Articles BRAIN HEALTH

Reduction in Anxiety and Panic disorder Subsequent to Chiropractic Care

Abstract
Objective: The purpose of this case study is to provide a detailed report on the symptomatic improvement of a patient with panic disorder undergoing Gonstead chiropractic care.
Clinical Features: A 27 year-old female, diagnosed with Panic disorder 10 years prior, presented to the Chiropractic office for generalized low back pain with concurrent Panic Disorder. She began to have back pain following a car accident in 2001 where she fractured L1 and L2.
Interventions and Outcome: Over a 2-month period, the patient was seen 3 times per week during which she was evaluated and adjusted using the Gonstead system. Following the first 2 weeks of care, patient reported a reduction in low back pain from 8/10 (0 being no pain and 10 being the worst pain) to 4/10. At 2 months into care patient visits were reduced to 2 times a week until December of 2011. 1 month into care patient reported the back pain as resolved and 5 months into care patient reported not having any further panic attacks and stopped taking her Xanax. Furthermore, improvements in ranges of motion, paraspinal thermography and sEMG were noted along with the patient’s subjective report of improvements in back pain and panic attacks.
Conclusion: Following the first two weeks of chiropractic care the back pain was considered resolved according to the patient. The anxiety and panic attacks took 2 months to resolve. Reduction in subluxation with Gonstead analysis and adjustment may be effective not only for relief of back pain, but in this case symptoms of panic disorder were seen to regress. There are some limitations to the study, which are that we are relying on subjective patient data and the length of time following start of care and resolution symptoms. The improvements described here suggest a possibility of a link between a subluxated spine and mental health function.
Key Words: panic disorder, vertebral subluxation, general anxiety disorder, chiropractic research, stress, back pain

Introduction
Panic Disorder
Panic disorder is a subset of Anxiety disorders. The Diagnostic and Statistical Manual, 4th ed. defines someone with panic disorder as a discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom.1 Most people with panic disorder anticipate and worry about another attack and avoid places or situations where they have previously panicked.2 People with panic disorder often worry that they have a dangerous heart, lung, or brain disorder and repeatedly visit their family physician or an emergency department seeking help.1 Unfortunately, in these settings, attention is focused on physical symptoms, and the correct diagnosis often is not made.2 Panic disorder is highly comorbid with other anxiety disorders, such as social anxiety disorder, generalized anxiety disorders (GAD), major depressive disorder (MDD), and substance use disorders.2,3 During these attacks, somatic symptoms such as shortness of breath, palpitations, chest pain, choking or smothering sensations, and cognitive symptoms such as fear of “going crazy” or losing control is present.1,2 The National Institute of Mental Health (NIMH) reports over 6 million American adults ages 18 and older, or about 2.7 percent of people in this age group in a given year, having panic disorder.4 About one in three people with panic disorder develops agoraphobia, a condition in which the individual becomes afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack.4 The anxiety that is characteristic of panic attacks can be differentiated from generalized anxiety by its paroxysmal nature, and its typically greater severity. Generalized Anxiety Disorder (GAD) is the most prevalent psychiatric disorder to be seen by primary care physicians.5 According to a study done by the World Health Organization (WHO), anxiety is present in 8% of the population and is more prevalent among women over 35 years old and men over 45.5 Panic attacks are a period of intense fear in which 4 of 13 symptoms (cognitive or somatic) develop abruptly and peak rapidly less than 10 minutes from onset of symptoms.1 The most common symptoms include1:

1. Heart palpitations in which subject can feel and hear intense beating of the heart
2. Arrhythmias
3. Tightness in the chest making it difficult to take a deep breath.
4. Difficulty swallowing or the feeling of a lump in the throat.
5. Sleeplessness.
6. Digestive problems or severe cramping in the intestines or bowel.
7. Constipation or severe diarrhea.
8. Seating of the hands
9. Tingling sensations in the arms, hands, legs, and feet.
10. Rapid and repetitive disturbing or frightening thoughts.

Additionally, to be diagnosed as Panic Disorder, the attacks cannot directly or physiologically result from substance abuse, medical conditions or another psychiatric disorder.1 Anxiety has now been implicated in several chronic physical illnesses, including heart disease, chronic respiratory disorders, and gastrointestinal conditions.6 We can assume that if people that have these diseases also have untreated anxiety, this can perpetuate and make these overlying diseases more complicated to treat, further posing a problem for these people.
According to the Anxiety Disorders Association of America, direct healthcare costs and lost productivity of these conditions cost more than $42 billion a year in the U.S., one third of the $148 billion total mental health bill. $22.84 billion in expenses is associated with repeated use of healthcare services.7

Overview of Anxiety and Contributing factors

Anxiety is a reaction to stress that has both psychological and physical features. The feeling is thought to arise in the amygdala, a brain region that governs many intense emotional responses. 6 As neurotransmitters carry the impulse to the sympathetic nervous system, heart and breathing rates increase, muscles tense, and blood flow is diverted from the abdominal organs to the brain and muscles to prepare you to fight or run away.6 In the short term, anxiety prepares us to confront a crisis by putting the body on alert.6 But its physical effects can be counterproductive, causing light-headedness, nausea, diarrhea, and frequent urination.6 And when it persists, anxiety can take a toll on our mental and physical health.6
In addition to persistent anxiety symptoms, panic patients in the non-panic state have a distorted cognitive perception of their bodily and mental functioning and they also hyperventilate.8 Additionally, anxiety has now been implicated in several chronic physical illnesses, including heart disease, chronic respiratory disorders, and gastrointestinal conditions.6 When people with these disorders have untreated anxiety, the disease itself is more difficult to treat, their physical symptoms often become worse, and in some cases they die sooner.6

Pathophysiology

Although there have been a number of studies on Anxiety and Panic disorder the exact pathophysiology remains largely unknown. The causes of anxiety/panic disorder are varied and range from biochemical imbalances to distortion in thinking processes due to stressful external events.(LE) Panic disorder appears to be a genetically inherited neurochemical dysfunction. With moderate heritability, any distinct deoxyribonucleic acid (DNA) linkages remain unknown.9 The apparent neurochemical dysfunction behind panic disorder may involve autonomic imbalances including decreased gamma-aminobutyric acid (GABA) tone, increased cortisol, or diminished benzodiazepine receptor function, and disturbances in serotonin.9 Some theorize that panic disorder may represent a state of chronic hyperventilation and carbon dioxide receptor hypersensitivity.8 Some epileptic patients have panic as a manifestation of their seizures.6
Recent animal models have suggested a role of serotonin type-1A receptors (5-HT1AR) in the development of chronic anxiety and have helped to generate animal models of anxiety-related disorders.9 However, Neumeister states these models of anxiety may not be relevant for panic disorder in humans.

Women are 2 times more at risk for development of anxiety disorders which is attributed to their hormonal and social factors, including cultural pressures to meet certain expectations.7 Mental health research on family environment factors documents that the emotions of the mother can have a powerful effect on both a young child’s immune system and social development.7 It seems to be common knowledge that stress taxes that immune system, this could have an effect of prolonging anxiety symptoms. 30 percent of strep infections in children was preceded by a stressful event and children with asthma were more bothered by symptoms if they lived in a family with many conflicts.7 Medical research has come a long way with technology and localizing even the most minute occlusions in tiny vessels in the brain. Science has used this imaging technology to study humans and animals alike to determine the exact location in the brain responsible for anxiety and fear. A small study on brain electrical activity during hypnotically induced anxiety and relaxation demonstrates source localization of EEG activity, with anxiety expressing maximally stronger activity that relaxation in right Brodmann area 10.7 Results agree with reports that emotional states are associated with activity of distinct neural populations and brain activity shifted to the right (especially fronto-temporal) during negative emotions.7

Nutritionally there are certain foods that when ingested cause an increase in the symptoms of anxiety. Different forms of sugar such as glucose, fructose, sorbitol, and xylitol have also been shown to cause an increase in anxiety and panic symptoms.33 It is thought that the sugars stimulate insulin release, which elevates the blood sugar. This rapid elevation then causes a reactive decrease in blood glucose, which may cause anxiety symptoms in susceptible people.33

Differential Diagnosis

Symptoms of Panic disorder correspond with symptomatology found in life-threatening medical disorders such as pulmonary embolus, which may manifest with anxiety as a primary symptom. 10 It is postulated, in one study that persons with panic disorder may be twice as likely to have coronary artery disease as the general population. 10 In one study, approximately 44% of emergency department patients with panic disorder had a history of coronary disease.10 Patients with supraventricular tachycardia have the potential to be misdiagnosed with panic disorder in more than 50% of cases.10 When making a diagnosis of panic disorder, it is important for the clinician to keep in mind the symptomatology of medical conditions such as the following: 10

Angina and myocardial infarction (eg, dyspnea, chest pain, palpitations, diaphoresis)
Cardiac dysrhythmias (eg, palpitations, dyspnea, syncope)
Mitral valve prolapse
Pulmonary embolus (eg, dyspnea, hyperpnea, chest pain)
Asthma (eg, dyspnea, wheezing)
Hyperthyroidism (eg, palpitations, diaphoresis, tachycardia, heat intolerance)
Hypoglycemia
Pheochromocytoma (eg, headache, diaphoresis, hypertension)
Hypoparathyroidism (eg, muscle cramps, paresthesias)
Transient ischemic attacks (TIAs)
Seizure disorder

An understanding of panic disorder is important for the chiropractor, because patients with this disorder may present with various somatic complaints that may be mistaken for a subluxation indicator. It is important for the chiropractic clinician to be well versed in many different causes of somatic complaints and make the proper referrals when indicated.
It is also important for the Chiropractor to be knowledgably about the presence of asthma as a risk factor for the development of panic disorder.11 The co-occurrence of panic disorder and asthma is greater than would be expected based on their individual prevalence rates.11 The presence of airways disease appears to contribute significantly to the risk of developing panic disorder due to hyperreactivity of CNS centers controlling respiratory drive, which can produce hyperventilation.11 Hyperventilation among panic disorder sufferers is a result of the body’s adaptive attempts to reduce panicogenic carbon dioxide.11

Medical treatment

Anxiety is probably one of the most universal human emotions. It is likely that many of us at some point, on some level, experienced symptoms of anxiety. Some have an extreme form, panic disorder that they commonly seek medication for.
Each year the United States has over 80 million prescriptions written for patients suffering from this condition.(Sullivan) The main treatment methods for panic disorder are psychotherapy and pharmacotherapy, especially benzodiazepines and anti-depressant medications. Mainstream drugs can prevent or greatly reduce anticipatory anxiety, phobic avoidance, and the number and intensity of panic attacks.12 According to the Merck Manual Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) offer symptom relief with fewer adverse effects in comparison with Benzodiazepines which work more rapidly than antidepressants but are more likely to cause effects as somnolence, ataxia, and memory problems.4
Serotonergic implication in PD has been demonstrated by the efficacy of serotonin reuptake blockers in treatment. Fluoxetine (Prozac) is a powerful serotonin-specific reuptake inhibitor reported to have anti-panic efficacy.12 Dr. Pecknold, MD, performed an open study examining 30 patients (eight males and 22 females) with an average age of 36.9 years, ranging from 18-62, who were treated for eight weeks with fluoxetine.12 36% of these patients ended up dropping out of the study due to increased anxiety.12 A 50% decrease in panic attacks was obtained in 66.6% of the patients by week 8.12
Gorman et al (1987) studied 16 patients who were treated with fluoxetine for 18 weeks at a dosage of 10mg per day to 80mg per day.13 Seven patients (43.7%) responded favorably while nine patients (56.3%) dropped out of the study because of adverse effects such as agitation, restlessness, diarrhea and insomnia.13 The question remains whether all antidepressants are effective enough to remain part of the mainstream method of treatment. Studying a variety of antidepressants with regard to their ability to block panic attacks should help us to elucidate common denominators.14
Another class of commonly used drugs to treat anxiety disorders are the benzodiazepines.2,4 High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with PD, who can take benzodiazepines for up to a year with harm.4
Another drug commonly used to treat the anxiety disorder associated with panic attacks in the drug, Alprazolam (brand name Xanax). This benzodiazepine is a tablet ingested orally and usually taken two to four times a day.14 Xanax is also used to treat depression, fear of open spaces (agoraphobia), and premenstrual syndrome. Xanax is a short-acting anxiolytic of the benzodiazepine class of psychoactive drugs. Xanax, like other benzodiazepines, binds to specific sites on the GABAA receptor.14 It is commonly used and FDA approved for the medical treatment of panic disorder. Clinically, all benzodiazepines cause a central nervous system depressant activity varying from mild impairment of task performance to hypnosis.14 Demonstrations of the effectiveness of Xanax by systematic clinical study are limited to 4 months duration for anxiety disorder and 4 to 10 weeks duration for panic disorder; however, patients with panic disorder have been treated on an open basis for up to 8 months without apparent loss of benefit. The physician should periodically reassess the usefulness of the drug for the individual patient.”15 Some adverse reactions noted with this medication include but not limited to: drowsiness, light-headedness, headache, tiredness, dizziness, irritability, talkativeness, dry mouth…etc.15

Alternative therapies

Complementary and alternative therapies (CAM) are used more often than conventional therapies by people with self-defined anxiety attacks and depression. Most patients visiting conventional mental health providers for these problems also use CAM therapies.16 Close to nine out of 10 patients with self-defined anxiety attacks who are seen by a psychiatrist also use some type of CAM to treat anxiety, while six out of every 10 patients with self-defined severe depression who are seen by a psychiatrist also use some type of CAM therapy.16 Patients with anxiety and subset PD often seek alternative therapies besides traditional medicine. This would include meditation, yoga, herbal supplements, dietary modifications, aroma therapy, comic relief, energy healing, and hypnosis.16
Meditation programs may have a place in the treatment arena of anxiety disorders. In the following study by Dr. Zinn et al, 22 participants who met the DSM-III-R criteria for generalized anxiety disorder (GAD) and anxiety disorder with or without agoraphobia were collected to participate. These Doctors used three major self-regulatory strategies for a unique method of treating anxiety. These were, meditation, relaxation, and biofeedback strategies. Research suggests that all three play a role in reducing both physiological and psychological components of anxiety in normal populations and that the latter two techniques are effective in anxious populations.17
Cognitive Behavioral Therapies
Cognitive Behavioral Therapy is based on the theory that is basically negative thinking, negative perceptions towards stressful events or negative thoughts towards oneself that predisposes a person to creating anxiety or panic attacks. When a person sees themselves in a negative way or perceives many of life’s daily stressors to negatively, this person can put their body into the flight or fight response.17

Nutrition

It is also thought that the deficiency of certain vitamins and minerals may contribute to anxiety symptoms.18 The following is a list of dietary items, which if deficient may cause an increase in the susceptibility of anxiety. Also listed are the recommended doses to be taken to help reduce the deficiencies.18,19
Deficiency – Advised Supplemental amount – Comments
1. Serotonin – 200-900mg daily in divided doses – The relationship between chronic stress, depression and anxiety is complex and very powerful. The chronic elevations in glucocorticoids (cortisol) caused by excessive stressors in industrialized societies lead to physical changes in brain structure38. Dendrites of neurons are shifted into less functional patterns upon chronic exposure to cortisol. This has been documented in key brain regions associated with mood, short-term memory, and behavior flexibility.39 Furthermore, glucocorticoids cause receptors for the mood-regulating neurotransmitter serotonin to become less sensitive to activation. 38
2. Calcium and Magnesium – 2,000mg/1,000mg daily – Natural tranqualizer. Helps relieve anxiety and tension through reducing muscular spasms and tics.
3. Floradix Iron + Herbs from Salus Haus – as directed – Iron deficiency can increase the risk of panic attacks. Floradix is a natural source of iron.
4. Liquid Kyolic with B1 and B12 from Wakunaga – as directed on label – Helps reduce stress and anxiety.
5. Potassium – 99mg daily – essential for proper function of adrenal glands
6. Selenium – 100-200mcg daily. – Low levels have been found in panic disorder. Its also a powerful anti-oxidant that protects the heart.
7. Vitamin B6 – 50-100mg daily – Facilitate conversion of Tryptophan to serotonin.
8. Omega-3 Fatty acids – 180mg EPA; 120mg DHA – These two essential fatty acids, EPA and DHA are necessary for proper brain function. The typical western diet has an overly high ratio of inflammatory omega-6 fatty acids to anti-inflammatory omega-3 fatty acids. In one double-blind, placebo-controlled and randomized clinical trial, medical students were given omega-3 vs placebo and were found to have a 20% reduction in anxiety.34

Case Report

A 27-year old female presented for chiropractic care at a private chiropractic office in 2010. Initial exam revealed a previous diagnosis of scoliosis by Doctor Bowen at DuPont Hospital, when the patient was in 6th grade (12 years old). At 16 years of age, the patient was involved in a car accident where she rear ended another vehicle. As a result of this accident she fractured her L1 and L2 vertebra and was put in a body cast for 3 weeks. Following the body cast the patient was then instructed to wear a brace 24 hours a day for a month.
Patient first noticed that she was having panic attacks at age 17. She described them as having heart palpitations, chest pain, dizziness, fear of losing control, nausea, shortness of breath and sweating. Soon after she saw a psychiatrist that diagnosed her with panic disorder. She was taking Xanax (1.25mg capsule for day), which helped relieve her symptoms for 2 years with no known side effects.
At age 19 the patient began seeing a chiropractor for back pain (most likely a residual from the car accident), three weeks into care her anxiety got worse. The patient described this chiropractors adjusting as “full spine” generalized mobilization. The doctor never adjusted her cervical spine and only “popped both hips and middle back.” Following each visit she stated that her anxiety escalated and at 3 weeks she terminated care.
Two years later the patient was 21 and described a simple slip and fall on the ice, where she landed on her back and immediately was stricken with intense anxiety and tunnel vision. This was the patient’s only experience with tunnel vision concurrent with anxiety. At age 25 the patient sought out chiropractic care for low back pain which she rated as an 8/10 (0 being no pain and 10 being the worst pain imaginable). Following an exam and X-rays, the patient began care at 3x/week for 2 months then 2x/week for 6 months, and finally 1x/week for maintenance. After the first two weeks of Gonstead chiropractic care the back pain was considered resolved, according to the patient. The anxiety and panic attacks took two months to resolve. During the duration of chiropractic care the patient was taking Xanax as needed. The patient had been prescribed Xanax for the past 10 years, following 5 months of care the patient discontinued using the Xanax all together.
Objective Data:
Thermal or EMG studies, exam findings…, interventions, frequency of care, duration of care, outcomes?
Pictures of the scans…
Outcomes:
Heart information:

Gonstead System
The Gonstead System is an example of a segmental model. Subluxation is described in terms of alterations in specific intervertebral motion segments. In segmental approaches, the involved motion segments may be identified by radiographic procedures which assess intersegmental disrelationships, or by clinical examination procedures such as motion palpation. Examples of segmental approaches are the Gonstead and Diversified techniques.20
The entire basis for the Gonstead methodology revolves around the intervertebral disc. The doctors must fully understand the role the disc plays in the vertebral subluxation. It is the analysis of the disc, and the changes it undergoes, which gives the most reliable information for locating the potential subluxation. Since the disc itself cannot be seen on the x-ray film, the state of the disc must be inferred from the condition of the disc space. Critical analyses of the degenerative conditions of the discs and of misalignments of the vertebral bodies are not in themselves sufficient evidence for locating a potential subluxation. Dr. Gonstead has found that the most severely misaligned vertebrae are often compensatory misalignments to actual subluxations elsewhere.21
According to Dr. Gonstead there are five criteria for Gonstead adjusting:21
1. Instrumentation: nervoscope to help localize the subluxation. Also tells when not to adjust
2. Static Palpation: digital palpation around the SP as well as over the facet joints will uncover any trophic or CT changes that occur w/ altered physiological response from the subluxation
3. Motion Palpation: The fixation cause the build-up of fluid around the facet jt which puts press on the nerve roots. The segments in the area of instrumentation reading and static palpation are brought into passive assisted flexion and extension, rotation and lateral flexion and evaluated for fixation.
4. Visualization: This criterion is used to help conform the listing. High muc
5. Xray: This criteria is used to give practitioner an accurate listing and confirms the likelihood of a subluxation at that level. In a subluxation complex, the endplates facet joints and disc can undergo degenerative processes and show signs of fixation.21
Gonstead chiropractic has a single definition of purpose; locating and correcting vertebral subluxations for the improvement of nerve function.21 The brain and the nervous system control every muscle and organ in the body. In fact every cell in your body is controlled and monitored by your nervous system and the slightest interference to this communication can cause health problems and pain. The Gonstead chiropractor utilizes unique skills of skeletal analysis to detect any harmful misalignments and then specifically corrects the misalignment, not the compensation. Gonstead coined the phrase “find it, fix it, leave it alone.”22

Discussion
Although there was ample information on panic disorder, the research articles relating specifically to the role of chiropractic treatment and panic disorder were minimal, and outdated. During its earliest years, chiropractic was recognized as affecting some forms of behavior. There was once considerable interest in chiropractic psychiatry but, as the directions of both chiropractic and psychiatry shifted, that interest waned. Dr. Quigley is probably the most accessible writer of the theory of chiropractic intervention in psychiatric problems.23
In a chapter in mental Health and Chiropractic, titled “Physiological Psychology of Chiropractic in Mental Disorders”, he states that the theoretical basis for the effect on psychological problems was threefold: First, A psychotherapeutic effect, a relief from a physical dysfunction that is psychophysiology in origin, and lastly, some type of biochemical balanced achieved which corrected the mental disorder.23 To illustrate the psychotherapeutic effects of chiropractic care, Quigley postulated that the area of the reticular activating system (RAS) is affected by the neural bombardment from visceral receptors.23 This constant arousal of the CNS leads to cortical over activity and has been shown to limit behavioral response and is currently the core of most theories concerning neurotic behavior. Quigley also noted that a chronic state of muscular tension can lead to neuroplasticity in those pathways which leads to an emotional response which in turn causes more muscle tension in a cyclical fashion.23 Chiropractic adjustments tend to normalize the excessive proprioceptive insult to the CNS thereby breaking this hypertensive muscle cycle.23
Much of this is parallel to Selye’s work of psychological stress reduction. Quigley stated that the core of chiropractic as psychotherapy is the reduction of anxiety and the induction of somatic relaxation. This is owed to a balancing effect the adjustment has on the sympathetic & parasympathetic nervous systems.23
Various other early writers have added to the literature of chiropractic psychotherapy, notably Homewood, Hinder, Schwartz, Weiant, Welberry, Nelson, Schmidt, and LaLorde. Most of what is reported is further anecdotal material on the effects of adjustment in individual cases of severe mental illness; however the sheer number of cases cited is noteworthy.
Dr. Homewood provides an excellent theory for chiropractic’s management of psychological disorders. His emphasis is on the possible methods of the production of a subluxation as types of “psycho-visceral-somatic” response to stress.23 Dr. Homewood suggests that just as a psychological component can cause subluxation, removal of a subluxation could alleviate that psychological component as well. He adds that stress has been shown to increase the swelling of the intervertebral discs. This can lead to anoxia and advance a further chemical-mechanical basis as well as emphasizing the possible somatic role in maintaining a psychological disorder.23
In 1993 Dr. Potthoff et al described a case in which a 52-year old diagnosed with chronic panic attacks experience resolution of symptoms and was taking off all medication at the request of her medical doctor.24 The patient was treated using specific adjustments to her cervical and thoracic spine. More specifically, intersegmental restrictions were found and adjusted at C1, C5, T1, T6 and the right ilium. As soon as the feeling of a panic attack approached the patient was instructed to come in for an adjustment. A blood pressure of 182/102 was recorded (normal baseline was 108/70) as well as a pulse rate of 120 beats per minute.24 Immediately following the adjustment the pulse rate dropped to 76bpm and blood pressure dropped to 140/80.24 Even more impressive is that it took this one adjustment for the patient to go 67 days without having any further panic attacks. This is the longest period between attacks that she has maintained for many years.
Patrick J. Goff, Elizabeth McConnell, DC, and Phil Paone, DC investigated if it could be demonstrated that the chiropractic adjustment could bring about a relaxation response and anxiety reduction.25 The investigation was conducted at Palmer College of Chiropractic. Each patient was tested psychometrically before and after care for anxiety. Surface EMG was used to measure muscle tension and later it was published in 1991 that chiropractic care caused “considerable decrease in muscle tension” and “a reason for chiropractic adjustment to affect mental health.”25
Another case study done by Dr. Sullivan et al revealed a 42-year-old white female diagnosed with panic disorder. This patients care began following an automobile accident in 1989 where she sought chiropractic care for back and neck pain. This patient gave a history of repeated anxiety attacks since the accident with agoraphobia. Upon exam, this patient was diagnosed by Dr. Sullivan with acute and chronic cervical/lumbar strain with superimposed subluxations of C5, T5, and L5 and degenerative disc disease of the lumbar spine. Additionally, post-traumatic stress disorder with generalized anxiety and somatization disorder and Dysthymia. After two months of Gonstead chiropractic 3 times a week, biofeedback once a week and one hour of cognitive counseling each week, the patient reported no more attacks of agoraphobia and a major reduction in frequency and intensity of anxious feelings.25
Chiropractic
Can regular chiropractic care reduce panic disorder? Recent research from Brown University suggests that there is a way.26 Harvard/Brown Anxiety Research Program looked at how Panic Disorder changed over time relative to a stressful event.26 They expected that panic symptoms would spike close to the time of the event, but this was not the case.26
They studied patients over time and found that panic disorder symptoms progressively worsened slowly over 3 months following a specific “stressful life event,” including serious family discord and losing a job.26 Regarding the current case, the patient suffered a serious car accident at age 16 years. Age 17 years old the patient started noticing the inception of panic attacks. In this case one can assume the physical stressors followed the car accident that led to distortion of spinal structures. This distortion happens in the intervertebral disc, the facet capsule, the muscle spindle and the golgi tendon organs.27 All this distortion is afferent proprioceptive information that must be relayed to the cerebellum and then the thalamus. 27 The thalamus then shuffles the information to the cortex where this information is compared to what “should” be happening in the body. 27 When these two are different then the body must react through compensation and this, is stressful to the body.27 Recent studies suggest that people with panic disorder have a low tolerance for the body’s normal physiological and psychological response to stress. A hypothesis is that panic disorder patients may have learned to perceive essentially normal physiological events as being dangerous. These people seem to have a lowered stress response threshold, which gives rise to false alarm.4
One very effective tool for this stress reduction is proper body mechanics and pain reduction through regular chiropractic care (the pathways of this will be outlined later). Reduced overall stress, and nervousness, should help minimize the long-term effect and perpetuation of panic disorder. It should be noted that as a Chiropractor, the purpose of this patient’s treatment was not to treat panic disorder. The goal was to reduce vertebral subluxations that stress out the nervous system and allow the body to express its full potential to heal. Easing pressure off the nervous system will allow the body to function at 100% so you can be equipped to handle the stress that life brings.7
As chiropractors we recognize the scientifically and philosophically defendable concept of the innate intelligence of the human body-mind relationship.28 We assume that the body-mind responds to its environment in the most physiologically appropriate manner at any given moment.28 Chiropractors study physiology not pathology because we recognize that most of what allopathy labels as pathology is actually the body attempting in the most intelligent way possible to adapt to the stressful environment in which it has been placed.28 Studying the physiology of the stress response is, in my opinion, the best way to explain the validity and uniqueness of the chiropractic approach to health and vitality. Traditional allopathic medicine concentrates heavily on fighting a disease with a given medication or somehow fighting symptoms. Many times what allopathic medicine is fighting is not disease but actually a physiological adaptive response from the body to a stressful event of some kind.28
The Physiology of the Stress Response
Freud noted realistic anxiety strikes an individual as something very rational and intelligible. He states: “We may say that it is a reaction to a perception of an external danger that is of an injury which is expected or forseen. It is connected with the flight reflex of the self-preservative instinct”25
When the body is subject to a stressful event of any kind (regardless if this stressful stimulus comes from mechanical, chemical, or psychological factors) the body will respond in much the same way everytime.29 These responses are often referred to as ‘stress responses’ and include the activation of the hypothalamic-pituitary-adrenal axis (HPA axis) and sympatho-adrenal system, resulting in the secretion of multiple hormones.30
The first thing that happens in a stress response is typically described as happening after a life-threatening event such as getting chased by a bear in the forest. Your nervous system detects these stimuli and reacts by activating the HPA Axis.27 Sensory information reaches the cortex via the thalamus and is conveyed to the amygdala.27 The amygdala in turn stimulates the hypothalamus to release corticotropin-releasing hormone (CRH) which travels to the anterior pituitary signaling it to produce adreno-corticotropin hormone (ACTH) to stimulate the adrenal cortex.30
As a result of this sympathetic stimulation, all catabolic activities are increased (heart rate and blood pressure) and all anabolic activities are decreased (digestion, reproductive cycles, immunity…). When a bear in the woods is chasing you your body doesn’t bother wasting time with fighting off an infection. You will, however need that immunity if you manage to out run this beast.
The sympathetic system sends a message from the IML, through the ventral root to the mixed spinal nerve, through the white rami communicates to the sympathetic chain ganglia (SCG) and via presynaptic nerve endings the signal reaches the adrenal medulla and synapses there via acetylcholine synapsing onto nicotinic receptors.31 The sympathetic supply to the suprarenal gland is exceptionally fast and efficient, it has to be because it’s a built in life-saving mechanism. The secretory cells of the medulla (chromaffin cells) are postsynaptic sympathetic neurons that lack axons or dendrites.31 Consequently, the medulla is supplied directly by presynaptic sympathic neurons. The neurotransmitters produced by chromaffin cells are released into the bloodstream to produce a FAST widespread response.31
As a result of this stimulation, the adrenal medulla produces the catecholamine’s epinephrine/norepinephrine & dihydroxyphenylalanine (L-DOPA which is the precursor to dopamine). Activation of this sympatho-adrenal system also results in the increased secretion of Interleukin-6, an important cytokine that connects the stress system and various immunological and inflammatory processes.28 Glucocorticoids (cortisol) are produced from the adrenal cortex as well. Glucocorticoids promote gluconeogenesis (make more glucose because you need to fight or run away and you need energy to do that and that’s your glucose), increase blood pressure and suppress aspects of immune and reproductive function. In excess they have been known to cause skeletal muscle atrophy, decrease in peripheral lymphocytes, monocytes, and eosinophils, decrease phagocyte activity, increased blood pressure, inhibition of collagen synthesis, inhibition of macrophage activity.30
Epinephrine causes glycogen to be broken down into glucose because you need energy to run away or fight. Catecholamines also act to constrict the peripheral precapillary arteriole beds to increase blood pressure. This decreases oxygen to the brain and after, a subsequent vasodilation occurs. Now you have the glucose and the vasodilation, this can explain where headaches come from, stress. The effect of increasing blood pressure is the body’s innate intelligence at work. When you need to run from a bear you need that message to be conveyed through the body ASAP, so increasing the blood pressure gets those hormones distributed immediately through the bloodstream.
Catecholamines also stimulate the amygdala in the brain so that the emotional/anxiety memories dominate during stress (so we remember where the bear was so next time we won’t run into it).6,28 Catecholamine’s actually have been shown to inhibit factual learning, working memory and the ability to focus attention at the hippocampus.28 This is again the body’s innate intelligence at work. There’s no reason for you to sit down and learn calculus when you are running from a bear! The amygdala releases CRH, which activates the locus ceruleus, which releases norepinephrine that acts on emotional centers and learning centers in the brain (areas for logical behavior and short term memory are inhibited; centers for emotional learning and instinctual behavior are stimulated).28
Release of norepinephrine during stress response causes an increased sensitivity of the sensory systems (improves chances of survival during fight/flight). However, this means our concentration is easily distracted and that pathways such as those for nociception become sensitized and exert greater effects. “Stress sharpens the signal detection system at the cost of concentration.”28 Therefore, the stressed person becomes easily distracted, sounds like ADHD to me. Studies show that chronic stress can lead to chronic changes in cognition – cells in the hippocampus actually shrink!28 Interestingly, the research also shows that exercise (proprioception via cerebellum) results in growth of the hippocampus.28
The chiropractic adjustment stimulates proprioceptive input into the cerebellar vermis (in much the same way that exercise stimulates the brain) that in turn acts on the amygdala, hypothalamus, and hippocampus in what some have termed the movement-pleasure and movement-learning pathways.28 In other words, an adjustment restores proprioception, which is normally present in the active non-subluxated human. This is the body’s innate way to return to homeostasis. It naturally decreases stress/anxiety and catabolic activities and increases learning and anabolic activities.28
Interestingly, humans have the ability to consciously choose to react differently to stimuli. The left prefrontal cortex can inhibit the stress response by releasing GABA at the amygdala.28 The longer a person is stressed the harder this process can be because of neuroplasticity develops in those pathways. The only way to break this cycle is to create neuroplasticity along stress response inhibition and logical thought stimulation pathways. During chronic stress pathways our system is over-reactive because these pathways are literally sensitized.28 We were never meant to be in a state of chronic stress, however unfortunately that is today’s society. Forcing our bodies to produce all these physiological changes, we are taxing our adaptability to the limit that physiological (cellular) dysfunction occurs.
Proposed Effects of the Subluxation on the Autonomic Nervous System
Neurodystrophic model aka Neuroimmunomodulation model:
Chiropractic revolves around the idea that stress, whether it be physical, chemical or emotional in nature, affects the body’s ability to properly function and leads to poor health. DD Palmer, the founder of Chiropractic, said this over 100 years ago when he proposed that causes of disease came from toxins, trauma or autosuggestion. This remarkable insight is in harmony with both Beck and Ellis in relation to autosuggestion as a cause of both anxiety and muscle spasm.25
In the 1950’s, Dr. Selye studied the effect of stress on the human body and presented his work to the world in the concept of the “General Adaptation Syndrome,” for which he won the 1964 Nobel Prize. This was a revolutionary concept of mental and physical illness and it was, at the time, acclaimed as the most important and far-reaching idea in the history of MEDICINE…that STRESS is the cause of all disease.32 Selye noticed as a young medical student that every patient suffered from similar signs of illness such as loss of energy and appetite, general aches and pain…etc.32
Selye stated that under optimum conditions the body can respond to stressors. He noticed that regardless of the problem, people reacted the same way. This was his neurodystrophic model. According to Selye, the body produces an alarm reaction to any form of stress that threatens its well-being. Unless the stress is unusually strong, we are not even aware of the body’s response as the body adapts. This initial alarm reaction is followed by a period of adaptation to the stress, or compensation (if the stress continues unmitigated).32 This process will continue until the body’s vital energy is exhausted and symptoms become apparent. It is at this point that the patient usually seeks help. It would seem that dis-ease is not a pathology, but rather a fight to maintain homeodynamic balance of all tissues, despite actual damage. These vague symptoms lead a person to think, there must be some kind of natural defense mechanism (innate intelligence). Chiropractic can assist this inborn defense mechanism by complementing the body’s innate ability to heal itself, by removing interference in the nervous system. Neural dysfunction is stressful to the viscera and other body structures. Thus lowered tissue resistance can modify the immune responses and alter the trophic function of involved nerves.22 Selye described the above health concerns as “diseases of adaptation.” The entire general adaptation syndrome (GAS) is based on the idea that under optimum conditions the body can respond to various stressors by adapting to them. The stages of adaptation are: Alarm, Resist, Adapt, Exhaust.22 Scientists and chiropractors now know that pathways exist which verify that the nervous system participates in the response to stress and may therefore be a factor in any of the so-called “diseases of adaptation”. Response to stress is coordinated by a neuroendocrine mechanism.22
Korr’s Facilitation Hypothesis:
Korr proposed that spinal muscles under strain caused the firing of proprioceptors embedded in the muscles.26 The key to comprehending the global pathological effects of the subluxation complex lies in understanding the structural component of segmental facilitation. This is when a vertebra is “stuck” in a abnormal position due to a muscle spasm or facet joint malposition.22,23 This kinesiopathology results in both increased nociceptive input into the CNS and decreased proprioceptive input into the CNS (afferent neuropathy).23 This proprioceptive information (which is conveyed to second-order neurons in the spinal cord) facilitated or lowered the firing threshold of the second-order neurons.26 When second-order neurons are facilitated, they become hyper-responsive to impulses arriving from any source in the body.26 This is what is meant my segmental facilitation. In the spinal cord, second-order neurons synapse with anterior horn cells and lateral horn cells (part of the sympathetic nervous system).26 Continuous irritation of the lateral horn cells causes them to be facilitated or hypersensitive.26 This facilitated or hyper-irritable SNS is considered by Korr to be a major contributing factor in perpetuation of musculoskeletal dysfunction and visceral organ disease.26 Numerous conditions have been linked to hyperactivity of the SNS, including various types of cardiovascular, gastrointestinal and certain musculoskeletal disorders.26
Component Model of Subluxation
Dishman and Lantz developed and popularized the five component model of the “vertebral subluxation complex” attribute to Faye.24 The original model had five components, however Lantz has since revised and expanded the model to include nine components:
1. Spinal Kinesiopathology
2. Neuropathology
3. Myopathology
4. Connective tissue physiology
5. Angiology
6. Inflammatory response
7. Anatomy
8. Physiology
9. Biochemistry

These bodily changes that occur contribute to a chronic increased stress response and a state of chronic catabolism in the patient (pathophysiology).23 The aberrant motion and alignment (kinesiopathology) associated with the subluxation complex also leads to joint and muscle degeneration (myopathology, connective tissue pathology and biochemical changes) and motor control errors in the vestibulospinal tract (efferent neuropathology), resulting in decreased strength, balance, and coordination, which in turn leads to increased susceptibility to injury and degeneration.23 Murphy24 summarized the neurological pathways associated with the maintenance of background postural tone: “Weight bearing disc and mechanoreceptor functional integrity regulates and drives background postural neurologic information and function through the unconscious mechanoreception anterior and posterior spinocerebellar tract, cerebellum, vestibular nuclei and descending medial longitudinal fasciculus.24 The anterior horn cells provide the motor output which travels via the corticospinal pathway to contract postural muscles.
The maintenance of postural balance is attained by the integration of sensory inputs such as vestibular, visual and somatosensory inputs. Concerning the maintenance of balance, a correlation between anxiety and postural instability is suspected.27 Since the subluxation can cause aberrant changes in the vestibular system through efferent pathophysiology we can assume that a chiropractic adjustment would be beneficial to correct this by restoring proper proprioception. According to Wada27 patients suffering from vestibular disorders are prone to be anxious, and the vestibule-ocular reflex in anxious patients is exaggerated from that in normal subjects.27 A higher contribution of somatosensory activity is also observed in extremely anxious people.27 This may be explain by Korr’s segmental facilitation model which states that a hypomobile spinal segment bombards the somatosensory cortex with nociception (proprioceptive insult).22 A chiropractic adjustment can restore proper biomechanics and stop the stress response (caused by aberrant sensory information being relayed to the thalamus), therefore halting further perpetuation of stress hormones such as epinephrine and cortisol.
Korr also proposed that spinal lesions (subluxation) are associated with exaggerated sympathetic activity as well as exaggerated paraspinal muscle tone.24 According to Korr, “high sympathetic tone may alter organ and tissue responses to hormones, infectious agents, and blood components.”24 This mechanism is known as segmental facilitation. The decreased thresholds in efferent neurons arising from the anterior and lateral horn cells are postulated to result in increased impulse traffic to the somatic and visceral structures innervated the by affected neurons.24 When one asks themselves, how chiropractic can help a person with anxiety or panic disorder, this is the mechanism. We reduce subluxations which are perpetuating the sympathetic response, thereby allowing the body to return to its homeodynamic position.

Conclusion
Currently there is a sizeable amount of information on the probable causes and treatment of anxiety and panic disorder. As indicated by the majority of the information researched, the major methods of treatment are by medicatin, cognitive behavior therapy, and avoidance of specific foods that may elicit panic symptoms due to sensitivity. Although there was ample information on panic disorder, the research articles relating specifically to the role of chiropractic treatment and panic disorder were minimal, and outdated. Further updated information and its effects on panic symptoms is needed.
This report details the successful resolution of anxiety and panic disorder in a 27 year old woman. According to the retrospective questionnaires and subjective patient intake forms this patient had resolution of panic disorder symptoms following 5 months of chiropractic care. There are some limitations to this study which are that we are relying on subjective patient data and the length of time following start of care and resolution of symptoms. However, being that this patient was suffering from panic disorder for over 10 years, we believe that chiropractic care may have played a role in its amelioration as well as resolving her low back pain.
This case shows that there may be more of a connection between panic attacks and biomechanical alterations that previously thought. A growing body of evidence documents the impact of subluxations as an associated factor in various distortions of function and performance, and how the correction of subluxations can have a broad influence on the restoration of health. The improvements described in this case study suggest the possibility of a link between a subluxated spine and mental health function. Possible mechanical mechanisms exist for manjory forms of psychological disorders. Subluxations may produce or contribute to biomechanical faults and these, in turn, produce emotional disorders.35
When a person is subluxated there is constant stimulation from muscle spindles and facet joints that bombards the thalamus. Some of these signals reach the limbic system, where emotions arise, while others travel to the hypothalamus which controls hormonal responses and functions such as sleep, body temperature, and appetite.20 The hypothalamus also influences the sympathetic nervous system via the HPA axis, which releases ACTH signaling the adrenal medulla to secrete cortisol.20 Cortisol release is the only way the human body knows how to deal with stress and it should be a temporary short term thing. However, today people are chronically in a state of stress which perpetuates this cycle. These proprioceptive insults facilitate neurological pathways (and nociceptive pathways) related to stress and created a hyper-irritable SNS which according to Korr is the cause of musculoskeletal and visceral organ dis-ease.26 According to Van Buskirk nociceptors are the primary receptors causing chronic segmental facilitation and sustained sympatheticotonia.30 The chiropractic adjustment can halt this process by restoring proper biomechanics to the spine and stopping the sensitization of nociception pathways leading to activation of the HPA axis.
The purpose of chiropractic research is to contribute chiropractic’s unique and innovative principles to help expand the understanding of health and well-being. Despite chiropractic’s immense popularity with consumers, there is a relative paucity of research funding allocated to study chiropractic, especially as compared to medical funding. Despite the funding possibilities, modern medicine still struggles to provide an answer for many health concerns. Perhaps the answer isn’t simply symptom-based treatment methods, but rather a more holistic broader understanding and awareness of the body-mind, such as may be found in chiropractic’s approach. Anxiety conditions burden the U.S. with $42 billion annually in health care expense and lost production, clearly this is a serious problem calling for full attention and broad resources.7
This patient’s results could have been attributed to lifestyle changes, or maybe just a placebo effect from manual therapy. Although, this is not as likely in this case because of the exacerbation of symptoms following Diversified chiropractic care. More research, especially studies of many subjects exhibiting similar panic disorder symptoms, musculoskeletal symptoms and anxiety, is needed to further our understanding of the relationship chiropractic care benefits these patients.

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