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Anxiety: A Naturopathic Psychiatric Approach
Dr. Maya Nicole Baylac
Anxiety StatisticsAnxiety is the most common psychiatric disorder in the US and Europe
Affects 18% of the US population (1), 7.3 % of the rest of the world (2)
One of the major health problem of the western world (WHO, 2004)
Poorly detected and treated: Only one third of those suffering from anxiety receive treatment
Economical burden is high: People with anxiety disorders use doctors three to five times more than those without anxiety disorder
(1) US statistic anxiety and depression association of america: http://www.adaa.org/about-adaa/press-room/facts-statistics
(2) Prevalence of worldwide anxiety disorders was obtained from 87 studies across 44 countries http://www.ncbi.nlm.nih.gov/pubmed/22781489
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What is Anxiety?
A state of anhedonia due to the perception of a hostile environment threatening survival
It is an allostatic state due to the disruption of the homeostasis by acute or chronic stress
HOMEOSTATIC STATE ALLOSTATIC STATE
Pleasure, safe Anhedonia, insecure, fear
Oxytocin NE, Epinephrine, cortisol, fatty acids
GABA and glutamate are in physiological equilibrium
Glutamate > GABA
Parasympathetic dominance Sympathetic dominance, HPA axis
Normal heart rate, blood pressure and blood sugar
Increased heart rate, blood pressure, blood sugar, respiration rateFat and carbohydrate breakdown
Rest digest Increased insulin, blood sugar LDLImmune digestive systems suppressed
Homeostasis and Allostasis
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The Symptoms of Anxiety
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Psychological Symptoms
Restlessness, excessive alertness, hypervigilence
Difficulty concentrating or mind going blank
Irritability, impatience, worry
Anger, negativity
Easily fatigued
Sleep disturbance
Bad dreams
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Physical Symptoms
Cardiovascular: pain or pressure in the chest, palpitations, tachycardia
Respiratory distress: hyperventilation, dyspnea, tachypnea, choking
Gastro-intestinal: diarrhea, nausea, heartburn
Neuromuscular: muscle tension, sweating, dizziness, tremors and twitches, headache
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DMS V: Anxiety DisordersDisorder SymptomsGeneralized Anxiety Disorder Exaggerated worry about health, safety, money, and other aspects of daily
life that lasts six months or more. Often accompanied by muscle pain, fatigue, headaches, nausea, breathlessness, and insomnia.
Phobias Irrational fear of specific things or situations, such as spiders (arachnophobia), being in crowds (agoraphobia), or being in enclosed spaces (claustrophobia).
Social Anxiety Disorder (social phobia)
Overwhelming self-consciousness in ordinary social encounters, heightened by a sense of being watched and judged by others and a fear of embarrassment.
Post-Traumatic Stress Disorder (PTSD)
Reliving an intense physical or emotional threat or injury (for example, childhood abuse, combat, or an earthquake) in vivid dreams, flashbacks, or tormented memories. Other symptoms include difficulty sleeping or concentrating, angry outbursts, emotional withdrawal, and a heightened startle response.
Obsessive/Compulsive Disorder (OCD)
Obsessive thoughts, such as an irrational fear of contamination, accompanied by compulsive acts, such as repetitive hand washing, that are undertaken to alleviate the anxiety generated by the thoughts.
Panic Disorder Recurrent episodes of unprovoked feelings of terror or impending doom, accompanied by rapid heartbeat, sweating, dizziness, or weakness.
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Pathological Anxiety: A Response To Chronic and
Acute StressThese symptoms are due to the effect of chronic stress on
the brain
Chronic stress creates anatomical and physiological changes in the limbic system For example: amygdala shrinking
Chronic stress causes mental emotional changes: For example: the misinterpretation of symptoms of chronic
stressChronic stress becomes the new homeostatic state.
Neurophysiology of Stress
HPA Axis Activation and Negative Feedback
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Neuroendocrine Secretions In The Stress Response
Catecholamines activate the sympathetic nervous system and the HPA axis: Increased secretion of Dopamine and Norepinephrine in the locus coerulus induces secretion of CRF in the hypothalamus.
CRF is released in the amygdala
Glutamate receptors are activate either by CRF or disinhibited by GABA
(Decavel and Van Del Pol, 1990, 1992)
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Catecholamine Synthesis
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Brain NeurotransmittersInhibitory
• GABA
• Dopamine
• Glycine
• Taurine
• Serotonin
Excitatory
• Glutamate
• Norepinephrine
• Epinephrine
• Histamine
• Aspartic acid
• PEA
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GABA and Glutamate Receptors
Glutamate and GABA make up 90% of the brain’s neurotransmitters
Excessive Glutamate is neurotoxic to GABA
Receptors for glutamate are NMDA
Receptors for GABA are GABAA
NMDA receptors can be excited by other chemicals, heavy metals, exogenous neurotoxins and too much glutamate
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Cofactors for Neurotransmitter
Synthesis
Iron
Copper
Magnesium
Zinc
Folic acid or MTHF
B6
B12
Vitamin C + D
SAMe
Tetrahydrobiopterin
Approximately 75% of the population has an MTHFR genetic defect
Glutamate/GABA Cycle
Patel A B et al. PNAS 2005;102:5588-5593
©2005 by National Academy of Sciences
Adapted and Maladapted Stress
ResponseAcute and Chronic Stress
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Adapted and Maladapted Stress Response
Adapted Stress Response or Acute Stress
Temporary mood that disappears when the challenge of acute stress is resolved
Triggered by external or internal circumstances perceived as threatening and disturbing the state of homeostasis (taking an exam or getting married)
Maladapted Stress Response or Chronic Stress
Stressors are permanent or permanent perception of stress.
Adaptation to chronic stress
Stressors Disrupting Homeostasis
Biochemical: toxins, excess glutamate, blood acid imbalance, low oxygen supply
Psychological-Emotional: fear threatening emotional homeostasis, insecurity, trauma, abuse
Mental: negative thought activating neurological fear pathway
Social: family, major life events, personal conflicts
Physical-physiological: excessive weight, pain, intense heat or cold, vigorous exercise
Environmental: pollution from crowding or noise
* Many of these stressors are experienced on a long term basis in chronic stress
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Acute Adapted Stress Response
Perception of Danger
Activation of Amygdala
Interpretation by Prefrontal Cortex
SNS
Feedback Loop to Hypothalamus
Homeostasis
Catecholamine Release
Glutamate Release
GABA Inhibition
Fight or Flight
NE + E Decrease
Return to Homeostasis
Chronic Stress Response
Perception of Danger
Activation of Amygdala
Activation of HPA axis
Disruption of feedback loop to hypothalamus and pituitary
Atrophy of neurons in hippocampus and prefrontal cortex
Adrenal Fatigue + Thyroid Dysregulation
Catecholamine Release
Glutamate Release
GABA Inhibition
CRH ACTH Cortisol
Thyroid + Sex Hormone Inhibition
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Chronic Stress Response and Neuroendocrine
ChangesDisruption of the feedback loop
Shrinkage of the hippocampus and amygdala
Cortisol decrease and adrenal failure
Hormonal imbalance
Pregnenolone Steal
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Physiological Symptoms of Chronic Stress
Prolonged secretion of cortisol causes multiple symptoms in a variety of systems:
Gastrointestinal: Increased appetite, increased centralized weight gain
Immunological: frequent colds, prolonged healing times
Central Nervous System: Memory loss
Endocrine: Decreased thyroid function, increased risk of developing Cushing’s Syndrome, bone loss, menstrual irregularities in women, decreased libido in men
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Maladaptive Chronic Stress Response
Adaptation to abnormal state: chronic stress is the new homeostatic state
Chronic anhedonia and difficulty to return to the normal state of homeostasis.
Life is centered on manipulating circumstances to return to the homeostatic state.
Quality of life is negatively affected.
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Chronic Stress Alters Mental
State
Misperception and misinterpretation of physiological symptoms and external stimuli leads to acute stress reactionStress induced anaphylaxisPTSDPhobias
Accumulation of chronic stress and acute stress evolve into acute anxiety crisis or panic attack that may takes the patient to the emergency room
Effect of Anxiety on Mental and Physical
Health
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Anxiety and Mental Disorders
Bipolar disorders
Eating disorders
Headaches
Sleep disorders
Substance abuse or drug withdrawal
Adult ADHD
Body Dysmorphic Disorder
Schizophrenia
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Medical Disorders Associated with Anxiety
Heart disease
Diabetes
Hyperthyroidism
Asthma and COPD
Withdrawal from alcohol, anti-anxiety medications (benzodiazepines) or other medications
Irritable bowel syndrome
Rare tumors that produce certain "fight-or-flight" hormones
Premenstrual syndrome
Chronic pain
Fibromyalgia
Cancer
Conventional Treatment of Anxiety
Benzodiazepines + SSRIs
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BenzodiazepinesBenzodiazepines are hypnotic, sedative, anxiolytic and
anticonvulsant
Enhance the action of GABA by binding to GABAA receptors
Manipulate brain chemistry to achieve calmness but it does not restore normal levels of neurotransmitters
Memory impairment and interaction with alcohol can occur
Psychomotor impairment: studies show increased road accidents
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Benzodiazepine Side Effects
Paradoxical side effects: Increased depression, hallucinations, personality changes
The most common adverse side effects are: ability to induce tolerance and dependence, sedation and myorelaxation (Millan, 2003)
Tolerance and drug withdrawal between dosage lead to increased doses and dependency, even at therapeutic doses and in a short course of treatment
Addiction occurs most often with short half life drugs such as ativan (lorazepam) and Xanax (alprazolam)
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SSRI Selective Serotonin Reuptake Inhibitor (SSRI)
Serotonin is involved in the regulation of mood, appetite and sleep
SSRI’s prevent the degradation of serotonin in the synaptic cleft
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SSRI Side EffectsSSRIs cause weight gain, insomnia, headaches, nausea,
diarrhea, sexual dysfunction: decreased libido, male impotency, anorgasmia. (Prim Care Companion J Clin Psychiatry. Feb 2001; 3(1): 22–27.)
Doubles suicidal ideation: “When compared with a placebo, all antidepressants, including SSRIs, seem to double the risk of suicidal thinking, from 1%–2% to 2%–4%, in both children and adults.” (SSRI Side Effects: Harvard Mental Health Letter discusses the real risks of antidepressants, May 2005)
Increases suicide risks by 2
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Beta BlockersUsed in extreme cases
Can relieve acute anxiety by slowing the heart rate and reducing blood pressure; they are often used to treat stage fright
Naturopathic Assessment
History taking – Physical Exam - Laboratory testing
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History TakingRule out any mental or physical condition
Rule out family abuse and external causes of stress
Rule out drug / alcohol use
Exposure to toxic chemicals such as organophosphate, chlorinated compounds, heavy metals
Nutrition: processed versus whole, organic food
Assess stress
History TakingPhysical Conditions
Underlying physical illness threatening survival:
Cardiovascular: mitral valve prolapse, myocardial infarction, abdominal aortic dissection
Respiratory: COPD, asthma
Hyperthyroidism
Diabetes, hypoglycemia
Cancer
Drug abuse
Anaphylaxis
Cushing’s Syndromewww.HawaiiNaturopathicRetreat.com
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Anxiety and the Cardiovascular System
Chest pain is a symptom of both anxiety and heart attack.
Mitral valve prolapse causes anxiety and panic attack
Anxiety is a risk factor for heart attack In the Nurses' Health Study, women with the highest levels of phobic anxiety were 59% more likely to have a
heart attack, and 31% more likely to die from one, than women with the lowest anxiety levels. Data from 3,300 postmenopausal women in the Women's Health Initiative showed that a history of full-blown panic attacks tripled the risk of a coronary event or stroke.
Two studies — one involving Harvard Medical School and the Lown Cardiovascular Research Institute; the other, several Canadian medical colleges — concluded that among both men and women with established heart disease, those suffering from an anxiety disorder were twice as likely to have a heart attack as those with no history of anxiety disorders.
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Anxiety and the Respiratory System
Asthma
Most studies have found a high rate of anxiety symptoms and panic attacks in people suffering from Asthma
COPD
In several studies involving COPD patients, anxiety has been associated with more frequent hospitalization
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The Gut Brain Connection
Anxiety and IBS
A 2007 New Zealand study of subjects with gastroenteritis found an association between high anxiety levels and the development of IBS
Anxiety can trigger symptoms in the gut and a troubled gut can send signals to the brain
Microbiota imbalance
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Anxiety Endocrine Connection
Hypoglycemia
Hyperthyroidism/Hypothyroidism
PMS
Menopause
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Self-Medicating Anxiety:Substance Abuse
Alcohol blocks NMDA receptors to glutamate, binds to GABA, acetylcholine and serotonin
Benzodiazepines bind to GABAA and have the same effect as alcohol
Nicotine increases dopamine
Opiates bind to endorphins and increase dopamine
Coffee, cocaine and methamphetamines increase dopamine, epinephrine, NE and serotonin secretion
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Observation
General demeanor: how the patient responds to the environment, personal hygiene
Posture: buffalo hump, abdominal obesity
Signs of nervousness: rapid speech, knuckle cracking, nail biting, finger tapping, hand wringing, trichotillomania
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Lab Tests CBC, Comp Metab Panel
TSH, FT3, FT4, RT3, TSH, Thyroid AB
Pregnelonone, DHEA’s
Adrenal stress index ASI
25-OH vitamin D3
Mg, Zn, Cu, Fe, TIBC, Ferritin
Folate, B12, B6
MTHFR DNA mutation
Homocysteine
Lipid panel
CRP
Heavy metal test
HGB A1C
ION test Genova Diagnostics
Biopterin
Stool analysis
Physical ExamVitals: HR, BP, Respiratory rate,
temperature
HEENT: hair distribution, pupillary reflex test, moon face, thinning eye brows
Thyroid: size, nodules, boggy, symmetry, tenderness
CVS: JVP, auscultation of valves
Respiration: auscultation (Asthma, COPD)
Skin: scars, sores, temperature
Abdomen: obesity, tenderness (IBS)
Extremities: nervous movement, nail biting, capillary refill (COPD)
Reflexes: prolonged Achilles tendon reflex (hypothyroid)
Genitals: hair distribution pattern (excess androgens)
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Special Tests Seargent's white line test
Take a sharp object and draw a line on the abdomen length and width.Normal response: line turns redStage 1 adrenal fatigue: line turns white and widens
Rogoff’s SignTenderness in the mid to lower back area. A sign of adrenal dysfunction
Ragland's Sign- a test for postural hypotensionTake BP while the patient is seated have them stand up and immediate check the blood pressure again. The systolic BP should increase about 4-10 mm indicating adequate adrenal activity. If the BP is the same or lower it can indicate sluggish adrenal activity.
Treating the CauseFear, Emotional Stress and Oxidative Stress
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Causes of Anxiety: FearSome fears are inherent to the species: fear of dying, dark,
aloneness
Fears can be from a current abusive relationship or family environment
Fears can come from national or job insecurity
Fears can be triggered by reactivation of past trauma in personal history
Fear of change perpetrates chronic stress
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Example: Fear of Change Past History of Abuse
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Acute Stress Response: Flight
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Acute Stress Response: Fight
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Homeostasis Maintained: Chronic Stress
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Neither Fight or Flight or Chronic Stress
Psychotherapy: Cognitive behavioral therapy
Exposure therapy
Mindfulness, meditation
Identifies and challenge negative thinking patterns and irrational beliefs feeding anxiety. Ex: I have a terminal illness
Identifies feared object or situation and repeats exposure to the object or repeats feared action in a controlled environment
Dis-identify from anxious thoughts, focus on the present
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Causes of Anxiety: Oxidative Stress
Oxidative stress occurs when free radicals are in excess of antioxidants
The brain is susceptible to lipid peroxidation and oxidative damage from high O2 consumption, its lipid rich constitution and low anti-oxidant defenses
Studies to determine a causal relationship between oxidative and emotional stress suggest that oxidative stress can provoke anxious behavior in rats
Masood A, Nadeem A, Mustafa SJ, O'Donnell JM. Reversal of oxidative stress induced anxiety by inhibition of phosphodiesterase-2 in mice. Masood A, Nadeem A, Mustafa SJ, O'Donnell JM. Reversal of oxidative stress-induced anxiety by J Pharmacol Exp Ther. 2008;326:369–379
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Chemicals and NMDA Receptors
Ammonia: ammonia produced by the body can cross the BBB and produce biochemically induced anxiety
Heavy metals: in particular mercury
Chemicals from food
TreatmentEliminating Environmental and Social Stressors
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The Inpatient Model
Removes External Life Stressors Substitutes a safe space in nature Provides a compassionate staff and multiple caring therapists dispensing
hydrotherapy treatments, massage, spiritual and emotional support Reestablishes trust in the environment Allows a progressive de-structuration of chronic stress adaptation syndrome
and the emergence of the natural self healing power Encourages daily focus on personal growth
Ecotherapy and the healing power of Nature “Vis Medicatrix Naturae” Emphasizes interaction with natural environment Mindful walking produces grounding
Group Therapy Sessions Generates community and support
Treatment:Biochemistry of
AnxietyNutrition – Detoxification – IV – Exercise
Nutrition
Mediterranean Diet• Eating traditional ‘Mediterranean’ diets – lower rate of mood and anxiety
symptoms
Processed Food• Eating ‘Western’ processed diets – higher rate of mood and anxiety
symptoms
Fried Food• Avoid fried foods forming advanced glycation end products’ (AGE’s)
during the frying/crisping of foods (increase oxidative stress in the body)
GMO• Avoid GMO
Davison & Kaplan (2012), “Nutrient intakes are correlated with overall psychiatric functioning in adults with mood disorders,” Cdn J Psychiatry, 57(2):85–92
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Nutritional CompoundsMagnesium:
• Magnesium deficiencies cause HPA dysregulation
Flavonoids:• Flavonoids modulate the activity of GABAA receptors and have demonstrated
anxiolytic, sedative and anti convulsing activities.
GABA Modulators:• Such GABA modulators have been found in fruit (e.g., grapefruit), vegetables (e.g.,
onions), various beverages (including tea, red wine, and whiskey), and in herbal preparations (such as Ginkgo biloba and Ginseng).
Astaxanthin:• Astaxanthin is a powerful antioxidant and anti inflammatory compound that can
balance the inflammatory effect of cortisol
Zinc:• Zinc studies show that zinc behaved as typical NMDA antagonist. C.E. Brown, R.H.
Dyck, Distribution of zincergic neurons in the mouse forebrain, J Comp Neurol, 479
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DetoxificationHeavy Metal
Detoxification
Candida Detoxification
FIR Saunas
Coffee Enemas and Colon
Hydrotherapy
Juice Fast or Raw Food Diet
Fermented Foods to
Replenish the Beneficial Flora
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IV Therapy
Supports detoxification pathways : Glutathione, ALA
Replenish quickly vitamins and mineral deficiencies with IV nutrient therapy: B vitamins, magnesium, amino acids, calcium, vitamin C.
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Exercise TherapyIncreases serotonin levels
Oxygenates the brain
Reduces epinephrine and cortisol
Case Study: JS
•26 year old Female Nurse
Patient:
•Eating Disorder, Panic attack, General Anxiety Disorder, Agoraphobia
Diagnosis:
•Food Allergies, Weight Loss, Reducing Food Intake to Familiar Foods
Presenting Complaints:
•Started 3 years ago when she had her first panic attack after eating some Chinese food at her friend’s wedding. Had several hospital emergency visits after that (6 in 3 years).
History of Panic Attacks:
•Flying, Any substance entering her body: New Foods, IV, Supplements
Phobias:
•Hx of Claustridia Difficile treated with antibiotics
Dysbiosis:
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Case Study: JS
Patient symptoms self-management:• remaining close to a hospital, no more than 3 miles radius, having her car nearby and
carrying an epi-pen
Recreational Life: • Could not socialize, go for hikes, which she was doing a lot prior (she was an athlete).
Was hard for her to take a plane and come and visit us in Hawaii from Canada
Relationship with Food:• Could only eat some foods that she felt safe with. Believed that she had food
intolerance and reacting to foods would lead to a panic attack
Weight:• Was losing weight
Emotions:• Crying all the time
Professional Life:• Could not work any more and resigned 6 months before coming for treatment.
Secondary Complaints: Life Limitations and Health Effects
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Case Study: JS
Benzodiazepine: Lorazepam, Ativan• 1 mg 5 AM and 5 PM
SSRI Citalopram 25 mg for the last 2 years
Pantoprazole for Acid Reflux
Pharmaceutical Management:
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Treatment ION Test from Metametrix (Genova Diagnostics) shows elevated
homocysteine level, low tyrosine and phenylalanine, low vitamin D, yeast infection
Oral supplementation to treat deficiencies: Vitamin D, Folic Acid as Methyltetrahydrofolate, Neurotransmitter Precursors and Cofactors including Biopterin, Tyrosine, Phenylalanine, GABA, B Complex, Fish Oil, Probiotics, Antioxidants, Adaptogenic and Anxiolytic Herbs.
IV Therapy: Anxiety Protocol, Benzodiazepine Withdrawal Protocol, Glutathione, Nutritional IV, Myers Cocktail.
Raw Food Nutrition with Green Juices (organic, non-GMO)
Exercise Program: Reformer Pilates, Walking, Swimming
Treatment: Psychotherapy Meditation Mindfulness
Address the presenting layer: fear of new foods, supplements, IV
Treat the eating disorder with cognitive behavioral therapy and exposure therapy
Challenge her belief system
We taught her how to take her pulse and test new foods prior to eating them. She learnt that she did not have any reaction to any of the foods she was eating. She was very upset, crying each time she was eating or waking up or taking supplements. We were present at the beginning every time she was eating holding her and talking to prevent a panic attack.
Preventing panic attack: breathing and mindfulness
She learnt that she could prevent a panic attack with breathing while crying in fear of having a reaction
We taught her how to practice mindfulness to watch how she could stop herself from having a full blown reaction
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Treatment OutcomeFollowing 3 weeks of in-house treatment she was eating all
foods without doing the pulse test or having anxieties
She was taking her supplements under 15 minutes
Her pharmaceutical medications were tapered down:Citalopram: Off, Lorazepam: From 1mg to 0.25mg
6 Month Follow Up: She got off Lorazepam herself the following monthShe has resumed working and her social life and has no panic
attack
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Thank you! Merci!
Mahalo!
Dr. Maya Nicole Baylac www.hawaiinaturopathicretreat.com239 Haili street, Hilo, HI 96720,
USdrbaylac@HawaiiNaturopathicR
etreat.com808.933.4400www.facebook.com/HawaiiNaturopathicRetreatCenter