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.)
However in mainstream allopathic medicine, the thinking frequently stops here, and the prescription pen and pad come to the rescue. Sadly, 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 consideration do not exist, because as physicians we are not taught to think about contributing or promoting factors. Again, 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.
Now, I am quick to offer the disclaimer that I am not a psychiatrist, and I certainly do not specialize in the myriad numbers of psychoactive drugs that are helpful in the treatment of anxiety. Modern pharmacology has the ability to quiet the nervous system, but often at the expense of alertness, clarity of thought and a normal state of perception. By altering neurotransmitters we are able to give the patient a sense of calm, but again this arrives at great expense. Addiction, diminished cognition and an ever escalating need to combat our body’s ability to develop tolerance against a drug work against our best intentions. My experience shows me that too often 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 I believe that there is ample evidence that several avenues of thought exist as possible causative and contributing factors that are easily considered with a functional eye. Frequently 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 am in agreement 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. Certainly a good medical workup includes a thorough thyroid evaluation, and it is similarly not unreasonable to obtain a basic blood count (CBC) or chemistry evaluation (CMP) to ensure that 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, as 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.
But 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 relaxing, parasympathetic system. “Rest and digest”. Yet the importance of this paradigm is frequently lost to the practitioner with decades of experience. In a simplistic form, the basic function of the adrenal gland is to keep the body alive- so much so that the only steroid hormone without which we would not be able survive is the adrenal hormone cortisol. When we are suddenly faced with the prospect of running from the tiger or fighting a sudden rip-tide, our adrenal hormones, cortisol and epinephrine (adrenalin) kick in. This heightened state of awareness, with 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 or swum back to shore, the life-saving elevated anxiety melts away as we recount the story to our peers back at the cave or at the local pub. What we are left with is a state of transient arousal, one which drifts over time into a memory. And so too does our physiology drift quite rapidly to resting state, at the ready for another, hopefully infrequent challenge.
But the modern warrior of the year 2105 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 mounting 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, our accelerating Alzheimer’s diagnoses, and our increasing need for Ambien, Valium, and Lyrica.
Cortisol is without question the singular most stimulating modulator of our brain by design, and 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, and 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.
However 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.
So one can see that over time a vicious cycle ensues. 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 erratically by hormones normally reserved for the purpose of basic survival, and we manifest this in the form of anxiety, nervousness and fear.
Unquestionably it is essential to get a grip on controlling our cortisol response when looking at a functional approach to anxiety. 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.
In the following blog we will expand on other biological factors that should be considered when developing a strategy to address a state of anxiety. Cortisol is only a small piece of the puzzle, albeit an important one. To fully appreciate the multiple influences in play that contribute to anxiety, we need to look into our own neurotransmitters, and their synthesis and degradation; we need to look into the environment, and to consider the presence of multiple toxins, including pesticides, hormones, heavy metals and common drugs such as alcohol; we need to look at the gut, and the developing relationships between our gut microbiome and our psychology; and of course we need to look at our stressors, our personal lives, our faith and our community. When all of this is considered in a functional framework, the hormones cortisol, epinephrine and norepinephrine can be kept in check, and allowed to function as intended in a natural setting.
Contact us to setup your free initial consultation.
Visit our Home Page to read more about Functional Medicine
Dr. Scott Resnick
Contact our offices at