The Comorbidity Of Anxiety And Depression On The Auricle

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Anxiety and depression co-morbidity is quite frequent in epidemiological and clinical settings throughout the world. Patients carrying both diagnoses have the highest utilization of medical services and consequently also incur a higher cost than those with either condition alone, even after accounting for differences in patient characteris-tics.39 There is still no clear evidence that a specific syndrome called 'mixed anxiety and depression' (MAD) exists besides co-morbidity; moreover, this diagnosis may not be stable across time and its utility is questioned by several authors.40-42

For the general practitioner it is useful to try to differentiate these conditions and co-morbidity is often found in patients asking to be treated with acupuncture. I tried therefore to make a contribution to this issue and examined the sectors of high value in 90 out of 357 randomly selected patients belonging to two groups of 30, each with self-rated anxiety and depression; the third group was a control group of 30 subjects not declaring any of these symptoms. As reported in Chapter 9, the patients were blindly examined by me after reporting their symptoms on a form and having them checked by an independent assessor.

If we look at the sensitized sites of the auricles in the case of self-rated depression (on the left of Fig. 5.22) and in the case of self-rated anxiety (on the right of Fig. 5.22), at first glance we may have the impression of a simple overlapping of clusters, justifying a diagnosis of anxiety-depression co-morbidity. However, if we consider the relative size of the identified clusters, we may notice that depression presents a threefold sensitization of the areas corresponding to cyclothymic temperament (sectors 4, 5 and 6) and to the external genitals (sectors 25, 26 and 27) according both to Nogier's and the Chinese map. These clusters correspond to two sectors (5 and 26) which are more significantly sensitized in comparison to the control group (P<0.05).

The area representing the external genitals seems out of place, but could be associated with difficulties in sexual functioning accompanying mood disorders. In my opinion, however, this area is not only sensitized by the reduction of sexual desire but also by symptoms such as frustration, irritability and increased appetite which develop, for example, in the nicotine withdrawal syndrome after abrupt cessation of cigarette smoking.

If we consider the anxiety group (on the right of Fig. 5.22), we can see a threefold sensitization of an area of the tragus corresponding presumably to the adrenal gland and a remarkable sensitization of the Chinese and French spleen area which seems often involved in anxiety disorders.

These clusters correspond to two sectors (14 and 38) which are more significantly sensitized in

Fig. 5.21 Tender points in 12 patients having experienced at least one panic attack within the previous 6 months (left); colored sectors (right) are the significantly sensitized sectors in 31 subjects with at least one phobic response rated 'very disturbing' at FSS III compared to 20 subjects with no phobic response. Dots = lateral surface; circles = medial surface.

Fig. 5.22 Cluster of tender points and significantly sensitized sectors compared to control group in patients rating themselves 'depressed' on the left; the same for patients rating themselves as 'anxious' on the right.

comparison to the control group (P<0.05). Sector 19, moreover, could be related to the stiffness of thoracolumbar muscles or to the activation of the Shen men area which is often associated with somatoform disorders.

I took the opportunity to better differentiate the auricular areas involved with depression and anxiety by a psychometric study on patients in my practice with behavioral eating disorders. Besides the specific scales for this disorder I applied two of the widely used inventories for measuring depression and anxiety, the Beck Depression Inventory (BDI-II)43 and the State and Trait Anxiety Inventory (STAI-Y) of Spielberger44 which measures either the state anxiety 'right now, at this moment' (STAI 1) or the trait anxiety which refers more generally to the proneness of the subject to responding to perceived threats in the environment with anxiety (STAI 2). If the reader will permit a brief reminder, possible scores using the BDI-II are: 0-13 for minimal depression; 14-19 for case of mild depression; 20-28 for moderate depression; and 29-63 for severe depression. STAI-Y scores are 0-80 for both inventories.

In a total of 99 patients (80 female and 19 male, average age 41 years) I compared two groups of subjects: those with minimal to mild depression (<19) vs. those with moderate to severe depression (>20). For the scoring of STAI-Y, I carried out a comparison between randomly chosen subjects with a score of <40 and subjects with >41.

The paired sample test showed a higher sensiti-zation of sectors 2, 5, 8,12 and 26 associated with a higher level of depression (on the left of Fig. 5.23) and a higher sensitization of sectors 5, 7 and 8 associated with a higher level of trait anxiety (STAI 2) (on the right of Fig. 5.23).

My group of patients therefore showed an overlapping of areas which corresponds to the clinical evidence of an anxiety-depression co-morbidity or a syndrome with mixed characteristics.

As yet we have not discovered the key for decoding the structures and functions of the brain that could possibly correspond to these auricular

16 15 14

13 12

16 15 14

13 12

Fig. 5.23 Sectors with a significantly higher number of points in patients rated with BDI-II as moderate-severe vs. minimal-mild depression (left); the same for patients rated with STAI 2 as having higher vs. lower score of anxiety


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Fig. 5.24 Tender points on the right ear (A) and on the left ear (B) in a 33-year-old female scoring 'very disturbed' to the following fears: crowds, being in an elevator, enclosed places, witnessing surgical operations; scoring 19 (mild depression) at BDI-II and 22 at BNSQ (classified as worse sleeper in this section).

areas and we have to rely upon every tender point we may find in each patient. We need therefore to interpret this syndrome through clinical observation and with the help of some basic psychometric tools, as for example in the following case (Fig. 5.24).

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