Anxiety Disorders

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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New approaches and related pathologies being explored to expand treatment of Generalized Anxiety Disorder (GAD)

One new approach being considered for treatment of GAD in women is the use of a drug to block or antagonize the corticotropin-releasing hormone (CRH) receptor in the pituitary gland of the brain. Corticotropin is a hormone that stimulates increased adrenal response to stress. Scientific study has linked both adrenal deficiency and dysfunction, as well as hypothalamic deficiency and dysfunction, to generalized anxiety disorder. Hormonal deficiencies and imbalance are common in modern society, with women commonly experiencing problems around the menopausal change, or with menstrual problems such as premenstrual syndrome. Since the hormonal system is a complex feedback system that is also tied intricately to the neurological system, improved health and function of the whole neuroendocrine system is important in resolving all related health problems. To holistically improve the health of the neuroendocrine system, the patient and the physician must look at the health of the kidney adrenals, the hypothalamic function, and the various systems that may impact healthy function of the adrenal-pituitary axis. This includes thyroid and parathyroid function, estrogen-progesterone balance, and sometimes the insulin response. A drug to block specific excess of adrenal stimulation may resolve symptoms of anxiety disorder, but the smart patient will also look to therapies to fix the underlying causes and restore their health, taking the time to obtain an individualized thorough diagnosis and working on restoring healthy function and balance. The end result to this approach is control of anxiety disorder without drug dependancy, and also restoration of overall health to obtain a better quality of life and prevent other serious health problems.

One curious scientific link between hypothalamic dysfunction and anxiety concerns research into the effects of the neurohormone oxytocin. Not long ago scientists considered oxytocin as a hormone related only to birthing and breastfeeding, but now we have discovered many measurable effects of this neurohormone. Oxytocin is mainly produced in the hypothalamus and stored in the pituitary, but neurons in the amygdala may also produce oxytocin. Nasally administered oxytocin has been shown to reduce fear response, possibly by inhibiting the amygdala hyperexcitation. A reduced hypothalamic function could be responsible for poor control of amygdala hyperexcitation, leading to generalized anxiety disorder and exagerrated responses in fearful situations. Oxytocin receptors have also been found in heart tissues, possibly explaining some symptoms of racing heart and palpitations. Reduced oxytocin bioavailability has also been linked to poor sexual arousal, and difficulties maintaining erection, and intitiating female orgasm. Subjects given oxytocin displayed enhanced emotions of trust and were able to take risks more readily in studies. All of these scientific findings may be applicable in some cases to hypothalamic dysfunction and anxiety disorder. A number of nutritional deficiencies have been linked to poor hypothalamic dysfunction, such as calcium AEP (aminoethanolphosphate). Oxytocin bioavailability may also be a problem with deficiency of key amino acids, such as glutamine and tyrosine, and oxtyocin receptors may be inhibited with deficiency of magnesium, and well as a lack of healthy cholesterol. TCM combines these nutrient therapies with herbal formulas and acupuncture to create a thorough treatment protocol.

A 2010 NIH sponsored study at the Cedars-Sinai hospital associated with UCLA Medical College found that deep tissue massage, or physiotherapy, was effective in stimulating increased oxytocin, when compared with normal massage, or surface tissue, or lighter massage. Other beneficial physiological effects included reduced cortisol needs, improved lymphocyte production, and normalization of a variety of excess inflammatory cytokines. These unexpected results, measured in a placebo-controlled study, showed that a combination of TCM therapies, acupuncture, herbal, nutrient, and Tui Na, or deep tissue massage, could be very synergistic in achieving better outcomes. The time spent with the physician, and the resulting cognitive and perhaps behavioral changes than could result, also may improve the outcomes with various anxiety disorders.

As studies of the brain with functional MRI and a number of devices to measure brain function as well as structure proceed, findings of neurodegeneration in specific areas of the brain in anxiety and depression mood disorders have been discovered. In 2010, studies with volumetric MRI at Leiden University Medical Center, in The Netherlands, found that a reduced volume of neurological tissue in the rostral-dorsal anterior cingulate gyrus is consistently seen in anxiety and depression mood disorders (PMID: 20921116). Clearly, aid to growth of neurological tissues, stimulation of specific areas of the brain with acupuncture and electroacupuncture, and neuroprotective effects of herbal and nutrient medicines could play an important role in both treating and potentially curing anxiety and depression mood disorders, rather than just managing the condition with drugs.

Scientific studies of acupuncture in the treatment protocol of Anxiety Disorder

Chinese universities and medical research facilities have long investigated acupuncture and its effects on the anxiety state. Both acupuncture and electroacupuncture have been proven to effect neurotransmitters and neurotransmitter receptors, both locally, in the spinal column, and in the brain. Acupuncture and electroacupuncture have been shown to have modulating effects, meaning that this stimulation is often producing enhancement of the normal physiological controls of anxiety, but specific types of stimulation have also been shown to effect different types of neurotransmitter receptors more strongly than others. Such scientific study has helped to guide proper treatment. In recent years, the protocol of human clinical studies using a control group has also been conducted. Electroacupuncture has been proven effective for Generalized Anxiety Disorder and anxiety in drug withdrawal, favorably compared with standard pharmaceutical treatment. In addition, combination of cognitive and behavioral therapy with electroacupuncture has been shown to produce significantly improved results over cognitive and behavioral therapy alone (see the studies cited below).

As these findings are published in Western Medical Journals and incorporated into the NIH database of medical studies, PUBMED, there are calls for larger studies on human outcomes. So far, there have only been positive findings for the use of acupuncture and electroacupuncture in treatment of Anxiety Disorders, and we can expect more of the same from larger studies, prompting an eventual incorporation of acupuncture into standard treatment protocols. The key point to remember, though, is that acupuncture stimulation is just a part of the TCM protocol, acting synergistically with a more holistic array of treatments in actual clinical practice, which include counseling, herbal and nutrient medicine, and even physiotherapy. For those patients with a fear of needles, the TCM physician can still provide reliable integrated therapy with these other treatment protocols, although acupuncture is shown to be the safest manual medical treatment in world history.

In real clinical practice, individual patients are treated with a more comprehensive and individualized therapeutic protocol than that which is seen in scientific studies. Patients that are treated with a variety of protocols will likely have a better outcome, and patients that integrate the TCM therapies with cognitive and behavioral therapy may have an even better outcome. With pharmaceutical therapies, combining a number of protocols, and switching protocols during a course of therapy, is problematic, due to side effects and contraindications of combined drugs. With a combination of acupuncture, herbal and nutrient medicines, there is no worry over side effects, and these protocols often have a synergistic effect. To achieve better results, the TCM physician may alter the therapy during the course and observe the effects. Generally, a sufficiently long course of acupuncture is recommended, which may be different for each individual. Improvement might not be seen until repeated treatments are administered, and the effects become cumulative or altering of the physiology. Ideally, in disorders of the nervous system, which is a fluid, or changing physiological system, frequent acupuncture visits are generally more effective over a short course than infrequent acupuncture over a longer time.

Cognitive Concerns in Anxiety Disorders

While there was a reluctance to authorize and pay for cognitive and behavioral psychotherapy in treatment of anxiety mood disorders for decades, instead steering patients toward an unhealthy reliance on just benzodiazepines and SSRI/SSNRI medications, this trend is reversing, and many studies now demonstrate that even a short course of treatment with a competent cognitive and behavioral psychologist is very effective in the overall treatment protocol. Of course, patient understanding of cognitive and behavioral mechanisms in anxiety mood disorders also allows the patient to make much progress in this realm even without professional guidance, although professional treatment is of course highly recommended. Anxiety is an emotional tool evolved to warn us of an impending threat, and of course, a threat in today's world can be very different from one in the far past. Today, many of us fear more uncertain events and outcomes than a simple predator, and sublimated memories of threat that are hard to understand often linger and affect our reactions. These less defined threats create a pattern of fearful emotion and reaction that is often hard to understand, and to positively deal with. The autonomic reactions in fearful anxiety, such as a more rapid heart beat, changes in the breathing pattern, blood pressure changes, muscular tension, etc. can also be triggered by a variety of factors, including altered sleep cycles and gastric function, and thus precede the emotional response of anxiety. By focusing on this whole cycle of events and dysfunction, we can alter our cognitive behavioral patterns while we correct these underlying autonomic dysfunctions as well. Neuroimaging technology in the last decade or two also clearly shows that anxiety and depressive mood disorders involve anatomical changes in the brain, as well as cognitive functional changes and patterns, suggesting that improving brain health, and working on this disease from a mind-body perspective, is very important for a successful outcome. This holistic approach to an anxiety mood disorder is very important.

We may not be able to eliminate anxiety cognitively or behaviorally, as anxiety is an evolved tool to alert us to impending threat, and is thus helpful to us, but we can enhance our evolved homeostatic mechanisms of controlling anxiety, and the emotional and physical symptoms triggered by it. Integration of cognitive behavioral approaches into the overall treatment plan is thus very sensible, and can easily be accomplished in a manner that suits individual needs.

There is a strong association in studies of anxiety mood disorders of mechanisms of selective memory and attention, called cognitive bias. For most people, when there are both threatening and non-threatening memories coming into the consciousness, the natural tendency is to focus on the non-threatening memory, while in anxiety mood disorders, studies have shown the strong tendency to focus on the threatening memories and triggers. Cognitively, patients could change this behavior if aware of it, recognizing and focusing on thoughts and memories that are non-threatening, and being aware that the disorder comes with a tendency to dwell on threatening memories and triggers, and that this should be avoided by redirecting the mind. In like manner, patients with anxiety mood disorders tend to direct their attention to threatening cues, which can increase in number the longer the anxiety mood disorder persists. By recognizing these threatening cues, looking more objectively at them, and simply avoiding them, much can be accomplished to diminish the symptoms of anxiety. While there is a general belief that a person with anxiety will try to avoid these triggers of anxiety and not think about them, the opposite is true in studies, and confronting and dealing with attention triggers objectively, as well as directing the mind to objectively assess and divert the attention to a non-triggering or threatening cue, is a positive way to handle anxiety. Avoidance of such objective analysis will not help with the cure, and often the patient tends to keep allowing their memory and attention go to these triggers of anxiety if they just try to avoid or sublimate them, rather than confront and deal with them. With memories that trigger anxiety, there are often two types, memories of events, circumstances, or people that trigger anxiety, and memories associated with identity. Often memories rooted in early life and childhood will be associated with negative patterns of identity, leading to a fear of what will happen in the future when the root of the personality is not well. Here too, avoidance of issues of identity are not healthy. By integrating such cognitive and behavioral actions with a positive and holistic restoration of normal neural and psychological function, a quicker and stronger resolution to the anxiety mood disorder can be accomplished.

A number of studies of brain activity in anxiety mood disorders have also elucidated mechanisms of cognitive behavioral control that could be very helpful in the overall treatment protocol. Functional MRI and other brain mapping methods have been used for over a decade to elucidate the mechanisms in anxiety disorder. The first finding noted in these studies was that in general, patients diagnosed with an anxiety disorder shifted their activity more often to a right brain dominance. The left and right brains are specialized and coordinated by the midbrain, especially the thalamus, to achieve more complex function. The left brain is more involved in sequential analysis, facts, and computation, while the right brain is more involved in solving problems by looking at the big picture, with imagination, feelings and daydreaming, as well as having non-verbal cues predominate. Normally, these two side of the brain work together to solve problems, the left side utilizing functions that look at life and problems in a step-by-step manner, and tying concepts and cues to language, and analytical thought, while the right brain takes the same problem and view of life and sees the potential end result, visualizing the outcome, tying it to emotion and imagining an outcome, and reacting to non-verbal cues. For a patient with chronic anxiety, focusing more on the left brain functions will perhaps bring the mood into a better balance. This means that upon waking, a conscious effort to avoid assuming that the day's events will go wrong, and instead adopting a step-by-step approach, and analyzing alarming cues, rather than just reacting to them, may help bring the brain into a more balanced function, better controlling mood. Of course, with these findings came more tests with study designs intended to challenge these findings, and today we have conflicting studies.

The question of coordination between specialized hemispheres in the brain and its relation to anxiety mood disorders and the reaction to anxiety triggers and memory association and processing is, of course, not a simple question. More detailed mapping of the brain in anxiety disorders has shown that the right brain, specifically the right insula cortex, is more active when patients have anxiety triggered by a specific phobia, such as a fear of spiders (PMID: 21132846 - Harvard Medical School, 2010). Increased reactivity and cross-talk between the amygdala and the right insula was also seen in patients with an anxious temperament (PMID: 176267796 - University of California San Diego 2007). The main focal area of the brain in anxiety mood disorders is the amygdala, part of the limbic system, and found deep in the temporal lobes of the cortex of the brain. The amygdala consists of two distinct nuclei, a right brain amygdala and a left brain amygdala, each connected directly to the larger thalamus, which is considered the processing and coordinating area in the brain, especially coordinating between the right and left hemispheres. Scientific studies have found that there is functional specialization that distinguishes the right amygdala from the left amygdala. In one 2007 study, direct electrical stimulation of the right amygdala induced negative emotions, especially related to fear, while the left amygdala stimulation induced both negative emotions and positive ones, such as satisfaction, happiness and a sense of reward, or accomplishment. Such study clearly shows that the tendency to process information and emotional memory more with the right brain would lead to a pattern of negative response, not a balanced, or rational response. By understanding that a cognitive behavioral approach that better utilizes the left brain by taking a step-by-step approach to each day's problems, and improving one's sense of self, as well as translating alarming cues into more objective, defined and nuanced threats, with language, may be very helpful in restoring the proper right-left brain coordination in mood control. Studies also show that specific memories and data input in the brain are processed at different areas of the brain, and a pattern of processing data linked more to memories that trigger alarm results in a poor ability to control negative emotional reactions. Cognitive behavioral awareness and retraining focus should play a major role in reversing anxiety mood disorders within a holistic treatment plan, and increased patient understanding and awareness is the key to this aspect of treatment. The act of gaining objective understanding, and objectively applying this in a proactive manner, also will lead to a feeling of greater self-control and mind-body connection.

These modern studies of the brain with functional MRI and other mapping devices are also revealing concerning emotional states. While modern allopathic medicine has tried to convince us that there must be specific genes, specific neurons, and specific areas of the brain specialized to express specific emotions, the actual study of these connections has revealed that this medical belief is wrong. One of the leading scientists in this realm of study, Dr. Lisa Feldman Barrett, a professor of psychology and the director of the Interdisciplinary Affective Science Laboratory at Northeastern University, of Boston, Massachusetts, U.S.A., associated with the famed Massachusetts General Hospital, has conducted numerous large studies of emotional responses and neurological biology, and has written a book entitled How Emotions Are Made: The New Science of the Mind and Brain. Dr. Feldman Barrett has found that, contrary to standard belief, our emotions are not associated with specific areas of the brain, or even with specific neurotransmitters, as is so often repeated. Emotional responses are tied to core systems, termed affect, conceptualization, language and executive control, that act synergistically in a quantum field, and create a variety of mental states, only some of which we term emotion. Affect is a term used to describe the feeling, tone and mood attached to a thought, including the external expression and manifestation of an emotion. Affect alone cannot define the emotion, though, and systems of standardized measurement of emotion have failed to find consistent and reliable results. Early studies found that the emotional affect excited a broad area of the temporal lobe of the brain, including the amygdala, frontal cortex, and lower medial prefrontal cortex, but a more complex mapping of emotional responses has revealed that these areas are not completely necessary to specific emotional responses. Dr. Feldman Barrett, in an August 2, 2015 article in the New York Times, entitled What Emotions Are (And Aren't), explains that she has virtually divided the brain into small sections in studies, reviewing as many brain imaging studies of emotion that she could find from 1990 to 2011, and found that "no brain region was dedicated to any single emotion". She also found that all of the alleged specialized emotional areas of the brain increased their activity during nonemotional thoughts and actions as well. She demonstrates that studies have shown that certain types of an emotion, such as fear, do not activate the amygdala at all, and a famous study of identical twins, known as BG and AM, who were born without an amygdala, found that BG has difficulty feeling any type of fear, while AM experiences a normal emotional life. Dr. Feldman Barrrett has also found that bodily reactions to specific emotions vary considerably from one individual to the next, and even from one experience to the next. The often repeated beliefs that human emotional states are consistent between individuals, and that specific areas of the brain, specific genes, and specific neurotransmitters are tied to these emotions, promising a simplistic allopathic treatment some day, are false.

Such apriori beliefs shape modern medicine, though. We now believe that specific emotions are tied to specific diseases, such as anger to hypertension and cancer. There is no specific response that we can call anger, though, only a field of responses within a more holistic, or quantum field. What we are learning is that emotions are changing and diverse responses that must be ordered within a field of emotions, memories, and even biochemical and neurohormonal events. Our genetic makeup has evolved ways to achieve this system of order within a complex framework, and this could be called emotional homeostasis. Traditional Chinese Medicine has stated for thousands of years that the goal in therapy should be to individually reassert this emotional balance of checks and controls, always keeping in mind that emotion is a phenomenon that is ever changing, like "wind". When the patient understands this, he or she can work with their physicians and therapists to achieve this restoration of emotional homeostasis, and thus control dysfunctional states of anxiety. The promise that a specific allopathic chemical or treatment, such as laser surgery, or genetic modification, will someday be able to correct emotional imbalances and anxiety disorders is a false promise.

Herbal and Nutrient Remedies tested for treatment of anxiety disorder

Much research has been performed confirming the scientific efficacy of various herbal anxiolytics and nutrient supplements. Other herbal and nutrient remedies involve indirect treatment of the causes of anxiety disorder. While GABA may be synthesized and taken orally, it does not cross the blood brain barrier, and has only an indirect effect on the complex GABA metabolism. Finding the right individualized herbal and nutrient protocol, and taking the right dose, avoiding overstimulation, may be the key to successful treatment. The scientific data accumulating on herbal and nutrient medicine in the treatment of Anxiety Mood Disorders is too large to present here in total, but a few well known herbs and supplements are presented in this section, and links to studies are also presented below in Additional Information.

Patients must be increasingly aware in the United States that a stubborn refusal to adopt international standards of regulation of herbal and nutrient medicines, primarily to delay the advent of professional acceptance once again of the physicians licensed to prescribe this type of medicine, and the competing interests with the pharmaceutical industry and their complex patent system for synthetic chemicals, has led to a very serious problem with herbal and nutrient products bought from an unprofessional source. In 2015, the culmination of this manipulation of the herbal and nutrient industry occurred as the New York State Attorney General's Office announced a cease and desist order against the 4 major drug store chains in the United States for manufacturing and selling herbal and nutrient medicines that were fake. This long investigation, involving nearly 200 randomly selected samples of these products off the drugstore shelves found that nearly 80 percent did not even have DNA evidence of the herbs on the label at all in the product, and that more than a third of the products randomly selected had no DNA evidence of any herbal chemical in them, just inert fillers. Such behavior presents a serious problem for patients trying to restore their health with the aid of these products, and often leads the patient to believe that herbal products just don't work. This is patently untrue, though, as abundant evidence of efficacy, some of which is cited in the section of this article entitled Additional Information and Links to Scientific Studies elucidates.

  • Valerian: In 2002, a double-blinded placebo controlled trial compared valerian with the medication valium, and a placebo. This 4 week study found a comparable effect of valerian extract (valepotriate) to valium, and improvement over placebo, but not enough to be considered statistically significant with the means of measurement. While the published report summarizes that Valerian had not been proven effective, published in the journal Phyotherapy Res. 2002;16:650-654, the whole extact of Valerian was not used, the effect was equal to the proven effective drug Valium, and the effects were greater than the placebo effect, which has always proven effective in studies of patients with anxiety disorder. Understanding how study design and bias often alters the summary findings is important when considering evidence of benefit in these standard studies, and we must sometimes read the details to discover the truth. Clinical use of Valerian extract has demonstrated that quality valerian extract in the proper dosage (low and variable with each patient), and combined with other herbs containing magnesium and various chemicals, is indeed effective for most patients, and has been one of the most popular herbal extracts used in this regards.
  • Kava: In 1990, the German Commission E, a government health institute, authorized the medicinal use of Kava extract for relieving states of nervous anxiety, tension and agitation, based on several double-blind studies. After this, a large amount of money and time was spent publishing reports of potential harmful interaction of certain chemicals in kava with various pharmaceuticals, because of competition at liver sites of enzymatic breakdown of the chemicals. This prompted a temporary ban of the sale of kava in a number of countries, but not the U.S., despite the lack of clinical evidence of harm. Subsequent studies have proved that a low dose of kava will not significantly alter the circulating dosage of any pharmaceutical drug, although these studies did reveal that many pharmaceuticals may have a harmful interaction and competition with liver catabolism and significantly alter the circulating levels of many drugs. Potentially harmful drug interactions are still largely ignored by prescribing physicians, yet use of such harmless herbs as kava and St. Johns Wort are still getting severe warnings from many medical doctors despite contrary evidence to date. To date, there is no evidence of clinical harm or negative herb-drug interaction with Kava. Subsequent studies and published reports of potential liver damage also were investigated and showed no evidence of truth either. One clinical incidence was deemed possible when long-term kava use was implicated in liver damage, but this isolated case seems implausible, as kava was consumed by millions of patients at the height of its popularity, with no other reports of potential liver damage have been found. Guidelines in herbal medicine also specify that Kava extracts should be taken in low dose and for relatively short periods of time, or as needed. Kava Kava root extract is proven very safe and effective, although clinically there are a variety of patient responses to kava. Some patients respond with low dose, and high dose will have an adverse effect on anxiety, some patients will respond immediately, and others note a positive effects after a few weeks of treatment. The dosage and length of treatment should be adjusted as therapy proceeds by a physician herbalist, optimally. Generally, starting with a low dose, and increasing until a therapeutic level is found is the best approach. Long-term continuous use is not recommended, and resolution of the Anxiety Mood Disorder, not just symptom management, is the goal in Complementary Medicine. Quality of the herbal product is also a problem in numerous studies of herbal quality. Be sure to purchase a professional product that can be trusted, as FDA quality regulation is almost nonexistent.
  • California poppy flower: Many studies have demonstrated significant anxiolytic benefit from California poppy extract, and finally, one French study, cited below, showed undisputed fact of beneficial effects when combined with Hawthorn flower extract and magnesium. In clinical practice, California poppy is the most popular of the anxiolytic herbal extacts. Quality is a problem with any flower extract, though. The flowers must be picked at the right time and immediately placed in alcohol. Professional product is highly recommended for best effect. The extract is extremely safe.
  • Lemonbalm, skullcap, verbena, and passionflower extracts: These have all been subjected to clinical trials and studies with positive results. Clinically, the effects have been less significant than Magnolia, Valerian, Kava and California poppy extracts. Each patient may have a different response though, and a formula combination could be tried and adjusted for maximum effect.
  • Choline and Inositol: inositol has been shown in clinical studies to be as effective or more effective than SSRIs for the treatment of obsessive compulsive disorder, and numerous studies now show that high dosage supplementation (e.g. 12 grams daily) of inositol has significant beneficial effects in the adjunct treatment of Major Depressive Disorder, Bipolar Disorder, Panic Disorder, and agoraphobia as well. Patients diagnosed with clinical depression generally have been found to have decreased levels of inositol in their cerebrospinal fluid. Choline is an essential nutrient that is useful in the brain for structural cell integrity, signaling roles in cell membranes, acetylcholine neurotransmission, and as a major source of methyl groups. Deficiency of choline has been linked to anxiety symptoms, but not to depressive symptoms. A percentage of the population has been found to exhibit choline deficiency despite adequate dietary intake. Lecithin is a type of choline, and the active lecithin metabolite, phosphatidylcholine is perhaps a better supplement for cell membrane integrity. Choline may also contribute to neural detoxification and reduction of homocysteine levels. There are 9 known stereoisomers of inositol, and a number of these are now touted as supplements in medical treatment. Inositol functions in the brain as an aid to cellular signaling and cellular processes (secondary messengers). A number of brain functions depend on inositol metabolites, including serotonin activity modulation, nerve guidance with epsin proteins, cell membrane potential maintenance, calcium concentration regulation, and insulin signal transduction (insulin has been shown to be produced by brain cells as well as pancreatic cells, and plays essential roles in brain function). Inositol is an essential component of Coenzyme A, one of the most important metabolic aids in our bodies. Both inositol and choline are synthesized by symbiotic bacteria in the gut, and problems with gut microbial health is potentially one of the contributing causes of deficiency. Some signs of inositol general deficiency include mood swings, irritability, constipation, hair loss, and high cholesterol. Food sources of inositol include buckwheat, lentils, sesame seeds, coconut, peas, brewer's yeast, unrefined molasses, raisins, and many fruits and vegetables. Food sources of choline include eggs, whole grains, legumes, soy, and whole milk. A typical supplement dosage is 650mg, and a 12 gram dosage would require about 16 capsules a day. Studies of high dosage inositol showed no adverse effects. Inositol hexanicotinate is a form of Niacin, or Vitamin B3, which is now widely used in nutrient medicine as well. CDP Choline is a supplement (Cytidine Diphosphate Choline) that is an active choline metabolite found to restore the levels of phophatidylserine, phsophatydilcholine, and sphingomyelin in the brain, as well as improve acetycholine, dopamine and norepinephrine production in the brain. RECOMMENDED: high dosage of Inositol and normal dosage of CDP Choline (Vitamin Research Products: Inositol 650 mg 4-16 capsules per day with meals (increase the dosage slowly and then taper the reduction of dose), and CDP Choline 250 mg, until symptoms improve, then maintenance with Phosphatidylserine 100 Plus).
  • GABA-ergic herbal and nutrient protocols: Since GABA is a molecule that acts as a modulating neurotransmitter in the brain, insuring bioavailability of GABA may be a productive therapeutic goal with Anxiety Mood Disorders, especially if the episodes of anxiety occur suddenly and without a strong trigger. Gamma-Aminobutyric Acid (GABA) was first synthesized in 1883, but it was not thought to be part of the human metabolism until 1950. Numerous studies have shown how GABA in circulation does not cross the blood brain barrier, a necessary mechanism as GABA also acts to regulate muscle tone, and performs integral functions in many organs, and since GABA is thought to be the main neurotransmitter regulating excitability in the brain, circulating GABA would have a potentially negative effect if it was allowed to freely cross into the brain. In the brain, a complex feedback quantum metabolic system is associated with GABA, with at least 2 types of GABA receptors, and metabolism of GABA within the neurons. GABA has been found to be synthesized from glutamate, regulated by the enzyme L-glutamic acid decarboxylase and P5P (pyridoxal phosphate), a form of Vitamin B6. GABA is converted to glutamate in the neuron as needed, and glutamate is converted to glutamine, which may be converted back to glutamate, to supply GABA as needed. GABA may act on the neuron producing it, and on other nearby neurons. This metabolism is dependent on the mitochondrial energy system, the maintenance of the right number of GABA producing cells, the expression of GABA receptors, bioavailability of metabolic cofactors, and effects on the GABA receptors by other inhibitory or exciting chemicals and receptors. To completely control this GABA metabolism is not possible, but to provide for bioavailability of this metabolism to maintain homeostasis is indeed possible. The basic components in this treatment protocol would be L-glutamine, P5P and inositol hexacotinate, although B12 and a magnesium/potassium supplement may help as well. GABA-ergic drugs are highly utilized now in standard medicine, but often produce alarming and erratic side effects. The study of herbal chemicals has revealed some beneficial mechanisms without side effects. For instance, in 2012, researchers at the Chinese University of Hong Kong found that a chemical in Hypericum Perforatum, or St. John's Wort, the flavonoid myricetin, modulates the activity of the GABA receptor type A through activation of calcium channels and calmodulin kinase 2 pathway. The U.S. National Institutes of Health acknowledge that at least 29 scientific studies show that this herbal extract, used for centuries in various countries to treat depression, does indeed work, and this 2012 study shows that one of the effects of St. John's Wort is modulation of the GABA receptor type A. Hypericum is only one of many herbs studied in the last 2 decades for GABA-ergic and GABA-modulating effects, though, and as these studies proceed to human clinical trials, it is believed that we will arrive at proven herbal formulas that affect this metabolic pathway beneficially that can be safely integrated into standard care. In 2012, a study at the University of South Carolina found that herbal chemicals in medicinal magnolia (Hou Pou), magnolol and honokiol, are shown to also modulate the GABA type A receptor and enhance their biological effects (PMID: 22445602).

Treatment of Post Traumatic Stress Disorder (PTSD) integrating Complementary Medicine

In 2012, the United States Department of Veteran Affairs, and the National Center for PTSD at the VA Medical Center in White River Junction, Vermont, fully endorsed Complementary and Integrative Medicine for treatment of PTSD in the publication PTSD Research Quarterly (2012; Vol 23 (2): 1050-1835). Dr. Jennifer L. Strauss of Duke University and Dr. Ariel J. Lang of the University of California San Diego outlined how Complementary and Integrative Medicine overlapped with conventional therapies in ways that expanded the "toolkit" of therapies that are needed to really treat PTSD. The National Center for Complementary and Alternative Medicine (NCCAM) outlined 5 categories of therapy in CAM, 1) herbal nutrient medicines, 2) mind-body medicine in the form of acupuncture, yoga and meditation, 3) manipulative physiotherapies such as Tui na and chiropractry, 4) energy and movement therapies, such as Qi Gong and Tai Chi, and 5) holistic medicine systems such as TCM (Traditional Chinese Medicine) and Ayurvedic medicine. The authors at the VA stated that while herbal nutrient medicine and holistic medicine fall outside of the normal area of expertise in standard psychotherapy, areas the overlap with CIM include breathing exercises and muscle control (neuromuscular reeducation), stress inoculation training and mind-body stress management techniques, mindfulness and other cognitive and behavioral interventions that are not dissimilar to Complementary and Integrative Medicine.

The report outlined how nearly 40 percent of patients with PTSD report use of CIM to address mental health concerns, with mind-body medicines such as acupuncture, yoga and meditation the most frequently reported and used. The authors noted that a review of such therapies in 2010 could only cite 7 small studies with randomized controlled human clinical trials, though, and a need for more funding of such treatment was needed. These studies, though, demonstrated efficacy and safety of acupuncture for PTSD, although the problem of full control of study parameters in the form of blinded needle stimulation at sham acupuncture sites was not performed, and thus not completely ruling out placebo effects, as the controls in the studies were standard group therapy compared to acupuncture with outcome measures immediately after a short course of therapy of 24 sessions in 12 weeks, and a 24-month follow-up. Other studies noted significant benefits from meditation, mindfulness techniques such as yoga, and insufficient proof of benefit of relaxation techniques. As usual in standard medicine, the authors stated that while Complementary and Integrative Medicine was popular and proven to work in randomized controlled human clinical trials, the evidence was not strong enough because there has not been much funding for, or publication of such studies, and that while there is proof of efficacy, these techniques cannot be recommended as an alternative to standard care. Once again, doctors involved in standard medicine missed the point, namely that Complementary Medicine such as TCM is meant to be integrated as a specialty with standard medicine, not promoted as an "alternative", and the study design of randomized controlled human clinical trials designed for pill placebos in pharmaceutical medicine are inappropriate for manual medicines such as acupuncture, where a fake needling cannot realistically be accomplished. One cannot stick someone with a placebo needle and have them blinded to whether this was a real or fake acupuncture needling. This type of intrinsic bias may never cease in standard medicine, it is now so ingrained. The good thing is that even the U.S. Military is now acknowledging that TCM therapies work and can be integrated into the treatment protocol, and obviously there is the need. It is too bad that there is still such a bias against the herbal nutrient medicine and holistic approaches. It seems that after 40 years of interaction, that standard physicians could actually understand these modalities, and review the enormous amount of research, to find a place in the integrative treatment protocol for these modalities.

By 2014, the VA Medical Center at White River Junction, Vermont, reported that yoga, acupuncture, hypnosis, meditation and recreational therapies were routinely provided to patients with PTSD, and now were offered elsewhere in the VA system. These Complementary and Integrative treatments were working well with standard practice, which consisted mainly of 2 forms of psychotherapy and pharmaceutical medication. The 2 distinct types of psychotherapy are cognitive processing and prolonged exposure. Currently, the latter is emphasized more, but questions about the real efficacy of the protocol are emerging as more and more patients complain of adverse effects. In prolonged exposure, the trauma is repeatedly remembered in detail so that the brain can reorganize the memory of the event. The reported efficacy of 85 percent, though, is partly due to the high dropout rate among patients, who complain of worsening PTSD, leaving the remaining 70 percent of patients with some improvement reported in 85 percent. Cognitive processing involves group discussion of traumatic experiences without reliving them to examine thoughts and feelings related to the experiences. It is no wonder that integration of Complementary Medicine into these prolonged treatment protocols has become popular, alleviating much of the stress of dealing with the cognitive aspects of the traumatic memories and changing reactive behavior in a mindful way.