Anxiety is one of the most unpleasant experiences known to man. Deep in our brain lives our fear for survival. When threatened, we are primed to experience a rush of feelings, hormones and nerves that put us in a state of alertness. This is often described as fight or flight, however it has an entire cognitive element as well; the fear of death and suffering itself.

On any regular day, this feeling will come to pass when the threat passes. However, for some, it can come at any moment, and stay, for no apparent reason; and dominate their life and wellbeing. This is called anxiety. When anxiety occurs, the brain is unable to calm itself down and produce a normal set of thoughts that allow us to get on with our lives; realistic, calm, measured and productive.

15-30% of people suffer anxiety on a regular basis. For some, this will lead to extreme episodes of anxiety called a panic attack. These can be entirely emotional but often become physical; fast heart rate, chest pain and unable to breath. For some, the mind will lose the ability to clearly put vision and sound together and they will have an out of body experience, freeze in time or lose vision.

Edvard Munch’s painting, The Scream, is based on a panic attack.

Reference https://en.wikipedia.org/wiki/The_Scream

Whatever the presentation, anxiety can be pure hell; if untreated, it will develop into depression and eventually suicide. It is also a risk for dementia.

Anxiety is a complex medical issue. It has psychological, environmental, personality and situational causes as well as nutritional ones. The brain relies on complex nutrition to get a balance of chemical neurotransmitters right. If our cells cannot function well, is it any surprise that it can result in anxiety, depression and dementia?  

Integrative doctors refer to mental and cognitive health problems as neuroinflammation; underlying these holistic interplays between our health and our brain.

With a global epidemic in anxiety, the impact of environment and nutrition on the brain cannot be underestimated. Anxiety needs to be treated holistically. All underlying factors of nutrition, lifestyle, sleep quality, day to day stress and especially hormonal and vitamin balances need to be addressed.

Psychosocial support is key; your total environment makes you anxious NOT your personality.

This article introduces key areas that I focus on when treating my patients for anxiety to deliver an improvement. Take it and share it; it is for you.

Panic attacks are defined as an intense episode of the experience of fear accompanied with a body reaction such as increased heart rate, sweating, breathing heavily etc. Some people will even have an ‘out of body experience’ or a sense that time has stopped in addition to the overall experience.

Panic attacks can occur in isolation, or they can accompany another mental health disorder. They may form a part of a Generalised Anxiety Disorder (recurrent, intrusive, irrational, unwanted thoughts and concerns that cause anxiety on most days), Depression (low mood and a change in sleep/appetite etc. for most days) or mixed Anxiety/Depression, Obsessive Compulsive Disorder (Either obsessions with certain things or compulsions to do things), Post Traumatic Stress Disorder (flashbacks and repeated experience of past traumatic event) or repeated stressful life events.

Those who have panic attacks can either have them infrequently, or repeatedly.

What role does personality and childhood have with anxiety? 

Underlying this, a person may have personality factors or experiences that are associated with panic attacks. Some patients may have an anxious personality, a history of separation anxiety, childhood anxiety or a general sense to have catastrophic thoughts and ‘fear acceleration’. Some might be in a toxic environment full of retribution, threat, negativity and hate. This is very common; both at home and increasingly in the workplace.

What does a doctor want to know when asking about your anxiety and panic attacks?

When approaching a patient with panic attacks, we like to know…

What the Panic Attack was like?

Whether this is the first attack or it has happened before?

Whether likely also has another problem like anxiety, depression, OCD, PTSD or an eating disorder?

Personality (Fear acceleration, catastrophic thoughts, inhibition, attachment style)

Effect on life (do you worry about the day that the next panic attack will happen, missing work, not going or doing things because of them?)

Childhood and life history (unhappy, happy, traumatic events, attachment with parents)

Substances: alcohol, other things to manage

General life situation (stressful things going on) .

Diet and nutrition

Where you live and who you live with (good environment, or poor environment)

Work: or lack of work – is this a positive story or a stressful one?

What are some of the medical factors that underpin good anxiety management?

Our brain uses multiple chemicals, called neurotransmitters, that help us see the world clearly and maintain a calm mood.

Dopamine is a neurotransmitter that helps alertness, concentration, mood and general ‘up and go’. It is also a reward neurotransmitter.

Serotonin is a calming and happiness neurotransmitter; it is mostly produced in the gut.

Noradrenaline is a concentration and mood neurotransmitter in the brain.

Acetylcholine is the main neurotransmitter of the ‘parasympathetic nervous system’ this helps us digest, relax and ‘slow down’ whilst the sympathetic nervous system is its opposite; for fight or flight responses.

Histamine is a chemical often made in the gut. It is a major cause of allergies such as hives. In the brain, it promotes wakefulness but also a form of aggression or poor treatment of others and irritability.

Endorphins are our happiness and pleasure molecules. They are released from pleasure, exercise and sex (Arnold Schwarzenegger once famously likened weightlifting to being like ‘I am coming’). Production of endorphins is lower in people with anxiety or depression.

Oxytocin is a love molecule. It helps bonding between people and is released during sex and socialising. It is sometimes used as a medication for couples needing an aphrodisiac. It is a potent treatment for anxiety.

Having a pump is like having sex. I train two, sometimes three times a day. Each time I get a pump. It’s great. I feel like I’m coming all day.

–Arnold Schwarzenegger

GABA and Glutamate

Gamma Amino-butyric acid, or GABA, is one of the main inhibitory neurotransmitters. It slows things down. Alcohol and diazepam (or valium) release more GABA. Drugs that produce GABA are actually used as the emergency treatment for epileptic seizures which are caused when the neurotransmitters misfire dramatically leading to uncontrolled muscle activity.

Glutamate is the precursor molecule to GABA; it turns into GABA. However, glutamate itself is associated with anxiety.

In order for glutamate to be made into sufficient amounts of GABA, the brain requires certain nutrients such as Vitamin B6 (Pyridoxal 5 Phosphate or P5P is the active form), Magnesium, Zinc and good levels of Vitamin B12 in order to make the conversion. People with deficiencies of these often have more anxiety. This is a part of the reason why magnesium is used to calm the mood and help with muscle cramps.

Inflammation

Inflammation is the chemical reaction that occurs when the cells are under threat. When there is an infection, trauma or injury, invasion of a bug into our gut or a lack of vitamins that the body needs to function, cells will get distressed. When this happens, they release special inflammatory chemicals. These chemicals also tend to cause more glutamate than GABA, diminish certain neurotransmitters and thus lead to anxiety.

Sleep

When we sleep, our brain releases a hormone called melatonin. Melatonin enhances how well GABA works. Furthermore, melatonin also promotes Brain Derived Neurotrophic Factor or BDNF. As this neat name suggests, BDNF helps our brain cells recover overnight, produce more neurotransmitters and also with memory.

When we wake up in the morning, melatonin is much less and cortisol is released from the adrenal gland. Cortisol is a stress hormone; it is typically at its highest at 5am in the morning when melatonin is at its lowest. By night, cortisol is lower and melatonin will be released.

You can read about relevant health topics by clicking the articles below:

• Neurotransmitters
• Neuroinflammation
• Dopamine
• GABA & Anxiety Herbs

Anything that disrupts our ‘diurnal rhythm’ (the day night rhythm in hormones) will cause poor sleep and poor brain health. This includes caffeine, late nights out, alcohol, certain drugs and jetlag.

Poor sleep is a major cause of anxiety. We need good melatonin to be released so that our nerves can rest, be awash in BDNF and produce good neurotransmitters. Ideally, we go to bed with the sun and we are up with the sun; early morning sun exposure has been shown to help release cortisol, improve serotonin and enhance melatonin falling at the right time. Studies have also shown an improvement on mood.

In summary, our brain needs good sleep to function.

Vitamins and Minerals

As mentioned before, our nerves need vitamins to fuel their recovery and produce neurotransmitters. Key vitamins matter in the production of neurotransmitters and the balance of glutamate/GABA. They include

Magnesium

P5P or Vitamin B6

Methylation (A process using all the B vitamins for cell function)

Vitamin B12

Zinc

Vitamins are not just about what we eat but also the total health of our gut. In order to have good nutrition we need to consider the foods we eat, how natural and whole they are, the function of our gut and also whether we live in a part of the world with low minerals in the soil. We will touch on this later in this article.

You can read about relevant health topics by clicking the articles below:

• Vitamin B12
• Vitamins (Whole Section)
• Zinc

What about our hormones?

Many of our hormones have a major impact on Glutamate/GABA, neurotransmitter production, brain function, melatonin and BDNF to name a few

Testosterone is generally good for anxiety; testosterone deficiency is associated with anxiety

High estrogen or ‘estrogen dominance’ is associated with anxiety; especially before menopause

Low progesterone is associated with lower GABA

High levels of thyroid hormone can cause anxiety

Low levels of thyroid can also cause anxiety as they lower GABA

Synthetic or ‘fake’ hormones from chemicals in the environment can lead to higher anxiety

You can read about relevant health topics by clicking the articles below:

• Thyroid
• Estrogen Dominance
• Testerone Deficiency

Heavy metals and poisons

For those who have read Alice in Wonderland, we are all familiar with the mad hatter. In the old days, Mercury was used in the production of hats. This is a toxic metal and would produce mental health symptoms.

Mercury, Cadmium, Lead, Arsenic and to a lesser degree, Copper excess can all be associated with anxiety.

There are a few specific disorders where people will accumulate copper in the body. One is called Wilson’s disease, due to a genetic defect. Another is called Pyrrole disorder; where zinc is lost and copper is retained.

You can read about relevant health topics by clicking the articles below:

• Heavy Metals
• Pyrrole Disorder
• Wilson’s Disease (Copper)

Environmental Toxicity

We live in a world of chemicals. Compared with our ancestors, we are faced with literally thousands of man-made chemicals that our body was never able, nor had to, break down. These chemicals can accumulate in the body and disrupt how well our nerves function and repair themselves.

Some of these chemicals are industrial such as fumes, building materials, paints, solvents, insecticides, pesticides, fragrances etc. whilst some are used in the household. Household chemicals include food preservatives and colourings, artificial flavours as well as chemicals in beauty products, cleaning products etc.

As an example, aspartame is a sweetener that has been linked to anxiety symptoms.

Eating a healthy diet, fasting, exercise, good sleep, sweating and sauna all help clear toxins and are associated with lower anxiety. The use of a sauna has been studied extensively in multiple studies and is worth reading more on.

Detoxification means getting the toxins out of your body. This starts with not putting them in! Consider smoking, alcohol and clean eating the foundation point for this. In addition, when we sweat and when we exercise we are able to get rid of a lot of toxins. This is a part of the reason why exercise is very good for mental health.

Exercise has many other benefits; light exposure, social connection, good hormones and sleep improvement. The health benefits of exercise are well known and there is very little that cannot be improved in your health from exercise.

You can read about relevant health topics by clicking the articles below:

• Environmental Toxicity
• Sauna and Sweating
• Exercise and Detoxification

Gut and Liver

Our gut contains 100 trillion bacteria, about three times as many cells as we have in our bodies.

These bacteria are critical for life. They are a biochemical factory; they produce significant amounts of vitamins, neurotransmitters, hormones and other chemicals that are essential for good health.

Sometimes, in the context of so many chemicals and synthetic foods in our world, our digestive system cannot cope. It is overwhelmed and instead of good bacteria getting into our gut (Commensals) we get a nest of bad bacteria (this is called Dysbiosis).

When this happens, our health can suffer dramatically. These bacteria will eat our food, produce toxins, rob us of key vitamins that the good bacteria should make and shower our body in toxic inflammatory chemicals. Overall, they will make it harder for our liver to process toxins and harder for our nerves to function.

There is an incredible association between gut health and mental health. Probiotics have repeatedly been shown to be modestly effective in anxiety. Imbalances in gut bacteria have been shown to be associated with anxiety.

The liver, digestive system and gut should be thought about as one big ecosystem. Considering the function of your gut, the presence of irritable bowel syndrome symptoms and your diet should be a major consideration in treating anxiety.

You can read about relevant health topics by clicking the articles below:

• Gut microbiome and dysbiosis
• Endotoxin
• Glucuronidation

Diet

Food is a major contributor to our health. As already mentioned, our brain cells require significant key nutrients to function well. Our gut is a major driver of good mental health with the bacterial balance being substantially influenced by the kinds of food we eat. Finally, toxic environmental chemicals get in the way of our brain cells functioning well.

Relevant nutritional tips:

Organic foods rich in fiber and nutrients (vegetables) are better for our gut bacteria, lower inflammation, provide higher nutrients and are associated with less anxiety. The mediterranean diet is associated with a lower chance of anxiety.

Foods which are high in saturated fats (like fried foods) are associated with more inflammation and more anxiety.

Non-healthy diet patterns are associated with ADHD in children demonstrating the toxicity to the brain.

Chronic alcohol consumption is a clear cause of anxiety; it significantly lowers Vitamin B12 levels.

You can read about relevant health topics by clicking the articles below:

• Omega 3 and 6
• Big Four Dietary Mistakes
• Bile
• Children’s Nutrition
• Cow’s Milk & other Milks

Dementia and Cognitive Decline

The dark underbelly of anxiety is neuroinflammation; damage and hardship to the cells in our brain. All the factors we have discussed in this article that combine to cause anxiety can also cause other cognitive and mental diseases.

Whilst some people may end up with anxiety, almost exactly the same bundle of factors can cause depression, memory issues, aggression, ADD and even psychosis. They are a variation on a theme.

Over the long term, neuroinflammation is a risk factor for dementia. Our cells will not live forever. Over time, all cells do not reproduce as well and we lose cells via programmed cell death. This is called ageing.

The more poorly we treat our cells, the faster they age. I often like to tell my patients to imagine two people; one is a person under a bridge drinking cheap wine every single day and smoking 40 cigarettes whilst the other is a farmer in the sun, non-smoker, eating organic food and exercising every day. Which one is more likely to get dementia?

All factors that underlie anxiety and depression are a risk factor for dementia. Anxiety is known to be a risk for dementia. This highlights how critical it is to treat the underlying factors of anxiety early and hard.

You can read about relevant health topics by clicking the articles below:

• Mitochondrial Function and Aging
• Nutritional and Environmental Medicine
• ADD and ADHD
• Cognitive Decline

Society and Human Connections

So far, we have discussed the chemistry of good mental health. However, our environment is more than just the sum of the chemicals that enter and play around in our body; it also includes the people in our lives.

In general, strong and warm relationships with people are essential to diminish fear and anxiety. When we feel that we can trust the people around us and have no reason to be in competition with them, we are more at ease with the world and will have lower anxiety.

Loneliness is the mother of all problems; an environment of retribution and fear will rub off on our psychology and lead to higher anxiety.

What to do about anxiety?

Treating anxiety is not as simple as counseling and medication. Whilst these are helpful, they do not address the underlying function of our body that our brain cells need to rely on.

There are some broad themes we can rely on to get started.

Do not take this journey alone. Anxiety involves real suffering. Human connection with an empathic health care provider is necessary to get better. Humans are social species and we need other people to be healthy; live that message, be strong and tell your friends and loved ones that you are in trouble.

Spend time to find a healthcare provider who understands you and build a long term relationship.

Everybody needs a doctor and everybody needs a psychologist; wouldn’t you want this for others too? If so, then live it and invest in yourself.

In medicine, the treatments may change but the principles of treatment never change. Support your body to support your brain.

For repeat or likely panic attack disorders, the goal of treatment is:

To improve brain rest and repair.

Support the vitamins.

Improve the neurotransmitter production.

Support a healthy gut.

Support the liver in detoxifying neuroactive compounds.

Lifestyle Changes

Minimise alcohol.

Optimise sleep; REM is an important hormonal cycle phase of sleep where many neurotransmitters are made.

Minimise stress as best you can; if necessary, change your work, home or environment.

Experience early morning sunshine.

Diet; consider regular fasting, it reduces inflammation from the gut.

A Keto diet has been used to assist with neurotoxic disorders; it has been shown to increase dopamine production.

Ketones also promote higher GABA to glutamate ratio, calming nerves down; consider the keto diet and minimising carbohydrates.

Foods: high vegetable intake, soups, cut out saturated fats (fries, burgers) and consume fresh food and vegetables.

Take up cooking.

Get rid of soft drinks in your fridge and juice (they have too much sugar).

Eat with others at the dinner table; this is more social and better for your digestion.

Take up a new hobby; this can be very social and helps to distract the mind and reward your brain with dopamine.

Exercise: group exercise is often easier and more motivating.

Form key relationships with supportive people.

Consider adopting a dog or spending time with one; they are good friends for the price of a bit of food!

If friends pressure you to go out and get drunk, start forming friendships over lunch or informal house parties; it is less anxiety provoking and confronting.

Take up reading; it is a great distraction.

Supplements are best taken with the advice of your doctor, ideally based on blood tests. Nonetheless, there are some key starting points for most people. These treatments are based on adults and should not be done for children <50kg.

The following are the supplements I prescribe most often for anxiety:

Vitamin B6 or P5P (the activated version) 40mg taken once in the morning.

Magnesium, such as Magnesium citrate 500mg twice per day; although I find that powdered magnesium is more effective in water.

Zinc Picolinate 15mg twice per day (be careful not to take too much over time).

Lactulose 5-10mL twice per day is a useful prebiotic; it boosts the number of  good bacteria in the gut and can help reduce inflammation.

Saccharomyces Boulardii taken once per day is a yeast probiotic that helps.

Fish Oil supports brain health.

Phosphatidyl Choline supports nerve cell walls.

Liquid Melatonin at night time (easy to take).

NAC 600mg twice per day for 3 months can help the liver detoxify; it is best not to take it more than 3 months.

SAMe is a supplement used to support ‘methylation’, this is the pathway that involves folate and B12 helping cells reproduce. It is especially helpful for some patients.

Folate 400mcg or 0.4mg once per day.

CBD and low dose THC: this is illegal in many jurisdictions but when used appropriately it has a role to play.

For those who are really keen:

L Theanine 100mg Taken before bed

Taurine 250mg

GABA itself (150mg) best taken before bed

Inositol (antiinflammatory and insulin sensitising)

L Tyrosine (a precursor amino acid to Dopamine),

Rhodiola and Curcumin are anti-inflammatory.

Probiotics: Aim for high doses >250 billion colony forming units including L casei, L rhamnosus

Aim for good Vitamin D levels (best to have blood tests)

Herbal: Ashwagandha, Chamomile, Lemon balm, Valerian

Disclaimer: Treatments for anxiety should always be done in conjunction with your healthcare professional.

Supplement Tips

Supplements are best taken in discussion with your healthcare provider.

Consider starting supplements a short while after eating, it softens the blow on the stomach.

Start one supplement at a time and wait a few days; your stomach won’t like it if you swallow 20 capsules at once!

If a new supplements causes stomach problems or an unwanted reaction, stop it immediately, discuss with your healthcare provider and wait a while before trying to take it again.

The Bottom Line

Supplements will not help if they are not addressing a problem that actually exists in you. You will always get more out of supplements if they are targeted and rational.

Medications

For severe cases, the first line medication therapy would be a class of antidepressants known as SSRIs or SNRIs, followed by more advanced medications.

It is important to remember that depression and anxiety medications do not produce more neurotransmitters, they only redistribute them. They are very valuable and rightly used medications, however a nutritional and lifestyle focus is also important to heal the underlying issues.

Finally, the use of benzodiazepines for ‘short term’ panic attacks can be considered in patients without a history of drug abuse; but as a last resort.

Further treatments exist for more significant cases and referral to a psychiatrist may be considered.

Anxiety and Panic attacks should be taken very seriously. They produce much suffering for the person involved. Strangely, often it is very hard to notice that somebody is suffering from anxiety. Not only do they hide it, but they second guess themselves when assessing their own level of anxiety and are not sure whether to address it. Sometimes it is easier seen than told to you.

Neuroinflammation, an attack on the optimal function of our brain cells, is at the heart of anxiety. There is a link with neurotransmitters, vitamins and sleep underlying the genesis of anxiety.

Treating anxiety involves developing a strong bond with an empathic long term healthcare provider and engaging in a holistic treatment plan to address every area of the body’s function. Good environment, good living and good health are the key to solving anxiety. Only this way can we improve the lives of people living under the darkness of fear and worry.

You can read about relevant health topics by clicking the articles below:

● Mitochondrial Function and Aging
● Nutritional and Environmental Medicine
● ADD and ADHD
● Cognitive Decline
● Omega 3 and 6
● Big Four Dietary Mistakes
● Bile
● Children’s nutrition
● Cow’s milk & other milks
● Gut microbiome and dysbiosis
● Endotoxin
● Glucuronidation
● Environmental toxicity
● Sauna and sweating
● Heavy metals
● Pyrrole disorder
● Wilson’s Disease (Copper)
● Thyroid
● Estrogen Dominance
● Testosterone deficiency
● Vitamin B12
● Vitamin (whole section)
● Zinc
● Neuroinflammation
● Neurotransmitters
● Neuroinflammation
● Dopamine
● GABA & Anxiety herbs

Becker, E., Orellana Rios, C. L., Lahmann, C., Rücker, G., Bauer, J., & Boeker, M. (2018). Anxiety as a risk factor of Alzheimer’s disease and vascular dementia. The British journal of psychiatry : the journal of mental science, 213(5), 654–660. https://doi.org/10.1192/bjp.2018.173

Choudhary, A. K., & Lee, Y. Y. (2018). Neurophysiological symptoms and aspartame: What is the connection?. Nutritional neuroscience, 21(5), 306–316. https://doi.org/10.1080/1028415X.2017.1288340

Chao, L., Liu, C., Sutthawongwadee, S., Li, Y., Lv, W., Chen, W., Yu, L., Zhou, J., Guo, A., Li, Z., & Guo, S. (2020). Effects of Probiotics on Depressive or Anxiety Variables in Healthy Participants Under Stress Conditions or With a Depressive or Anxiety Diagnosis: A Meta-Analysis of Randomized Controlled Trials. Frontiers in neurology, 11, 421. https://doi.org/10.3389/fneur.2020.00421

Clapp, M., Aurora, N., Herrera, L., Bhatia, M., Wilen, E., & Wakefield, S. (2017). Gut microbiota’s effect on mental health: The gut-brain axis. Clinics and practice, 7(4), 987. https://doi.org/10.4081/cp.2017.987

Nakajima, S., Fukasawa, K., Gotoh, M., Murakami-Murofushi, K., & Kunugi, H. (2020). Saturated fatty acid is a principal cause of anxiety-like behavior in diet-induced obese rats in relation to serum lysophosphatidyl choline level. International journal of obesity (2005), 44(3), 727–738. https://doi.org/10.1038/s41366-019-0468-z

Pinto, S., Correia-de-Sá, T., Sampaio-Maia, B., Vasconcelos, C., Moreira, P., & Ferreira-Gomes, J. (2022). Eating Patterns and Dietary Interventions in ADHD: A Narrative Review. Nutrients, 14(20), 4332. https://doi.org/10.3390/nu14204332

Roy-Byrne, P., Craske, M. (2019) Approach to treating panic disorder with or without agoraphobia in adults. Hermann, R (Ed.), UpToDate . Retrieved 12 July 2019, from:

https://www.uptodate.com/contents/approach-to-treating-panic-disorder-with-or without-agoraphobia-in-adults