anxiety: a naturopathic psychiatric approach

Anxiety: A Naturopathic Psychiatric Approach

Dr. Maya Nicole Baylac

Anxiety StatisticsAnxiety is the most common psychiatric disorder in the US and Europe

Affects 18% of the US population (1), 7.3 % of the rest of the world (2)

One of the major health problem of the western world (WHO, 2004)

Poorly detected and treated: Only one third of those suffering from anxiety receive treatment

Economical burden is high: People with anxiety disorders use doctors three to five times more than those without anxiety disorder

(1) US statistic anxiety and depression association of america: http://www.adaa.org/about-adaa/press-room/facts-statistics

(2) Prevalence of worldwide anxiety disorders was obtained from 87 studies across 44 countries http://www.ncbi.nlm.nih.gov/pubmed/22781489

www.HawaiiNaturopathicRetreat.com

http://www.adaa.org/about-adaa/press-room/facts-statistics






What is Anxiety?

A state of anhedonia due to the perception of a hostile environment threatening survival

It is an allostatic state due to the disruption of the homeostasis by acute or chronic stress

HOMEOSTATIC STATE ALLOSTATIC STATE

Pleasure, safe Anhedonia, insecure, fear

Oxytocin NE, Epinephrine, cortisol, fatty acids

GABA and glutamate are in physiological equilibrium

Glutamate > GABA

Parasympathetic dominance Sympathetic dominance, HPA axis

Normal heart rate, blood pressure and blood sugar

Increased heart rate, blood pressure, blood sugar, respiration rateFat and carbohydrate breakdown

Rest digest Increased insulin, blood sugar LDLImmune digestive systems suppressed

Homeostasis and Allostasis


The Symptoms of Anxiety


Psychological Symptoms

Restlessness, excessive alertness, hypervigilence

Difficulty concentrating or mind going blank

Irritability, impatience, worry

Anger, negativity

Easily fatigued

Sleep disturbance

Bad dreams


Physical Symptoms

Cardiovascular: pain or pressure in the chest, palpitations, tachycardia

Respiratory distress: hyperventilation, dyspnea, tachypnea, choking

Gastro-intestinal: diarrhea, nausea, heartburn

Neuromuscular: muscle tension, sweating, dizziness, tremors and twitches, headache


DMS V: Anxiety DisordersDisorder SymptomsGeneralized Anxiety Disorder Exaggerated worry about health, safety, money, and other aspects of daily

life that lasts six months or more. Often accompanied by muscle pain, fatigue, headaches, nausea, breathlessness, and insomnia.

Phobias Irrational fear of specific things or situations, such as spiders (arachnophobia), being in crowds (agoraphobia), or being in enclosed spaces (claustrophobia).

Social Anxiety Disorder (social phobia)

Overwhelming self-consciousness in ordinary social encounters, heightened by a sense of being watched and judged by others and a fear of embarrassment.

Post-Traumatic Stress Disorder (PTSD)

Reliving an intense physical or emotional threat or injury (for example, childhood abuse, combat, or an earthquake) in vivid dreams, flashbacks, or tormented memories. Other symptoms include difficulty sleeping or concentrating, angry outbursts, emotional withdrawal, and a heightened startle response.

Obsessive/Compulsive Disorder (OCD)

Obsessive thoughts, such as an irrational fear of contamination, accompanied by compulsive acts, such as repetitive hand washing, that are undertaken to alleviate the anxiety generated by the thoughts.

Panic Disorder Recurrent episodes of unprovoked feelings of terror or impending doom, accompanied by rapid heartbeat, sweating, dizziness, or weakness.


Pathological Anxiety: A Response To Chronic and

Acute StressThese symptoms are due to the effect of chronic stress on

the brain

Chronic stress creates anatomical and physiological changes in the limbic system For example: amygdala shrinking

Chronic stress causes mental emotional changes: For example: the misinterpretation of symptoms of chronic

stressChronic stress becomes the new homeostatic state.

Neurophysiology of Stress

HPA Axis Activation and Negative Feedback


Neuroendocrine Secretions In The Stress Response

Catecholamines activate the sympathetic nervous system and the HPA axis: Increased secretion of Dopamine and Norepinephrine in the locus coerulus induces secretion of CRF in the hypothalamus.

CRF is released in the amygdala

Glutamate receptors are activate either by CRF or disinhibited by GABA

(Decavel and Van Del Pol, 1990, 1992)


Catecholamine Synthesis


Brain NeurotransmittersInhibitory

• GABA

• Dopamine

• Glycine

• Taurine

• Serotonin

Excitatory

• Glutamate

• Norepinephrine

• Epinephrine

• Histamine

• Aspartic acid

• PEA


GABA and Glutamate Receptors

Glutamate and GABA make up 90% of the brain’s neurotransmitters

Excessive Glutamate is neurotoxic to GABA

Receptors for glutamate are NMDA

Receptors for GABA are GABAA

NMDA receptors can be excited by other chemicals, heavy metals, exogenous neurotoxins and too much glutamate


Cofactors for Neurotransmitter

Synthesis

Iron

Copper

Magnesium

Zinc

Folic acid or MTHF

B6

B12

Vitamin C + D

SAMe

Tetrahydrobiopterin

Approximately 75% of the population has an MTHFR genetic defect

Glutamate/GABA Cycle

Patel A B et al. PNAS 2005;102:5588-5593

©2005 by National Academy of Sciences

Adapted and Maladapted Stress

ResponseAcute and Chronic Stress


Adapted and Maladapted Stress Response

Adapted Stress Response or Acute Stress

Temporary mood that disappears when the challenge of acute stress is resolved

Triggered by external or internal circumstances perceived as threatening and disturbing the state of homeostasis (taking an exam or getting married)

Maladapted Stress Response or Chronic Stress

Stressors are permanent or permanent perception of stress.

Adaptation to chronic stress

Stressors Disrupting Homeostasis

Biochemical: toxins, excess glutamate, blood acid imbalance, low oxygen supply

Psychological-Emotional: fear threatening emotional homeostasis, insecurity, trauma, abuse

Mental: negative thought activating neurological fear pathway

Social: family, major life events, personal conflicts

Physical-physiological: excessive weight, pain, intense heat or cold, vigorous exercise

Environmental: pollution from crowding or noise

* Many of these stressors are experienced on a long term basis in chronic stress


Acute Adapted Stress Response

Perception of Danger

Activation of Amygdala

Interpretation by Prefrontal Cortex

SNS

Feedback Loop to Hypothalamus

Homeostasis

Catecholamine Release

Glutamate Release

GABA Inhibition

Fight or Flight

NE + E Decrease

Return to Homeostasis

Chronic Stress Response

Perception of Danger

Activation of Amygdala

Activation of HPA axis

Disruption of feedback loop to hypothalamus and pituitary

Atrophy of neurons in hippocampus and prefrontal cortex

Adrenal Fatigue + Thyroid Dysregulation

Catecholamine Release

Glutamate Release

GABA Inhibition

CRH ACTH Cortisol

Thyroid + Sex Hormone Inhibition


Chronic Stress Response and Neuroendocrine

ChangesDisruption of the feedback loop

Shrinkage of the hippocampus and amygdala

Cortisol decrease and adrenal failure

Hormonal imbalance

Pregnenolone Steal



Physiological Symptoms of Chronic Stress

Prolonged secretion of cortisol causes multiple symptoms in a variety of systems:

Gastrointestinal: Increased appetite, increased centralized weight gain

Immunological: frequent colds, prolonged healing times

Central Nervous System: Memory loss

Endocrine: Decreased thyroid function, increased risk of developing Cushing’s Syndrome, bone loss, menstrual irregularities in women, decreased libido in men


Maladaptive Chronic Stress Response

Adaptation to abnormal state: chronic stress is the new homeostatic state

Chronic anhedonia and difficulty to return to the normal state of homeostasis.

Life is centered on manipulating circumstances to return to the homeostatic state.

Quality of life is negatively affected.


Chronic Stress Alters Mental

State

Misperception and misinterpretation of physiological symptoms and external stimuli leads to acute stress reactionStress induced anaphylaxisPTSDPhobias

Accumulation of chronic stress and acute stress evolve into acute anxiety crisis or panic attack that may takes the patient to the emergency room

Effect of Anxiety on Mental and Physical

Health


Anxiety and Mental Disorders

Bipolar disorders

Eating disorders

Headaches

Sleep disorders

Substance abuse or drug withdrawal

Adult ADHD

Body Dysmorphic Disorder

Schizophrenia


Medical Disorders Associated with Anxiety

Heart disease

Diabetes

Hyperthyroidism

Asthma and COPD

Withdrawal from alcohol, anti-anxiety medications (benzodiazepines) or other medications

Irritable bowel syndrome

Rare tumors that produce certain "fight-or-flight" hormones

Premenstrual syndrome

Chronic pain

Fibromyalgia

Cancer

Conventional Treatment of Anxiety

Benzodiazepines + SSRIs


BenzodiazepinesBenzodiazepines are hypnotic, sedative, anxiolytic and

anticonvulsant

Enhance the action of GABA by binding to GABAA receptors

Manipulate brain chemistry to achieve calmness but it does not restore normal levels of neurotransmitters

Memory impairment and interaction with alcohol can occur

Psychomotor impairment: studies show increased road accidents


Benzodiazepine Side Effects

Paradoxical side effects: Increased depression, hallucinations, personality changes

The most common adverse side effects are: ability to induce tolerance and dependence, sedation and myorelaxation (Millan, 2003)

Tolerance and drug withdrawal between dosage lead to increased doses and dependency, even at therapeutic doses and in a short course of treatment

Addiction occurs most often with short half life drugs such as ativan (lorazepam) and Xanax (alprazolam)


SSRI Selective Serotonin Reuptake Inhibitor (SSRI)

Serotonin is involved in the regulation of mood, appetite and sleep

SSRI’s prevent the degradation of serotonin in the synaptic cleft


SSRI Side EffectsSSRIs cause weight gain, insomnia, headaches, nausea,

diarrhea, sexual dysfunction: decreased libido, male impotency, anorgasmia. (Prim Care Companion J Clin Psychiatry. Feb 2001; 3(1): 22–27.)

Doubles suicidal ideation: “When compared with a placebo, all antidepressants, including SSRIs, seem to double the risk of suicidal thinking, from 1%–2% to 2%–4%, in both children and adults.” (SSRI Side Effects: Harvard Mental Health Letter discusses the real risks of antidepressants, May 2005)

Increases suicide risks by 2


Beta BlockersUsed in extreme cases

Can relieve acute anxiety by slowing the heart rate and reducing blood pressure; they are often used to treat stage fright

Naturopathic Assessment

History taking – Physical Exam - Laboratory testing


History TakingRule out any mental or physical condition

Rule out family abuse and external causes of stress

Rule out drug / alcohol use

Exposure to toxic chemicals such as organophosphate, chlorinated compounds, heavy metals

Nutrition: processed versus whole, organic food

Assess stress

History TakingPhysical Conditions

Underlying physical illness threatening survival:

Cardiovascular: mitral valve prolapse, myocardial infarction, abdominal aortic dissection

Respiratory: COPD, asthma

Hyperthyroidism

Diabetes, hypoglycemia

Cancer

Drug abuse

Anaphylaxis

Cushing’s Syndromewww.HawaiiNaturopathicRetreat.com


Anxiety and the Cardiovascular System

Chest pain is a symptom of both anxiety and heart attack.

Mitral valve prolapse causes anxiety and panic attack

Anxiety is a risk factor for heart attack In the Nurses' Health Study, women with the highest levels of phobic anxiety were 59% more likely to have a

heart attack, and 31% more likely to die from one, than women with the lowest anxiety levels. Data from 3,300 postmenopausal women in the Women's Health Initiative showed that a history of full-blown panic attacks tripled the risk of a coronary event or stroke.

Two studies — one involving Harvard Medical School and the Lown Cardiovascular Research Institute; the other, several Canadian medical colleges — concluded that among both men and women with established heart disease, those suffering from an anxiety disorder were twice as likely to have a heart attack as those with no history of anxiety disorders.


Anxiety and the Respiratory System

Asthma

Most studies have found a high rate of anxiety symptoms and panic attacks in people suffering from Asthma

COPD

In several studies involving COPD patients, anxiety has been associated with more frequent hospitalization


The Gut Brain Connection

Anxiety and IBS

A 2007 New Zealand study of subjects with gastroenteritis found an association between high anxiety levels and the development of IBS

Anxiety can trigger symptoms in the gut and a troubled gut can send signals to the brain

Microbiota imbalance


Anxiety Endocrine Connection

Hypoglycemia

Hyperthyroidism/Hypothyroidism

PMS

Menopause


Self-Medicating Anxiety:Substance Abuse

Alcohol blocks NMDA receptors to glutamate, binds to GABA, acetylcholine and serotonin

Benzodiazepines bind to GABAA and have the same effect as alcohol

Nicotine increases dopamine

Opiates bind to endorphins and increase dopamine

Coffee, cocaine and methamphetamines increase dopamine, epinephrine, NE and serotonin secretion


Observation

General demeanor: how the patient responds to the environment, personal hygiene

Posture: buffalo hump, abdominal obesity

Signs of nervousness: rapid speech, knuckle cracking, nail biting, finger tapping, hand wringing, trichotillomania


Lab Tests CBC, Comp Metab Panel

TSH, FT3, FT4, RT3, TSH, Thyroid AB

Pregnelonone, DHEA’s

Adrenal stress index ASI

25-OH vitamin D3

Mg, Zn, Cu, Fe, TIBC, Ferritin

Folate, B12, B6

MTHFR DNA mutation

Homocysteine

Lipid panel

CRP

Heavy metal test

HGB A1C

ION test Genova Diagnostics

Biopterin

Stool analysis

Physical ExamVitals: HR, BP, Respiratory rate,

temperature

HEENT: hair distribution, pupillary reflex test, moon face, thinning eye brows

Thyroid: size, nodules, boggy, symmetry, tenderness

CVS: JVP, auscultation of valves

Respiration: auscultation (Asthma, COPD)

Skin: scars, sores, temperature

Abdomen: obesity, tenderness (IBS)

Extremities: nervous movement, nail biting, capillary refill (COPD)

Reflexes: prolonged Achilles tendon reflex (hypothyroid)

Genitals: hair distribution pattern (excess androgens)



Special Tests Seargent's white line test

Take a sharp object and draw a line on the abdomen length and width.Normal response: line turns redStage 1 adrenal fatigue: line turns white and widens

Rogoff’s SignTenderness in the mid to lower back area. A sign of adrenal dysfunction

Ragland's Sign- a test for postural hypotensionTake BP while the patient is seated have them stand up and immediate check the blood pressure again. The systolic BP should increase about 4-10 mm indicating adequate adrenal activity. If the BP is the same or lower it can indicate sluggish adrenal activity.

Treating the CauseFear, Emotional Stress and Oxidative Stress


Causes of Anxiety: FearSome fears are inherent to the species: fear of dying, dark,

aloneness

Fears can be from a current abusive relationship or family environment

Fears can come from national or job insecurity

Fears can be triggered by reactivation of past trauma in personal history

Fear of change perpetrates chronic stress


Example: Fear of Change Past History of Abuse


Acute Stress Response: Flight


Acute Stress Response: Fight


Homeostasis Maintained: Chronic Stress


Neither Fight or Flight or Chronic Stress

Psychotherapy: Cognitive behavioral therapy

Exposure therapy

Mindfulness, meditation

Identifies and challenge negative thinking patterns and irrational beliefs feeding anxiety. Ex: I have a terminal illness

Identifies feared object or situation and repeats exposure to the object or repeats feared action in a controlled environment

Dis-identify from anxious thoughts, focus on the present


Causes of Anxiety: Oxidative Stress

Oxidative stress occurs when free radicals are in excess of antioxidants

The brain is susceptible to lipid peroxidation and oxidative damage from high O2 consumption, its lipid rich constitution and low anti-oxidant defenses

Studies to determine a causal relationship between oxidative and emotional stress suggest that oxidative stress can provoke anxious behavior in rats

Masood A, Nadeem A, Mustafa SJ, O'Donnell JM. Reversal of oxidative stress induced anxiety by inhibition of phosphodiesterase-2 in mice. Masood A, Nadeem A, Mustafa SJ, O'Donnell JM. Reversal of oxidative stress-induced anxiety by J Pharmacol Exp Ther. 2008;326:369–379


Chemicals and NMDA Receptors

Ammonia: ammonia produced by the body can cross the BBB and produce biochemically induced anxiety

Heavy metals: in particular mercury

Chemicals from food

TreatmentEliminating Environmental and Social Stressors


The Inpatient Model

Removes External Life Stressors Substitutes a safe space in nature Provides a compassionate staff and multiple caring therapists dispensing

hydrotherapy treatments, massage, spiritual and emotional support Reestablishes trust in the environment Allows a progressive de-structuration of chronic stress adaptation syndrome

and the emergence of the natural self healing power Encourages daily focus on personal growth

Ecotherapy and the healing power of Nature “Vis Medicatrix Naturae” Emphasizes interaction with natural environment Mindful walking produces grounding

Group Therapy Sessions Generates community and support

Treatment:Biochemistry of

AnxietyNutrition – Detoxification – IV – Exercise

Nutrition

Mediterranean Diet• Eating traditional ‘Mediterranean’ diets – lower rate of mood and anxiety

symptoms

Processed Food• Eating ‘Western’ processed diets – higher rate of mood and anxiety

symptoms

Fried Food• Avoid fried foods forming advanced glycation end products’ (AGE’s)

during the frying/crisping of foods (increase oxidative stress in the body)

GMO• Avoid GMO

Davison & Kaplan (2012), “Nutrient intakes are correlated with overall psychiatric functioning in adults with mood disorders,” Cdn J Psychiatry, 57(2):85–92


Nutritional CompoundsMagnesium:

• Magnesium deficiencies cause HPA dysregulation

Flavonoids:• Flavonoids modulate the activity of GABAA receptors and have demonstrated

anxiolytic, sedative and anti convulsing activities.

GABA Modulators:• Such GABA modulators have been found in fruit (e.g., grapefruit), vegetables (e.g.,

onions), various beverages (including tea, red wine, and whiskey), and in herbal preparations (such as Ginkgo biloba and Ginseng).

Astaxanthin:• Astaxanthin is a powerful antioxidant and anti inflammatory compound that can

balance the inflammatory effect of cortisol

Zinc:• Zinc studies show that zinc behaved as typical NMDA antagonist. C.E. Brown, R.H.

Dyck, Distribution of zincergic neurons in the mouse forebrain, J Comp Neurol, 479



DetoxificationHeavy Metal

Detoxification

Candida Detoxification

FIR Saunas

Coffee Enemas and Colon

Hydrotherapy

Juice Fast or Raw Food Diet

Fermented Foods to

Replenish the Beneficial Flora


IV Therapy

Supports detoxification pathways : Glutathione, ALA

Replenish quickly vitamins and mineral deficiencies with IV nutrient therapy: B vitamins, magnesium, amino acids, calcium, vitamin C.


Exercise TherapyIncreases serotonin levels

Oxygenates the brain

Reduces epinephrine and cortisol

Case Study: JS

•26 year old Female Nurse

Patient:

•Eating Disorder, Panic attack, General Anxiety Disorder, Agoraphobia

Diagnosis:

•Food Allergies, Weight Loss, Reducing Food Intake to Familiar Foods

Presenting Complaints:

•Started 3 years ago when she had her first panic attack after eating some Chinese food at her friend’s wedding. Had several hospital emergency visits after that (6 in 3 years).

History of Panic Attacks:

•Flying, Any substance entering her body: New Foods, IV, Supplements

Phobias:

•Hx of Claustridia Difficile treated with antibiotics

Dysbiosis:


Case Study: JS

Patient symptoms self-management:• remaining close to a hospital, no more than 3 miles radius, having her car nearby and

carrying an epi-pen

Recreational Life: • Could not socialize, go for hikes, which she was doing a lot prior (she was an athlete).

Was hard for her to take a plane and come and visit us in Hawaii from Canada

Relationship with Food:• Could only eat some foods that she felt safe with. Believed that she had food

intolerance and reacting to foods would lead to a panic attack

Weight:• Was losing weight

Emotions:• Crying all the time

Professional Life:• Could not work any more and resigned 6 months before coming for treatment.

Secondary Complaints: Life Limitations and Health Effects



Case Study: JS

Benzodiazepine: Lorazepam, Ativan• 1 mg 5 AM and 5 PM

SSRI Citalopram 25 mg for the last 2 years

Pantoprazole for Acid Reflux

Pharmaceutical Management:


Treatment ION Test from Metametrix (Genova Diagnostics) shows elevated

homocysteine level, low tyrosine and phenylalanine, low vitamin D, yeast infection

Oral supplementation to treat deficiencies: Vitamin D, Folic Acid as Methyltetrahydrofolate, Neurotransmitter Precursors and Cofactors including Biopterin, Tyrosine, Phenylalanine, GABA, B Complex, Fish Oil, Probiotics, Antioxidants, Adaptogenic and Anxiolytic Herbs.

IV Therapy: Anxiety Protocol, Benzodiazepine Withdrawal Protocol, Glutathione, Nutritional IV, Myers Cocktail.

Raw Food Nutrition with Green Juices (organic, non-GMO)

Exercise Program: Reformer Pilates, Walking, Swimming

Treatment: Psychotherapy Meditation Mindfulness

Address the presenting layer: fear of new foods, supplements, IV

Treat the eating disorder with cognitive behavioral therapy and exposure therapy

Challenge her belief system

We taught her how to take her pulse and test new foods prior to eating them. She learnt that she did not have any reaction to any of the foods she was eating. She was very upset, crying each time she was eating or waking up or taking supplements. We were present at the beginning every time she was eating holding her and talking to prevent a panic attack.

Preventing panic attack: breathing and mindfulness

She learnt that she could prevent a panic attack with breathing while crying in fear of having a reaction

We taught her how to practice mindfulness to watch how she could stop herself from having a full blown reaction



Treatment OutcomeFollowing 3 weeks of in-house treatment she was eating all

foods without doing the pulse test or having anxieties

She was taking her supplements under 15 minutes

Her pharmaceutical medications were tapered down:Citalopram: Off, Lorazepam: From 1mg to 0.25mg

6 Month Follow Up: She got off Lorazepam herself the following monthShe has resumed working and her social life and has no panic

attack


Thank you! Merci!

Mahalo!

Dr. Maya Nicole Baylac www.hawaiinaturopathicretreat.com239 Haili street, Hilo, HI 96720,

USdrbaylac@HawaiiNaturopathicR

etreat.com808.933.4400www.facebook.com/HawaiiNaturopathicRetreatCenter

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anxiety: a naturopathic psychiatric approach

Health & Medicine

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anxiety statistics anxiety

chronic stress chronic

pathological anxiety

glutamate receptors

gaba receptors

brain chronic stress

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