This presentation, Anxiety: A Naturopathic Psychiatric Approach, was delivered by Dr. Maya Nicole Baylac at the 2014 ICNM (International Congress on Naturopathic Medicine) in Paris, France.
The presentation discusses:
- The symptoms of anxiety, its physical and psychological symptoms and anxiety disorders.
- The origin of anxiety, the body's response to chronic and acute stress.
- The Neurophysiology of Stress.
- Adapted and Maladapted Stress Response. Acute and Chronic Stress.
- Effect of Anxiety on Mental and Physical Health.
- Conventional Treatment of Anxiety. Benzodiazepines + SSRIs.
- Naturopathic Assessment of Anxiety. History taking, Physical Exam, laboratory Testing.
- Treating the Cause. Fear, Emotional Stress and Oxidative Stress.
- Treatment. Eliminating Environmental and Social Stressors.
- Treatment: Biochemistry of Anxiety. Nutrition, Detoxification, IV, Exercise.
- Case Study with Treatment Outcome.
2. Anxiety Statistics
Anxiety 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
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3. 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
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4. 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 rate
Fat and carbohydrate breakdown
Rest digest
Increased insulin, blood sugar LDL
Immune digestive systems suppressed
Homeostasis and Allostasis
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7. 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
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8. DMS V: Anxiety Disorders
Disorder Symptoms
Generalized 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.www.HawaiiNaturopathicRetreat.com
9. Pathological Anxiety: A Response
To Chronic and Acute Stress
These 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
stress
Chronic stress becomes the new homeostatic state.
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13. 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)
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16. 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
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17. 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
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20. 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
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21. 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
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22. 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
23. 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
24. Chronic Stress Response and
Neuroendocrine Changes
Disruption of the feedback loop
Shrinkage of the hippocampus and amygdala
Cortisol decrease and adrenal failure
Hormonal imbalance
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26. 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
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27. 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.
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28. Chronic Stress Alters Mental State
Misperception and misinterpretation of physiological
symptoms and external stimuli leads to acute stress reaction
Stress induced anaphylaxis
PTSD
Phobias
Accumulation of chronic stress and acute stress evolve into
acute anxiety crisis or panic attack that may takes the
patient to the emergency room
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34. Benzodiazepines
Benzodiazepines 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
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35. 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)
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36. 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
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37. SSRI Side Effects
SSRIs 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
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38. Beta Blockers
Used in extreme cases
Can relieve acute anxiety by slowing the heart rate and
reducing blood pressure; they are often used to treat stage
fright
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40. History Taking
Rule 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
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42. 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.
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43. 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
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44. 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
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46. 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
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47. 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
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48. 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
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50. 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 red
Stage 1 adrenal fatigue: line turns white and widens
Rogoff’s Sign
Tenderness in the mid to lower back area. A sign of adrenal dysfunction
Ragland's Sign- a test for postural hypotension
Take 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.
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52. Causes of Anxiety: Fear
Some 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
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53. Example: Fear of Change
Past History of Abuse
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57. 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
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58. 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
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59. 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
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62. 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
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64. 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
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65. Nutritional Compounds
Magnesium:
• 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
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67. 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.
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68. Exercise Therapy
Increases serotonin levels
Oxygenates the brain
Reduces epinephrine and cortisol
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69. Case Study: JS
• 26 year old Female NursePatient:
• 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 antibioticsDysbiosis:
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70. 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
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71. 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:
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72. 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
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73. 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
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74. Treatment Outcome
Following 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 month
She has resumed working and her social life and has no panic
attack
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75. Thank you!
Merci!
Mahalo!
Dr. Maya Nicole Baylac
www.hawaiinaturopathicretreat.com
239 Haili street, Hilo, HI 96720, US
drbaylac@HawaiiNaturopathicRetreat.com
808.933.4400
www.facebook.com/HawaiiNaturopathicRetreatCenterwww.HawaiiNaturopathicRetreat.com
Editor's Notes
Anxiety is a psychosociophysiological phenomenon
This slide may need fight and flght on the right and text flush to the left
CRF cortocotropin releasing factor
GABA and Glutamate form 90% of brain neurottransmiters
Genetic defect prevent the transformation of folic acid to the active form: MTHF
Kreb cycle in the mitochondria of the neuron shows equilibrium of GABA and glutamate
Schematic depiction of Glu/Gln and GABA/Gln cycling between glutamatergic (orange) and GABAergic (green) neurons and astroglia relevant to 13C NMR experiments using [1-13C]glucose or [2-13C]acetate as tracer. Metabolism of [1-13C]glucose through glycolysis and the TCA cycle labels neuronal Glu-C4 and GABA-C2 with label transfer to Gln-C4 by neurotransmitter cycling, Vcyc(tot) = VGlu/Gln + VGABA/Gln. [2-13C]acetate metabolism in astroglia labels Gln-C4 directly with label transfer to neuronal Glu-C4 and GABA-C2 by neurotransmitter cycling, Vcyc(tot). VGAD, rate of GABA synthesis via Glu decarboxylase; Vshunt, rate of neuronal GABA catabolism; VGln, rate of Gln synthesis; and VPC, rate of pyruvate carboxylation.
THYROID- Cortisol blocks the peripheral conversion of T4 T3
Pregnenalone precursor to sex hormones and cortisol is shunted to the cortisol pathway
(as it should), resulting in prolonged elevation of cortisol levels. Thus, chronic stress leads to daily increases
of cortisol secretion. Cortisol is known to stimulate appetite during the intermittent recovery periods that
occur while a person is experiencing chronic stress. Cortisol (with the help of slightly elevated insulin levels)
has also been shown to activate lipoprotein lipase, the enzyme that facilitates the deposition of fat
(Björntorp 2001). In the presence of slightly higher insulin levels, elevated cortisol levels inhibit the
breakdown of triglycerides, thus promoting fat storage. Epel et al. (2000) report that chronic stress
consistently contributes to greater central fat accumulation in females.
Additionally, chronic stress is associated with emotional changes that can include increases in anxiety, apathy
and depression (Torres & Nowson 2007). The response to chronic stress may lead to much higher
consumption of food, referred to as stress-induced eating.
Memory loss- Reference http://dujs.dartmouth.edu/fall-2010/the-physiology-of-stress-cortisol-and-the-hypothalamic-pituitary-adrenal-axis#.U5KwPV6bS1U
Menstrual irregularities- d/t the suppression of LH and FSH
Decreased thyroid function- cortisol suppressed the conversion of T4 to T3 in the periphery
Bone loss- Decreases Ca absorption in GIT (max 100mg), increases Ca resorption from bone & loss from kidney
PTSD causes people to project intense fear on to benign circumstances
Phobias cause a heightened stress response to a stimulus
Format the words better
40 different types of benzo. The first one on the market was diazepam.
Make references consistent
Make references uniform
MAYA FIND SOME REFERENCES
Remove TV, aggressors,
Send me an email I will send you the link to the presentation