combination of mindfulness-based stress reduction and yoga in an 8-week training program found positive changes in psychological or physiological outcomes related to anxiety and/or stress.
  • A 2014 randomized controlled trial in 64 women with chronic, treatment-resistant PTSD found that over the course of 10 weeks, yoga significantly reduced symptoms of PTSD compared to health education, with effect sizes comparable to psychotherapeutic and psychopharmacologic interventions.
  • Some studies suggest that practicing tai chi may be associated with improvements in stress, anxiety, and depression, mood, and self-esteem. However, a 2010 systematic review and meta-analysis of 40 studies involving 3,817 participants could not provide definitive conclusions due to variation in designs, comparisons, heterogeneous outcomes and inadequate controls.
  • A 2010 review of 29 studies with more than 2,500 participants did not offer clear evidence about the effectiveness of tai chi on anxiety, depression, stress, mood, and self-esteem. The majority of these studies did not look at psychological distress as the primary goal and did not intentionally recruit participants with mental health issues.
  • A 2014 systematic review and meta-analysis on the effects of tai chi on depression, anxiety, and psychological well-being found that tai chi interventions had beneficial effects on a spectrum of psychological well-being measures, including general stress management. However, many of the studies included in the review had significant methodological limitations.
  • Results of a 2014 randomized controlled trial in prostate cancer survivors, which examined the effects of qi gong compared to stretching, found that men in the qi gong group reported less symptoms associated with a decline in quality of life, including fatigue and distress than the stretching group.

Safety

  • Overall, clinical trial data suggest yoga as taught and practiced in these research studies under the guidance of skilled teacher has a low rate of minor side effects. It is not uncommon for practitioners to have some minor, transient discomfort, as with most physical activity programs. However, injuries from yoga, some of them serious, have been reported in the popular press.
  • People with health conditions should work with an experienced yoga instructor who can help modify or avoid some yoga poses to prevent side effects.
  • Tai chi appears to be a safe practice. Complaints of musculoskeletal pain after starting tai chi may occur, but have been found to improve with continued practice. Women who are pregnant and those with heart conditions should talk with their health care providers before beginning yoga, tai chi, or any other exercise program.

Meditation and Mindfulness-Based Stress Reduction

The scientific evidence to date suggests that mindfulness meditation—a mind-body practice which cultivates abilities to maintain focused and clear attention, and develop increased awareness of the present—may help reduce symptoms of stress, including anxiety and depression.

The Evidence Base

  • The current evidence base on efficacy of meditation for symptoms of stress consists of a few systematic reviews and meta-analyses and many randomized controlled trials.

Efficacy

  • A 2014 systematic review and meta-analysis of 47 trials in 3,515 participants found that mindfulness meditation programs had moderate evidence of improved anxiety, depression, and pain, and low evidence of improved stress/distress and mental health-related quality of life. No evidence of benefit was found on meditation for health-related behaviors affected by stress, such as substance abuse and sleep.
  • A 2014 systematic review of 17 studies on mindfulness-based stress reduction as a stress management intervention for health individuals found benefits in psychological or physiological outcomes related to anxiety and/or stress; however, many of the studies included in the review had methodological limitations and small sample sizes.
  • A 2012 systematic review and meta-analysis of 36 randomized controlled trials examining the efficacy of meditation for anxiety symptoms found that 25 of the studies reviewed reported statistically superior outcomes in the meditation group compared to the control.
  • A 2010 longitudinal MRI study examined the relationship between changes in perceived stress with changes in amygdala gray matter density following an 8-week mindfulness-based stress reduction intervention. Following the intervention, participants reported significantly reduced perceived stress, and reductions in perceived stress correlated positively with decreases in right basolateral amygdala gray matter density.
  • 2014 clinical practice guidelines from the Society for Integrative Oncology on the use of integrative therapies as supportive care in patients treated for breast cancer recommend the routine use of meditation, yoga, and relaxation with imagery for common conditions, including anxiety and mood disorders (Grade A). The guidelines recommend stress management, yoga, massage, music therapy, energy conservation, and meditation for stress reduction, anxiety, depression, fatigue, and quality of life (Grade B).

Safety

  • Meditation is considered to be safe for healthy people.
  • There have been rare reports that meditation could cause or worsen symptoms in people who have certain psychiatric problems, but this question has not been fully researched.

References

  • Campo RA, Agarwal N, LaStayo PC, et al. Levels of fatigue and distress in senior prostate cancer survivors enrolled in a 12-week randomized controlled trial of Qigong. J Cancer Surviv. 2014;8(1):60-69.
  • Can der Kolk Ba, Stone L, West J, et al. Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry. 2014;75(6):e559-e565.
  • Chen KW, Berger CC, Manheimer E, et al. Meditaative therapies for reducing anxiety: a systematic review and meta-analysis of randomized controlled trials. Depress Anxiety. 2012;29(7):545-562.
  • Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress: Guideline summary. Available at: www.healthquality.va.gov/guidelines/MH/ptsd/CPGSummaryFINALMgmtofPTSDfinal021413.pdf (1.2MB PDF). Accessed on January 7, 2016.
  • Dickinson HO, Beyer FR, Ford GA, et al. Relaxation therapies for the management of primary hypertension in adults. Cochrane Database of Systematic Reviews. 2008;1: CD004935.
  • Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):357-368.
  • Greenlee H, Balneaves LG, Carlson LE, et al. Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. J Natl Cancer Inst Monogr. 2014;2014(50):346-358.
  • Halm MA. Relaxation: a self-care healing modality reduces harmful effects of anxiety. Am J Crit Care. 2009;18(2):169-172.
  • Hölzel BK, Carmody J, Evans KC, et al. Stress reduction correlates with structural changes in the amygdala. Soc Cogn Affect Neurosci. 2010;5(1):11-17.
  • Jahnke R, Larkey L, Rogers C, et al. A comprehensive review of health benefits of qigong and tai chi. Am J Health Promot. 2010;24(6):e1-e25.
  • Lahmann C, Schoen R, Henningsen P, et al. Brief relaxation versus music distraction in the treatment of dental anxiety: a randomized controlled clinical trial. J Am Dent Assoc. 2008;139(3):317-324.
  • Lang EV, Berbaum KS, Faintuch S, et al. Adjunctive self-hypnotic relaxation for outpatient medical procedures: a prospective randomized trial with women undergoing large core breast biopsy. Pain. 2006;126(1-3):155-164.
  • Mizrahi MC, Reicher-Atir R, Levy S, et al. Effects of guided imagery with relaxation training on anxiety and quality of life among patients with inflammatory bowel disease. Psychol Health. 2012;27(12):1463-1479.
  • Nestoriuc Y, Rief W, Martin A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J Consult Clin Psychol. 2008;76(3):379-396.
  • Ruotsalainen JH, Verbeek JH, Mariné A, et al. Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews. 2015;4:CD002892.
  • Sharma M, Rush SE. Mindfulness-based stress reduction as a stress management intervention for healthy individuals: a systematic review. J Evid Based Complementary Altern Med. 2014;19(4):271-286.
  • Verhagen AP, Damen L, Berger MY, et al. Behavioral treatments of chronic tension-type headaches in adults: are they beneficial? CNS Neurosci Ther. 2009;15(2):183-205.
  • Wang C, Bannuru R, Ramel J, et al. Tai chi on psychological well-being: systematic review and meta-analysis. BMC Complement Altern Med. 2010;10:23.
  • Wang F, Lee EK, Wu T, et al. The effects of tai chi on depression, anxiety, and psychological well-being: a systematic review and meta-analysis. Int J Behav Med. 2014;21(4):605-617.

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NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

The National Center for Complementary and Integrative Health is dedicated to exploring complementary health products and practices in the context of rigorous science, training complementary health researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCIH's Clearinghouse toll-free at 1-240-618-3313, or visit the NCCIH Web site at nccih.nih.gov. NCCIH is 1 of 27 institutes and centers at the National Institutes of Health, the Federal focal point for medical research in the United States.

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This page last modified January 21, 2016