Functional Medicine Approach to Generalized Anxiety Disorder: A Case Study

Generalized anxiety disorder (GAD) can occur at any age. The condition has symptoms similar to panic disorder, obsessive-compulsive disorder, and other types of anxiety. A Functional Medicine Approach to Generalized Anxiety Disorder focuses on the root cause and can be used alongside conventional treatments for a comprehensive approach. Below is an excellent example of one patient's integrative healthcare journey with GAD.  

CC: Generalized Anxiety Disorder

Libby* was a 30-year-old cis female who presented to our clinic looking for natural options to manage generalized anxiety disorder (GAD). Libby had some classic symptoms that people with GAD experience, including

• "Excessive worry about everyday things
• Knowing that they worry much more than they should
• Trouble controlling worries or feelings of nervousness
• Feeling restless / having trouble relaxing
• Having a hard time concentrating
• Startling easily
• Feeling tired all the time
• Having headaches, muscle aches, stomachaches, or unexplained pains for no known medical reason
• Feeling irritable or "on edge"
• Sweating a lot, feeling lightheaded, or feeling out of breath
• Having to go to the bathroom frequently"

Libby noticed that her anxiety affected her most at work and when she was out. She would be sitting and working, trying to talk to someone, or leading a group when suddenly she would feel "odd."

She described that it felt hard to breathe or think during these episodes. She experienced brain "zaps," or the sensation of an electrical spark in her head. She would also feel panicked - looking to get outside as quickly as possible.

Libby also experienced generalized anxiety about her health in particular. She had been to the doctor's enough to know that nothing was wrong with her heart, but she still quite often felt chest pain and palpitations that made her wonder if she should seek urgent care. Her EKG and workup were normal each time she went to the doctor, and she'd be sent home with instructions to manage her anxiety. She wanted to get back to living her life without feeling worried about her body sensations or future events.

Patient Background

Libby did important work in the world - she was a marine biologist and enjoyed a wide variety of activities that ranged from educating the public to helping baby sea turtles make it back to the ocean after they hatched.

She'd worked hard to create the life and career she wanted, but she wasn't experiencing the complete joy she could have had because of her anxiety symptoms.

In addition to her anxiety, Libby was also experiencing frequent allergy symptoms, including postnasal drip, rashes, and brain fog during high pollen days.

She had bladder issues, frequent urination, and yeast infections.

Libby also had intense fatigue and occasional hypotensive episodes during the luteal phase of her cycle that often interrupted her workouts, work, and social life.

Finally, Libby's bloating after meals made her uncomfortable and interfered with her ability to fit in her clothes like she wanted to.

She was worried that her symptoms would interfere with her upcoming wedding and even worried that she wouldn't be able to make it down the aisle due to a panic attack.

Our plan for Libby was to craft an easy-to-do, natural medicine recovery protocol that would allow her to identify and heal the root causes of her anxiety, manage them, and eliminate them moving forward so that she could thrive.

Nutrient Analysis

Libby's nutrient analysis revealed that she tended to consume a diet low in vitamins D and E.  

Vitamin D supplementation improves outcomes in GAD, so we always check to make sure our clients are getting optimal levels of this nutrient.

Vitamin E is a powerful antioxidant that helps decrease oxidative stress in the brain and body, which is associated with anxious behavior and panic in the medical literature.

Additionally, Libby didn't routinely consume enough minerals zinc, calcium, iron, magnesium, sodium, or potassium.

Zinc is a critical mineral for hundreds of reactions in the body, and serum zinc levels are commonly low in people with anxiety disorders.

Magnesium supplementation is linked with improved outcomes in anxiety.

Iron deficiency anemia is linked with GAD and its symptoms.

Libby also under-consumed total energy (calories), carbohydrates, fats, and proteins and waited several hours to eat after waking up in the morning. This eating pattern can often result in hypoglycemic events, fatigue, and mood and cognitive issues.

Libby also tended to consume high-fodmap foods and was eating fruits, meats, and dairy products at most meals, which can cause gastric upset in some people.

Laboratory Workup Ordered At Initial Visit

Lab Analysis

Normal TSH, CBC, CMP, Iron Panel

It's good medicine to rule out causes of anxiety disorders like thyroid disorders, anemias, and endocrine issues. Libby's lab work revealed that she had healthy thyroid function, adequate iron levels, and no anemias. This was great news! It meant we could optimize the other aspects of her health.

When I began to work with Libby, it was the middle of the 2020 COVID-19 pandemic, and the ability to get labs drawn at a typical Labcorp or Quest was limited. Thankfully, we were able to use a collect-at-home blood spot kit to give us an idea of her micronutrient status. This yielded an abundance of results, including those listed above.

Low Manganese

Most studies involving manganese focus on manganese toxicity. However, there is some evidence that inadequate manganese intake is associated with increased pain and mood instability premenstrually - a symptom Libby reported.

Low Chromium

In some studies, it's been shown to improve anxious behaviors in mice. Since Libby reported anxiety that occasionally was worse when she hadn't eaten in a while, we made sure to build her a program that ensured she got 100% of the chromium she needed every day to avoid the possibility of a chromium deficiency playing a role in her symptoms.

Low Copper / Zinc Ratio

Copper is involved in antioxidant production and neurohormone production, both of which are involved in the pathogenesis of anxiety. Copper and zinc compete for absorption, and excessive levels of one can lead to a functional deficiency of the other. The low copper/zinc ratio alerts us to the need to be careful with zinc supplementation and ensure adequate copper consumption when building a food-as-medicine plan.

Interventions

To help Libby heal, we did the following:

Nutrition

My team and I worked with Libby to create a customized food-as-medicine meal plan that allowed her to swap out high histamine, high glycemic foods for high protein, low histamine, whole foods that provided her vitamins, minerals, fiber, and omega 3's, which are associated with improved outcomes in anxiety. We also made the following key changes:

• Eliminated caffeine and swapped morning coffee for decaf
• She swapped regular wine for sulfate-free and organic wines when possible for the first phase of her plan. As her wedding got closer and she wanted more control of her symptoms, we had her eliminate alcohol for two weeks.
• Had Libby eat within 30 minutes of waking up to avoid morning hypoglycemia. We also designed a food-as-medicine menu that included meals and snacks staggered no more than 3 hours apart to prevent blood sugar fluctuations from impacting her mood and energy levels.
• Increased hydration to 96 ounces, given her high energy expenditure in the heat. We had her include trace mineral drops in her hydration agents.
• Emphasized low FODMAP foods and educated Libby about proper food combining to avoid gas, bloating, and other GI symptoms.

Supplements

• Inositol powder as needed for panic and tonically throughout the day not to exceed 4000mg per day. Inositol is a glucose isomer that is typically used to help restore insulin sensitivity and improve PCOS symptoms. Clinically I have also found that it's incredibly helpful to people who have panic attacks in bolus doses before anxiety-producing events.
• Comprehensive once daily multivitamin to serve as nutritional insurance so that Libby could stay flexible with her diet and lifestyle but still meet her goals. The vitamin recommended contains vitamins A-K, biotin, choline, iodine, zinc, selenium, manganese, chromium, molybdenum, boron, inositol, CoQ10, Alpha lipoic acid, lutein, zeaxanthin, lycopene. We also added iron and vitamin D supplements to ensure that her vitamin supplementation was complete.
• Omega 3's 2000mg per day in pill form, given the evidence that this level of supplementation can help improve anxiety.
• Gaba Ease: This product contains passionflower, hops, skullcap, l-theanine, GABA, and vitamin B6. It helps promote sleep and decreases anxiety. I had Libby take this at night to avoid sedation during the day and promote restful sleep.
• Licorice root tea: 1 cup in the mornings to help prevent hypotensive episodes during the day.
• Several months into this program, Libby's bloating was still an issue, so we tried a round of antimicrobial herbs that often help with SIBO. One month of this protocol decreased Libby's symptoms, and she was able to discontinue them without symptoms.
• Glutashield: a glutamine and demulcent herbal product each night designed to heal leaky gut and address symptoms of the irritable bladder.

Mindfulness

• We had Libby practice autogenics meditation for at least 10 minutes per day for the first six months of this program. For the second 6 months, we had Libby practice resonant frequency breathing (6 breaths per minute: 5 seconds in and 5 seconds out) for 20 minutes twice per day. Libby also found the phrase, "I am capable of tolerating discomfort," to be a ground mantra, so we had her use this during meditation for a few minutes each day.

Follow Up Nutrient Analysis

Nutrient Analysis After Individualized Program

Libby's individualized nutrition plan was designed to be healthy, easy to cook, and fun to eat. It was also designed to correct her inadequate intake of vitamins D and E, protein, fiber, and minerals.

The nutrient analysis below reveals that she has met >100% RDI for these nutrients each day on average for the past six months.

Additionally, she now consumes enough zinc and iron and eats every 3 hours. Our current work for Libby is now centered on optimizing calcium, potassium, and omega 3 intake.

Results from a Functional Medicine Treatment Program

Libby's Results from a Functional Medicine Treatment Program

Libby's anxiety symptoms greatly improved within six months of this protocol. She enjoyed her wedding day without excess anxiety or issues walking down the aisle. She no longer experiences frequent worries about her health or the anxiety episodes that used to make her seek urgent medical care.

Her yeast infection symptoms, frequent urination, hypotension, brain zaps, and fatigue are gone. Libby uses inositol episodically when she feels stressed and is afraid that this might cause symptoms. She feels empowered with her supplements, breathwork, and mindfulness tools to manage anxiety if it comes.

Summary

You can heal and prevent generalized anxiety by treating the whole person. In this case, Libby used a combination of a food-as-medicine plan, good nutrition, and supplementation protocol helped to improve her symptoms and give her much more control over her life and mood. She's now panic-attack free and experiences less anxiety. We hope her story inspires you to know that you and your loved ones can heal anxiety, too!

*Note: The clients' name has been changed to protect her privacy. All other details are the same.

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