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Anxiety: A Naturopathic Psychiatric Approach

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.

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Anxiety: A Naturopathic Psychiatric Approach

  1. 1. Anxiety: A Naturopathic Psychiatric Approach Dr. Maya Nicole Baylac
  2. 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: (2) Prevalence of worldwide anxiety disorders was obtained from 87 studies across 44 countries
  3. 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
  4. 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
  5. 5. The Symptoms of Anxiety
  6. 6. Psychological Symptoms  Restlessness, excessive alertness, hypervigilence  Difficulty concentrating or mind going blank  Irritability, impatience, worry  Anger, negativity  Easily fatigued  Sleep disturbance  Bad dreams
  7. 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
  8. 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
  9. 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.
  10. 10. Neurophysiology of Stress
  11. 11. HPA Axis Activation and Negative Feedback
  12. 12. 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)
  13. 13. Catecholamine Synthesis
  14. 14. Brain Neurotransmitters Inhibitory • GABA • Dopamine • Glycine • Taurine • Serotonin Excitatory • Glutamate • Norepinephrine • Epinephrine • Histamine • Aspartic acid • PEA
  15. 15. 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
  16. 16. 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
  17. 17. Glutamate/GABA Cycle Patel A B et al. PNAS 2005;102:5588-5593 ©2005 by National Academy of Sciences
  18. 18. Adapted and Maladapted Stress Response Acute and Chronic Stress
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. Chronic Stress Response and Neuroendocrine Changes  Disruption of the feedback loop  Shrinkage of the hippocampus and amygdala  Cortisol decrease and adrenal failure  Hormonal imbalance
  24. 24. Pregnenolone Steal
  25. 25. 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
  26. 26. 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.
  27. 27. 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
  28. 28. Effect of Anxiety on Mental and Physical Health
  29. 29. Anxiety and Mental Disorders  Bipolar disorders  Eating disorders  Headaches  Sleep disorders  Substance abuse or drug withdrawal  Adult ADHD  Body Dysmorphic Disorder  Schizophrenia
  30. 30. 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
  31. 31. Conventional Treatment of Anxiety Benzodiazepines + SSRIs
  32. 32. 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
  33. 33. 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)
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. Naturopathic Assessment History taking – Physical Exam - Laboratory testing
  38. 38. 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
  39. 39. History Taking Physical 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 Syndrome
  40. 40. 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.
  41. 41. 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
  42. 42. 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
  43. 43. Anxiety Endocrine Connection  Hypoglycemia  Hyperthyroidism/Hypothyroidism  PMS  Menopause
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. Physical Exam  Vitals: 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)
  48. 48. 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.
  49. 49. Treating the Cause Fear, Emotional Stress and Oxidative Stress
  50. 50. 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
  51. 51. Example: Fear of Change Past History of Abuse
  52. 52. Acute Stress Response: Flight
  53. 53. Acute Stress Response: Fight
  54. 54. Homeostasis Maintained: Chronic Stress
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. Treatment Eliminating Environmental and Social Stressors
  59. 59. 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
  60. 60. Treatment: Biochemistry of Anxiety Nutrition – Detoxification – IV – Exercise
  61. 61. 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
  62. 62. 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
  63. 63. Detoxification Heavy Metal Detoxification Candida Detoxification FIR Saunas Coffee Enemas and Colon Hydrotherapy Juice Fast or Raw Food Diet Fermented Foods to Replenish the Beneficial Flora
  64. 64. 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.
  65. 65. Exercise Therapy  Increases serotonin levels  Oxygenates the brain  Reduces epinephrine and cortisol
  66. 66. 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:
  67. 67. 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
  68. 68. 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:
  69. 69. 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
  70. 70. 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
  71. 71. 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
  72. 72. Thank you! Merci! Mahalo! Dr. Maya Nicole Baylac 239 Haili street, Hilo, HI 96720, US 808.933.4400