Anxiety: An Integrative Approach

The stresses of the last two years have created an epidemic of anxiety. In 2021, the rates of anxiety disorders across the population in the US were estimated at 19.1% in the past year and 31.1% in lifetime prevalence¹, which refers to the number of individuals ever having had the disease during their lifetime.²Using the US Census’ Household Pulse Survey, moderate to severe anxiety peaked during the pandemic, rising 6.9% when compared with 2019.³But what do we mean by anxiety? And how do we assess it through lab testing and treat it through lifestyle and supplementation?

Anxiety is an umbrella term and includes milder states of enhanced arousal, increased worry, and several somatic symptoms including fatigue, light-headedness, or chest pain. It is also a symptom of psychiatric disorders including generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive-compulsive disorder, or phobia-related disorders. On a psychological level, anxiety can be caused by several factors, a history of traumatic events, increased demands at home or at work, isolation, habitual negative thought patterns, or genetic and inherited tendencies. Anxiety is also caused by physiological responses to physiological factors—a largely underappreciated area of contributions to its origins that we are learning more about. Some of these factors can include blood-glucose deregulation, physical ailments such as cardiac or thyroid disorders, a standard American diet (low in fibre), increased sugar consumption, and low protein consumption.⁴Given that symptoms of anxiety may come from psychological and physiological levels, it’s important to understand that most of these factors are modifiable. Let’s look at how to assess for anxiety, and what lifestyle and supplement interventions can be included in a treatment plan.

Assessing Anxiety

As practitioners, it’s vital to consider a client’s presenting concern of anxiety and other underlying conditions. It’s possible that someone comes to us with “anxiety” that is actually the symptom of an underlying disorder, such as PTSD or drug withdrawal. Symptoms of anxiety can be caused by withdrawal of alcohol, marijuana, and several prescription drugs, as well as countless other substances, or may also be a symptom associated with an illness. Anxiety may also be a normal symptom; however, if the discomfort is too much for the person to manage, they will seek help.

A useful screening tool, to assess for generalized anxiety disorder (GAD), is the well-studied GAD‑7.⁵ A copy of the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM) can be useful to have on hand in office to guide the direction of a treatment plan before further assessment, or to refer to a specialist. Keeping in mind that a mental health diagnosis is not performed by a naturopathic doctor (ND) in many jurisdictions, they can be a primary-care provider to help identify when it is normal versus pathological or impairing their functioning. For example, if a client’s case includes symptoms of obsessive-compulsive disorder, lowering anxiety levels naturally can reduce symptomatology, but a thorough assessment and more complex treatment plan including other health-care practitioners would be necessary. This may include psychologists, nurse practitioners, or psychiatrists, depending on the nature of the anxiety and behavioural tendencies, as well as access to care.

When it comes to blood work, several commonly performed lab tests have associations with anxiety, including:

• B12: Low levels of B12 are correlated with both anxiety and depression.⁶
• Thyroid function can affect anxiety levels, with hyperthyroidism and associated conditions often known to increase anxiety levels. Chris Kresser, a renowned functional-medicine practitioner, discusses optimal ranges of TSH, T3, and T4 in ensuring abnormal thyroid function is ruled out, which can be a potential physical cause of anxiety.⁷
• Plasma blood glucose: Hypoglycemia can contribute to increased anxiety levels and is generally tested for during a hypoglycemic episode. Reactive hypoglycemia, which is hypoglycemia that occurs after a meal as opposed to during fasting, is another consideration and can be tested with a glucose tolerance test.
• Vitamin D: Many studies suggest an association between low vitamin D levels and increased anxiety, as well as other mental health concerns.⁸
• Ferritin and hemoglobin: Many sources suggest a link between iron status and anxiety levels.⁹

Other functional testing that might be indicated include:

• Out-of-balance gut flora levels can contribute to both anxiety and depression.¹⁰
• One company offering well-studied gut microbiome panels uses a specialized form of sequencing technology to analyze and report on an individual’s gut microbiome biochemistry.¹¹
• James Greenblatt, a leading clinician in integrative psychiatry in the US, discusses the association between magnesium deficiency and anxiety, emphasizing the testing of red-blood-cell magnesium analysis if a few presenting symptoms come up. Clinical symptoms of magnesium deficiency can be insomnia, anxiety, irritability, and constipation. If someone has two out of four of these symptoms, he purports a trial of magnesium can be very helpful.¹²

Functional genetic testing can be a useful tool in establishing root-cause factors and in creating individualized and targeted treatment plans. Genetic predispositions have been shown to be linked to different kinds of anxiety and differing treatment interventions.

Genetics: How Much Can Be Predicted?

Do genes play a role in our tendency towards anxiety? The DNA Company has been looking into this topic. While still in its early stages, the company has uncovered some correlations detailed hereafter. While not the magic cure for anxiety, this information may provide some clinical explanation, which may help validate patient concerns or provide motivation in further optimizing mental health. Some people may be relieved to know it’s all in their genes, rather than all in their head!

• COMT is a gene that encodes for the COMT enzyme that metabolizes neurotransmitters. Those with the slow variation of COMT have been described as “worriers” v. the fast-COMT variations being more likely associated with the “warrior” attitude to struggles and challenges. Those with slow COMT also tend to have a greater response to noradrenaline, one of our majority stress neurotransmitters, increasing the anxiety response, and be more prone to obsessive-compulsive tendencies.¹³Approximately 20–30% of Caucasians of European ancestry have this variation.¹⁴
• ·ADRA2Bis a gene associated with the sensitivity of noradrenaline binding, with suboptimal variations leading to an increased fear and therefore anxiety response.¹⁵These more sensitive variations can also increase memory of negative events and make individuals with them more prone to posttraumatic stress disorder (PTSD).¹⁶
• 5HTTLPR is a gene associated with serotonin secretion and reuptake, where suboptimal variations can lead to increased irritability, increased fear response, and an increased sensitivity to stress.¹⁷
• BDNF is a gene responsible for coding brain-derived neurotropic factor (BDNF), which helps the brain recover from physical or emotional trauma. Those with suboptimal variations have been demonstrated to have a greater attention bias to social threats as well as being more inclined to trait introversion and neuroticism.¹⁸

With this, it should be mentioned that these associations have not all been validated, and the field of functional genomics is in its infancy. Lifestyle interventions can be a powerful tool, particularly for long-term management of anxiety. Anxiety is not simply “in your head,” but also in your body, and that can be a relief to hear for some caught in a cycle of self-blame and powerlessness in the face of their condition.

Sleep

Sleep is paramount in maintaining cognitive health, and individuals who suffer from anxiety and depression should be aiming for no less than seven hours of sleep per night. A systemic review and meta-analysis on the effects of sleep deprivation on state anxiety levels demonstrated sleep deprivation, either total or partial, will induce a state of increased anxiety in individuals, regardless of their predisposition towards it.¹⁹

Diet

Within the growing functional medicine community, clinicians are working with the effect that diet has on mental health and anxiety. Dr. Allison Allott is a naturopathic doctor with a focus on mental health, who has studied the specific effect of blood-sugar deregulation on anxiety in her practice over the last 15 years, and she has formed clinical evidence, based on physiology, that the speed at which our blood sugar increases and decreases can have a dramatic effect on our anxiety levels (i.e., the glycemic index of food). Based on the physiological response, incorporating protein, even without cutting out carbohydrates, will slow the glycemic dip and—based on Dr. Allott’s extensive clinical experience—also lower the anxiety response. Her first recommendation for patients with anxiety is to eat within the first hour of waking and have an individualized amount of protein every three hours. She recommends aiming for approximately 70 g of protein per day, and for patients who have a carbohydrate-heavy diet, she does not suggest cutting them out, as increasing protein consumption will often be enough to improve symptom severity.²⁰

Exercise

Exercise can help to reduce anxiety in several ways. Dr. John Ratey, a psychiatrist from Harvard University, has placed a great emphasis in his career on studying the positive effects of exercise on different mental-health outcomes. When it comes to treating anxiety, individuals studied through a meta-analysis who were in a “high-exercise” category were better protected against the debilitating effects of anxiety than those who were in a “low-exercise” category. Instead of focusing on the specific type and amount of exercise, he concludes that it is more important to choose factors including exercise you enjoy, working to get your heart rate up, and exercising in nature or with others in a social setting.²¹

Supplements

Lavender

A systematic review and network-meta-analysis (NMA) was performed to estimate the anxiolytic effect of lavender oil taken orally, using the Hamilton Anxiety Scale (HAMA), with results revealing a statistically significant effect of 160 mg of oral lavender oil versus placebo, an SSRI medication, and a benzodiazepine. The p‑value of the effect was 0.05 and was considered statistically significant.²² Lavender is being used for anxiety more and more in clinical practice, in both oral food–grade capsules and with the use of lavender essential oils being diffused.

Ashwagandha

Ashwagandha, a traditional medicine which has been used for centuries in Ayurvedic medicine, was studied in a prospective, randomized, double-blind, placebo-controlled study, demonstrating a significant reduction in anxiety and stress levels when compared to placebo. The treatment group that was given the high-concentration ashwagandha exhibited a significant reduced in scores on multiple stress-assessment scales (p < 0.0001), and serum cortisol levels were substantially reduced (p = 0.0006).²³

Inositol

Inositol has been studied for its hormone-regulating and insulin-regulating effects in women with PCOS and fertility difficulties, but its effects on mental health and anxiety may be considered as well. A double-blind, controlled, crossover trial of inositol versus fluvoxamine for the treatment of panic disorder was associated with significant reduction in panic-attack symptoms. Inositol reduced the amount of panic attacks per week by 4, compared with a reduction of 2.4 with fluvoxamine (p = 0.049). Improvements in generalized anxiety as measured.²⁴

As anxiety and mental-health concerns have increased in the population, it has become increasingly important to develop understanding at both psychological and physiological levels. Lifestyle and supplementation can have far-reaching effects in the management of anxiety. Equipping ourselves and our patients with the best tools and information is the most empowering way of approaching care in the sensitive realm of mental health.