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Why So Many People Still Struggle with Anxiety

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Anxiety & the Stress Response: Traditional vs. Functional Medicine

Anxiety disorders affect 18.1% of adults in the United States (approximately 40 million adults between the ages of 18 to 54), according to the National Institute of Mental Health (NIMH).

The traditional western medical approach to treat patients with anxiety disorders centers around manipulation of the serotonergic and gabaminergic systems, which includes prescriptions for medications like Lexapro, Prozac, Zoloft (serotonin-focused) and/or benzodiazepine-based medications such as Xanax, Valium, and Ativan (GABA-receptor focused).

The functional medicine/psychiatry based approach relentlessly attempts to uncover and then treat the root cause of EACH patient’s anxiety disorder. These causes may include hormonal imbalances, inflammatory cytokine elevations, dietary sources of neuroinflammation, blood sugar dysregulation, trauma or abuse history, nutritional deficits that lead to pyroluria, homocysteinemia or low amino acid status, and can extend to toxic tissue burden and inherited genomic impairments such as MTHFR gene defects.

Chronic Anxiety and the HPA Axis

At the core of chronic anxiety, and where all roads (i.e., root causes) lead, is the dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, essentially your body’s stress response system. The true diagnosis from a biological psychiatry perspective then becomes “HPA axis dysfunction”. The tail end of the HPA axis controls the production of stress hormones such as cortisol and DHEA, as well as catecholamines like epinephrine and norepinephrine. Chronic activation of the HPA axis from chronic stress, triggers and leads to the dysregulation of the HPA axis and subsequent imbalances in stress hormone levels, of which a critical feature is abnormal production of cortisol.

Chronic activation of the stress response can be caused by:

  • diet
  • toxins
  • metabolic stress
  • hormonal imbalances
  • sleep cycle disruption
  • pain and overt inflammation

Chronic stress is akin to the wear and tear on the tread of a tire. It takes its toll. As the tread on a tire wears with chronic stress/use, the performance of the tire goes down as well, and so does the performance of the homeostatic, self-regulating, self-healing powers of the body as it manages the incoming feedback and perception of stress. The result: poor stress tolerance and increasing stress-related symptoms such as anxiety.

Cortisol: the ‘Just Right’ Hormone

Cortisol can be a tricky hormone. While a certain amount of cortisol is necessary for optimal health, too much or too little can be disruptive and lead to symptoms that may not necessarily rise to the level of a diagnosable adrenal disease like Addison’s or Cushing’s disease. The term “adrenal fatigue” is used often by patients (and some practitioners), but is misleading and not understood nor recognized by traditional medical doctors. Better, more accurate terms might be “hypocortisolism”, “hypercortisolism”, and “adrenal dysfunction or dysregulation”.

During acute episodes of stress, more cortisol is released to help the body cope with physical or psychological stressors (1). Depending on diet, exercise, stress, and time of day, levels of cortisol will vary. During healthy conditions, cortisol levels peak in the early morning hours (usually around 8AM) and dip to their lowest after midnight. In the face of chronic psychological stress, the adrenal glands excrete an abnormal amount of cortisol in an abnormal rhythm. Receptors for cortisol reside throughout the body, including in the brain, and can therefore disrupt many seemingly separate bodily systems (1-3), producing wide-ranging effects and symptoms.

Regaining Control: Neurotransmitter Testing

To alleviate cortisol dysregulation and the anxiety it can induce, controlling the stress response is a crucial aspect of treatment. Research has clearly linked excessive stress and reduced stress tolerance to an increased incidence of anxiety (4-5).

Proper treatment of individual patients presenting with anxiety must include assessment of HPA axis function, in addition to patient-specific biomarkers that can become more clear via a thorough medical history. Assessment is straight-forward with the availability of urinary neurotransmitter measurements along with salivary cortisol and DHEA from waking through bedtime.

In our practice in Atlanta we typically assess over 175 biomarkers, including HPA axis data points, and taken together, a picture of a previously cloudy, distorted puzzle begins to emerge that allows for treatment of the individual and his/her specific causes along the metabolic, hormonal, nutritional, genomic and lifestyle continuum.

It is crucial to understand that treatment of one anxiety patient may differ significantly from another anxiety patient, and the reasons for this difference. Biochemical and genetic individuality must be factored into the treatment plan for every patient and extend to an individualized dietary regimen, nutraceutical plan, stress management and resilience building program such as mindfulness training (6) and/or cognitive therapy (7), exercise prescription and the like. At the core of any successful treatment plan for the patient with anxiety will be assessment and correction of HPA axis dysfunction.

References

  1. Endocr Rev. 2004 Oct;25(5):831-66. 11beta-hydroxysteroid dehydrogenase type 1: a tissue-specific regulator of glucocorticoid response. Tomlinson JW1, Walker EA, Bujalska IJ, Draper N, Lavery GG, Cooper MS, Hewison M, Stewart PM.
  2. Intensive Care Med. 2001 Oct;27(10):1584-91. Patterns of corticosteroid-binding globulin and the free cortisol index during septic shock and multitrauma. Beishuizen A1, Thijs LG, Vermes I.
  3. Early Hum Dev. 2003 Aug;73(1-2):39-52. Development of cortisol circadian rhythm in infancy. de Weerth C1, Zijl RH, Buitelaar JK.
  4. 2003 Nov;36 Suppl 3:S207-14. Stress responsive neurohormones in depression and anxiety. Ströhle A1, Holsboer F.
  5. Mol Psychiatry. 2010 Jun;15(6):574-88. doi: 10.1038/mp.2009.141. Epub 2009 Dec 15. The CRF system, stress, depression and anxiety-insights from human genetic studies. Binder EB1, Nemeroff CB.
  6. J Clin Psychiatry. 2013 Aug;74(8):786-92. doi: 10.4088/JCP.12m08083. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. Hoge EA1, Bui E, Marques L, Metcalf CA, Morris LK, Robinaugh DJ, Worthington JJ, Pollack MH, Simon NM.
  1. Cogn Affect Behav Neurosci. 2005 Mar;5(1):37-40. Regulation of hypothalamic-pituitary-adrenal activity in response to cognitive therapy in patients with generalized anxiety disorder. Tafet GE1, Feder DJ, Abulafia DP, Roffman SS.

 

 

 

Bradley Bongiovanni, ND

Bradley Bongiovanni, ND

For over 18 years, Dr. Bradley Bongiovanni has been a caring and accomplished Naturopathic Physician with an extraordinary background serving the greater Atlanta metropolitan area and the southeastern United States. As founder of Wholistic Medicine Specialists of Atlanta (WMSOA), Dr. Bongiovanni is famous for personalizing every patient’s diet by identifying specific food sensitivities and HPA-T Axis imbalances to reverse existing disease as well as prevent future illness.

Early on in his career, Dr. Bongiovanni also developed expertise in clinical laboratory medicine by serving as a clinical specialist to a premiere specialty laboratory in Georgia focusing on nutritional and hormonal testing. His practice combines excellent patient care, innovative laboratory and genomic assessments and cutting-edge natural medicines to provide a unique service that is highly tailored to each patient and their individual biochemistry. Dr. Bongiovanni is one of a select few Naturopathic doctors in the state of Georgia that is fully licensed, trained and credentialed by the US Dept. of Education.

Dr. Bongiovanni earned his B.S. degree from the University of Richmond and then his Doctor of Naturopathic Medicine degree from the National College of Naturopathic Medicine in Portland, Oregon. After completing eight full years in both college and medical school, he then went on to complete a Family Practice residency and several training programs working alongside medical doctors practicing truly ‘integrative medicine’.

He now integrates his cumulative education, training, and experience for the benefit of all his patients in metro Atlanta and the surrounding areas. He is highly trained to treat a wide variety of physical and emotional conditions but maintains a special focus on anxiety, depression, and stress/fatigue-related disorders.

Disclaimer: The information provided is only intended to be general educational information to the public. It does not constitute medical advice. If you have specific questions about any medical matter or if you are suffering from any medical condition, you should consult your doctor or other professional healthcare provider.

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