Stressors that Trigger Panic & Anxiety Disorders

and the importance of gut health

During my first emergency room visit back in January 2011, the ER doctor told me there was nothing to be concerned about — all my vitals were good, this was just a panic attack. This was “just in my head.”

He explained to me that this experience was a “false alarm” from my autonomic nervous system signaling the fight-or-flight response. That this is a physiological reaction triggered by a perceived attack or threat. He wrote me a prescription for lorazepam (benzodiazepine) and recommended that I see a psychiatrist or psychologist to address my stress levels.

And this is exactly where I believe our healthcare system fails people with Panic Disorder.

“One of the primary shortcomings of psychiatry is its seeming inability to acknowledge that anything is wrong with the way we are living.” — Dr. Kelly Brogan, MD

Generalized Anxiety and Panic Disorders are categorized as mental health illnesses, and consequently, there is an inherent assumption (even among many doctors) that the root of the issue is psychological. We seem to assume, which is evident by typical treatment approaches (psychotherapies), that the physiological response is precipitated by a psychological stressor.

Even worse, Panic Disorder is socially perceived as a self-inflicted mental illness; if we just had control over our negative thought patterns, if we weren’t such high-strung Type A personalities, if we weren’t catastrophic what-if thinkers then our problem would be solved. Mind over matter, right?

Sort of. We know that in the case of a traumatic experience (ie car accident) that the Panic Disorder is precipitated by a psychological stressor. Neuroplasticity is the brain’s ability to rewire itself, for better and for worse. (1) So yes, we know that a traumatic experience can rewire the brain’s fear network. And we also know that cognitive behavior therapy can unwind this fear circuitry to heal people.

But for many of us, there is no traumatic event that we can pinpoint in our lives before the onset of our Panic Disorder. In fact, a distinguishing feature of Panic Disorder is that the attacks are spontaneous and yet we are still treated as though our psychology is to blame. (2)

Defining the stressors that underlie anxiety disorders

I quickly realized while suffering from Panic Disorder that how we socially and medically define the words stress, anxiety, and panic leads to confusion and misinterpretation.

Socially we tend to use these words loosely to describe the condition of being overwhelmed (stress), fearful of the future (anxiety), or an emotional breakdown (panic). These terms are so nebulous and ubiquitous that their overuse to describe our daily lives has almost diluted their medical meaningfulness (even among doctors from my experience). Anxiety and Panic Disorders, however, are much different.

From a medical perspective, stress is the body’s physiological reaction (sweating, rapid heartbeat, increased blood pressure, etc.) to an actual or perceived stressor. Anxiety is the result of chronic stress, meaning repeated or constant exposure to an actual or perceived stressor. And a panic attack is a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent threat. (3)

What is most shocking to me, however, is the lack of dialogue about the stressors. Mainstream healthcare in the US only takes into consideration the emotional/psychological stressors and fails to address with patients all the other types of stressors that can equally (often disproportionately) impact stress levels, exposures, and resilience:

Emotional/Psychological Stressors

• traumatic events or accidents
• unhealthy relationships
• workplace issues or financial stress
• worry about the future

Environmental Stressors

• sensitivity to carbon dioxide levels (4)
• industrial toxicants through food and water (5)
• exposure to pesticides, herbicides, etc through food and water (6)
• other endocrine disruptors like BPA (canned foods, receipts, plastics) (7)
• Lyme Borreliosis (8)
• Lead poisoning (37)

Dietary & Lifestyle Stressors

• high fructose sugar intake (9)
• excessive alcohol consumption (10)
• smoking cigarettes (11)
• highly processed, low plant-based Standard Western diet (12) (13)
• sedentary lifestyle (14)
• sleep apnea (15)

Biological Stressors

• oxidative stress (16)
• genetic variants (COMT Met/Met, high-activity MAOA-uVNTR) (17, 18)
• DNA methylation (19)
• histamine intolerance (20)
• disturbance to the gut-microbiome brain axis (21)(22)
• chronic gastrointestinal inflammation (23)
• intestinal permeability (leaky gut) (24) (25)
• eye alignment disorder called Vertical Heterophoria (38)

Why does our healthcare system fixate on the psychological/emotional stressors and completely disregard all these other known stressors? Why do our first-line healthcare providers fail to mention, in what to me feels like a negligent dismissal of overwhelming evidence, the magnitude of all these other genetic, biological, and environmental stressors?

Whether a tiger or abnormally high levels of histamine, for example, these are both actual stressors to our bodies. It is interesting to note that in a randomized, double-blind, placebo-controlled trial study of 369 patients diagnosed with Generalized Anxiety Disorder that the anti-histamine drug, Hydroxyzine, was found to be just as effective as benzodiazepines. (26) This finding implicates the immune system as a major component of anxiety disorders.

So within just a few minutes of my emergency room visit, how could the ER doctor have possibly known that my panic was just a “false alarm?” Why aren’t we referred to a neuroimmunologist or neurogastroenterologist instead of the psychologist or psychiatrist?

What if the fight-or-flight response is not a false alarm elicited by emotions or thoughts, but triggered by something you are eating? Or something you literally are feeding? There is more and more evidence that suggests improving intestinal health holds the most promising solution.

The second brain and our inner kingdoms

Generalized Anxiety and Panic Disorders develop from a complex set of risk factors which can include traumatic experiences but is more than likely a combination of genetics, brain chemistry, and the environment that influence our psychology. And more recently substantiated, our intestinal microbiome.

With new technologies developed leading up to 2007, scientists were able to begin sequencing the genes of the bacteria that collectively make up the human microbiome in a National Health Institute funded effort known as the Human Microbiome Project (2008–2013). Our intestines are our own personal inner ecosystems with different cohabitating species of microorganisms. Science is just beginning to understand how each of our unique bacterial communities influence human health and disease. (27)

“Among the variables that might afford resiliency against mental disorders or, on the other hand, contribute to risk, diet has emerged as a strong candidate.” Journal of Physiological Anthropology

Our bodies outsource work to these microbes that reside in and on us; from vitamin production to immune system development, these bacteria are performing functions critical to our health. (27) We also know that there exists a bidirectional relationship between the gut and brain via this vagus nerve which means the brain communicates to the gut and the gut communicates to the brain (termed the gut-brain axis).

We have actually known that the gut plays a major role in our overall health and particularly in our mental health for quite some time. In the past decade, medical research seems to be confirming what we already knew from Metchnikoff (1908 Nobel Peace Prize Winner for Physiology) and his research on autointoxication (gut-derived putrefactive chemicals burdening the brain), a theory that was stifled when the serotonin-model theory dominated Western Medicine. (28)

Why you might want to pay attention to your intestinal health

Biochemistry, genetics, and environment are all major players in with Panic Disorder that seem to influence (and be influenced by) the gut, a place where all our critical infrastructures (central nervous system, immune system, endocrine system) physical meet and interact.

Evidence shows that the gut microbiota is important in supporting the epithelial barrier and therefore plays a key role in the regulation of environmental factors that enter the body. (29) There have been 85,000 industrial chemicals developed in America in the last 70 years and 1,000+ chemicals added to that list per year. (30, 31) We simply do not know how all these toxicants independently and synergistically affect us.

Some toxicants and even ingredients in processed foods, particularly high fructose corn syrup, are responsible for degrading the integrity of our intestinal walls (intestinal permeability) which has an incredible impact on human health from allergies to cancers. Toxicants also cause chronic low-grade inflammation which increases the release of stress hormones. (32)

And this is why you might want to pay attention to the health of your intestines, especially as someone with Anxiety or Panic Disorder:

• There are approximately 500 million neurons (brain cells) in your gut (33)
• 95% of our body’s serotonin is produced in our intestines (33)
• 50% of our body’ dopamine is produced in our intestines (33)
• Serotonin is synthesized from tryptophan in the epithelial lining of the digestive tract (28)
• Gut microbes produce neurotransmitters like serotonin, dopamine, glutamate, norepinephrine and nitric oxide (33)
• Gamma-aminobutyric acid (GABA), an important chemical messenger responsible for calming neuron activity and associated with anxiety, is produced by the gut bacteria Lactobacillus and Bifidobacterium (29, 34)
• 70%-80% of our body’s immune system is located in the intestines (35)

Whether we are feeding certain species associated with specific diseases or whether our environment influences our genetic expressions including the genetic expressions of the bacteria, diet most certainly influences our microbes and therefore has the potential to also prevent even reverse disease processes. We just don’t know exactly how yet.

Feed your head to mind your gut

While science continues to search for the definitive cause (or causes), we deserve to be informed about these risks, associations, stressors, etc to make more informed lifestyle choices. Furthermore, it is unsafe (and should be considered a public health crisis) to make someone believe that their health problems are in their head and utterly ignore panic/anxiety as a potential symptom of a gastrointestinal disorder.

One of the most fascinating (and equally enraging) findings during my research over the years was that in Ancient Greek medicine, doctors believed certain disease originated from imbalances in the stomach they called hypochondriasis:

“This concept was rejected as science evolved and, for example, we could look under a microscope and see bacteria, parasites, and viruses. The meaning of the term changed, and for many years doctors used the word ‘hypochondriac’ to describe a person who has a persistent, often inexplicable fear of having a serious medical illness.” (36)

To me as someone who has been physically and mentally tortured by Panic Disorder, it is equally as torturous to disregard our health concerns by reducing them to simply worries. There seems to be a major disconnect between medical researchers and medical providers: why are we trying to calm people down by telling them panic is “just in your head” when we know there is an unbelievable amount of quality research that strongly suggests otherwise?

It has never been more clear that more relevant and effective management strategies for these disorders are needed, within both primary and emergency care.

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