UNDER PRESSURE: A SERIES ON STRESS MANAGEMENT
Stress: It’s Not Just Sleepless Nights
Of all the factors contributing to a person’s health status, stress is perhaps the most overlooked – but it is also one of the most important. Why? Because even if your diet is clean, you exercise regularly and you take your daily supplements, leaving stress management unaddressed puts you at an increased risk for heart disease, depression, autoimmunity and hormone imbalances. Stress management is a crucial part of leading a healthy life.
Unfortunately, we live in a culture that doesn’t place much value on stress management or self-care. We have lost the art of slowing down, instead embracing a breakneck pace and even revering those who seem to thrive with multiple irons in the fire. Slowing down and taking time for yourself can feel indulgent at best, and leave you guilt-stricken at worst. But the truth is, this paradigm of all work and no play can have devastating effects on a person’s health.
What Is Stress?
First, let’s gain an understanding of what stress really is:
Stress can take a number of forms – even some you might never have thought of. While we typically think of stress as negative, it can also be positive, as with the birth of a new baby and the ensuing sleepless nights, or even exercise. It can be real (a traffic accident) or perceived (watching a scary movie). Stress can be chronic (undiagnosed infection or autoimmunity), acute (rushing to meet a deadline), major (moving to a new country) or mild (dissatisfaction at work).
It’s important to note that negative emotions are an enormous stressor. We are unable to control most of the world around us, but we do have some control over our response to it. This is what makes stress management so important – if we can learn and utilize proper stress management techniques, we can mitigate some effects of the physical, physiological and mental components of the stressors inherent in modern life.
The Body’s Response to Stress
Our bodies are well-equipped to deal with acute stressors. During these events, the body’s “fight-or-flight” response is triggered and the stress hormones cortisol, epinephrine and norepinephrine are released into your bloodstream. This initiates a sequence that signals your body to prioritize functions such as controlling blood flow, increasing mental focus and releasing glucose into your blood stream to give your brain and muscles the fuel they need to help you outwit or flee from the danger – whether real or perceived.
In an acute setting, this is an appropriate response. Problems begin to arise, however, when stress becomes chronic and pervasive and cortisol remains elevated. Under these conditions, your body remains in fight-or-flight mode constantly. Because you are on high alert, your body chooses to down-regulate non-essential functions so it can focus on supporting your survival. Consequently, functions that don’t serve an immediate survival purpose including digestion, immunity, reproduction, growth and bone formation are set aside until the perceived danger has passed.
How the Body Handles and Adapts to Chronic Stress
At the most basic level, anxiety occurs when the sympathetic nervous system is in overdrive. The brain perceives a fear and warns the body. It is a helpful warning adaptation when there is a true physical or emotional threat. However, it becomes problematic when it persists and elevates beyond the level of the current threat, when the threat is eliminated, or activates when there is no specific stimulus. For example, on a scale of 1-10, the threat is a 1, perhaps the thought of being chased by a bear when you are nowhere near the woods. But your body acts as if you truly are being chased in the woods, right now, by a bear, therefore responding to the threat like it was a 10.
Cortisol (fight or flight hormone) levels chronically elevated are often seen in this sympathetic nervous system overdrive situation. As a result, the cortisol receptors become worn out and desensitized. When this happens, the body finds another way to deal with the cortisol overload and this results in higher levels of cortisol, epinephrine, and norepinephrine in the body. This suppresses the calming neurotransmitters designed to bring anxious feelings under control, and the anxious feelings loop continues. Circadian rhythms also become compromised with high cortisol levels so sleep becomes an issue. As anyone who has experienced it knows, poor sleep further complicates anxiety.
Long bouts of chronic stress slowly reduce the body’s ability to calm itself. When the excitatory activity of the brain has full reign, the neurotransmitters and adrenal hormones become depleted. They can simply no longer keep up with the demand. This is where high levels of fatigue can now accompany the anxious feelings, and some people begin to develop depression as well because of the lack of resources the body has to provide normal adrenal, hormone and neurotransmitter function.
GABA (gamma-aminobutyric acid) is often used to calm the excitatory response, but that does not always mean the root cause of the anxiety is addressed and is sometimes only a short term solution. Determining the root physiological imbalance to anxiety is often not addressed because it is not always simple. Practitioners must use specialty lab data, be skilled and experienced in interpreting the results, and as skilled and experienced in knowing how to support the body based on the results.
In many cases, conventional doctors will use medications instead of or before a functional medicine approach is considered. This can be in the form of a SSRI medication (selective serotonin reuptake inhibitor) which can be effective for some when there are only small amounts of serotonin present. These effects are also usually temporary and can have negative side effects. For many people experiencing anxiety, the body has actually adapted to a place of producing high serotonin levels in which case a SSRI medication can be like adding fuel to the fire and worsen anxiety. Other medications seek to stimulate GABA receptor activity (benzodiazepines). Both of these approaches ignore the person’s overall levels of neurotransmitters, stress hormones and glutamate levels therefore never being able to address the real imbalance. That is not to say medication is sometimes not needed, but there are other ways to think about addressing anxiety before assuming medication is the only option.
Many people do not realize that there are alternatives to struggling with anxiety and using pharmaceuticals which often result problematic side effects or don’t work as well as hoped.
Anxiety disorders are the most common mental illness in America, affecting about 18% of the population according to the National Institutes of Health (NIH). NIH data also reports that women are 60% more likely to experience anxiety issues than men. There are a multitude of factors that can lead to anxiety, the obvious ones being substance abuse, adverse medication reactions, trauma or difficult relationships.
However, a wide variety of less obvious factors contribute to anxiety are at the cornerstone of how Functional Medicine and nutrition can help find a solution for anxiety. Genetic factors (errors with neurotransmitter production and/or receptors), hormone levels, and environmental factors (heavy metal toxicities and fungal exposures) are two of many often missed causes of anxiety. Most of the time, a combination of these factors are at play.
THE FUNCTIONAL MEDICINE APPROACH TO ANXIETY IS ESSENTIALLY THREE-PRONGED:
- Understand: Hear and understand the patient’s history regarding to anxiety. Learn the patient’s childhood, social, environmental and medical history. This includes exposures to heavy metals, mold and chemicals.
- Assessment: Use lab data to accurately assess the source of the the imbalance causing the anxiety.
- Address: Support the person immediately with nutraceuticals, diet, exercise and adjunct therapies like: counseling, social support, and biofeedback if indicated while correcting the underlying imbalances. If a patient is already taking prescription medications for anxiety, those are not discontinued and are addressed when the patient has felt well for a period of time, determined together with the patient and practitioner.
Because anxiety can be present in a variety of ways with many different physiological and social causes, there is no “magic bullet” or formula for a functional medicine approach to anxiety. Individualizing nutraceutical therapies based on lab data, patient’s response, biomarkers and lifestyle can have a powerful and meaningful impact on those struggling with anxiety.
There are a wide variety of nutraceutical interventions used for anxiety, many of which are amino acids commonly found in food, but easily supplemented to replete the deficiencies/imbalances caused by chronically stressed sympathetic nervous system. Some of these include: N-acetylcysteine, L-theanine, Phosphatidylsterine, Taurine, Glycine, 5-HTP, L-tryptophan. While these types of products are very effective, they need to be directed by an experienced, skilled practitioner who can develop the plan that is individual to the patient.
Effects of chronic stress on the body and mind
Chronic stress has been shown to increase susceptibility to a variety of diseases including autoimmunity, heart disease, depression, hormone imbalances and cancer. Let’s look at a few of the effects of stress on the body during periods of chronically elevated of cortisol:
- Memory Loss
- Increased Blood Glucose – leading into increased Insulin
- Sugar Cravings
- Weight Gain
- GI Dysfunction – due to increased sympathetic nervous system response
- Night Sweats
- Compromised Immunity (autoimmunity and immune suppression)
- Low DHEA and Sex Hormones
- Osteopenia and Osteoporosis
- Altered immunity: Chronically-elevated cortisol turns on the part of the immune system that causes inflammation and attacks foreign invaders. Even absent pathogens to fight, this part of the immune system remains activated and increases the risk for autoimmune disease. Chronically elevated inflammation is also a huge problem as inflammation is the root cause of all diseases.
- Gut permeability and digestion: To put it simply, the gut contains a thin barrier that allows nutrients to pass through to your bloodstream and prevents pathogens from passing. Elevated cortisol loosens the tight junctions between the cells of this barrier, which allows larger proteins and pathogens that previously would have been too large to pass over, to come through. This, in turn, creates an immune response and inflammation. Over time, this inflammation creates additional stress in the body, perpetuating the stress. Additionally, stress slows gut motility and nutrient assimilation, and decreases the number and variety of gut flora in the intestines.
- Blood pressure: Stress elevates your blood pressure and also raises blood sugar, both of which are contributing factors to heart disease.
- Brain chemistry and memory: During periods of stress, neurotransmitters called catecholamines suppress activity in the areas of the brain that deal with short-term memory, concentration, inhibition and rational thought. Neurotransmitters also signal the brain to store emotionally-loaded experiences as a long-term memory. In doing so, it is preparing you to avoid the same stressful event in the future. This is why when someone cuts you off in traffic, you have an immediate stress response – your brain recognizes this danger and is calling on the stored memory for a reaction.
- Adrenal function: As we have previously discussed, stress initiates the release of the stress hormone cortisol, which is secreted by the adrenal glands. Circulating cortisol influences or regulates many of the body’s functions, including some of those previously mentioned, like blood sugar, immune function and inflammation. When chronic stress is present, the adrenal glands are forced to constantly pump out cortisol. Over time, the adrenals become “exhausted” and are unable to secrete the cortisol necessary to sustain normal levels. The result is decreased energy, increased inflammation, poor blood sugar control, poor sleep, decreased muscle mass and a host of other uncomfortable and vague symptoms that are often diagnosed as something else entirely.
As you can see, stress can have a huge effect on your health and wellbeing. Some symptoms of chronic stress make themselves apparent, but we also offer lab testing to uncover chronic stress issues early and get you back on the right track. Fortunately, there are many techniques you can incorporate into your life to help you manage stress, including herbal supplements, simple lifestyle changes, EFT and more.
Your root cause of anxiety is not my root cause of anxiety. There is not a one size fits all approach. The complexity of anxiety is the reason personalized medicine is needed and the reason some practitioners shy away from really trying to address the root cause.
We offer real solutions and part of that means getting data to tell us what’s really going on “under the hood,” as Dr. Priest often says. One of the ways we address anxiety is to use neurotransmitter testing. Neurotransmitters (NTs) are the chemical messengers in the body that direct mood and behavior.
NTs circulating in the blood are filtered by the kidneys and subsequently excreted in the urine. The existence of intact NTs in urine is not disputed, as evidenced by studies demonstrating renal transporters capable of filtering accurate levels of neurotransmitters from the blood to the urine. A simple urine collection can be used to see the levels of the main neurotransmitters that regulate mood and behavior.
So, without further ado… let’s dive into a case study! You’re smart, come on in with us.
A Case Study
The best way to see the way functional medicine can help anxiety is to, as best we can, show you the process in action. Because functional medicine is based on balancing, supporting, and repairing the body’s own mechanisms and pathways, it is not as simple as matching a set of symptoms to a medication or even supplement for that matter. Here we will look the case of a 3-year-old girl struggling with high levels of anxiety. We will discuss the NT test results, treatment approach, and outcomes/retest results. This same type of testing, interpretation and treatment is done with adults in our office too.
(reported by parents at time of testing)
– extreme anxiety in public, crowds, new situations
– high sensory input need to control anxiety (holding tightly by parents for comfort)
– picking at skin on face
– difficulty sleeping
– GI issues
– recurrent, frequent illnesses
It is obvious from these test results that neurotransmitters (NTs) are high. Some may be tempted to think that more is better, particularly when it comes to inhibitory (calming) NTs in regard to anxiety. However, what this case represents is an amped up sympathetic nervous system. The body’s “fight or flight” response was in overdrive, as if she was being chased by a whole pack of bears 24/7. The body then responds by doing everything it can to compensate by increasing the inhibitory NTs like Serotonin and GABA to try to calm down the high excitatory NTs (epinephrine and norepinephrine).
In this case, the indication from these results is the body simply couldn’t read and translate the NT’s attempts at regulating the fight flight response so it just kept churning out more of everything. In a high level or chronic state of fight or flight, the body can lose the ability to balance the excitatory and inhibitory NT’s because the receptor sites that make the chemical signaling connections simply cannot keep up. You can consider them overworked and underpaid. When this continues chronically, the receptor sites can permanently lose function. In this case, at only 3 years old, the receptor site functionality could restore back to proper signaling. This rest result matches clinically with her symptoms which is important to consider when interpreting NT tests.
With everything in overdrive, the treatment aim was to get the body to not only calm down, but to improve the NT receptor site signaling, therefore preventing further receptor site damage. Here are the tools used, in this case, to do this:
- L-theanine was used to for two purposes: 1) damper or slow down the conversion of glutamate to GABA; 2) help the brain to register the decrease in excitatory NT response.
- Herbs to decrease the fight or flight response and support the adrenals.
- GABA downstream metabolite used during the daytime instead of, when it is normally used, at nighttime in order to tell the system it did not need to make as much GABA. At such high levels of GABA production + anxiety, this approach calms the anxiety. For someone with normal GABA or low production, it would likely make them sleepy or be used to help with getting to sleep.
- Acetylcholine was used to provide more raw material for making neurotransmitters since she was burning through them at a rapid rate which affects the NT communication with each other. With more raw material, the body has more capacity to appropriately signal and regulate instead of overproducing more of everything in the chaos of the fight or flight/survival mode.
- A high quality multivitamin to provide methylation support, co-factors and b-vitamins for all the processes addressed above. This was an additional way of providing more raw material to a system that rapidly using necessary brain nutrients.
- Specific type of magnesium that works directly in the brain to help neurotransmitters bind to their receptor sites.
After six months of treatment, NTs were more balanced with none in the high range. This correlated to the clinical picture with parents reporting that she was significantly improved. Every area of concern had improved. She is currently participating in all age appropriate activities and is even handling new challenges very well. The process of tweaking her treatment and support will continue. In some areas like dopamine and glutamate, perhaps a bit too calm. This likely due to receptor site functionality and signaling improving through the treatment time, however there are not overt clinical symptoms that are of concern at this time. Dr. Priest is now working with the family to fine tune her care by making minor shifts in dosing patterns of supplements (when and how much) along with addition of glycine to support sleep and detoxification (a weak spot genetically for her family).
Not specifically mentioned in the treatment conversation above is that immune supportive supplements have continued through the course of treatment since the fight or flight state taxes the immune system which was evident in her being frequently sick, even at age 3. When the connection of anxiety, NT levels and immunity is not made or addressed, this can lead to autoimmune conditions or a chronically suppressed immune system.
For this child, the NT testing provided a clear path forward in treating her specific imbalances leading to the anxiety. Over the course of 6 months, both her clinical presentation (symptoms) and her lab tests showed significant improvement. Her parents report now that she is really doing great in all areas.
Without pursuing the root cause through data and an experienced practitioner, this family and their daughter could have spent years struggling to find solutions for her mood and behavior while at the same risking damage to NT receptor sites and immune system function.
Regarding the practical aspects of the supplement protocol, the most challenging aspect, for children, is getting the supplements in forms that they will take, which for most kids looks like powders, or opening capsules into foods they like or mask the flavor. We work closely with families on this and have developed many helpful strategies along the way. For adults, treatment can be quite easy to implement in the form of a clear supplement plan.
In all cases, we always recommend continuing or adding as needed, necessary support through the treatment process which could be things like counseling, play therapy, psychiatry care, or continued involvement of a primary care doctor.
We view high levels or chronic anxiety as a biochemical imbalance that can be addressed through the use of integrative, functional medicine tools. We also believe lifestyle factors play a role in the severity of anxiety, how and when anxiety is triggered, as well how well treatment can be implemented. Therefore, lifestyle factors that are known to help anxiety should be considered adjunct therapies to the lab testing, supplement support and social support.
Below are lifestyle factors we believe are important to address in the anxiety conversation with resources for information and support.
Mindfulness, grounding and meditation
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