At the Intersection of Anxiety & ADD-A Holistic Approach to a Common Concern
Updated: Mar 7, 2022
“This brain fog is so bad", “I have a lot of anxiety, maybe I have ADHD?” “I just can’t remember things or get things done. “I'm just so overwhelmed.” "I have a ton of half-finished projects." "Is there a medication or a supplement I can take?"
These are patient statements that we've been fielding a lot lately in our integrative primary care practice. So what's causing it? And what labs, supplements, and medications are best? We've got you covered. Read on.
Over the last four years, our clinic has had a sharp rise in both adult and youth patients wanting evaluation or treatment for a combination of ADHD-like symptoms, brain fog, fatigue, anxiety, inability to complete tasks, low motivation and memory difficulty. Since mid-pandemic, requests for stimulant medications like Adderall are skyrocketing, especially from adults.
If you’re curious about how our practitioners approach these concerns, such as identifying underlying causes, ordering lab work, medications, and natural options such as supplements, this is the read for you. In no way is this blog intended to provide medical advice, and right off the bat, I want to establish that this is how our clinic approaches this topic, which may differ from other practices. We are family practice providers, not psychiatrists. Further, each approach is individualized to both the patient and the provider, so this is a general example using our dear friend Hannah as a guide.
She fidgets nervously on the cushioned chair in my exam room. Sheepishly, she looks up as I enter, brushing bangs out of her eyes, tapping her foot nervously.
Before entering, I had read the chief complaint notated next to the appointment slot on the schedule, a snap-shot of what the patient wants to talk about: “Thinks she has ADHD. Would like to discuss meds.” If there are past records available from other providers, I would have reviewed those as well.
This would be my 3rd such visit just today and it is still morning. I've already received five refills requests for Adderall in the last 2 hours.
I settle onto my stool and greet Hannah—as we will call her for the purpose of this writing. Hannah is not an actual patient but serves as an example only for this author.
“Hannah, tell me a little more—what do you feel is going on?”
She speaks haltingly at first.
“Well, my sister has ADHD and takes Adderall. I was telling her I struggle with organization and remembering things, and I feel anxious. She said I should try medication, so I tried hers, and it really worked. My therapist even told me my anxiety might actually be ADHD, not anxiety.”
I nod, understandingly. This is a conversation, nearly verbatim, I have with patients almost daily now. Yes, Adderall works very well for most people, with a diagnosis and without. That is why it is so popular and also a controlled substance with high abuse potential. Does that mean it can't be used as an effective tool? No, it means it needs to be used with caution, and in my opinion, only after other options have been explored and exhausted.
I thank Hannah for sharing her story with me and ask her if she has ever had a formal “work up” for ADHD symptoms and some of the possible underlying causes. She shakes her head, “I don’t think so.”
So, I tell my shy patient in the cushioned chair, “I’d love to share with you a bit about my approach to ADHD as it may be different than other providers’ approaches.”
I explain to Hannah that as integrative providers, we do just that—we integrate conventional approaches with alternative/non-traditional approaches. We view medications as a sometimes necessary tool, and I am grateful, very grateful, for science and modern medicine when other approaches have failed.
In our practice at Hearthside Medicine, we are not opposed to medications when they are used appropriately and safely, when underlying causes of symptoms have been thoroughly assessed and addressed. The difficulty with ADHD, however, is that the symptoms of ADHD also mimic and overlap with symptoms of many other conditions, such as low thyroid function, nutrient deficiency, sleep disorders, depression, anxiety, medication interactions, and much more. Certainly, not being able to accomplish tasks, remember things, pay attention or complete projects can be anxiety provoking, so in many cases, it is a "what came first scenario."
For example, both depression and chronic anxiety impact the brain, often resulting in decreased concentration, memory, motivation, and executive functioning. The treatment for anxiety and depression and ADHD is slightly different, so it is important to tease this out.
We always want to do our due diligence to look for and treat any contributory factors, also known as “root causes.”
How the Integrative Approach differs from a Conventional Approach
Hannah has only been to traditional “big box” conventional medical clinics, where the visits are typically very short, if not rushed. She is used to walking in with a problem, getting a diagnosis, and usually, a prescription --all within the 10- 15 minutes of her appointment.
In our integrative practice, we do things a bit differently, I explain to Hannah. We treat the whole person, not just the symptoms. First and foremost, we recognize the complexity of ADHD, anxiety, memory, and motivation issues like an onion with many layers. Our patients are best served when we take the time to look at every contributing layer of that “onion”, from sleep, to nutrition, to micronutrient status, hormonal balance and so forth. We want to do our due diligence to rule out other diagnoses as well. This requires time on part of both patient and practitioner.
Inside the Brain of Someone Experiencing Anxiety or ADHD
I explain to Hannah that despite how common ADHD is, medical providers and researchers still aren’t sure exactly what causes it. Genetics may play a role. Prenatal development and exposures may play a role. Research also suggests that insufficient dopamine is a factor. Dopamine is a chemical in the brain that helps with emotional responses and movements. Other research suggests a structural difference in the brain. Findings indicate that people with ADHD symptoms have less grey matter volume. This can also be seen in depression and chronic anxiety. There is also plenty of evidence to suggest that nutritional imbalances, food intolerances, a disrupted gut microbiome and sleep issues can contribute to chemical and structural changes in the brain, leading to mood disorders and difficulty with concentration, motivation, energy and memory. Many times, low serotonin is also a major factor.
One thing that both conventional and integrative medicine agree on is that treating above symptoms through diet and lifestyle modifications can go a long way to easing symptoms.
I explain that some of “risk factors” include the following:
· Family history of ADHD
· Gender –(more common in boys, but there is dispute if this is due to poor diagnosis in girls)
· Food sensitivities, especially sugar, gluten, casein and food additives (artificial colorings (esp. yellow and red), preservatives (esp. benzoates and propionates), MSG)
· Poor diet: high sugar and refined carbohydrates, low protein, low essential fatty acid, low fruit and vegetables
· Dietary stimulants
· Maternal stress, drug, alcohol and cigarette use
· Premature birth or oxygen deprivation at birth
· Heavy metal toxicity (especially exposure to lead in early life or occupational/environmental exposure to mercury, for example)
· Chemical exposure (especially organophosphate pesticides)
· Hypoglycemia (low blood sugar)
· Family dysfunction, neglect and abuse (childhood or even adult trauma)
· Overstimulation from electronic screens
· Lack of exercise
· Insufficient sleep or sleep disorder such as apnea
· Underlying hormonal imbalances
· Food allergies/intolerances
· And so much more….
I explain to Hannah that people with ADHD often have impaired digestion, environmental and food sensitivities, nutritional insufficiencies, heavy metal toxicities, fatty acid and amino acid imbalances, sensitivity to food additives and sugar. Some of these concepts are acknowledged by Western medicine, and others are viewed skeptically.
By looking at each element, we can begin to understand how to manage symptoms through diet and lifestyle. Looking at the body’s biochemistry rather than focusing on symptoms allows the body to heal and rebalance naturally.
I share with Hannah that as her provider, I also don’t want to miss anything critical that could be mimicking ADHD, such as a low functioning thyroid, iron deficiency anemia, low blood sugar, hormonal imbalance, food intolerance, or an underlying sleep disorder. Depression can also mimic ADHD.
Starting the work up
We like to get baseline blood work to rule out any contributing factors. Hannah is amenable to this idea and eager to take a more holistic approach to her symptoms; so to start, I order a complete thyroid panel, a complete blood cell count, a complete metabolic panel, an iron panel, vitamin D, B12, several other micronutrient levels, a fasting insulin and blood sugar level, markers of inflammation, cortisol (stress hormone). I also have her keep a food, sleep, stress, exercise and mood journal for me for 3 days to get a better idea of her life and all the factors that may contribute to her symptoms.
I ask more about her sleep. Hannah tells me she struggles to fall asleep and often “does stuff on the phone” till she finally doses off around 11 or midnight. She has to wake for work by 6, so she is averaging about 6-7 hours a night. Sometimes she also wakes frequently or very early, like 2 or 3 am.
Cortisol, Sleep, Focus
This is pertinent information for me, because without adequate hours of REM sleep, Hannah will mostly definitely have worsened ADHD-like symptoms. I ask Hannah if she knows about cortisol and how it impacts sleep and focus and memory. She shakes her head no. I explain: poor sleep quality is associated with diminished awakening cortisol levels and dysregulated cortisol patterns—cortisol is one of our “stress” hormones. Our cortisol levels ebb and flow over a roughly 24-hour period to dictate our sleep-wake cycle. The rise and fall of this stress hormone is crucial for helping us fall asleep by our target bedtime, stay asleep throughout the night, and wake up in the morning. When our cortisol is dysregulated, so is our attention and concentration and our sleep. I like to often check cortisol as well as melatonin (sleep hormone) levels on patients struggling with these issues.
Some medications block important vitamins and nutrients needed for the chemicals in our brain that help regulate mood, memory, focus, etc. Hannah tells me she takes an oral birth control pill daily, which is known to block B6. B6 is needed for proper brain function. I will check her B6 levels, but encourage her to start taking a B complex daily. Other medications that block key nutrients for the brain include anti-depressants, metformin (for diabetes), and acid-blockers, among many others.
In an era of email, text messages, Facebook and Twitter, we’re all required to do several things at once. Earl Miller, a neuroscientist at MIT and one of the world experts on divided attention, says that our brains are “not wired to multitask well… When people think they’re multitasking, they’re actually just switching from one task to another very rapidly. And every time they do, there’s a cognitive cost in doing so.”
According to Daniel J. Levitin in his book The Organized Mind: Thinking Straight in the Age of Information Overload"
"Multitasking has been found to increase the production of the stress hormone cortisol as well as the fight-or-flight hormone adrenaline, which can overstimulate your brain and cause mental fog or scrambled thinking and symptoms of ADHD. Multitasking creates a dopamine-addiction feedback loop, effectively rewarding the brain for losing focus and for constantly searching for external stimulation."
Hannah and I review her sources of overstimulation that are likely contributing to her concentration deficit and increasing her anxiety:
-Her cell "dings" or "chimes" every time she gets a text or email, several times an hour. She interrupts what she is doing repeatedly and checks/answers these demands for her attention.
-The TV is on in background in most rooms in her home
-She is constantly in front of her computer or her cell phone screen
-To relax at night, she is back on her cell phone or watching TV
-At work, colleagues are constantly coming into her office and asking questions
Constant auditory and visual stimuli are exhausting to the brain and create cognitive deficits with prolonged exposure. Hannah rarely goes on hikes or walks without her cell phone in her hand.
Heal the Brain, Don’t Inflame.
I ask Hannah what a typical diet looks like for her. She lists off the following:
Breakfast: cereal, latte, OJ
Lunch: cheese & turkey sandwich, pretzels, grapes
Snack: yogurt or chips
Dinner: white pasta, milk, small iceberg salad, cookie
I notice her diet is lacking “color” and fiber and nutrient-dense foods (brain foods)—such as colorful produce and whole grains, which provide important phytochemicals for brain function. Her foods choices are also high in inflammatory foods (wheat, milk, sugar, processed /refined foods) and high glycemic foods (foods with a high carb/sugar content that spike blood sugar, leading to “sugar crashes” and inflammation). Inflammation and high glycemic foods are linked to brain fog and decreased focus, depression, anxiety, and more.
I encourage Hannah to incorporate anti-inflammatory “brain” foods and nutrient-rich foods, such as fish, avocado, quinoa, lentils, avocados, blueberries, spinach, broccoli, etc. Our modern American diet (called the SAD diet -- Standard American Diet) is highly inflammatory. Research shows that omega-3 fatty acids can benefit people with ADHD as they can stimulate the brain’s dopamine receptor and help reduce inflammation.
There is a close connection between the obesity epidemic (1:3 Americans!) we are seeing and the epidemic of ADHD and mental health problems. One study correlated higher sugar intake with a higher level of hyperactivity and ADHD-like attention deficiencies. Sugar isn’t just in candy—sugar hides in most high-carb, processed foods—start paying attention to grams of sugar and carbs on food labels. Ketchup, for example, is a high-sugar food, as are most cereals and yogurts.
Fruit and fruit juices, while “healthy”, are also full of sugar. Choose your fruits wisely. Some have more sugar than others—choose blueberry over pineapple for example. Children and adults with ADHD are more sensitive to dysregulated blood sugar (up and down rollercoaster) - a high intake of reﬁned carbohydrates such as white bread, white rice, white sugar, white pasta robs the brain of a steady supply of blood sugar.
The Mediterranean Diet
I encourage Hannah to explore The Mediterranean Diet—based on many, many clinical studies, it may be the most healthy diet to follow. It is loaded with colorful vegetables, nuts, berries and whole fruits, whole grains, ﬁsh, olive oil. It is a low-glycemic, low-inflammatory diet.
Blood sugar: Hannah and I review how her food choices may be driving a large part of her mood—the high sugar content of the cereal, yogurt, yes, even toast, will spike her insulin levels, later causing low blood sugar. The up and down of blood sugars is a major player in anxiety and focus. I encourage her to eat a high protein breakfast, lunch, and dinner with a generous serving of veggies, small amount of whole grain like quinoa, and some healthy fats--this will keep her blood sugar levels more stable contributing to better focus and mood. She likes to settle down at night with a glass of wine before bed, which unfortunately is very high in sugar and contributory to poor sleep cycles and blood sugar. We talked about replacing this with a calming bed time tea.
Hannah opted to change out her morning OJ full of simple sugars for tea or water, her boxed cereal for steel cut oats with blueberries and nuts, her white pasta for whole grain pasta, and her iceberg salad for dark, green salad. Instead of a sugary yogurt and refined white flour pretzels or chips, she switched over to an apple with almond butter and celery dipped in hummus.
Food Allergies and sensitivities –sometimes certain foods cause “neuroinflammation” and manifest as anxiety or ADHD-like symptoms. High inflammatory foods that may contribute often include dairy, wheat/gluten, corn, soy. Behavioral issues, dark circles under the eyes, eczema, body odor, and headaches are some of the symptoms to look for. Testing can be done for this. For Hannah, we decided to check for gluten (wheat) intolerance. Her markers came up high.
Preservatives and Food Dyes
Artiﬁcial colors and ﬂavors - some children (and adults) are genetically more sensitive than others to these chemicals and react to them. Foods containing synthetic food dyes make children vulnerable to hyperactivity and other behavioral problems, according to an extensive report by California state scientists.
The California Office of Environmental Health Hazard Assessment, or OEHHA, published the results of a two-year study that reviewed extensive research. They found that food dyes, such as Red No. 40 and Yellow No. 5 – two of the nine color additives approved by the federal Food and Drug Administration for use in food and drinks – pose significant risks to children when their brains are in a critical stage of development. Food dyes and flavors are ubiquitous in most kids’ foods such as some brands of mac n’cheese, breakfast cereals, ice cream and cones, icing, sugary drinks, yogurts and crackers.
Since 2010, food sold in the European Union with six dyes of concern – including Yellow No. 5, Yellow No. 6 and Red No. 40 – must be labeled with the warning “May have an adverse effect on activity and attention in children.”
The American Academy of Pediatrics now agrees that eliminating preservatives and food colorings from the diet is a reasonable option for children with ADHD. Some experts recommend that people with ADHD avoid these substances:
Artificial colors, especially red and yellow; Food additives such as aspartame, MSG (monosodium glutamate), and nitrites. Some studies have also linked hyperactivity to the preservative sodium benzoate. Hannah noted that her almost daily “blueberry” and “raspberry” yogurts contained Blue 1 and Red40. Her turkey contained nitrites.
Hannah doesn’t eat many dark, leafy greens and doesn’t take any vitamins. We discussed the role micronutrients play in ADHD/anxiety and many other health conditions. Many children and adults with ADHD, depression, and anxiety are deficient in crucial vitamins and minerals. Some studies estimate that 1:10 Americans is deficient in at least one or more nutrients.
A host of nutrient deficiencies, including magnesium, iron, zinc, selenium, tyrosine, and fatty acids, play significant roles in brain development and function, with many of these nutrients working synergistically.
*Omega 3 Fatty Acids - EPA/DHA - The brain is 60% fat by weight and the 2 most important fats for optimal brain function are EPA and DHA. They support brain neurotransmitters and help them get across the brain faster and easier. The frontal part of the brain is called the “Executive Center” and it has a very high level of brain neurons involved with behavior and self control. For adults, I prefer brands like Nordic Naturals, or Barlean’s Omega swirl - Key Lime for the best tasting oil for children - the dose will be closer to 1 TBS a day.
*Zinc – which is necessary for the metabolism of neurotransmitters, specifically dopamine (the “happy hormone”). Zinc deficiency has been linked to ADHD, and many studies suggest that zinc supplementation may help reduce symptoms, especially of hyperactivity in children. You can get zinc from eating more dark leafy greens, wild-caught salmon, and meats.
Excess copper levels can exacerbate hyperactivity. Supplementing zinc lowers excess copper levels. Zinc is especially important in reducing hyperactive, impulsive and impaired socialization. It can also help methylphenidate therapy work better. Zinc lozenges are an easy way for children to supplement zinc. Look for white spots on the ﬁngernails to spot deﬁciency, also low appetite.
*Activated B Vitamins – Research supports a connection between B-vitamin deficiencies and ADHD symptom severity. Activated B vitamins support healthy neurological function; people with MTHFR should avoid folic acid and use either folinic acid or methyl folate. B-6, B-12 and Folate are important - B6 is critical to helping neurotransmitters work optimally, such as serotonin. Low serotonin is highly associated with depression and anxiety. A good multi-vitamin or B complex can cover many nutrients at one time. Hannah asks to be tested for MTHFR, and her result comes back positive.
* Grape Seed Extract or Pine Bark Extract (Pycnogenol) –these contain OPCs, found in colorful berries such as blueberries, blackberries, cherries and purple sweet potatoes. They have been demonstrated to decrease the inattentive Theta Brain Waves ie.”Daydream” and increase Beta brain waves - focusing paying attention brain waves. Green Tea may help with this also. 50mg to 100mg of Grape Seed extract or Pine Bark extract.
*Magnesium – symptoms of magnesium deficiency include irritability, difficulty with concentration, insomnia, depression, muscle cramps, spasms, restless legs, and anxiety. It is estimated that up to 95% of those with ADHD are deficient in magnesium. Magnesium is one of the most common deﬁciencies in our culture as our soils are deﬁcient in magnesium. Stress also depletes magnesium – as our cortisol goes up, our magnesium levels go down. Additionally, phosphates in soda and sugars increase the depletion of magnesium. People with ADHD might have a genetic need for higher amounts of magnesium. Magnesium modulates the stress response, working with the GABA receptors in the brain to keep us calm. It is also a sleep aid - when we sleep better, we focus better. It is safe and easy to use unless there is serious kidney disease. Magnesium Citrate powders that make ﬁzzy drinks work really well for children and adults.
Take twice a day to help with behavior. Take a dose 1 hour before bedtime to support sleep quality. If you are on a medication for ADHD, magnesium can help lessen the side eﬀects of insomnia. I keep a large container of CALM magnesium powder in my home for myself and my children and husband.
*Iron - low ferritin ( iron ) is associated with more hyperactivity in children, fatigue in adults, and difficulty concentrating. Iron supports the production of the neurotransmitter dopamine, a key player in attention and focus and mood.
*Note: Replenishing mineral status in the body takes time sometimes several months to get replenished fully. Some peoples don’t absorb nutrients well and may need alternate routes or forms of supplements that they can be absorbed. Work with a trained provider to determine your needs.
Mind the gut
Look after your gut microbiome. What’s this? Your bacteria. You need them, simply put. Probiotics, prebiotics, and other fiber-rich options feed good gut flora and eliminate the bad. Gut-healing foods such as fermented choices like sauerkraut and fiber-rich options like nuts, seeds, and legumes are all recommended. Often intestinal permeability and gut dysbiosis (bacterial imbalance) can play a major part in ADHD. Functional medicine testing can test your gut health and microbiome. In fact, our gut bacterial play a critical role in the synthesis of chemical neurotransmitters like serotonin, which is vital for brain function and mental health.
Consume plenty of antioxidants. What are they? –a substance such as vitamin C or E that removes potentially damaging oxidizing agents in a living organism. Oxidative stress and glutathione deficiency have been connected to dementia, depression, Parkinson’s, autism, and ADHD. An antioxidant-rich diet includes plenty of colorful plant foods. Selenium, and carotenoids such as beta-carotene, lycopene, lutein, and zeaxanthin are other examples of antioxidants.
An overload of heavy metals such as lead and mercury in people who are genetically susceptible to their effects is believed to be one of the root causes of ADHD and "broken brains". Each person responds differently to toxins, and they are more common than you may think. Some people are great detoxifiers—their bodies are efficient at getting rid of waste products; others, like those with ADHD, are often not efficient at detox. Hannah also tells me she loves making stained glass for a hobby, which exposes her potentially to lead—and high consumption of fish can result in mercury toxicity. She doesn’t eat a lot of fish, but she did in college. She also has silver mercury fillings in her teeth, which additionally raises her risk. We test her for lead and mercury using the Mayo Clinic lab, and her levels come back borderline high. Other ways to help the body detox include regular exercise, drinking plenty of water, sweating, and daily bowel movements.
Hannah has poor sleep hygiene—or habits. She stays up late, often on her phone (screen). There is a correlation to screen time and ADHD. Additionally, the stimulating blue light from screens inhibits sleep. Improving sleep hygiene can play a role in managing ADHD symptoms. Insomnia is a common symptom in those diagnosed with ADHD, as the hyperactive component can make it hard to settle down and rest. Behavioral sleep intervention has been shown in clinical trials to improve sleep patterns, which in turn also helped improve hyperactivity, focus, and other symptoms of ADHD. On this note, I often examine someone’s tonsils, especially children, as large tonsils can create sleeping problems that can lead to ADHD and behavioral concerns.