Anxiety; A Naturopathic Perspective

Dr. Todd Born ND reviews some of the botanical, lifestyle and nutritional approaches available to manage anxiety.

Picture the world in 2050. A demographic shift towards older age that began generations ago will have reached its peak, and 2 billion individuals will be aged 60 and older. In the United States and much of Europe, one in three persons will be in this old-age demographic (compared with one in five today). It is increasingly clear that the common mental disorders of emotion—anxiety disorders and unipolar depression—are a terrible scourge across the lifespan: they not only induce significant misery and suffering for the patient and his/her whole family, but with increasing age they become increasingly deleterious to health and cognition, even increasing mortality risk in older adults. Given such deleterious effects, understanding the common mental disorders in this large and growing demographic would seem to be a practical question of some importance. Anxiety is a ubiquitous experience amplified during lifespan, rooted in genetic determinants that evolved over millennia to complement the natural desire to survive in an unknown world. However, these triggers are frequently exceeding a level that exceeds easy compensation and adaption.

Anxiety can present in many different ways and forms. Phobias (particularly social and specific phobias) may predominate in childhood; panic disorder and post-traumatic stress disorder (PTSD) may be at their highest prevalence in adulthood; while worry disorders (ie, general anxiety disorder- GAD) may be most common in old age. Anxiety disorders with a strong autonomic nervous system component (eg, resulting in panic attacks or panic-like symptoms) are usually considered to be more common in childhood or early adulthood than later in life, particularly with respect to social phobia and panic disorder. Whilst many of these patterns are derived from epidemiological studies, most practitioners and clinicians will recognise these patterns.

The “Diagnostic and Statistical Manual of Mental Disorders” (DSM-IV), published by the American Psychiatric Association, discusses the various conditions within the anxiety spectrum ad nauseam and is beyond the scope of this article.  It describes this spectrum anywhere from panic attacks, to phobias, to obsessive-compulsive disorder, to post-traumatic stress disorder (PTSD), to generalised anxiety and its subsets.  Anxiety is even more prevalent that depression, and many times these go hand in hand.[1]  It is important prior to intervention for organic causes such as hyperthyroidism, carcinoid syndrome and pheochromocytoma to be ruled out.

Anxiety can be acute (lasts more than 2 days and doesn’t last more than 4 weeks) or chronic (occurs more days than not for at least 6 months).  It can be a beneficial part of our existence when used in the short term.  For example, alerting us to danger.  But sometimes it can take over one’s life and interrupt daily activities, sleep, diet and lifestyles, and even to the point one just doesn’t even want to go out and socialise.  This can lead to serious health concerns and cause or amplify relationship issues.[2]^,[3]

Anxiety is multifactorial and can stem from a myriad of causes or a combination of them.  Besides the aforementioned pathological conditions, caffeine, poor sleep habits, poor diet, unique nutrient deficiencies, lack of exercise and other reasons as outlined below can all play a factor.[4]^,[5]

“Anxiety is love’s greatest killer… It makes others feel as you might when a drowning man holds on to you.” Anais Nin

Anxiety facts:[6]

• Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older (18% of U.S. population). It is less clear of their impact in the UK, as they are classified amongst other diagnostic criteria, but the office for National Statistic estimates that 44 adults in 1,000 are affected.
• Anxiety disorders cost the U.S. more than $42 billion a year, almost one-third of the country’s $148 billion total mental health bill, according to “The Economic Burden of Anxiety Disorders,” a study commissioned by ADAA (The Journal of Clinical Psychiatry, 60(7), July 1999).
  • In the UK, The cost of services for anxiety disorders for the whole of England in 2007 was approximately 1.2 billion. Including lost employment costs brings the total to £8.9 billion. By 2026 it is projected that service costs for anxiety disorders will be £2 billion with total costs at £14.2 billion.[7]
• More than $22.84 billion of those costs are associated with the repeated use of healthcare services; people with anxiety disorders seek relief for symptoms that mimic physical illnesses.
• People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalised for psychiatric disorders than those who do not suffer from anxiety disorders.
• Anxiety disorders develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events.

Speaking of genetics, methylenetetrahydrofolate reductase (MTHFR) polymorphisms have clear links to mood, anxiety and personality disorders.  The MTHFR gene provides instructions for making an enzyme called methylenetetrahydrofolate reductase.  This enzyme plays a role in processing amino acids.  MTHFR is important for a chemical reaction involving forms of the B-vitamin folate (also called folic acid or vitamin B9), specifically, this enzyme converts 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate.[8]^,[9]

Let’s face it:  we live in very stressful times, or at least times when many feel ill equipped to manage their stressors – whether it is the economy, our jobs, inclement weather, our health or the health of loved ones, or even our pets.  These events in time can take deleterious tolls.  For example, numerous studies have linked anxiety with cardiovascular disease.  Not only does it increase its occurrence, but it also increases the risk of an adverse cardiovascular event (stroke or heart attack).  Studies have shown that the prevalence of anxiety is high at approximately 70% to 80% among patients who have experienced an acute cardiac event.  Even among the patients that have not experienced these events, the prevalence of anxiety is estimated to be between 20-25%.[10]

A meta-analysis (a combination of many similar studies) looked at 249,846 people and the association of anxiety with the incidence of coronary heart disease (CHD) in initially healthy people, using data from the US, Europe, and Asia.  They determined that anxious people had around a 25% greater risk of CHD and an almost 50% higher risk of cardiac death over a mean follow-up period of 11.2 years.  The study factored in all other risk factors and health conditions and still found that anxiety caused these results.[11]

For many a decade, conventional medicine has ignored, or undervalued the mind-body connection.  Naturopathy on the other hand has seen mind, body and emotions as one, working interchangeably and as a whole.

Only until recently has conventional medicine and research paid more attention to these matters.  This is especially due to the work on Mindfulness-Based Stress Reduction by Jon Kabat Zinn, PhD from MIT in molecular biology.[12]^,[13],[14]

Conventionally, anxiety, regardless of aetiology or form, tends to be managed primarily with anti-anxiety medications, anti-depressants, sleeping medications, and at times, counselling, CBT or more recently mindfulness.[15] Naturopathically, we tend to go a step further.  We encourage counseling, but at the same time will look at the whole person:  diet, lifestyle, nutrition and social support.  We follow a therapeutic order, utilising the less forceful, least invasive means possible, while always still meeting the patient where they are.  We have nutrition and lifestyle modifications at our fingertips.  We might use botanical medicines or physical medicine (examples include massage, craniosacral therapy, osseous manipulation therapy and hydrotherapy).  We can utilise other methods such as cell salts (tissue salts), flower essences or homeopathic medicines.

Working in a manner associated with functional medicine, the intersecting antecedents and triggers of an individual’s life are recognised as having relative value in causation and resolution. Simple single strategies may resonate as being preferable, but many studies have shown that this simplistic approach (in terms of treatment offering) has limited and often only short term benefits.

Naturopaths tend to utilise such diet and lifestyle modifications and additions as simple as cutting back on caffeine, breathing exercises, yoga and exercise in general.[16]  The list is extensive, varied and highly personalised.

Many patients may already be on medications and might be worried about potential interactions.  These are logical, justifiable and legitimate concerns. This is where nutrition can play a significant role in your healthcare.

There are certain precautions that should be taken with certain conventional treatments. For example, if the individual is on selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs).  These drugs work by blocking the reabsorption (reuptake) of the neurotransmitter serotonin in the brain and block the absorption (reuptake) of the neurotransmitters serotonin and norepinephrine in the brain, respectively.[17]^,[18]

Nutrients like tryptophan, 5-hydroxytryptophan (5-HTP), S-Adenosylmethionine (SAMe) can work to increase the amount of serotonin, and combined with the medication may in susceptible people cause serotonin syndrome (SS), SS can range in severity from mild to life-threatening. Most cases of SS are mild and resolve with prompt recognition and supportive care.[19]^,[20],[21]  Herbs like Hypericum perforatum (St. John’s Wort) interact with the Cytochrome P450 enzyme that detoxifies many medications, making it relatively contraindicated with the use of most medications.[22]^,[23] 

All of this begs the question, what can be used that is both safe and efficacious?  For purposes of this article, I will only discuss the well known, readily available nutritional interventions that are safe and which garner the greatest results.

1. Inositol, 18 grams per day:  Equivalent or better than fluvoxamine.[24]^,[25]
2. Piper methisticum (Kava): 50 mg three times daily of standardised extract.[26]  Caution in those with pre-existing liver disease.
3. Passiflora incarnata (passion flower): 45 drops per day.  Just as effective as oxazepam.[27]
4. Niacinamide: 500 mg 2-3 times daily.  In some cases, liver enzymes can be elevated and this does should not be used in those that have liver disease.[28]^,[29]
5. Magnesium citrate: 300-600 mg daily in divided doses.[30]
6. Pyridoxine: 40 mg daily.[31]
7. Moderate potency multivitamin/mineral.[32]
8. Silexan (standardised Lavender oil).  Alternative to benzodiazepines.[33]
9. High potency B-complex.  Decreases deleterious stress responses and improves mood.[34]
10. Omega 3 essential fatty acids.  Reduces inflammation and anxiety at 2500 mg daily.[35]
11. Rhodiola.  100-400 mg daily.  Adaptogen, decreases anxiety and enables better adaptation to stress response.[36]^,[37]  Not to be used in those with bipolar disorder.
12. L-theanine: 200-400 mg daily.  An amino acid found in tea (higher amounts in green tea), can reduce anxiety.[38]^,[39]
13. Gamma-Aminobutyric acid (GABA):  100-200 mg up to three times daily.  Natural relaxant effects.[40]^,[41],[42]
14. Withania somnifera (Ashwagandha):  anti-aging, haematopoeitc, immunomodulating, anxiolytic, anti-depressant, cardiovascular protection, anti-tumor and anti-neoplastic.  3000-6000 mg of dried root, 300-500 mg standardised extract.[43]^,[44],[45]
15. Garum Amoricum extract, as an alternative to benzodiazepines.[46]

Comment

The management of people with diagnosed anxiety is complex and in all but the most transient cases should also involve the support of suitably qualified medical teams. However, clinicians, once they have tried pharmacological interventions and standard talking therapies, still forget about the many lifestyle interventions that have over many years shown excellent supportive strategies. Communication between the patient, physician and teams of the recommendations and their potential interactions as well as benefits will ensure a collaborative knowledge base, and may improve outcomes far more than expected.

It is the aggregation of small gains in the resolution of anxiety rather than the single silver bullet that provides the best chance of resolution and clinical success.

by Michael Ash

References