Anxiety & Stress
Anxiety is a mood of fear, worry, and uneasiness resulting from the apprehension of something bad happening, the source of which may or may not be identified. While anxiety can be a normal, appropriate response to circumstances, chronic and irrational or excessive anxiety in response to normal life events can be debilitating and is considered to be an anxiety disorder. In the United States, anxiety disorders effect 40 million adults, representing 15-25% of the population and affecting women 2-3x more often than men.
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Anxiety & Stress
Anxiety can occur due to a variety of causes. It can be the consequence of medications, dietary deficiency, hormonal changes, illness, traumatic experiences, bad habits and life stressors. Vitamin, mineral and amino acid deficiencies in the diet are associated with increased risk for anxiety disorder. Changes in hormonal balances, particularly associated with women during menstruation, pregnancy, post-partum periods, and menopause are all associated with increased frequencies of anxiety disorder. A traumatic violent experience may lead to post-traumatic stress disorder (PTSD) There may be an inherited genetic basis for anxiety: some studies suggest that variation in neurotransmitter receptor genes are associated with certain forms of anxiety.
Chronic anxiety is associated with greater risk of both cerebrovascular and cardiovascular diseases as well as depression and increased risk of suicide. This relationship with depression can work both ways: anxiety can lead to depression and depression can lead to anxiety. The co-occurrence of anxiety and depression is about 60%. The neurochemistry of anxiety and depression is similar, each sometimes involving imbalances of dopamine and serotonin and both sometimes responding to the same medications.
There are five main types of anxiety disorder. They are: generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), phobia and PTSD. In all cases, central nervous system neurotransmitter levels are inappropriate and/or their is imbalance of the Hypothalamic-Pituitary (HPA) axis (which controls noradrenaline and cortisol, the stress hormone).
General Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by worry in the absence of a real threat or problem. People with GAD are constantly apprehensive and are unable to relax. People with GAD may experience insomnia and fail to concentrate well. A person with mild GAD can manage to keep a career and a social life, however, severe GAD can lead to failure at work and an avoidance of social situations. Women are at a greater risk for GAD than are men and a diagnosis of GAD is made when an individual has three or more of the above symptoms almost daily for six consecutive months.
Panic disorder manifests as sudden attacks of fear and a sense of impending doom. This can cause elevated heart rate, sweating, and dizziness. During a panic attack the person may experience shortness of breath, nausea or chest pain. Often these physical symptoms can feedback and make the panic attack worse. Panic attacks are unpredictable, sudden and average 10 minutes duration. Panic disorder effects 6.0 million Americans and is twice as common in women as it is in men.
Obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder (OCD) is characterized by persistent thoughts (obsessions). The obsessions then cause anxiety and this anxiety leads to the use of ritualistic actions (compulsions) in an attempt to alleviate this anxiety. A good example of OCD is an obsession with bacteria in the environment and a subsequent compulsion to wash hands repeatedly. Approximately 2 million American adults suffer with OCD which affects men and women equally.
Phobias are unjustifiable fears. There are specific phobias and social phobias. Specific phobias are a fear of certain agents while social phobia is anxiety about everyday social situations. Social phobia is a chronic fear of being judged by others. A social phobia can last weeks prior to a scheduled encounter or social event. Social phobias affect a 15 million Americans.
Posttraumatic Stress Disorder (PTSD)
Posttraumatic stress disorder (PTSD) is initiated by an experience of a traumatic or violent event. This could include a serious accident, a violent crime, or a natural disaster. People with PTSD relive this violent experience in nightmares or wakeful memories. Subsequent ordinary events can trigger “flashbacks” that cause the afflicted person to believe or feel like the event is happening again. Approximately 5 million Americans are affected by PTSD.
Treatment of Anxiety
For the most part, while conventional medicine provides reasonably effective medications for short term managment of anxiety and stress, conventional medicine offers very limited options regarding the treatment of chronic anxiety and stress.
In an attempt to help patients with chronic anxiety and stress, conventional management has tended to “over-medicalize” anxiety and stress. By this it is meant that lifestyle and life circumstance problems are too often treated as medical problems and a medical solution is offered when, in fact, the more appropriate solution lies in lifestyle or cognitive and behavioral solutions rather than the use of medications. As a result of this “over-medicalization,” patients are too often started on medications that have adverse effects, long-term dependency and other problems while at the same time these medications never actually correct the underlying problem.
In truth, while the medical community bears responsibility for the problem of “over-medicalization,” so does western society which seeks a “pill for every ailment,” regardless of the nature of the ailment – medical or not.
This page will review medical solutions for acute anxiety and stress along with the limited medical options for managing chronic anxiety and stress. At the same time, however, emphasis will be placed on behavioral and mind-oriented solutions that have greater effectiveness with better chances of a “cure,” given that there really is no actual “cure,” but instead the “cure” lies in engaging effective methods for managing the inevitable anxiety and stress that present to all those who are alive.
Conventional Medical Management of Anxiety
Anxiety disorders are treated with conventional “anxiolytic” medicines that fall into four categories:
1.Benzodiazepines that include xanax (alprazolam), klonapin (clonazepam), valium (diazepam) and ativan (lorazepam). These work by acting on the receptor for the neurotransmitter, GABA.
2. Anti-depression drugs, which increase serotonin and dopamine levels, including trazodone, the selective serotonin reuptake inhibitors (SSRI’s) (Prozac, Zoloft, Paxil, Lexapro, and Celexa) and monoamine oxigenase inhibitors (MAOIs) (Nardil,Parnate, Marplan and Emsam) and tricylic antidepressants (TCAs) (Elavil, Doxepin, Desipramine).
3. Tranquilizers such as buspirone (BuSpar) which elevate serotonin and dopamine.
See: Buspirone (BuSpar)
4. Gabapentinoids [(gabapentin (Neurontin) and pregabalin (Lyrica)] which are used frequently in treating nerve pain are also effective for managing general anxiety as well as benzodiazepine withdrawal-related anxiety.
5. Beta-blockers (blood pressure medications) which act on the Hypothalamic-Pituitary (HPA) axis (the connection between the brain and adrenal gland’s release of noradrenaline and cortisol) by blocking the effects of noradrenaline.
Complementary and Alternative Medical (CAM) Management of Anxiety
Medical management of anxiety and stress also includes the use of Complementary and Alternative Medicine (CAM) treatment options, including herbal and natural supplements. Anxiety depression, and insomnia are among the most common reasons for people to use complementary (CAM) therapies. CAM approaches to the treatment of anxiety include use of nutritional, dietary and herbal supplements, acupuncture, aromatherapy, light therapy, meditation and hypnosis.
For the purposes of this section, only nutritional, dietary and herbal supplements and aromatherapy will be reviewed. It should be noted that research evidence for the following CAM treatments are weak due to a lack of large, well-designed studies. While the evidence is encouraging, few agents have strong evidence to recommend their effectiveness. With certain caveats, however, for the most part most of these agents are considered safe with only mild side effects likely. As with all supplements, it is advised that you discuss their use with your physician prior to self-treatment to review safety and dosing precautions.
Various amino acids are proposed to be effective in anxiety, largely related to their role as precursors to the biologic formation of different neurotransmitters including dopamine, serotonin, noradrenaline and GABA, all key players in the neurochemistry of anxiety.
L-tryptophan, L-tyrosine and L-phenylalanine
Deficiencies of L-tryptophan, L-tyrosine and L-phenylalanine lead to reduced serotonin production and are associated with anxiety. While the prevalence of these dietary deficiencies is not established in the U.S., supplementing with L-tryptophan is known to increase serotonin synthesis and is often recommended for anxiety and sleep. Supplementing with 5-hydroxytryptophan (5-HTP), the tryptophan precursor, and tryptophan have been shown to elevate brain serotonin levels and enhance a sense of well-being.
Supplementing with D,L-phenylalanine and L-tyrosine increases synthesis of dopamine and norepinephrine supporting their role in fighting anxiety. D,L-phenylalanine is also recommended in opioid withdrawal and may have a role in reducing chronic pain.
In a placebo controlled clinical study, when magnesium was taken orally along with calcium supplements, anxiety was decreased compared to placebo. Similarly, supplementation with magnesium and vitamin B6 was shown to reduces premenstrual-related anxiety and GAD in women. Magnesium supplementation has also been found to be effective in many conditions often associated with anxiety including chronic muscle pain/spasm, migraine headaches and insomnia.
It should be noted that the absorption of magnesium may be superior when absorbed through the skin through the use of epsom salt baths as well as less diarrhea, commonly seen with oral use supplementation with magnesium. It has been reported that dietary insufficiency of magnesium is common in the U.S., with estimates as high as 80% prevalence in women and 70% in men. The argument for epsom baths 3-4x/week for patients with chronic pain and anxiety is particularly high when factoring in the benefit of 15-20 minutes of “off-time” with a quiet soak…
In clinical trials people given daily oral supplementations of 100 mg of selenium for 5 weeks reported less anxiety. Confirmatory research is lacking as to cause-effect and to prevalence of selenium deficiency as a contributor to anxiety.
Omega-3 fatty acids
Dietary supplementation with omega-3 fatty acids has been shown to both improve mood and reduce the risk of anxiety. Again, studies are lacking to confirm these benefits for anxiety, but omega-3 fatty acids are also thought to have beneficial roles in cardiovascular health and oxidative stress. That being said, it is likely that the best approach here would be to include fish in one’s diet with at least 5 servings/week to maintain adequate nutritional quality and balance of the omega-3 fatty acids.
Because Vitamin C is a cofactor for enzymes involved in biosynthesis, and it is effective for oxidative stress and possibly reducing levels of stress-related cortisol, supplementation with Vitamin C to reduce anxiety has been advocated by some. One clinical study did show that high dose vitamin C improves mood, but substantial research for this anxiolytic benefit is lacking. Vitamin E also may reduce anxiety and vitamin D supplementation may reduce anxiety in patients with fibromyalgia-associated anxiety.
See: Vitamin D
Herbs and Botanicals for Anxiety
Kava Kava (Piper methysticum)
The best studied botanical with the most established benefit is kava kava (Piper methysticum). Unfortunately, recommendations for its use have been clouded by controversial concerns regarding its safety with respect to liver toxicity. The controversy is based on rare reports of liver toxicity, but apparently the only reported cases of this liver toxicity stemmed from the use of extracts from kava that included not just the kava root that is the traditional source for use, but also extracts from the stems and leaves. It is believed that the solvents and/or the extraction process is what lead to the few reported cases rather than traditional use of simple water extracts from the kava root. As a result of these insights, kava once banned in Canada and the United Kingdom is now again available. It has never been banned in the U.S.
There are six psychoactive agents in kava, kavalactones, and they bind to GABA receptors, dopamine receptors and opiate receptors and they also uncouple sodium potassium channels thereby reducing impulses to muscles causing muscle relaxation. The anxiolytic benefits of Kava have been compared to the use of benzodiazepines. It may also be effective for symptoms of premenstrual syndrome.
GABA is an inhibitory neurotransmitter of the central nervous system that reduces nerve impulse transmission between neurons (through the hyperpolarization of postsynaptic membranes and the reduction of neurotransmitter release into the synapse through presynaptic G-protein coupled receptor inhibition of voltage-gated Ca++ mechanisms). GABA is also found occurring naturally in herbs and plants and it works by reducing the excitability of a neural network thereby functioning as a brake on the neural circuitry during stress. Low GABA levels are associated with restlessness, anxiety, insomnia and a poor mood state. Dietary GABA supplement has been shown in some clinical studies to relieve anxiety.
Based on a recent literature review, it was concluded that extracts of M. officinalis are effective in reducing anxiety and stress due to its action on the central nervous system, particularly the cholinergic and GABAergic systems, though its exact mechanism of action is still controversial.
The GABA-A receptors are ionic channels that mediate the effects of GABA, producing an inhibitory action through the opening of chloride channels preventing a neuronal action potential. This is seen as the mechanism of action of diazepam (Valium) and is believed to be one of the possible mechanisms of action of Lemon Balm.
Valerian (Valeriana officiaonalis)
Valerian is a temperate plant root that has been used medicinally since the time of Hippocrates as a remedy for sleep and anxiety. It has been shown to be effective as a hypnotic (sleep agent), with particular effectiveness for benzodiazepine withdrawal-related insomnia, suggesting that it is likely to also be effective for benzodiazepine withdrawal-related anxiety.
Valerian root components have been shown to both increase GABA synthesis and decrease synaptic GABA reuptake. Valerian root activates glutamic acid decarboxylase, an enzyme involved in the synthesis of GABA. The active Valerian root extract known as valernic acid acts as a GABA agonist by binding to GABA receptors. These Valerian root extracts have anxiolytic properties at doses of 400–900 mg daily. Valerian root has been shown in some research to be as effective as diazepam in reducing anxiety. More research is needed to confirm these findings but Valerian root has established safety profiles that would argue for an initial trial of Valerian root for anxiety before starting benzodiazepines.
Anxiety and Hormones
Anxiety disorders in general affect more women than men. Furthermore, pregnant, postpartum, premenstrual and menopausal women also experience symptoms of anxiety to a greater extent than at other times in life. This general observation has lead researchers to investigate a link between hormones and anxiety. By now, it is well known that most steroid sex hormones (e.g., pregnenolone, estrogen, progesterone, testosterone, and DHEA – a precuror to building the sex hormones) are neurologically active. In fact, the brain has large quantities of DHEA along with estrogen and progesterone receptors. These hormones have a number of effects within the brain, including regulation of mood.
A number of studies have linked abnormalities in hormone levels to various anxiety disorders. During the first week of menses when there are increased levels of estrogen, women produce more serotonin and have improved mood. Decreased estrogen and serotonin levels are associated with the premenstrual period when there is often impaired mood and increased anxiety. In addition, the drop in estrogen during menopause is associated with reduced serotonin production and more anxiety. It has been shown that the selective serotonin reuptake inhibitors (SSRIs) used to treat anxiety have also been shown to improve mood and cognitive function in menopausal women.
During times of prolonged stress a greater proportion of cortisol (the stress hormone) is made compared to DHEA such that increased blood cortisol/DHEA ratios are believed to be a marker of stress and are associated with anxiety disorder. Women with insufficient progesterone levels are more susceptible to anxiety and studies indicate supplementing these women with proegesterone, or DHEA, can reduce anxiety.
Cordoncillo (Piper hispidum)
Recent research has looked at a Central American plant (Piper hispidum) that has been traditionally used by Q’eqchi Maya healers, midwives, and community members in Guatemala for female reproductive disorders. The leaves of Piper hispidum are used to prepare a tea for the treatment of amenorrhea (lack of menses), dysmenorrhea (abnormal menses), menopause and pain and are considered effective.
Researchers have found that that extracts of the leaves of Piper hispidum (butenolides) bind to both the estrogen receptor and serotonin receptors and act as serotonin and estrogen agonists, thus explaining the mechanism of benefit for these disorders and suggesting a possible use for anxiety related to menstrual complaints. No evidence was found for drug interactions related to inhibition of CYP450 liver enzymes. More research is needed.
Behavioral Management of Anxiety
Bebavioral management of anxiety and stress includes Cognitive Behavioral Training (CBT), meditation, hypnosis, yoga and other “mindful exercises,” even listening to muic, that are actually very effective and easily learned and engaged into dail practice. All of these modalities are offered at Accurate Clinic to those interested in pursuing them. While they all require greater commitment than simply swallowing a pill, these options are very effective with their outcome and benefits proportional to the effort placed in engaging them.
This page remains unfinished: an overview and summary of the articles below is forthcoming. In the meantime, please review the articles below.
Benzo.org.uk is the best resource for learning about discontinuing benzodiazepines:
Anxiety & Stress – Overviews
Anxiety & Stress – Prescription Medications
Anxiety & Stress – Benzodiazepines
Anxiety & Stress – Buspirone: MedlinePlus Drug Information.pdf (Buspar)
Anxiety & Stress – Gabapentinoids: (Lrica (pregabalin) & Neurontin (gabapentin)
Anxiety – Lyrica
- Pregabalin in acute treatment of anxious depression – 2013
- Pregabalin in Generalized Anxiety Disorder – A Placebo-Controlled Trial – 2003
- The treatment of generalized anxiety disorder with pregabalin, an atypical anxiolytic – 2007
- Efficacy of pregabalin in the treatment of generalized anxiety disorder: double-blind, placebo-controlled comparison of BID versus TID dosing. – PubMed – NCBI no higlights
- Pregabalin – A guide to its use in fibromyalgia, neuropathic pain and generalized anxiety disorder – 2014
Anxiety – Gabapentin
- Gabapentin – long-term antianxiety and hypnotic effects in psychiatric patients with comorbid anxiety-related disorders – 1998
Anxiety & Stress – SNRIs (Selective Norepinephrine and Serotonin Reuptake Inhibitors)
Anxiety & Stress – SSRIs (Selective Serotonin Reuptake Inhibitors)
Anxiety & Stress – Exercise
Anxiety & Stress – CAM Treatment
Anxiety & Stress, CAM Tx – Overviews
- What Can CAM Do for Anxiety?
- Complementary and alternative medicine in the treatment of anxiety and depression – 2008
Anxiety & Stress, CAM Tx – Natural, Herbal Options Overviews
- Dietary_and_botanical_anxiolytics – 2012
- Natural Nutritional Supplements for Anxiety and Depression Treatment
- Herbal remedies for anxiety – a systematic review of controlled clinical trials. – PubMed – NCBI
- [Medicinal plants for the treatment of generalized anxiety disorder: a review of controlled clinical studies]. – PubMed – NCBI
- Plant-Based Medicines for Anxiety Disorders, Part 1 – A Review of Preclinical Studies – 2013
- Plant-Based Medicines for Anxiety Disorders, Part 2 – A Review of Clinical Studies with Supporting Preclinical Evidence. – PubMed – NCBI
- Complementary and alternative medicine in the treatment of anxiety and depression – 2008
Anxiety & Stress, CAM Tx – Ashwaganda (Withania somnifera)
- An Alternative Treatment for Anxiety – A Systematic Review of Human Trial Results Reported for the Ayurvedic Herb Ashwagandha (Withania somnifera) – 2014
- Naturopathic Care for Anxiety – A Randomized Controlled Trial – 2009
Anxiety & Stress, CAM Tx – Lemon Balm (Melissa Officinalis)
- Anxiolytic properties of Melissa officinalis and associated mechanisms of action – A review of the literature – 2015
- Lemon balm | University of Maryland Medical Center
Anxiety & Stress, CAM Tx – Yoga
- Yoga for the primary prevention of cardiovascular disease. – PubMed – NCBI
- iRest Yoga-Nidra on the College Campus – Changes in Stress, Depression, Worry, and Mindfulness
- Individualized yoga for reducing depression and anxiety, and improving well-being: A randomized controlled trial
- Yoga Practice Associations with Mindfulness, Kundalini, and Mystical Experiences – 2015
- Yoga as an Adjunctive Treatment for Posttraumatic Stress Disorder – A Randomized Controlled Trial – 2014
- The Effects of a Hatha Yoga Intervention on Facets of Distress Tolerance – 2015
- Recent Development in Yoga – A Scientific Perspective – 2016
Anxiety & Stress, CAM Tx – Music Therapy
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.
Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.
For more information, please contact Accurate Clinic.
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