About six months ago a patient came to see me in my psychiatry practice—let’s call her Sarah (this is a general example of the kinds of patients I see rather than a specific person).
Sarah was a 32-year-old woman who worked in digital marketing. She was recently married and had a good relationship with her husband, enjoyed her job, and tried to take care of herself with decent diet and lifestyle habits, including going to regular yoga classes.
However, over the few months before seeing me, Sarah had been dealing with progressively worsening anxiety that led to her having a panic attack while giving a presentation at work. Now she felt constantly afraid it would happen again and found herself avoiding situations where she might have to speak in front of other people. The anxiety started to spread over to her personal life, and she stopped seeing friends and started relying on her husband to drive her places, afraid that she might have a panic attack while driving.
Sarah had been hesitant about seeing a psychiatrist because she was afraid of taking psychiatric medication, but her progressive trouble functioning at work, and her husband’s insistence, let her to google local psychiatrists, find me, and make an appointment.
As I was getting to know Sarah she described herself as always being an anxious person with a tendency to worry. She identified as being a “perfectionist” and often held herself to unreasonably high standards, feeling guilty if she ever made a mistake.
She was highly conscientious and had always done well in school and at work, but the intense stress she put on herself was beginning to come at a great personal cost. She would often have trouble sleeping because she couldn’t “shut off” her brain at night.
What Does It Mean to Heal Holistically?
Before I go into the details about how I treated Sarah, I want to introduce the concept of Integrative Psychiatry.
Integrative psychiatry addresses the “whole” person—mind, body, and spirit
Mental health issues do not exist in a vacuum, and stressors on one part of the system will inevitably affect the system as a whole. For example, if I am working with a patient with severe depression because of a divorce, it would not make sense for me to treat the depression with medication without also talking through the patient’s divorce and helping him come to an understanding and peace about what happened, and helping him find a healthy way of moving forward.
Similarly, if a person has anxiety, even the perfect nutritional regimen will not be effective if they live in an apartment polluted with noise where they can’t relax. Each part of the system affects the other, and the major levers all need to be addressed to have a successful outcome.
Integrative Psychiatry is NOT anti-prescription medication
Extreme opinions are usually unwise opinions. I’ve seen a lack of wisdom on both sides of the table, both from medical doctors who criticize supplements and herbal medicine as nonsense and alternative providers who perpetuate stigma against prescription medications, telling misleading tales about how pharmaceuticals will destroy your brain.
To me there is more in common between how prescription medications, supplements, and herbal medicines work than there are differences, and all are just MOLECULES that work on our brains, often on the exact same neurotransmitter pathways.
To generalize broadly (there are exceptions to this), medications are stronger, work faster, and are more likely to have side effects, while supplements take longer to take effect, have more subtle benefits, and are less likely to have side effects.
Therefore they can work well when used together, with prescription medications used to acutely stabilize the system and then supplements added in order to create a healthy micronutrient environment in the body, allowing us to use lower doses of the medication and taper off of them sooner.
But most important to the definition of Integrative Psychiatry is this:
Integrative psychiatry respects the patient’s individual belief systems and preferences, and emphasizes a relationship between doctor and patient characterized by respect, kindness, and genuine concern
My job is not to tell someone they’re “wrong” about what they’re experiencing or what they think is causing their symptoms—my job is to listen, understand, and create a treatment program to help the patient achieve his or her goals safely and effectively in a way consistent with that person’s beliefs and preferences.
I get very frustrated when a patient tells me their last doctor told them their symptoms were “not possible” or “in their head.” If a patient tells me they are experiencing something, I believe them. I am trained in medicine, but the patient is the expert in his or her own body. I am also always learning, and no matter how much I study there will always be things I don’t know. Therefore my patients are also my teachers.
Let’s get back to Sarah:
The first thing I did for Sarah was start her on Lexapro (a prescription SSRI) for anxiety. Within a few weeks, she was already starting to notice a difference.
We used low doses of Valerian Root, Lavender oil capsules, and Kava tea for acute episodes of anxiety as we were waiting for the Lexapro to start working.
I also saw Sarah weekly for psychotherapy, where I taught her how to challenge the perfectionistic thinking that led her to create rigid standards for herself and contributed to anxiety. I showed her how to shine a light on her negative thinking, and rather than believe her anxious thoughts automatically, to look at them objectively. She began to realize that she tended to overestimate the possibility of bad things happening while underestimating her ability to handle those things. I taught her concrete skills she could implement on a day-to-day basis to better cope with stress.
I taught Sarah about good sleep habits, and worked with her to create a calming evening routine to help her relax her mind at night. I also taught her to prioritize sleep, and to shut down anything work-related at least two hours before bed.
I taught Sarah about the concept of mindfulness meditation and led her through guided meditations in session. I showed her that meditation is not actually a relaxation practice, but rather a practice of being at peace with our present experience without criticism or judgment, even when that experience is painful. I taught her that instead of getting caught up in the narrative of her anxious thoughts, she could watch them pass through her without believing their story.
Within two months, Sarah felt the tide was turning in a positive direction. She hadn’t had a single panic attack, was driving again, and was starting to branch out at work and volunteer for presentations. I was happy with her progress but knew our work wasn’t done—I wanted to make sure we stabilized these gains and continued them.
We started to take a closer look at her diet. I had her keep a food journal for two weeks, and after looking at it more closely I noticed she ate more processed food than she initially described and tended to rely on caffeine and sugar to get through the day. I was concerned she could have some micronutrient deficiencies and ordered specialized nutritional lab testing for her.
In fact, we found she had evidence of elemental nutrient deficiencies and low B vitamins (very common these days with the high amount of processed foods in the typical American diet). We added an an elemental nutrient supplement and B vitamin complex from a reputable company that makes pharmaceutical-grade supplements.
I also referred Sarah to a resource that teaches meal planning so she could work on improving her diet without having to rely on frozen meals or convenience foods. We eliminated caffeine and reduced refined sugar, which gave her a more stable level energy over the course of the day and improved her sleep.
After about six months, Sarah told me she felt “completely better” and “like myself again.” I see her periodically for tune ups, and in another six months our plan is to taper her off the prescription Lexapro and maintain her gains with behavioral change and lifestyle modifications.
Using an integrative and holistic approach isn’t a “silver bullet,” but rather seeks to achieve small gains over time in a healthy way consistent with the patient’s values.
It’s important to recognize that anxiety isn’t “wrong” or “bad.” Anxiety is an adaptive emotion that in many situations keeps up motivated, helps us work toward our goals, and helps us recognize dangers and prevent them. Healing anxiety holistically is not about eliminating the emotion, but rather about restoring balance.
Are you interested in working with an integrative psychiatrist? If you’re near the Los Angeles area you can work with me, or check out the provider listings on the website of the Academy of Integrative Health & Medicine.