Saturday, March 8, 2008

Orthomolecular treatment of anxiety disorders

Anxiety disorders are life altering psychiatric conditions that severely impair the quality of life of those suffering from them. They are the most common psychiatric disorders in the United States, (1) and are characterized by numerous somatic symptoms, such as facial flushing, hyperhydrosis (excessive sweating), muscle tension, paresthesias (numbness and tingling), shallow breathing, syncope (fainting), and tachycardia (rapid heart rate).

The emotional symptoms of anxiety disorders occur simultaneously with the somatic ones and include agitation, derealization (feelings of unreality), fearfulness, feelings of impending doom, irritability, nervousness, and shyness. Patients with anxiety disorders often report escape and avoidance behaviors that merely reinforce and perpetuate their ongoing anxiety.

They also tend to engage in catastrophic thinking by over-predicting the negative consequences of events. (2) Patients tend to misinterpret benign bodily sensations as warning signals for more serious conditions. For example, heart palpitations are common among the anxiety sufferers, yet this symptom is often misinterpreted as being a heart attack.

Anxiety sufferers desperately want their anxiety to go away, but they cannot control it. What these patients suffer from is a heightened autonomic nervous system (ANS) reaction to a perceived threat. There might even be some link between the anxiety of modern times and the lifesaving mechanism that was required of our prehistoric ancestors. (3)

For example, when the early hominids had to hunt and kill to feed themselves, they had to mobilize and react to real threats to their survival. By contrast, the anxiety sufferer of today manifests the same mobilization as if fleeing from a predator, but this mobilization is out of proportion to the actual threat. In some of us, anxiety might actually be built into our genes.

Evolution might favor those who have anxiety because it makes sense to have a built-in system that ensures survival. (3) Is it better to have a system that gives more false positives then false negatives? The advantage might be survival, but at a tremendous cost to the sufferer due to a lifetime of discomfort (Table 1).

Even with the unfortunate reality that anxiety might "live in" the genes of those susceptible to it, patients do not have to endure a lifetime of suffering. Anxiety sufferers want viable treatment options that can lessen their anxiety and improve their quality of life. An orthomolecular approach does just that--it is simple, effective, reduces the somatic and emotional symptoms of anxiety, and dramatically improves quality of life. The first part of this report will focus on the diagnosis of anxiety disorders. The second part will examine orthomolecular treatment strategies and will include case reports demonstrating the effectiveness of this approach.

Diagnosing Anxiety Disorders

To diagnose anxiety disorders it is necessary to first rule out organic causes before a psychiatric diagnosis can be made. Certain questions should be posed during the history when evaluating the anxious patient for organic causes (Table 2).

Once a thorough history has been obtained the diagnostic work-up involves various tests depending on the nature of the anxiety. (8) If the anxiety was found to be intermittent, it might be necessary to perform a wake-and-sleep electroencephalogram (EEG) and possibly a computed tomography (CT) scan to rule out a cerebral tumor. In addition, the work-up might require a 24-hour urine collection for catecholamines (to rule-out pheochromocytoma) or a 24-hour Holter monitor (to rule-out paroxysmal cardiac arrhythmia). If the anxiety is more constant than intermittent, the work-up involves other tests such as a thyroid panel (to rule-out hyperthyroidism), a drug screen, and an EEG. In cases of chronic anxiety, a 24-hour Holter monitor might also be helpful.

When the work-up does not reveal an organic cause, or when the history strongly indicates a non-organic cause of anxiety, a psychiatric diagnosis needs to be considered. Anxiety disorders are classified into various categories such as generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder (PD), posttraumatic stress disorder (PTSD), and social phobia/social anxiety disorder (SAD). (9) See Table 3 for a brief description of the main types of anxiety disorders. To make an appropriate psychiatric diagnosis, it is necessary that certain criteria be met for the anxiety disorder being considered.

Orthomolecular Treatment Strategy #1: Niacinamide (Nicotinamide)
The main treatment approach for anxiety disorders is to use a high enough dose of certain nutrients to diminish the ANS reaction, eliminate the fear of anxiety symptoms, decrease the cycle of avoidance and anxiety, and improve quality of life. One of the most effective ways to accomplish this is through the use of the amide of niacin (nicotinic acid) known as niacinamide (nicotinamide).

This B-vitamin has remarkable therapeutic benefits for those suffering from anxiety. In a recent report, a review of the literature was undertaken to determine the biological mechanism for niacinamide's anxiolytic effects. (10) It appears that niacinamide has therapeutic effects comparable to the benzodiazepines, a class of medications commonly used for GAD, PD, and SAD. (11) Benzodiazepine medications bind to a macromolecular complex that is found within the central nervous system (CNS), referred to as the GABA (gammaaminobutyric acid) benzodiazepine receptor-chloride ion channel complex. (12) When benzodiazepines bind onto or near this macromolecular complex they potentiate GABA-ergic synaptic inhibition through membrane hyperpolarization, thus enhancing the conductance of the chloride ion by increasing the frequency of channel-opening events. (12)

The net result is the reduction of anxiety and related symptoms via the diminution of neurotransmission (e.g., neuronal firing) among many brain regions such as the spinal cord, hypothalamus, hippocampus, substantia nigra, cerebellar cortex, and cerebral cortex. (12)

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