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Depression and Panic Attacks

Case Background Summary

49 year old female with complaints of depression. Suffered a major loss with the death of a close loved one two years ago and has had trouble coping with life since then. She was put on a SSRI antidepressant to assist which she is not taking regularly.

Panic attacks are another presenting complaint, these attacks occur randomly and she experiences 2-3 attacks per week. The attacks started when she was 21 with palpitations and shortness of breath being chief symptoms when she is having an attack. She also sweats profusely and cant has to sit down when a panic attack occurs. The attacks last for 5-10 minutes with pain and twitching in her leg muscles and feels the attacks are stress related.

At night, she often feels her heart beating rapidly and this makes her feel nervous and often prevents her from having a good night’s sleep. She often feels like she doesn’t get enough air; generally she also sweats a great deal and has to sit down as her legs won’t hold her up.

Since the loss of her close family member, she has withdrawn from social activities, including spending time with her husband and now spends most of her time indoors watching television. She has lost motivation for normal daily activities such as cooking and shopping. She often misses meals or just snacks on toast and jam, breakfast cereals and processed snack foods. Dinner is often a take-away which her husband picks up on the way home from work.

Treatment Evaluation

The client is suffering from a number of nervous system issues. The depression started around the time of the loss of her family member and this event seems to be an obvious trigger for this however she has been suffering panic attacks for most of her life indicating a very long standing nervous system complication.

Depression is a disorder that is characterised by a sadness that is severe and persistent enough to interfere with function and often by decreased interest of pleasure in activities. There are a number of signs and symptoms that can be common with depression, these can be categorised under the following headings;

Many people have the feelings and behaviours in the above table from time to time however depression is diagnosed when these feelings and behaviours have been going on for a number of weeks and disrupting life. The client has noticeably withdrawn herself and has lost motivation for general life activities and socialisation.

It is common for other disorders to coexist with depression, panic and anxiety disorders are a common condition that coexists with depression. The client’s anxiety and panic attacks are regular and quite severe, Common symptoms of anxiety and panic attacks include;

• Shortness of breath
• Palpitations
• Excessive sweating
• Chest pain
• Dizziness
• Numbness of face and/or extremities
• Fear of dying

Panic attacks start suddenly and unpredictably, the cause of anxiety disorders and panic attacks is not well understood. Traumatic life events, personality traits and medication can be contributing factors. Over stimulation of the hypothalamus-pituitary-adrenal (HPA) axis is thought to be involved with increased cortisol, adrenaline, noradrenaline and dopamine output.

The client’s diet is very poor with skipped meals, multiple processed food snacks and many takeaways. A diet that is deficient in key nutrients, notably essential vitamins and minerals and omega 3 fatty acids can contribute to the effects of depression, anxiety and panic disorders.

The prescription drug Zoloft that the client is taking is a selective serotonin reuptake inhibitor (SSRI) that is commonly prescribed to treat depression and panic and anxiety disorders. The effectiveness of this drug may be hard to measure with the client as she often forgets to take it. There are a number of side effects attributed to this drug, these include fatigue, dizziness, insomnia, dyspepsia and nausea. Some of these symptoms the client is currently experiencing. The client indicated she would like to come off this medication, this needs to be done in conjunction with the prescribing doctor if it is not benefitting her, particularly as she is not taking it regularly.

Treatment Protocol

As there are often a number of contributing factors that affect depression, anxiety and panic disorders, a multifaceted treatment approach is required. With regards to a naturopathic framework, brain function can be affected by a range of factors including hormone balance, digestion, insulin levels, liver function, infection, gut health, inflammation and diet.

Diet

The client’s diet is very poor and requires much attention. Assistance was sought from the husband in this area to assist with the organisation of meals and to stop enabling the consistent takeaway consumption. He was more than happy to assist. A whole food, Mediterranean based diet that is balanced with complex carbohydrates, adequate lean protein and healthy fat that promotes blood sugar regulation is beneficial. There are numerous studies supporting this including a study involving over 10,000 Spanish adults that showed a lower incidence of depression is those consuming a Mediterranean diet when compared to a more heavily processed food diet.

Tryptophan à 5HTP

Tryptophan is an essential amino acid that is used in the biosynthesis of proteins. Tryptophan is required in the synthesis of serotonin, a neurotransmitter associated with mood improvement. Tryptophan converts to 5HTP in the body, naturally increasing levels of serotonin in the brain. Foods high in tryptophan include pumpkin seeds, cheese, turkey, lamb, beef, tuna, oats and egg white and are to be increased in the client’s diet. Foods that deplete or block serotonin in the body include sugars and refined carbohydrates and food additives, these should be avoided. Tryptophan has also been linked to improving sleep duration and quality. A number of studies have been performed with increasing the consumption of tryptophan. Results showed an improved quality of sleep, decrease in the time taken to fall asleep and a decrease in total wakefulness. The studies also found that the patients were more alert and clearer upon waking in the morning.

GABA

GABA is a neurotransmitter responsible for calming and can assist greatly with anxiety, panic attacks, poor sleep and stress in general. GABA works by inhibiting nerve transmission in the brain, therefore exhibiting a calming effect.

Activated B Vitamins

A quality B complex including activated B6, B9 (folate) and B12 would be of great benefit. B vitamins are required for the synthesis of neurotransmitters such as serotonin and dopamine and help support the body when under stress. B vitamins work together synergistically so it is advisable to always take a B complex by itself or in addition to single B formulas. Activated B vitamins are readily available to the body when consumed and can assist in clients that are not converting the vitamins, or methylating the vitamins effectively, therefore increasing the bioavailability of the vitamin to the client. Clients with methylation issues, COMT polymorphisms or other neurotransmitter related snps will need special consideration here. See my other articles on the different types of folate and various snp polymorphisms. (link to MTHFR specialty page)

Vitamin B6 is a cofactor in the tryptophan-serotonin pathway and may have a positive influence on depression. A study on 869 individuals assessing activated B6 blood levels, pyridoxyl-5-phospate (P5P), found that low plasma levels of P5P below 20nmol/L doubled the likelihood of depressive symptoms.

Folate is another major B vitamin that has been found to be effective in the management of depression. Folate is required for the synthesis of noradrenaline, dopamine and serotonin. Studies show that low plasma or serum folate is linked to patients with depression, alcohol disorders, and other mood disorders. Folate has been used in the form or calcium folinate or methylfolate (5MTHF) to assist in the treatment of depression. Studies have shown that it appears to enhance the effect of SSRI’s and to assist in reducing the symptoms of depression. Folic acid is he synthetic form of folate and should generally be avoided.

Magnesium and Zinc

Magnesium is required for a range of cellular functions including supporting the regulation of neurotransmitters. It is required for energy production and is often burned up quickly in stressed and anxious people. Zinc is an essential nutrient that is part of many enzyme reactions in the body and brain. A study that gave 25mg of zinc as an adjunct treatment with an antidepressant found that depressive symptoms were reduced significantly vs placebo suggesting zinc plays a role in the reduction of depressive symptoms.

Omega 3

Omega 3 fatty acids are required by the brain both functionally and structurally. A systematic review conducted in 2010 found that levels of DHA and EPA were found to be significantly lower in depressed patients. DHA appears to be associated with serotonin and dopamine transmissions and EPA is understood to produce antidepressant effects through antagonising arachidonic acid and reducing prostaglandin E2, stabilising neuronal function.

Chromium

Chromium is another supplement that is well regarded for assisting with blood sugar stabilisation. Low levels of chromium can contribute toward blood sugar instability, a common occurrence in depressed individuals. Regulating blood sugar can assist in balancing mood, sweet cravings and control appetite.

Probiotics

Probiotics have long been used to treat digestive issues, however there is evidence to suggest they have a role in mental illness. Stress influences the gut microbiota balance and several studies and reviews suggest that alterations in the microbiota modulate plasticity related serotonergic and GABAergic signalling systems in the central nervous system. The positive alteration of the gut microbiota may play a large role in the influence on positive mood and the reduction of depression and anxiety related symptoms.

Herbal Medicine

Herbal medicine also played a vital part in this case. Chief actions sought included nervines, tonics, adaptogens, mild sedatives, anti-depressants and antioxidants.

Exercise

The link between mood and exercise is well researched and strong. Exercise assists in the release or endorphins and fires up neurotransmitters, improving mood. Exercise has been shown to assist with the reduction of depression and anxiety symptoms and should be included in and plan to combat there illnesses. In addition, calming exercise such as tai chi or meditation is recommended.

Homeopathy

Homoeopathically, for this case I prescribed Nat Mur at a 200C potency. Nat Mur is indicated for sadness after the death of a loved one with particular mention of silent grieving, being alone and loss of interest in life.

Prescription

Outcome

After 4 weeks of the modified diet and lifestyle, nutritional supplements, targeted herbal medicine and homeopathic, the clients symptoms had improved a lot with the panic attacks ceasing, some anxiety was still being experienced but much less. Overall mood had increased with the client reporting that she “felt a big improvement and feel I am able to do things and no longer stuck with a dark cloud over my head”. Additional testing was requested to assess thyroid function, heavy metal accumulation and methylation status.

***This case and dosages prescribed were specific to the individual and presenting condition, this protocol may not suit everyone with these symptoms. A consultation with a suitably qualified practitioner should be undertaken before commencing any treatment ***

Irritable Bowel Syndrome (IBS)

Background

49 year old married woman with three children, aged 15, 13 and 7. Client performs home duties and presented with gastritis, IBS and fibromyalgia. She has previously sought advice from a GP and been trying a low FODMAP diet for IBS and takes pantoprazole for her gastritis and Vitamin D for the past 4-5 years. Neither of these two approaches have provided much relief for her, the FODMAP diet reduces symptoms some but not significantly. The client undertakes walking and Pilates, sometimes the gym as part of her exercise routine, undertaking these activities 2.5 times per week on average.

Gastritis – Presents with sharp pains, acid reflux after meals, common triggers are coffee, onions, alcohol, garlic. Present for the past 18 months.

IBS – presents with regular bloating, stomach pain, daily fluctuations of diarrhoea and constipation, up to 5 bowel movements daily. Average is 2-3 times daily, stools are commonly on the soft and loose side and a darker brown colour.

Fibromyalgia – aches and pains in ankle, tennis elbow, some flare-ups, started around 18 months ago, primary issues are the gastritis and IBS.

Current Diet

Breakfast – banana smoothie with milk and oats

Lunch – soup with sour dough bread and cheese

Afternoon Tea – Fruit

Dinner – Meat and vegetables or meat and salad

Client would on average eat 2 serves of fruit, 2 serves of vegetables, ½ cup muesli, 2-3 serves of milk and dairy and uses olive oil and butter, prepares most of her meals at home and bakes and steams her food with 50% cooked and 50% raw.

Treatment Plan

• Avoid common symptom triggers of IBS (all dairy and gluten) ie milk, cheese, bread, flour, oats etc. for a three month period.
• Minimise pro-inflammatory foods (sugar, refined carbs, trans-fats, excess red meat.
• ncrease anti-inflammatory foods (small oily fish, berries, turmeric, ginger).
• Use of targeted herbal teas such as ginger, turmeric, peppermint
• Stress reduction techniques.
• Switch to non-dairy alternatives – examples provided such as coconut yoghurt.

Prescription

High Strength Fish Oil – inflammation

Glutamine – gut repair

Magnesium – spasms, enzyme reactions

Specific Probiotics – microbiota balance

Custom herbal formula – addressing reflux, inflammation, gastrointestinal health, reducing spasms and GIT protection.

Follow Up

Client reported in for her follow up visit on the four weeks later looking more relaxed, refreshed and a few kilograms lighter. She could not believe how well that she felt and hadn’t felt this good in years. The diet protocol was followed closely along with the lifestyle changes and supplement and herbal routine.

The exclusion of gluten and dairy from the diet enabled the triggers to be removed and the inflamed and damaged GIT time to heal. The supplements and herbal medicine were targeted at gut and mucous repair and balancing the gut microbiota. The client also reported less aches and pains.

Despite the marked improvement, the client reported that, she still did still mildly suffer some gastritis on occasion. Some further diet, herbal and supplementation changes were made with the client coming back a further 4 weeks later, completely symptom free.

***This case and dosages prescribed were specific to the individual and presenting condition, this protocol may not suit everyone with these symptoms. A consultation with a suitably qualified practitioner should be undertaken before commencing any treatment ***

Diabetes

Case Background

46 year old obese male presenting with diabetic symptoms. Current symptoms are increased thirst, increased hunger and increased urination. His vision has also been getting increasingly blurry.

Diet is heavy in refined foods and animal products with his favourite foods being pasta and white bread. A couple of beers are consumed most nights and he drinks three to four cups of coffee per day. Afternoon sluggishness and headaches are common, coffee helps alleviate this. He is constantly hungry and snacks on sugary and fatty food such as biscuits and chips.

There are spider nevi on his face, is sweaty and is uncomfortable sitting in the chair. The client mentions that lately he has been moody and losing his temper quite easily at trivial things. His wound healing and recovery from illness has also been slow.

Treatment Evaluation

Diabetes type 2 is a progressive condition where the body becomes resistant to insulin and insulin production in the pancreas is reduced. Key symptoms of diabetes type 2 include

• Infections that take a long time to heal
• Fatigue
• Increased thirst and hunger
• Blurred vision
• Increased urination
• Pain or numbness in hands or feet
• Erectile dysfunction

There are a number of diet and lifestyle factors that contribute toward the onset of type 2 diabetes, these include

• Excess weight and obesity
• Diet high in refined foods, sugars and fat, particularly trans fat
• Stress
• Alcohol consumption
• Low levels of physical activity

The client’s diet and lifestyle are clearly contributing majorly towards his current symptom picture, he has most of the key diabetic symptoms and also exhibits most of the dietary and lifestyle risk factors. A total overhaul of the client’s diet and lifestyle would be required.

The client also is showing signs of liver insufficiency. Excess sweating, fatigue and spider nevus are all key indicators of a liver under stress. In addition, excess weight, alcohol consumption, high fat intake, excess coffee consumption and prolonged raised blood glucose levels would all be further stressing the liver. A referral to a GP is recommended to undertake a liver function test as there could be a possibility of non-alcoholic fatty liver disease (NAFLD).

Being uncomfortable sitting and crossing and uncrossing legs constantly may be a sign of poor circulation, another common side effect of diabetes. Diabetes can cause plaque to build up in the blood vessels restricting blood flow. Stress, irritability and emotional outbursts can also be contributed to by an unstable blood sugar level.

Treatment Protocol

Diet

Diet and lifestyle is a major focus in this case with a low glycaemic load (GL) diet being a key objective. A low GL diet involves the elimination of sugars, refined carbohydrates, alcohol and fruit juice from the diet. Grains, starchy vegetables, dried fruits and fruit in general should be limited. Dietary intake will focus on whole foods, high in fibre including adequate protein and healthy fats at each meal. Adequate protein needs to be a minimum 0.8g/kg of body weight with studies suggesting a higher level of protein of around 1.5g/kg being beneficial in assisting stabilising blood sugar, promoting weight loss and lowering cardiovascular risk. Healthy Fats such as extra virgin olive oil, oily fish, avocado, nuts and seeds etc. are also encouraged while eliminating trans-fats and minimising saturated fats.

Foods high in chromium, magnesium and Omega 3 fatty acids should be included. High Chromium foods include liver, fish, vegetables and whole grains. Chromium is required for the uptake of insulin into the cells and strengthens the action of insulin. Studies show improved blood glucose and lipid profiles with supplementation of chromium in type 2 diabetic patients.

Magnesium

Magnesium deficiency has also been associated with poor glycaemic control and impaired insulin secretion and function. Magnesium has many actions in the body including energy production, insulin signalling, fatty acid synthesis and glucose utilisation. Foods high in magnesium include leafy green vegetables, whole grains and nuts and seeds.

Omega 3

Omega 3 fatty acids have a beneficial effect on blood lipids and reduce inflammation. High Omega 3 intake assists with energy and glucose regulation and positively assists in fat loss through increasing beta oxidation and glycogen synthesis, therefore reducing fat storage.

Alpha Lipoic Acid

Alpha lipoic acid (ALA) is a water and fat soluble anti-oxidant that protects against diabetes by minimising the detrimental effects diabetes has on the eyes, blood vessels and kidneys. It does this by enhancing the uptake of glucose into the cells via the GLUT4 transport system, similar to the uptake of glucose initiated by insulin.

B Vitamins

B complex vitamins are important for all people and are indicated in diabetic cases, B-complex vitamins greatly assists in the metabolism of carbohydrates as well as support a multitude of other functions within the body.

SAM-e

In regards to the liver, S-Adenosylmethionine (SAM-e) and betaine would be of benefit. SAM-e is an important methyl donor and required for the production of CoQ10, carnitine, methyl cobalamin, and phosphatidylcholine. SAM-e is indicated to up-regulate and increase the antioxidant glutathione in the body and reduce inflammation by upregulating interleukin 10. It also inhibits apoptosis of normal liver cells. A deficiency of SAM-e impairs function of the liver and leaves the liver more susceptible to damage. Clients with methylation cycle impairment, such as those with the MTHFR polymorphism, are at a much higher risk here.

Betaine

Betaine is another major methyl donor and used in the creation cycle of methionine, further assisting to help raise SAM-e levels in the body. A study on betaine supplementation with humans over one year found that the aminotransferase enzymes ALT and AST where significantly improved and liver biopsy showed reduced fatty infiltration and fibrosis.

The client was prescribed the following, this is a high number of supplements with most being only initially for a period of less than 3 months.

Prescription

Outcome

After 2 weeks of the modified diet and lifestyle, nutritional supplements and herbal protocol, the diabetic and liver symptoms were reduced considerably. Much greater improvement was made at the 12 week follow-up consultation with the client reporting much more energy, losing 15kg of weight, feeling much happier and stable in his mood and food cravings completely gone. The lifestyle changes will need to be kept up long term to avoid the symptoms reappearing and continue weight loss.

***This case and dosages prescribed were specific to the individual and presenting condition, this protocol may not suit everyone with these symptoms. A consultation with a suitably qualified practitioner should be undertaken before commencing any treatment ***