Worrying About Worrying

Massage Therapy and Anxiety Disorders

By Ruth Werner
[Pathology Perspectives]

Anxiety disorders affect roughly one in every eight adults in the United States. These conditions cross over all races and ages, but because they can make it difficult to keep a job or maintain relationships, and because medical intervention can be difficult to access, they are disproportionately high among the lowest socioeconomic groups.
Anxiety and stress are closely related, but they are not the same thing. An experience of emotional stress in response to everyday challenges is considered normal, but anxiety is considered by some professionals to be a complication of living in a stressful state over a prolonged period of time. In other words, stress is a response to life’s challenges; anxiety is a pathological reaction to stress.
Anxiety can be a transient problem in connection with specific events like surgery or other major challenges, or a freestanding condition that may last a lifetime. A person can be affected by multiple anxiety disorders, along with other mental conditions, all at the same time. And, amazingly, massage therapy may help. Research shows that massage therapy can be a useful intervention for these common, complicated, convoluted conditions.
How do we know this? How do we measure the severity of a mental state? Does the effectiveness of massage therapy in this context impact our scope of practice? And if massage therapy is helpful, does that make us mental health-care providers?

What is an Anxiety Disorder?
Anxiety disorders are mental conditions that center on the experience of various kinds of fear. That fear may be altogether irrational or based on something realistic, but distorted out of proportion. While we are occasionally overwhelmed by events around us, people who live with anxiety disorders may be mildly or completely debilitated by their perceptions of threat; feeling overwhelmed and powerless threatens their physical health and becomes a defining feature of their lives.
Anxiety disorders are common—affecting up to 40 million Americans—but they are often undiagnosed and untreated. Anxiety disorders and other mental health challenges can also overlap, so a person may be affected by more than one challenge at any time.

What is the DSM-5?
The DSM-5 refers to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is the reference doctors around the world use to study and treat psychiatric conditions. It is regularly updated to reflect the most current findings in mental disorder diagnoses, treatments, and prognoses. The most current edition has reorganized the way some of the psychiatric conditions are classified and discussed. A brief overview of the new DSM-5 organization of anxiety disorders and related conditions is included under “DSM-5 Headings” on page 41.

Types of Anxiety Disorders
• General anxiety disorder (GAD): GAD describes constant consuming worry and anticipation of any possible catastrophe. Primary symptoms include restlessness or a feeling of being on edge, easy fatigability, irritability, muscle tension, poor concentration, and sleeping problems.
• Panic attack, panic disorder: Panic disorder is characterized by the sudden onset (often with no identifiable trigger) of very extreme sympathetic symptoms: a pounding heart, alternating flushing and chilling, chest pain, dizziness, faintness, and sweatiness. Hyperventilation causes numbness and tingling in the lips and extremities. A feeling of being smothered, of impending doom, and the nearness of death usually lasts for about 10 minutes, but may persist for many hours.  
A person can have a single panic attack without having panic disorder. But when episodes repeat, especially if they are associated with a certain place or situation, panic disorder may be diagnosed.
• Agoraphobia: About one-third of panic disorder patients develop agoraphobia—a situation where people avoid any situations they feel might trigger a panic attack. Agoraphobia can also be a freestanding disorder, without a preliminary history of panic attacks. It is frequently defined as fear of open spaces, but a more accurate description might be fear and avoidance of places or circumstances that feel threatening for any reason.
• Phobias, social and specific: Social phobia—Also called social anxiety disorder, social phobia is characterized by fear of being judged negatively by others. Physical symptoms are not always present, but may include blushing, nausea, sweating, and trembling. People with social phobia may be unable to manage a job, school, or relationships.
Specific phobias—A specific phobia is an intense, irrational fear of something that poses little or no real danger. Some common phobias include fear of air travel, blood, certain animals, closed-in places, and heights.  
• Separation anxiety: This condition is usually associated with young children, but it is also seen in adults. It is often missed because it occurs with other anxiety disorders or depression. Treatment for other disorders, that does not specifically address separation anxiety for these patients, may not be successful.
• Selective mutism: This describes a condition in which a person can speak freely and normally in some settings, but in others he or she cannot. It is frequently seen alongside social phobia. It appears to be triggered by anxiety, but can also have a physiological component, as tight muscles around the throat may physically inhibit the ability to speak.

How Is Anxiety Identified and Measured?
One of the greatest challenges in identifying and then treating anxiety disorders has been creating a way to identify them that is accurate and sensitive—that is, a true reflection of how or whether a diagnosis fits a person’s situation. This information is typically gathered by using questionnaires.
The challenge, however, is in creating a survey that is both specific and short; making a patient fill out a long form with each appointment (or even before and after each appointment) is simply not feasible.
Several anxiety scales have been developed to detect the presence and severity of anxiety disorders. These surveys are often administered along an arc of time to see how the condition progresses and if treatment strategies are successful.
Some of these surveys are proprietary and available only through paying a fee. The best-known, most-used, and most consistently validated one of these anxiety scales is the State-Trait Anxiety Inventory (STAI). It collects information on how a person feels in the moment (state anxiety), but also over time as a general attitude (trait anxiety). Sample questions look like this:
For “state” anxiety:
1 = not at all; 2 = somewhat;
3 = moderately so; 4 = almost always
A. I feel at ease…..1  2  3  4
B. I feel upset…....1  2  3  4
For “trait” anxiety:
1 = almost never; 2 = sometimes; 3 = often; 4 = almost always
A. I am a steady person…...1   2   3   4
B. I lack self-confidence…..1   2   3   4
Other anxiety scales are offered in the box at left.

Treatment for Anxiety
Conventional treatment for anxiety disorders typically involves some combination of talk therapy and medication. Panic disorder is often treated with beta-blockers to manage heart symptoms. Specific phobias may be treated through controlled exposure to the trigger stimuli.
Drugs for anxiety disorders are usually anxiolytics and/or antidepressants. Common antidepressants used in this context include Celexa, Paxil, Prozac, and Zoloft. Anti-anxiety drugs are usually benzodiazepines, including Ativan, Valium, and Xanax.
The type of talk therapy used for general anxiety disorder and social phobia disorder (by far the most common types of anxiety disorders) is usually some version of cognitive-behavioral therapy (CBT). This is an approach to mental health that focuses on changing patterns in thinking and behaviors to improve general coping skills and relationships.

Massage Therapy Appears to Be Useful for Anxiety
We have known for some time that massage therapy appears to have a consistently positive impact on anxiety for people in many situations. Research on anxiety related to surgical procedures, caring for terminally ill loved ones, chronic pain, burn scars, and many other circumstances shows that symptoms are often reduced and quality of life improves with massage therapy. Some evidence also suggests that the more massage a person receives, the longer lasting the benefits are. But we don’t know the mechanism of these effects, and they do not appear to be universally generalizable. Further, we don’t know that massage therapy is substantially more effective than other interventions like yoga or exercise.
What does that mean for our profession? I see three main questions to begin this discussion:

Are Massage Therapists Mental Health-Care Providers?
The temptation is to answer that question with a resounding no, but it’s not that simple. If the evidence shows that massage therapy is effective for many clients with anxiety and depression, then it is not unreasonable to claim that benefit. Whether that makes our work mental-health therapy is another question.

What Does Doing Therapy Even Mean?
It is interesting to note that doing therapy is not a well-defined term, even within psychotherapeutic circles. Therapy can refer to any treatment intended to reduce illness or improve health. We call ourselves massage therapists, because we engage in an active intervention designed to lead to a positive outcome. But so do yoga teachers. And people who lead Pilates classes. And belly dance instructors. Dance, exercise, yoga—all of these have demonstrated value for mental health. Does that make the people who offer them mental-health therapists? Or is it more accurate to say that the mental-health benefits in these activities are simply a positive side effect of healthy activity?

What Would a Mental-Health Specialty for Massage Therapy Look Like?
At this time, it is possible to obtain advanced training in massage therapy to work with athletes, cancer patients, children, people with orthopedic injuries, pregnant women, and many other specialties. It doesn’t seem farfetched to suggest that a specialty in working with mood disorders might also be possible. Indeed, in relaying the clearly and consistently positive findings about massage therapy in this context, Christopher A. Moyer, PhD, suggests the following: “Building on what is already known about the effects of massage therapy on anxiety and depression, everything possible should now be done to better understand and optimize the ways that massage therapy influences affect, the observable components of an individual’s feelings, moods, and emotions.”1
To my knowledge, no advanced education program for massage therapists to work with this specific population exists at this time. If such a specialty were developed, here are some of the components it would need for it to be safe, ethical, client-centered, and within established scope of practice:
• MTs need a well-developed team of other health professionals, specifically medical doctors, psychiatrists, psychologists, or other counselors who are available for consultation and referrals.
• Clients need to be fully informed of the limitations of the massage therapy scope of practice and encouraged to include other professionals as their mental health-care providers; this includes giving permission for their provider team to discuss their case whenever necessary.
• MTs need instruction in how to use validated anxiety and depression scales so they have a method of tracking progress for their clients; these scales should be consistent with the ones used by other members of the team.
• MTs should be familiar with the principles of CBT in order to use communication practices that are consistent with the rest of the client’s health-care team.
• MTs must be able to recognize signs of mental-health emergencies and have the resources to take appropriate action for clients who are at risk of causing harm to themselves or others.
• MTs must have access to their own support system of colleagues—a peer supervision group—with whom they can appropriately explore their emotional and professional challenges in working with this population.
These suggestions are by no means comprehensive; this is simply a list of some of the skills and abilities that a massage therapist who wants to specialize in working with clients with mood disorders might need.
The best role for massage therapy in the context of anxiety disorders is something of a moving target right now. But, if practitioners feel called to pursue this specialty, I hope they do so with the best possible support system for themselves and their clients. And, then, I hope they report back to the profession.  

DSM-5 Headings
Three closely related groups of disorders used to be discussed under the heading of anxiety. They have now been separated, although it is recognized that they can occur together in the same person.
• Anxiety disorders include the conditions discussed in this article.
• Obsessive-compulsive and related disorders (OCRDs) used to be considered subtypes of anxiety disorders, but they are now recognized as discrete conditions. They include body dysmorphic disorder, hair-pulling disorder, hoarding disorder, obsessive-compulsive disorder, and skin-picking disorder.
• Trauma and stressor-related disorders (TSRDs) also used to be classified as anxiety disorders, but are now recognized as freestanding conditions. They include acute stress disorder, adjustment disorders, posttraumatic stress disorder, and others.
All of these labels include qualifiers that describe situations where the conditions are related to drug use or abuse, or other factors, as well as where they overlap each other.        

Anxiety and Depression Association of America. “DSM-5: Changes to the Diagnostic and Statistical Manual of Mental Disorders.” Accessed February 2016. www.adaa.org/understanding-anxiety/DSM-5-changes.
Brownback, Mason & Associates, P.C. “10 Principles of Cognitive Behavioral Therapy (CBT).” Accessed February 2016.
Julian, L. “Measures of Anxiety.” Arthritis Care and Research (Hoboken) 63, Supplement S11. (November 2011). doi:10.1002/acr.20561. Accessed February 2016. www.ncbi.nlm.nih.gov/pmc/articles/PMC3879951/.
Moyer, C. A. “Affective Massage Therapy.” International Journal of Therapeutic Massage and Bodywork 1, no. 2 (2008): 3–5.
ScienceDaily. “New Scale to Measure Anxiety Outcomes Developed.” Accessed February 2016. www.sciencedaily.com/releases/2010/03/100309091452.htm.
Zimmerman, M. “Outcome Tracker.” Accessed February 2016.

1. Christopher A. Moyer, “Affective Massage Therapy,” International Journal of Therapeutic Massage and Bodywork 1, no. 2 (2008): 3–5.

Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.