The search into the cause of anxiety is frequently derailed by a perfunctory medical evaluation that looks for anemia -- a low blood count and a good reason to feel anxious. Drug use. Certainly, frequent use of cocaine, methamphetamine or the commonly prescribed Ritalin can cause a sense of nervousness or anxiety. Or thyroid dysfunction. Hyperthyroidism being a reasonable yet relatively rare cause for a prevailing sense of dread, worry or concern.
Sadly, the thinking frequently stops here in mainstream allopathic medicine and the prescription pad comes to the rescue. There is little consideration that an organic factor, such as a metabolic or nutritional deficiency, could be the factor that is promoting an individual’s nerves to fray. There is little consideration that an imbalance in neurotransmitters, promoted by nutritional or amino acid imbalances, could be promoting symptoms.
Modern medicine is scarcely able to consider that toxins, mineral imbalances, or even bacterial populations in the gut could be contributing to the symptoms. These considerations do not exist. As physicians we are not taught to think about contributing or promoting factors.
The anxiety exists and needs to be treated. And there the thinking stops. That’s it. Maybe there is some genetic factor, and perhaps there is some predisposing event or PTSD. But the event has simply presented out of the blue and therefore mandates a pharmacologic treatment.
I offer the disclaimer that I am not a psychiatrist. I do not specialize in the countless numbers of psychoactive drugs that are helpful in the treatment of anxiety. Modern pharmacology can quiet the nervous system but often at the expense of alertness, clarity of thought and a normal state of perception. By altering neurotransmitters, we can give the patient a sense of calm, but again this arrives at great expense. Addiction, diminished cognition and an escalating need to combat our body’s ability to develop tolerance against a drug work against our best intentions. My experience shows me that patients are progressively ramped up on a shifting platform of medications with no real cure. Just a bridge over to the next refill. It’s sad. Patients just feel drugged.
But with a functional eye, I believe there is ample evidence that several avenues of thought exist as possible causative and contributing factors. Great inroads are made into a patient’s health when the physician allows him or herself to expand the thinking. To begin to consider what other realms of anatomy, physiology, pathophysiology and infection could be contributing to a patient’s symptoms of anxiety. We will review several of these considerations in the following paragraphs.
Good medical care requires careful and deductive thinking. I agree with the “modern” paradigm of obtaining some laboratory testing to see if there is an “organic” cause of the patient’s symptoms. Organic refers to something that can be traced to an established biochemical or toxic abnormality. A good medical workup includes a thorough thyroid evaluation. It is similarly not unreasonable to obtain a basic blood count (CBC) or chemistry evaluation (CMP) to ensure there is no obvious alteration in the patient’s blood count (anemia), or ions such as sodium, potassium or calcium. All of this is prudent medicine.
And should a mainstream doctor’s thinking be so advanced to begin to see out of the box? This workup might consider looking for toxins such as heavy metals. It is well documented that metals such as lead, mercury or arsenic are classically associated with neurological findings such as nervousness, anxiety or tremor. Did your patient work in a smelting plant, or drink out of the same well for 30 years? It may be that the answer to your diagnostic quandary might just be found in a careful history.
Let’s assume that these mainstream labs are all normal. Time to reach for the valium, right? Hold your horses, partner, we’re just getting started.
A frequently overlooked contribution to a feeling of anxiety comes, not surprisingly, from the patient’s adrenal function. A first-year medical student knows the difference between the “fight or flight” response of the sympathetic nervous system, and that of the “rest and digest,” parasympathetic system. Yet the importance of this paradigm is frequently lost to the practitioner with decades of experience. The basic function of the adrenal gland is to keep the body alive. We would not be able to survive without the adrenal hormone cortisol.
Our adrenal hormones, cortisol and epinephrine (adrenaline) kick in when suddenly faced head on with a tiger. This heightened state of awareness, dilated eyes, racing heart, elevated blood pressure and a sharpened kinesthetic sense is all normal. When the challenge is over, and we have successfully evaded the tiger, the life-saving elevated anxiety melts away as we recount the story to our peers back at the cave or at the local pub. We are left with a state of transient arousal, which over time drifts into a memory. And our physiology also drifts rapidly to resting state, at the ready for another, hopefully infrequent challenge.
But the modern warrior of the year 2015 is not so fortunate to mount a hyper-vigilant stress response and return to a state or relaxation. With our 24/7 stresses, our constantly pinging phones, our endless bills and responsibilities, and our accelerated world we are often pushed to a state of hyper arousal that we never turn off. We live in a treacherous state of elevated cortisol secretion, and we are seeing it reflected in our deteriorating health. Our expanding waistlines, accelerating Alzheimer’s diagnoses and the increasing need for Ambien, Valium and Lyrica.
Cortisol is without question the singular most stimulating modulator of our brain by design. Yet its contribution to anxiety is evaluated by zero psychiatrists caring for our country’s anxious patients.
But with so many of the systems in nature, excessive demands on our physiology come with a price. In the case of cortisol, the brain knows that such a sustained drain on our physiology cannot be sustained. It begins to limit the production of the cortisol messaging hormone, ACTH, to shut down cortisol production at the adrenal glands. In addition to a central drive to suppress the drain on our physiology, we find ourselves depleting the essential co-factors required to make cortisol: cholesterol, vitamin C and several of the B vitamins.
In addition to its essential function as a stress hormone, cortisol has another essential function – to act as a “counter-regulatory” hormone to the effects of insulin. For as insulin strives to pull sugar from the bloodstream into muscle and liver cells. Cortisol offsets this process in a yin-yang fashion, opposing the effects of insulin and maintaining a stable amount of glucose in the blood.
Two other hormones, both wilder and less well regulated, work alongside cortisol as the wayward “henchmen” to help keep up our blood sugar levels. These counter-regulatory hormones are known as epinephrine and norepinephrine. In more common parlance they are known as adrenalin. With stress cortisol rises and stays elevated, often for years. But after time, the adrenal’s release of the hormone is either shut down by the brain, or it runs out of the vitamins, minerals and cholesterol it needs to make the hormone cortisol. With today’s typical diets, many of these cofactors are likely not being adequately replenished. So who gets called in to the charge, at times of mild stress, slightly low blood sugar or a perceived challenge? You guessed it, our twin troublemakers epinephrine and norepinephrine. Adrenaline.
A vicious cycle ensues over time. The human body requires energy and requires at least a modicum of glucose to oversee and effect these energetic needs. But as our ability to mount a defined, and controlled cortisol release is hindered by either our brains or our nutrient deficiencies, we are left with little option with which to provide the essential fuels for our body’s functions. Our “counter regulatory” pathway to maintain our blood sugar levels is now driven by hormones normally reserved for the purpose of basic survival. We manifest this in the form of anxiety, nervousness and fear.
When looking at a functional approach to anxiety, it’s unquestionably essential to get a grip on controlling our cortisol response. It all boils down to basic energetics. If we are unable to obtain and maintain energy (glucose) in a sustained and predictable fashion, we have no recourse but to exist in a state of anxiety. Life becomes survival –fight or flight.
We will expand on other biological factors in the following blog that should be considered when developing a strategy to address a state of anxiety. Cortisol is only a small yet very important piece of the puzzle. To fully appreciate the multiple influences in play that contribute to anxiety, we need to investigate our own neurotransmitters and their synthesis and degradation.
When all this is considered in a functional framework, the hormone cortisol, epinephrine and norepinephrine can be kept in check and allowed to functional in a natural setting.
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Dr. Scott Resnick
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