REVIEW

Acupuncture for Anxiety

Nick Errington-Evans
Nick Errington-Evans, Hywel Dda Health Board, Physio Department, Bro Cerwyn Centre, Haverfordwest, Pembrokeshire, UK

Keywords
Acupuncture; Anxiety disorders; Panic; Phobia.
Correspondence
Nick Errington-Evans, Hywel Dda Health Board,
Physio Department, Bro Cerwyn Centre,
Haverfordwest, Pembrokeshire, SA61 2QN, UK.
Tel.: +44 1437773162;
Fax: +44 1437773162;
E-mail: nickerringtonevans@yahoo.com
Received 11 February 2010; revision 7 February
2011; accepted 17 March 2011
doi: 10.1111/j.1755-5949.2011.00254.x
SUMMARY
This review aims to examine the volume and quality of the evidence base which sup-
ports the use of acupuncture in the treatment of anxiety disorders. A literature review was
conducted using Pubmed, Google scholar, AMED, BMJ, Embase, Psychinfo, Cochrane li-
brary, Ingenta connect, and Cinahl databases. Keywords were anxiety, anxious, panic,
stress, phobia, and acupuncture limited to year 2000 onwards and English language
where available. The quality of research examining the use of acupuncture in the treat-
ment of anxiety disorders is extremely variable. There is enormous variety regarding points
used, number of points used in a session, duration of sessions, frequency of treatment and
duration of treatment programme. While the generally poor methodological quality, com-
bined with the wide range of outcome measures used, number and variety of points, fre-
quency of sessions, and duration of treatment makes firm conclusions difficult. Against this,
the volume of literature, consistency of statistically significant results, wide range of con-
ditions treated and use of animal test subjects suggests very real, positive outcomes using
a treatment method preferred by a population of individuals who tend to be resistant to
conventional medicine.

function of the brain, can result in variations in psychiatric con-

Introduction ditions and hence the treatments of these individuals [3].
Anxiety is defined as The apprehensive anticipation of future Anxiety is estimated to cause 1% of all disability adjusted life
danger or misfortune accompanied by a feeling of dysphoria or so- years lost worldwide in the form of PTSD, OCD and panic at-
matic symptoms of tension. The focus of anticipated danger may tacks [4]. Anxiety in the UK affected 16.8/100 population in 2004
be internal or external [1]. However, the Diagnostic and statisti- [5]. In China, Japan, and Korea, it is common practice to treat
cal manual of mental disorders (or DSM IV) goes on to state that emotional, psychological and spiritual conditions, including anx-
it is better described as a collection of conditions [1], being: iety, stress, depression, and insomnia, with Traditional Chinese
Medicine (TCM) acupuncture [6]. This management approach,
(1) Panic attack and the use of complementary and alternative medicine (CAM) as
(2) Agoraphobia history of panic disorder a whole, has been identified as a growing trend within the West-
(3) Panic disorder agoraphobia ern world [7,8], with some reports suggesting that those individ-
(4) Specific phobia uals with psychiatric conditions are more likely to use CAM than
(5) Social phobia those without a psychiatric medical history [9]. Despite this trend,
(6) Obsessive compulsive disorder (OCD) there is, as yet, no evidence to suggest that the compliance with
(7) Posttraumatic stress disorder (PTSD) CAM is superior to that with conventional management [10].
(8) Acute stress disorder There is an ongoing tension between the Western and the TCM
(9) Generalized anxiety disorder approach to acupuncture. TCM methodology has a history stretch-
(10) Anxiety disorder due to a medical condition ing back over 3000 years [11], but due to its antiquated assessment
(11) Substance-induced anxiety disorder techniques and terminologies, its prescientific notions [12], it
(12) Anxiety disorder not otherwise specified has been modified through evidence based medicine and research
There are also suggestions that symptomology associated with into the modern Western style among many health professionals
anxiety disorders have to be understood in the context of the who have learnt to use acupuncture as an adjunct to their train-
cultural background of the patient [2]. Others take this further, ing. Western acupuncture, being underpinned by anatomy, neu-
suggesting that biological and genetic variations between ethnic rophysiology and an orthodox medical model, is the paradigm
groups, including those directly involved in the structure and used by many health care professionals due to its growing


c 2011 Blackwell Publishing Ltd CNS Neuroscience & Therapeutics 18 (2012) 277284 277
Acupuncture for Anxiety
evidence base, relative cost-effectiveness and ease of use. That its
scientific evidence base is increasing is something that has been
acknowledged for over a decade [13].
Aims
The aim of this review is to examine the research that has investi-
gated the use of acupuncture in the treatment of anxiety disorders.
This will give readers a greater understanding of the quality and
quantity of evidence which supports (or refutes) acupuncture as
a worthwhile treatment for these conditions. The quality of arti-
cles will be considered in light of repeatability (i.e., point location,
duration, frequency of visits, etc.), participant allocation (i.e., ran-
domization, sample size, etc.), data acquisition (i.e., objective vs.
subjective measures) and analysis techniques used. It is not the
aim of this review to offer explanation of TCM diagnosis or treat-
ment rationally, nor to offer an explanation of why the points
described were chosen, nor to suggest a mechanism of why they
work. This review deals only with the points that have been cho-
sen and proven to be effective in the literature, and a critique of
the standards of research at this time.
Methods
A literature review was conducted using PubMed, Google scholar,
AMED, BMJ, Embase, Psychinfo, Cochrane library, Ingenta con-
nect and Cinahl databases. Keywords used were anxiety, anx-
ious, panic, stress, phobia, and acupuncture limited to analysis of the quality of the research detailed above. However,
year 2000 onwards and English language where available. The
search was not limited to human subjects. Results were combined
and abstracts obtained, reviewed and relevant articles sent for.
Reference lists were also examined to ensure seminal articles were
included. Initial searching provided several million articles, which
was reduced through combining keywords and then by reviewing
abstracts. Unfortunately, many foreign language articles were ex-
cluded also, although a sample of their abstracts were included in
providing an insight into the research worldwide. Previous review
articles were used to obtain their references to ensure conclusions
drawn were first-hand where possible. In total 32 relevant articles
were identified.
Results
This section will be divided into subsections to deal with the lit-
erature in terms of components of articles, e.g., issues regarding
the study sample, in terms of recruitment, randomization, blind-
ing, sample size, etc. The final section with examine the evidence
base obtained through the use of the animal model.
Prior to this, a note must be included regarding the exclusion
of foreign language articles. While the articles themselves were
excluded, often the abstracts were published in English, allowing
an insight into the areas of treatment dosage, point selection, etc.
For example, Zhu and Ding [14] reviewed the literature from 1994
to 2008 and state from this that GV20, PC6, HT7, SP6, and ExHN3
were the points most commonly selected. They suggested that the
acupoint selection was based on treatments directly effecting the
278 CNS Neuroscience & Therapeutics 18 (2012) 277284
N. Errington-Evans
heart and brain, which emphasized the importance of the Zang
and Fu organs in TCM.
Su and Zhu [15] performed a literature search of articles
19962004 and agree with the points selection, however, they
suggest that the emphasis of treatments should be pushed towards
the brain, with the Du meridian, with local head acupoints. They
go on to state that the evidence needs to be improved with an
increased sample size, randomization and multicenter trials.
Wang and Zhang [16] offer the opinion of an expert, Professor
Sun Shen-Tian, that GV 20, EX-HN3, emotional area and Zone
1 of Suns abdominal acupoints are often selected to aid in mal-
functions of the brain. While Western literature has a heavy em-
phasis on the research of control groups, randomization, statistical
analysis, etc., and very rarely offers an expert opinion outside an
editorial piece, the Eastern literature places a greater emphasis on
the knowledge and experience of their experts in particular fields.
It would be reasonable to suggest that this difference is cultural, as
the East has a tradition of martial arts schools, etc with a master
teaching their particular style.
The debate regarding treatment dosage is also a hotly contended
issue in the East, with both over and under treatment acknowl-
edged as potentially worsening the patients condition, while cur-
rently lacking agreement as to the correct treatment dosage [17].
This is also suggested as being an area that desperately needs a
large research undertaking to improve standardization and pro-
vide optimal treatment [18,19].
It must be noted that, as these statements are taken from the
translated abstracts, it is impossible to conduct any meaningful
as an indication of the general trends, the abstracts show similar
patterns of concern within the research community of the East
and the West. These abstracts show the same questions regarding
point selection, treatment dosages, treatment frequency, standard-
ization, etc. are actively investigated world wide.
Methodological Components
Participants were either healthy volunteers or patients who con-
sented to join the trials, most often taken from a convenient, avail-
able population such as students at university [20], although some
general population recruitment through advertising on local me-
dia and posters did occur [21,22]. Many introduced a random-
ization element [20,2227], including some quasi-randomization
[20,26], although it is often not described [24,25] and some
included some degree of blinding the assessor and/or analyst
[24,25,27], although obviously blinding the acupuncturist is im-
possible. Additional to these current findings, it has been shown
in the past that the randomization procedure is poorly described
by previous authors [6]. It must be stated that the Wang et al. [25]
study states it is blinded, but does not describe the method used to
ensure this. It must also be noted that the animal studies [28,29]
also provided statistically significant results in a population where
randomization and blinding are considered absolutes.
Sample size was exceptionally variable, ranging from 240
patients [30] to 4, with one drop out [31]. Generally, large
study populations were used in the majority of the research
[20,2226,32,33].

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N. Errington-Evans
Many articles [20,2229,31,34] described the location, duration
and frequency of visits with sufficient specificity to make the re-
search repeatable. In these articles, the rational given for point se-
lection was generally poor. Exceptions to this include the Karst
et al. [24] study, who described the methodology well, stated
that the points selected had been documented to reduce pre-
operative anxiety [25] to justify this selection. The article they
cited [25] described the rational for TCM and non-TCM point
selections, based on a previous pilot study, plus reasoning from
the Shanghai college of traditional medicine, as well as provid-
ing the methodology used to a degree that made the procedure
repeatable.
Further articles failed to describe the points at all, often referring
to TCM methodology of an individually based treatment [32,35]
or failing to mention the technique at all [21,29]. This stems from
the problem that conversion of a western diagnosis to a TCM is in-
exact, often resulting in several different TCM diagnoses for what
western medicine would count as the same condition [36]. Some
practitioners go further, stating that no two individuals could be
treated using the same methodology [35].
Review articles often had this lack of detail, with an exam-
ple of this being Samuels et al. [10], who describe the quality
of the research and the evidence behind the use of acupuncture
well, but then fail to describe any acupuncture points at all, leav-
ing the reader without the knowledge of which points lead to
an efficacious outcome. Another example, being van der Watt
et al. [37], who aimed to review the literature regarding com-
plimentary and alternative treatments both anxiety and depres-
sion. Due to the extremely broad scope, the result is the most su-
perficial of references to acupuncture, consisting of two articles
[22,27].
In contrast to this, the excellent Pilkington et al. [8] review
describes the points used in most studies, but does not give any
form of analysis as to which points were used most often to the
best effect. This is an unsurprising finding as the methodological
quality of many studies, combined with the extensive variety of
points used, makes it very difficult to produce anything other
than point-frequency based inferences. This Pilkington review has
been repeated with updated, more recent references in the same
style [38].
These problems are compounded on several levels. Often the
educational background of the acupuncturist is also lacking [20,
2326,28,29,31,32,34], which would reasonably lead to questions
regarding the non-justification of point selection. There is also the
on-going difficulty of the transition between a Western diagnosis
of anxiety and the TCM diagnosis system, where the treatments
are modified so extensively. In one article the acupuncturist was
an individual described as a master acupuncturist [21], the di-
rector of an acupuncture training programme and clinic [21].
Another was a doctor of oriental medicine with 4 years postgrad
TCM clinical experience [22]. A further study described a specialist
physiotherapist who had performed over 2000 treatments of this
type [26]. The Liu et al study [30] describes a treatment method-
ology based on the acupuncturist selecting between 3 and 6 points
from a choice of 11, giving the very real possibility that members
of the same study group receiving completely different treatments.
While some practitioners can be expected to have knowledge and
experience, but there is no evidence that some of the individu-

c 2011 Blackwell Publishing Ltd
Acupuncture for Anxiety
als who develop unique, tailored treatments, based on TCM diag-
noses, have the experience to do so.
The data acquired was generally of high quality, with objec-
tive, validated measures used in the vast majority of studies. These
ranged from the Visual Analogue Scale at the most basic level
[24,26,31], through the Hospital Anxiety and Depression Scale
(HADS) [26,27], Hamilton anxiety scale [23], State-trait anxiety
inventory [25], to functional MRI [34]. An article focused on
PTSD specifically used the Posttraumatic Symptom Scale-Self Re-
port [22]. The Patterson et al. [39] study describes the develop-
ment of new outcome questionnaires within a multibedded, high
volume, high flow rate clinic (with 17% of patients describing psy-
chological conditions), where a senior practitioner performs a
TCM assessment of the individual before passing their treatment
to a practitioner. These questionnaires were proven reliable and
validated within this population.
Analysis was carried out and results provided regarding
their statistical significance for the vast majority of cases
[20,2229,31,34,39].
Animal Studies
There is growing evidence regarding acupunctures therapeutic ef-
fect within animals. Behavioral measures, specifically designed to
ascertain levels of stress and depression, such as the elevated maze
test (a cross shaped apparatus 50 cm above the floor with four
40 cm long, 10 cm wide arms) where time spent and number of
entries into the open two arms compared to the closed two
arms (which have 30 cm tall enclosing walls) over 5 min is in-
dicative of anxiety levels. Another test is the sucrose intake test,
where subjects with matched food intakes differ in consumption
of sucrose solution, with resulting differences in body weight pro-
portional to levels of anxiety, with low weights linked to higher
anxiety levels. Further to this, animal studies offer the opportu-
nity to examine the biochemical effect of acupuncture through
immunohistochemistry performed directly to the brain tissue for
anxiety and/or stress-induced depression markers, most often, but
not exclusively, markers related to neuropeptide Y.
There is an obvious concern that the use of acupuncture, which
requires the test rat to be immobilized for the insertion and dura-
tion of the needling, would in itself cause anxiety. The implications
of this have been researched and found that, even when the rats
are introduced to regular immobilization, thus somewhat inuring
their response, they have an experience consistent with those rats
who do not become desensitized [40].
A well designed study by Kim et al. [28] described a four arm
experiment which compared a natural group, which received no
stresses, a control group, acupuncture group (Pericardium 6) and
sham acupuncture group, which experienced chronic mild stresses
[41]. They examined both behavioral (elevated maze test and su-
crose intake test) and biochemical markers to assess the treatment
outcomes. This study showed that the stress experienced by the
control group had a statistically significant effect (P < 0.001), but
that there was a statistically significant difference between the
control group and the acupuncture group in terms of bodyweight
(P < 0.05) and immunohistochemical markers (P < 0.001). There
was no statistical difference between the control and the sham
CNS Neuroscience & Therapeutics 18 (2012) 277284 279
Acupuncture for Anxiety N. Errington-Evans

acupuncture group (P < 0.071). There was also a nonstatistically Table 1 Table showing frequency of points used (animal studies specically
significant increase in the volume of sucrose solution consumed, a identied)
behavioral marker of stress-induced depression [42].
BL 14 BL 15 BL 18 BL 20 BL 21 BL 23 BL 62
Chae et al. [43] examined whether acupuncture could help to
alleviate the significant levels of anxiety caused by nicotine with- Bladder 1 2 2 2 1 3 2
drawal during smoking cessation. First, three groups of rats were GB 5 GB 8 GB 13 GB 20
given repeated injections of nicotine to develop an addiction, with Gall Bladder 1 1 1 2
one additional group injected with saline to act as the normal PC 6 PC 7
group. Of the addict rats, one group became the control, one Pericardium 6+2 1
the acupuncture group (Heart 7) and the final group the sham animal
acupuncture group (Stomach 36). There was a statistically signifi- LI 4 LI 11 LI 20 LI 24
cant difference between the control and the acupuncture group, Large Intestine 2 2 1 1
both on the elevated maze test and the immunohistochemical HT 7
markers during dissection (P < 0.05) and no statistical difference Heart 7+1
between the sham acupuncture and the control group. animal
GV 4 GV 20 GV 24
Park et al. [29] studied the use of acupuncture in anxiety within
Governor Vessel 1 4 1
a population of rats. In an experimental study involving maternal
ST 25 ST 36
separation from day 3 to day 14 among infant rats, result suggested
Stomach 1 2
a statistically significant increase in anxiety on the elevated maze
KI 3 KI 6
test (P < 0.05) and immunohistochemical markers (P < 0.05). As
Kidney 1 1
with other animal studies, Park et al. [24] found that the use of a
SP 6
sham acupuncture point, in this case Stomach 36, had no signifi- Spleen 2
cant effect. The acupuncture point used in this study (Heart 7) had LR 2 LR 3
a statistically significant reduction in both anxiety (P < 0.05) and Liver 1 5
immunohistochemical markers (P < 0.01). Ear points
Finally, Lee et al. [44] gave their experimental group of rats Kidney 1
needling to Pericardium 6 in a well designed study examining Heart 1
whether acupuncture could be used prophalactically. The used Shenmen 3
the elevated maze test, plus the forced swim test, where a cylin- Tranquiliser 2
der is filled with water to a depth that prevents the rat reaching Master Cerebral 2
the bottom. Periods of immobility, not trying to get out of the Relaxation 3
cylinder, are linked to anxiety/depression. The control and ex- Extra point
perimental groups were injected with corticosterone, which was Yintang 4
proven to increase anxiety (P < 0.05) and immunohistochemical
markers (P < 0.05), with the acupuncture groups receiving their
treatment in advance. The acupuncture group had a significant
reduction in anxiety (P < 0.05) and immunohistochemical mark-
ers (P < 0.05) while the sham acupuncture points were proven almost universally positive, but also the almost universally poor
ineffective. quality of the methodology reporting [45]. This issue is highlighted
These results, and those described above, suggest that, in an an- as regards reporting the frequency, duration, point location, con-
imal model, both behavioral and biochemical marker changes oc- sistency of treatment, etc, and results in many studies that would
cur to reduce anxiety by statistically significant levels, in a study otherwise prove an excellent source of information being reduced
population which is immune to the placebo effect. The animal to another place to get the gist of the use of acupuncture to treat
model is also considered the gold standard in terms of random- anxiety problems. There is also the additional layer of complex-
ization and standardization of study population. ity associated with the fact that acupuncture in itself is proven to
induce both pain and anxiety in some patients [20,46].
Bearing in mind these points, to perform a literature review
is difficult in the extreme. A literature review should aim to re-
Discussion
view, critique and recommend a course of action, or describe a
Prior to starting the discussion proper, a major factor in this review range of options, highlighting the benefits and detriments associ-
must be acknowledged, being that there is a widely acknowledged ated with each. However, all literature reviews carried out to up
difference between the Eastern and Western approach, with East- to this point offer review and critique, but fail to provide a treat-
ern treatment dosage following a different prescription, especially ment recommendation, instead providing only a useful resource
as regards frequency of treatment, which is far higher than the to clinicians who wish to obtain the literature for themselves and
Western equivalent. Had it been possible to access the Eastern lit- divine their own conclusions. Ultimately this situation is will re-
erature, this difference would be highlighted. main unchanged as there is no single recommendation available,
The quality of the research pertaining to the use of acupuncture and, more importantly, an enormous number of options with little
in the treatment of anxiety disorders varies greatly. Results are rationale for which would provide the best outcome.

280 CNS Neuroscience & Therapeutics 18 (2012) 277284 

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N. Errington-Evans
Figure 1 Number of points used in the
treatment of condition as described in articles
reviewed.
Figure 2 Number of sessions per week as
described in the articles reviewed.
It could reasonably be argued that the question of what con-
stitutes an adequate dose [47] is a key component of this review.
What defines the correct point to use for a particular condition,
the number of points (and therefore needles) to use, sessions per
week, number of sessions, which constitute a treatment episode
and finally, the duration of the acupuncture treatment? These
details are paramount to determining the optimal acupuncture
technique, and therefore these details will be examined individ-
ually with the aim of providing some clarity into what the most
frequently used method is, thus offering clinicians a greater evi-
dence base in the method they use.

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Acupuncture for Anxiety
To gain an understanding of what is the correct technique,
Table 1 illustrates a frequency table listing the points used and
the number of articles in which those points are used, obtained
from the literature reviewed previously. Please note that all these
results are taken from articles in which the treatment group had
a beneficial effect and that often the points are used in synergy
with other points. It is not the aim of this table, nor this lit-
erature review as a whole, to provide recommendations for the
combinations to be used. A final point to highlight is that, as
mentioned throughout the previous sections, the different arti-
cles varied in the details described, resulting in some discrepancy
CNS Neuroscience & Therapeutics 18 (2012) 277284 281
Acupuncture for Anxiety
between each graph, i.e., number of points used = 19, sessions
per week = 15, number of sessions = 19, and duration of ses-
sion = 16.
As is shown in Table 1, the points, which were used the most
frequently were PC6 (8), HT7 (8), LR3 (5), GV20 (4), and Yintang
(4). It is worth noting that only PC6 and HT7 were used in ani-
mal studies (PC6 twice and HT7 once). The fact that these points
should be used so frequently in research from both TCM and West-
ern acupuncture perspectives, combined with the results from the
animal studies suggest that these points should be focused on in
future research.
282 CNS Neuroscience & Therapeutics 18 (2012) 277284
N. Errington-Evans
Figure 3 Total number of sessions constituting
a treatment episode as described in the articles
reviewed.
Figure 4 Duration of each session, as described
in the articles reviewed.
The next area to be examined is regarding the number of points
used to treat an individual condition, which in this case refers to
anxiety disorders, and is displayed in Figure 1. As can be seen,
when treating anxiety, the most frequently used number of points
is three, closely followed by one. This data is obviously limited to
the acupuncture in anxiety research as reviewed in this article,
but the general guidance is that acupuncture norm is between
five and fifteen needles [12]. However, this guidance appears just
as arbitrary as other guidance regarding point selection, etc. This
repeated use of an arbitrary figure could easily be suggested as
being the core problem facing acupuncture research today.

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N. Errington-Evans Acupuncture for Anxiety

The required number of sessions per week, again in the treat-
ment of anxiety, is shown in Figure 2. As can be seen, a frequency
of one session per week or three sessions per week are the most
common treatment regimes used. It must be noted that, while two
studies included seven sessions weekly, both were animal studies.
Surprisingly, the six treatment sessions per week article involved
human subjects.
Another factor is regarding the number of sessions, which con-
stitute a treatment episode. This data is displayed in Figure 3. As
can be seen, a set of ten sessions was the most commonly used
treatment regime. This was closely followed by a single session and
a set of thirty session treatment regimes. The articles describing a
single treatment session were universally describing acupuncture
used in prevention of situational anxiety, prior to an operation or
dental intervention. It must be noted that the highest number of
sessions to constitute a treatment intervention, being 40, was ac-
tually a set of ten session treatments repeated four times due to
continued improvements.
The final aspect of acupuncture is regarding the duration of the
acupuncture treatment itself. This data is displayed in Figure 4.
As can be seen, a half hour session was the most com-
monly used treatment regime. This was closely followed by a
25 min session and 30-second treatment session. The 30-second
sessions were both described in animal studies, which raise in-
teresting points in itself due to the statistically significant results
obtained through such a rapid intervention.
Conclusion
Research into the use of acupuncture in the treatment of anxiety
disorders is progressing in an uncoordinated manner, with gener-
ally poor methodological reporting and rationale for point selec-
tion often lacking. The conflict between the Eastern and Western
acupuncture theoretical paradigms adds to the levels of confusion
presented to the practitioner searching for a gold standard treat-
ment. It is reasonable to suggest that this is compounded further
by the obvious difficulties presented by language limitations en-
countered by most practitioners. These practitioners would not be
able to access the vast majority of literature, which is being pro-
duced by those who speak other languages.
As such, this literature review aims to present an overview of
the state of research into this area as it stands at this time, com-
bined with a degree of guidance for the practitioner regarding
point selection, number of points used, sessions per week, dura-
tion of sessions and duration of the treatment intervention, and to
provide an evidence base for those seeking to gain a rationale for
the points that they use.
Each paper showing statistically significant effects directly at-
tributable to an acupuncture treatment lends weight to the use of
acupuncture to significantly reduce the symptoms of anxiety dis-
orders, using both human and animal subjects. To some extent,
despite the methodological criticisms, it is this central point that
must be focused upon. There is evidence that acupuncture is com-
parable with CBT, which is a common intervention in the treat-
ment of this condition [22,43], but in a setting and environment in
which most patients seem to find less stressful, and are well known
to access voluntarily in preference to regular medical avenues. Fi-
nally, it must be a priority amongst researchers worldwide to pro-
vide consistent, evidence-based recommendations regarding the
adequate dose required for acupuncture to have a therapeutic
effect.
Conict of Interest
The author has no conflict of interest.

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