One of the most frequent patient symptoms I hear in the office is one of anxiety. This is one of the vague symptoms that are often very difficult to clearly characterize. As with dizziness and fatigue, a patient’s anxiety promotes little insight into the cause from a mainstream medical practitioner. Conventional medical thought process: “The patient is anxious. They need to be treated.”
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 consideration for a prevailing sense of anxiety).
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 let’s start adding drugs to make this person feel better.
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 a doctor’s 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 can be 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. In fact, in the complete absence of cortisol, a human being dies from an autoimmune condition known as Addison’s Disease. The steroid hormone cortisol is absolutely required for life. I might feel like I was going to die if my testosterone was zero, but it won’t kill me. Zero cortisol assuredly will.
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 then 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 adrenaline. With stress, cortisol rises and stays elevated, often for years. But after time, the adrenals 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. This is what is generally known as “adrenal fatigue”, although the adrenals are not really fatigued, but suppressed by the brain. With today’s typical diets, many of these cofactors are likely not being adequately replenished, so there is a likely deficit in metabolic materials for cortisol’s production, too. 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.
The treatment rests in several camps, both nutritional and emotional. If an individual is unable to shut down or improve the stress response, this cycle will perpetuate. An essential part of the treatment of anxiety is to utilize modalities known to modify our stress responses. I broadly recommend any or all of these following possibilities. Yoga, tai-chi, meditation all serve to diminish our stress response. Sometimes it is as simple as educating someone to turn off their computer and cell phone after work, put on come classical music, and to cook a nutritious meal with their family. We live in one of the most beautiful parts of the country. I have actually taken our my prescription pad and written out, “take a daily walk outside each day” for a patient. In my opinion, this is sound prescribing, and a reasonable use of a doctor’s prescription pad.
Ideally, one’s therapeutic approach is based on objective findings. My preference as a physician is to treat based on hard data. I feel that the best way to assess one’s cortisol level is through a four-point salivary cortisol test. Should someone be so fortunate to have a provider with the insight to at least check a blood cortisol test, know that often this under-represents one’s true state of cortisol secretion. In addition cortisol follows a diurnal pattern, which is to say that it naturally changes through the day, being high in the morning and lower throughout the day, so looking at it once only really gives a part of the whole picture.
Fortunately, nature has provided us with several natural options to help with our stress response. If you do not have the opportunity to do a cortisol study, you can treat empirically (without data) using supplements with remarkably safe and effective pharmacologic profiles. My favorite supplement for the high cortisol pattern is a product known as Relora. This is a proprietary combination of magnolia and philodendron, which has been evaluated in several clinical trials. One might also consider trying individual or combination adaptogenic herbs, to include ashwagandha, rhodiola, and holy basil. All of these are available at Nutrition World in various formulations. Nature’s Purest has a nice combination product that contains several of these herbs, and is highly recommended by Ed Jones. He also offers products with Relora alone. His favorite is a combination product from Megafood that adds vitamin C and B vitamins to the mix, along with cordyceps and reishi mushrooms. Vitamins B 6,9 12 and vitamin C may all influence cortisol production. Cordyceps has been studied in multiple clinical trials along with Reishi. These mushrooms are gaining attention as potent immune modulators.
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. 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 and insulin can be kept in balance. This triad of insulin, adrenaline and cortisol is essential for the body’s proper energetics.
To really care for your body, you have to first address your body’s energetics. When it comes to hormones, I always say that “cortisol is king.” Take care of your king.