Chelsea Smithback and Emily Takeuchi-Miller, ND

Abstract
Anxiety is a common condition with multiple treatment options, and the use of supplementation and homeopathy for the treatment of anxiety is shown in this case report. This case shows how homeopathy and supplementation can be effective; however if the root cause is not addressed, they can serve as palliative care, and this case report highlights the importance of treating the root cause of any condition. This case report shows the treatment for an adult female with anxiety who presented with a GAD-7 of 19 and two panic attacks within three weeks of visiting the clinic due to Covid stress. She was initially prescribed dietary interventions, an anxiety supplement with vitamin B6, magnesium, GABA, glycine, L-glutamine, passionflower and lemon balm, and homeopathy treatment as well as box breathing techniques and yoga for stress management. The patient initially reacted well at her third follow up visit; but at her 4th follow up telephone encounter, she reported a return of symptoms and a new onset of depression and a GAD-7 score of 20. This case report details the treatment plan and management of this patient during her initial clinic visits and shows that addressing the root cause is essential.

Introduction

Anxiety is a very prevalent condition. Anxiety disorders are present in as much as 13.3% of the US’s population. Stress is an important factor in the pathology of anxiety disorders, but the exact mechanism is still unclear. Symptoms of anxiety can come about after metabolic abnormalities caused by various illnesses. Neurotransmitters that are involved in anxiety include serotonin, GABA, dopamine, norepinephrine, and glutamate among others. Increased serotonin appears to be associated with anxiety; however, the pathology is not clear. GABA is the main inhibitory neurotransmitter and has anxiolytic effects. Dopamine D2 blockade, which is the mechanism of antipsychotic medications, is an anxiolytic. Norepinephrine, like dopamine, is upregulated in anxiety, but norepinephrine can mediate symptoms of anxiety. Glutamate is thought to be involved in pathways that are involved in anxiety, especially the N-methyl-D-aspartate (NMDA), in which augmentation and antagonism of the NMDA-mediated pathway is an effective treatment for anxiety disorders.¹

Generalized anxiety disorder is diagnosed clinically, and many tools to aid in diagnosis and assessment include GAD-7, HAM-A, CGI, and PHQ-4. The prognosis of anxiety can vary, in one 22-year follow up study of 105 patients with GAD (generalized anxiety disorder), the study found that less than 20% had persistent GAD.²

Management of anxiety is very individual to each patient and may include psychological therapy, pharmaceuticals, cognitive behavioral therapy, mindfulness, experimental off-label nonpharmacological treatments, and complementary and alternative medicine, such as botanical medicine, meditation, yoga, and acupuncture.¹ There is also strong evidence for the use of passionflower, kava, L-lysine, L-arginine, as well as magnesium supplementation.³

The DSM-5 criteria for diagnosing generalized anxiety disorder includes at least three of the six following symptoms occurring most days for 6 months of: restlessness or nervousness, being easily fatigued, poor concentration, irritability, muscle tension, and/or sleep disturbances.⁴ Other DSM-5 criteria include excessive anxiety and worry most days for at least six months, difficulty controlling worrying, and symptoms resulting in clinically significant distress and not due to an underlying medical condition or substance abuse and not better explained by another mental disorder.⁴ 

The following case is an anxiety case that is in the process of being treated holistically with supplements, homeopathy, dietary changes, and breathing techniques. In the following case, the patient initially improved and then worsened. This case highlights how patients are dynamic and that treating anxiety with supplements, homeopathy, dietary changes, and breathing techniques is beneficial and can improve anxiety; however if the root cause is not treated, the use of these modalities is only palliative. This case further highlights why understanding and treating the root cause is most important in treating the condition.

Case Presentation

K is a 45-year-old female presenting with asthma and anxiety. Her anxiety started in October 2020 due to Covid stress, and she had two panic attacks within the last three weeks of her first presenting to the clinic. She experienced anxiety Monday through Friday, with brain fog, difficulty breathing, racing thoughts, chest tightness, feeling overwhelmed, and difficulty sleeping. She had associated symptoms of back spasms, headaches, and hot flashes.  Symptoms of anxiety are worse with school stress and having racing thoughts. Symptoms ameliorate with lavender baths, melatonin, exercise, and yoga. Her general anxiety is rated at a 7/10 (0 is best, 10 is worst.)

She also presented with asthma, which she has had since childhood and experiences difficulty breathing, difficulty talking as well as anxiety, headaches, and lightheadedness. Her asthma was exacerbated seasonally, and she usually has exacerbations three times per week. She uses an inhaler once daily during acute exacerbations, but she tried not to use it. Her asthma is rated as a 6/10 (0 is best, 10 is worst). She usually only has one bowel movement per week. She has seasonal allergies. Her current medication and supplements include calcium carbonate, zinc sulfate, magnesium oxide, vitamin D3, melatonin, cranberry and vitamin C, vitamin E, albuterol, Advair diskus, and occasionally uses Benadryl for seasonal allergies.

Past medical history is significant for bursitis in the hip, a breast lump that was removed in 2004, and she reports possibly having eczema in her childhood.

Her family medical history is significant for MI, hypertension, and cancer on her maternal side. Her aunt has paranoid schizophrenia, and brother has schizophrenia, and the patient reports potentially asthma in the family.

Clinical Findings

ROS was positive for chest palpitations, little sharp pains, wheezing, shortness of breath, but she denies a cough.

Positive for constipation, slight abdominal pain, undigested foods in bowel movements, pruritis over body, dry skin, dry mouth, muscle tension. No blood or mucus in stools.

Reproduction ROS was positive for night sweats and hot flashes that occurred years ago. She has had one period since Covid started (within the year.)

Physical exam was deferred due to telehealth.

Diagnostic Assessment

The criteria used to diagnose her with generalized anxiety disorder was the DSM-5 criteria. The criteria for DSM-5 includes experiencing at least three out of six symptoms, and of the six symptoms, the patient reported experiencing four symptoms: restlessness or nervousness, poor concentration, muscle tension, and sleep disturbance. The other symptoms of criteria from DSM-5 being easily fatigued and irritability.⁴

A GAD-7 was also performed on her first visit and she scored 19, indicating severe anxiety disorder. The working diagnosis due to her DSM-5 criteria and GAD-7 was generalized anxiety disorder.

Table 1: Timeline

Date	Summaries	Diagnostic Test	Interventions
October 2020	Anxiety started due to Covid stress
April 2021	Patient experiences 2 panic attacks within 3 weeks of first presenting to the clinic.
Early May 2021	Patient first presented to the clinic for anxiety and asthma.	A GAD-7 score done during the visit was 19.	After initially presenting to the clinic, her first treatment plan was to increase foods rich in fiber, chia seeds, flax seeds, and to keep her blood sugar levels stable with proteins and health fats throughout the day, increase vegetables in her diet, eat 4-5 servings of fruit per day, limit caffeine to 1 cup daily, and increase water intake throughout the day. She was also prescribed ‘Anxiety Control Plus’ by Metabolic Maintenance, ‘Natural Calm’ Powder by Natural Vitality, a tincture of albizia, lobelia, fennel, matricaria and passiflora for her asthma, a ‘Vitamin C 1,000’ by Now Foods, and encouraged to drink lemon, ginger, and honey tea throughout the day for the hoarseness in her voice and Epsom salt baths for its magnesium and to increase daily relaxation for the patient. She was also referred to the homeopathy shift for her anxiety.  She was also encouraged to do yoga for anxiety and stress and do box breathing techniques when she is stressed and anxious to improve her anxiety.
Mid May 2021	Patient returned to the clinic for a follow up for a homeopathic intake.	No diagnostic assessment was done.	Her second follow up was a homeopathic intake in which Sepia 30C: 3-5 pellets under the tongue once daily was prescribed.
June 2021	A month later at her third follow up visit, she reported improvement in all symptoms. She reported feeling happier, decreased chest constriction, shortness of breath, increased stress management. The anxious feelings were still present, however she was less emotional and less easily angered.		The homeopathic dosage was changed to Sepia 30C of 3-5 pellets BID.
July 2021	4th telephone follow up encounter. Patient had adhered to all treatment recommendations and reported a return of anxiety and asthma symptoms and a new onset of depression.	A GAD7 was performed, which was a score of 20.	The patient had scheduled a clinic appointment for the next day and therefore no treatment was changed during the telephone encounter.

Therapeutic Intervention

Dr. Takeuchi-Miller, ND, and the clinical care team’s overarching treatment plan was to regulate her nervous system with an anxiolytic treatment plan and treat her asthma symptoms, as her anxiety and asthma were associated with each other. The plan included a supplement called ‘Anxiety Control Plus’ by Metabolic Maintenance, which was recommended due to its anxiolytic vitamins, minerals and herbs. The supplement contains 10 mg vitamin B6 (as pyridoxine HCl), 100 mg magnesium citrate, 400 mg gamma aminobutyric acid (GABA), 100 mg glycine, 140 mg L-glutamine, 150 mg Passiflora incarnata herb powder and 150 mg Melissa officinalis extract 6:1, which was enclosed in a vegetarian cellulose capsule.  The dosage was 2 capsules daily taken orally.

A study involving supplementation with vitamin B6 and magnesium reduced premenstrual anxiety.⁵ Magnesium has been shown to have a beneficial effect on subjective anxiety.⁶ Combining magnesium and vitamin B6 had a synergistic effect on reducing anxiety.³ Modulating GABA pathways can reduce anxiety, as GABA is the main inhibitory neurotransmitter in the CNS.¹ Glycine is an inhibitory neurotransmitter, and has a potential therapeutic benefit in many conditions, including anxiety and PTSD through regulating the activity of glycine receptors.⁷  Passionflower herb has long been used for the treatment of anxiety due to its anxiolytic properties and has been shown to be as effective as a benzodiazepine, with less job impairment than the group being treated with benzodiazepine.³  Melissa officinalis has been shown to be an antianxiolytic, decrease stress, and improve cognition and mood.⁸

We recommended a diet to keep her glycemic levels stable throughout the day by eating healthy fats and protein, as well as increase foods rich in fiber, chia seeds, flaxseeds, increase vegetables in her diet and eat 4-5 servings of fruit per day. One study found that anxiety was shown to be associated with hyperglycemia in diabetic patients.⁹ One of the proposed mechanisms was that those with anxiety have heightened sympathetic reactivity as well as higher cortisol reactivity, and excessive exposure to cortisol can promote insulin resistance and thus hyperglycemia and elevated HbA1C.⁹

We also decreased her caffeine consumption to 1 cup of coffee daily, as caffeine is associated with anxiety.¹⁰

The patient also experienced constipation, and we recommended ‘Natural Calm’ by Natural Vitality, consisting of 325 mg magnesium carbonate, that she can put 1 tbsp of the powder into 8 oz water, once daily, ideally in the morning.  Magnesium has been shown to be beneficial in treating constipation.¹¹

We also recommended ‘Vitamin C 1,000’ by Now Foods, which consists of 1,000 mg ascorbic acid, 100 mg citrus bioflavonoid complex, and 25 mg rutin powder. Other ingredients in this supplement consisted of hypromellose (cellulose capsule), stearic acid (vegetable source), magnesium stearate (vegetable source) and silicon dioxide. Dosage is one capsule daily by mouth.¹² The use of vitamin C in treating asthma is still under review; however, one review stated that vitamin C is a key antioxidant and low levels of vitamin C intake were seen in asthma patients. However, the use of vitamin C in treatment of asthma is still ongoing and further research is needed.¹³

An asthma tincture of 36 mL Albizia julibrissin (albizia), 36 mL Lobelia inflata (lobelia), 18 mL Foeniculum vulgare (fennel), 12 mL Matricaria recutita (chamomile) and 18 mL Passiflora incarnata (passionflower) that was made at Bastyr Clinic was prescribed. Dosage is three dropperfuls twice per day sublingually. Lobelia is useful for conditions of spasmodic natures, such as bronchial asthma, and has a long history of use for asthma.¹⁴ Fennel is a mild expectorant, antispasmodic and relaxes bronchodilator and is especially useful for coughs.¹⁴ Chamomile is an antispasmodic, anti-inflammatory, as well as a nervine for active nervous systems.¹⁴ Passiflora is a nervine that is helpful in nervous, tense patients and brings a sense of calmness, as well as being an anxiolytic, antispasmodic, and sedative.¹⁴ Albizia adianthifolia, in the same Albizia genus family, has been used in low-income countries to manage and treat lower respiratory infections, diarrhea diseases, and ischemic heart disease. It has been used as an herbal remedy for the use of bronchitis, cough, respiratory problems, and sinusitis.¹⁵

She was also encouraged to continue with yoga as that was a modality she herself stated helped with her feelings of anxiety. Yoga was shown to potentially be an effective and safe modality for anxiety in the short-term.¹⁶

Box breathing technique was recommended to increase relaxation and decrease stress and anxiety. A study found that slow breathing techniques interacted with the cardio-respiratory system and had a strong association with the parasympathetic nervous system. Paced breathing has been associated with relaxation and well-being, and some of the benefits of slowed breathing techniques include increased comfort, relaxation, pleasantness, vigor and alertness, reduces symptoms of arousal, anxiety, depression, anger and confusion.¹⁷

Her second follow up was a homeopathic intake in which Sepia 30C: 3-5 pellets under the tongue once daily was prescribed. Her keynote were feelings of anxiety, feeling overwhelmed with teaching, crying, hot flashes, wanting to be alone when crying, feeling helpless, brain fog, difficulty expressing herself when she is emotional, desires salt and vinegar, symptoms ameliorated with exercise and feelings of indifference.

Follow Up and Outcomes

In June of 2021, a month after her initial visit, in her third follow up visit, she reported improvement in all symptoms. She reported feeling happier, decreased chest constriction, shortness of breath, increased stress management. The anxious feelings were still present; however she was less emotional and less easily angered. The homeopathic dosage was changed to Sepia 30C of 3-5 pellets BID.

In July of 2021, a telephone encounter with the patient revealed that the patient had adhered to all treatment recommendations; however, she reported a return of anxiety and asthma symptoms and a new onset of depression. A GAD-7 was performed, and it was scored at 20.

Future considerations for her treatment plan need to include therapy to be able to assess and treat the root cause of her anxiety. Other treatment changes include re-assessing her dosage and remedy for homeopathy, since maybe the right dosage or remedy wasn’t chosen, as well as continuous treatment of her asthma.

Discussion

The patient came in for anxiety and asthma and the purpose of this case report is to focus on the management of her anxiety. As the patient initially reacted well to the treatment, we are hopeful that we are on the right path in her treatment but still need to finetune her treatment plan.

After initially presenting to the clinic, her first treatment plan was to increase foods rich in fiber, chia seeds, flax seeds, and to keep her blood sugar levels stable with proteins and health fats throughout the day, increase vegetables in her diet, eat four-to-five servings of fruit per day, limit caffeine to one cup daily, and increase water intake throughout the day. She was also prescribed “Anxiety Control Plus” by Metabolic Maintenance, ‘Natural Calm’ powder by Natural Vitality, a tincture of albizia, lobelia, fennel, matricaria, and passiflora for her asthma, a ‘Vitamin C 1,000’ by Now Foods, and encouraged to drink lemon, ginger, and honey tea throughout the day for the hoarseness in her voice, and Epsom salt baths for its magnesium and to increase daily relaxation for the patient. She was also referred to the homeopathy shift for her anxiety.  She was also encouraged to do yoga for anxiety and stress and do box breathing techniques when she is stressed and anxious to improve her anxiety.

We wanted her to make sure her inhaler was not expired and to check-in with her prescribing doctor for the inhaler to make sure she is being managed for the asthma.

At her third follow up, the patient initially benefited from the treatment and reported feeling happier, increased stress management, decreased chest constriction, decreased shortness of breath; and although the anxious feelings were still present, she was less emotional and less easily angered.

At her fourth follow up she reported anxiety symptoms had returned, and she had a new onset of depression. Her GAD-7 score was 20, which was higher than her initial intake at GAD-7 score of 19. The takeaway from this case is that more work needs to be done on treating the whole person and treating the cause, which would be therapeutic counseling for her to identify where the anxiety was originating from.  The treatment that was given to her was helpful, but palliative, and further work needed to be addressed to identify the root cause of her anxiety. The future plan would be to refer her to counseling to help treat the root cause of her anxiety, re-assess the homeopathy dosage, and potentially re-take the case, as well as re-assess her asthma treatment.

The strength of this case report was that the patient adhered to the treatment plan and followed all the recommendations. The limitations of this case was that a GAD-7 was not done at her third follow up and therefore we have subjective information that she improved, but no objective measurement.

Conclusion

The patient initially reacted positively in all of her symptoms; however, over time, the treatment plan wasn’t as effective. Since the patient initially reacted well to the treatment, it shows that the treatment was working as intended; however, since the patient had a return of anxiety symptoms, it indicates the treatment given was more of a palliative treatment and that the underlying cause of her anxiety needs to be assessed and treated. We need to identify and treat the cause and treat the whole person; therefore, a referral for counseling would be very beneficial in adding to understanding the root cause of her anxiety. In addition, homeopathy is very specific and sometimes takes trial and error, and we may not have gotten the right dosage for her yet.

Disclosure: I, Chelsea Smithback, have not been paid to write this article by any source outside of the Townsend Letter. I do not work for a proprietary company that will benefit by publication of this article and I do not sell or provide a product or service that will be benefitted by this publication.

Consent was given by the patient for this case report.

References

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3. Lakhan SE, Vieira KF. Nutritional and herbal supplements for anxiety and anxiety-related disorders: systematic review. Nutr J. 2010;9:42. Published 2010 Oct 7.
4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
5. De Souza MC, et al. A synergistic effect of a daily supplement for 1 month of 200 mg magnesium plus 50 mg vitamin B6 for the relief of anxiety-related premenstrual symptoms: a randomized, double-blind, crossover study. J Womens Health Gend Based Med. 2000;9(2):131-139.
6. Boyle NB, Lawton C, Dye L. The Effects of Magnesium Supplementation on Subjective Anxiety and Stress-A Systematic Review. Nutrients. 2017;9(5):429. Published 2017 Apr 26.
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8. Cases J, Ibarra A, Feuillère N, Roller M, Sukkar SG. Pilot trial of Melissa officinalis L. leaf extract in the treatment of volunteers suffering from mild-to-moderate anxiety disorders and sleep disturbances. Med J Nutrition Metab. 2011;4(3):211-218. 3.
9.  Sultan S, et al. A longitudinal study of coping, anxiety and glycemic control in adults with type 1 diabetes. Psychology & Health. 2008;23(1):73-89. Accessed August 25, 2021. https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105947722&site=ehost-live
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Published July 15, 2023

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About the Authors

Chelsea Smithback is a 4^th year naturopathic medical student at Bastyr University in California. The areas she would like to specialize in are sports medicine, women’s health, dermatology, and mental health, as well as being a general primary care provider. Her approach to health and wellbeing is using evidence based medicine to create individualized care and focusing on the whole person and getting to the root cause. Her goal for every patient is to see them truly thrive and become their best self.

Emily Takeuchi-Miller, ND, earned her Doctorate in Naturopathic Medicine from Bastyr University California where she went on to complete a one-year general medicine residency. At Bastyr, she served as a clinical supervisor and adjunct faculty member before relocating to her hometown of Tucson, Arizona, where she is currently practicing. She also holds a BA in biology from Bryn Mawr College in Philadelphia with a minor in Japanese.

Dr. Takeuchi Miller has presented research at several conferences including the Academy of Integrative Health and Medicine and the Association for Applied Psychophysiology and Biofeedback. Her research is centered around the use of biofeedback in retraining the nervous system to be more resilient to stress. Her special interests include primary care medicine, GI dysfunction, chronic illness, pediatrics, and mind-body medicine/biofeedback.

Baljit Khamba, ND, M.PH is a graduate of the Canadian College of Naturopathic Medicine and is currently completing her Doctorate in Education at the University of Western Ontario.  She is a board member of the American Association of Naturopathic Physicians (AANP) and , an alumni of both York University (H.BSc) and Lakehead University (M.PH). 

Dr. Khamba is the Chair of Clinical Sciences, Clinical Supervisor and an Assistant Professor at Bastyr University.  She has been successfully instructing and mentoring students for the past 5 years in a variety of different programs, such as naturopathic medicine, Master of Counselling Psychology, and Doctor of Acupuncture and Oriental Medicine.  Integrative medicine, clinical research, and motivational based teaching are factors that Dr. Khamba holds in high regard.  She has published in a number of journals, newsletters and disseminated research findings in conferences globally. 

Dr. Khamba has practiced in clinics in Toronto, Edmonton, and San Diego.  She approaches care using a holistic perspective and integrates the philosophies of naturopathic medicine to empower patients through their health goals.  Dr. Khamba is also an active member of the community, speaking at conferences, and various media often discussing her own journey through breast cancer and her use of integrative medicine.