Metabolic Systems and Procedures that influence anxiety, depression and stress
System I: A fresh look at your medical history
It’s easy to overlook subtle but important health problems that can block the healing process. For example: low grade infections such as Lyme disease; chronic sinusitis or urine infections; side-effects from medicines; disorders affecting sleep; borderline low thyroid; high or low blood sugar.
One of the main priorities of our first office visit is to identify problems that might have been overlooked. That's why we ask you to complete a very detailed history form and gather key lab reports before you book your first appointment.
System II: Nutrition-Metabolism of Essential Fats and Oils, especially the omega-3 class
The Science: Mild to moderate deficiency of essential oils is surprisingly common. This is especially so for the omega-3 oils (fish/flax/algae). Omega-3 oils are especially likely to be low among people with depression, autism, attention deficit disorder, schizophrenia, and also among those with heart disease, diabetes, and some forms of cancer.
Fortunately, lab science has progressed to where it is now practical to measure whether a person's essential oils are deficient.
Three recent double-blind studies, including one from Harvard Medical School, show that omega-3 supplements are effective treatments for depression. Double-blind studies also show benefit for Crohn's Disease, rheumatoid arthritis, heart disease prevention and some forms of cancer.
What We Might Do: Our dietary history questionnaire provides a reasonable estimate of your essential fatty acid intake. A red blood cell fatty acid analysis can measure this directly.
When appropriate, we would recommend supplementation. The best dose will vary for each individual and each setting.
CAUTION: There is no free lunch. As valuable as fish oil is proving to be, it's not totally without hazards. For example, in a manner similar to aspirin, high doses of fish oil acts to thin the blood. This is valuable if you need to prevent blood clots, but not if you already have an increased tendency to bleed. For instance, if you take Coumadin or anti-inflammatory medicines, have an ulcer, or are making plans for surgery.
System III: Building brain neurochemicals one carbon atom at a time - the methylation pathways, including SAMe, folic acid, and vitamin B12
The Science: The brain builds vital chemicals by adding carbon atoms or methyl groups to change the shape and form of molecules. The brain's main methylation work-horse is a special molecule, S-Adenyl methione (SAMe)
SAMe, as a supplement, is an effective anti-depressant with more than a dozen successful double-blind trials. The body also makes SAMe on its own, but optimal production requires generous amounts of folic acid and vitamin B 12, as well as trimethyl glycine (TMG), the amino acids Serine and methionine, and also omega-3 fish oil.
Weak methylation increases risk for depression and anxiety. Weak methylation also causes elevation of the blood level of the amino acid homocysteine. High homocysteine worsens heart disease risk. Weak methylation also reduces ability to repair damage to DNA. This increases risk of cancer.
Probably the most frequent obstacles to methylation occur with suboptimal intake of vitamin B12 and/or folic acid. Clinical studies have shown that under certain circumstances adding vitamin B12 and/or folic acid helps relieve depression.
What We Might Do: We can measure the efficiency of key enzymes that depend for their action on folic acid and B12. Such functional assays provide better information than does just measuring the level of each vitamin in the blood.
We seek to identify and reverse factors that block the effectiveness of your vitamins. For example, as many as 25% of Americans have a genetic variant that increases their need for folic acid. Birth control pills and other medicines also inhibit folic acid. Acid-blocking drugs (e.g. Prilosec), chronic low grade gastritis, which is very common in older people, and strict vegetarian diets all act to reduce our ability to obtain B12.
We recommend vitamin supplements in doses that are appropriate. We might also recommend supplementing SAMe, but with special care for its potential hazards. Like most effective anti-depressants, including Prozac and SAMe can sometimes trigger conversion from depression into mania among people who have a tendency toward bipolar disorder.
System IV: Nutrition-Amino Acid imbalances that alter brain neurotransmitters
The Science: Amino Acids are the raw material from which the brain forms key neurochemicals.
Serotonin, for example, is an important brain chemical. Serotonin deficiency is believed to contribute to anxiety, depression, PMS, insomnia, carbohydrate craving and a host of other ills. Adding Prozac is one way to increase Serotonin. Adding tryptophan, the starting molecule for serotonin, is another way to accomplish this. Tryptophan is available only with a doctor's prescription. 5-hydroxy tryptophan (5HTP), an over-the-counter derivative of tryptophan, is available in most health food stores.
During the 1970's, tryptophan was used to treat depression, but with only so-so success. However, those studies did not measure blood or urine amino acid levels to see who was actually low on tryptophan. Our experience is that only 15-25% of people with depression have the low tryptophan pattern. We confine tryptophan supplementation to those whose tryptophan ratios are low. This seems to provide much better results.
About 15 years ago, a manufacturing error in one large batch of tryptophan made many people severely ill. At that time, the FDA removed tryptophan from the market. There have not been further problems since tryptophan was reintroduced as a prescription drug.
What We Might Do: Measure blood or urine amino acid levels. Recommend specific amino acid supplements.
Be cautious about potential amino acid interactions with drugs and herbs. For example, except with special cautions, tryptophan should not be combined with Prozac-like drugs or with the herbal remedy St. John's Wort. (Nor should Prozac and St. John's Wort be combined with each other.)
System V: Hormone Imbalances-Thyroid, estrogen, testosterone, DHEA, prolactin, growth hormone
Thyroid: Does it ever make sense to take extra thyroid if your standard blood thyroid tests are normal? This has been a controversial issue for at least 50 years. However, recent research shows that in the right setting the answer can be yes. Most mainstream psychiatrists now agree that a small dose of added thyroid can help depression, even if standard thyroid blood tests are normal.
Who is likely to benefit from added thyroid? One can infer this from the medical history and physical. We can also measure standard thyroid blood tests as well as more sophisticated versions such as ‘free T3’ and ‘reverse T3’ thyroid hormone levels.
What We Might Do: Take a careful thyroid-related history. Monitor AM axillary temperature. Measure standard and special thyroid tests. Consider supplementing with low doses of natural (Armour pork) thyroid or with synthetic T3 (Cytomel).
Female and Male Sex Hormones: During perimenopause estrogen levels fluctuate wildly. A steady dose of estrogen supplements can have a stabilizing effect. When women are depressed during perimenopause, adding estrogen is very likely to help.
In contrast, during menopause itself, women who become depressed do not usually improve by being treated with estrogen. Correcting low testosterone levels can help mood in some and this is true for both men and women.
What We Might Do: Measure key thryoid, adrenial or sex hormones. Consider the pros and cons of a short trial of treatment.
DHEA, Prolactin,Growth Hormone: Abnormal levels of these hormones can adversely affect mood. Consider measuring these hormones and the pros and cons of treatment.
System VI: Respiratory Bio-rhythms-Proper breathing induces the relaxation response.“Disordered” breathing worsens distress
The Science: Both physical and mental distress tend to push the rhythm of breathing into a disordered pattern of shallow, rapid breathing from the chest instead of slow, deep breathing using the diaphragm and muscles of the abdomen. This chest hyperventilation makes people feel stressed and not in control. Slow, abdominal breathing induces feelings of calmness and confidence.
Most people are not aware of their breathing pattern. Many even feel that they are breathing too little, rather than too much. Sighing, feeling breathless, or feeling unable to take a full, deep satisfying breath-- these are all tip-offs that breathing rhythms might be off.
Disordered breathing disrupts the carbon dioxide balance in the blood. This disturbs the flow of blood to various parts of the body. Among the symptoms that can result: mental fog, dizziness, chest pain, numb lips, tingling fingers, muscle aches, and weakness. These all foster a sense of feeling out of control.
Disordered breathing worsens many symptoms. More symptoms, worse breathing. Worse breathing, more symptoms. Reversing this process is crucial--and not too difficult, once we recognize the problem.
What We Might Do: We evaluate breathing rhythms and teach people how to restore the normal pattern. We can usually retrain in just two or three sessions. This almost always improves well-being and the feeling of self-control.
In addition to proper breathing, we teach several advanced bio-behavioral skills. One of these, Freeze Frame, entrains the natural biorhythms of the heart. This triggers the brain's relaxation response within just one minute. The beauty of Freeze Frame is that you can do it while you work or talk without anyone around you realizing that you are relaxing.
System VII: Nutritional Deficiencies and Food Sensitivities
The Science: Almost every molecule in our body starts out as a food, including the coenzymes or cofactors that turn on the enzymes which guide our metabolism. Almost all of the required coenzymes are basic vitamins and minerals. Two examples of nutritional therapies: Magnesium and Inositol.
Magnesium serves a vast range of biochemical reactions. Many Americans have less than optimal magnesium. Low magnesium increases vulnerability to stress, anxiety, headache, heart palpitations, muscle irritability, asthma, and also sensitivity to loud noises, bright lights and noxious smells.
However, stress, chronic pain, diabetes and other illnesses all act on our kidneys to increase magnesium loss through the urine. As with disordered breathing, there is often a low-magnesium vicious cycle that is important to reverse.
What We Might Do: By history or direct testing, we evaluate for low magnesium. We usually recommend oral magnesium supplements. For difficult problems, intravenous magnesium might be preferred.
Inositol, a food derived biochemical, acts as a messenger within nerve cells. At least four double blind studies have shown that high dose inositol improves both anxiety and depression. Like other anti-depressants, Inositol can (infrequently) convert depression to manic phase. Side-effects are uncommon, except that some people have G.I. upset. Few drug interactions have been reported; however, Inositol might counter act the treatment effects of Lithium.
What We Might Do: There is no commercially available lab test to measure Inositol. Therefore, if the history is suggestive, we might offer a therapeutic trial. Food sensitivities can be obstacles to healing and they are probably much more common than we had previously thought. Two examples are Celiac disease/wheat gluten and low blood sugar/hypoglycemia. Celiac/Wheat Gluten: Celiac disease had been thought of as a relatively rare condition in which gliadin, a protein component of wheat gluten, causes immunological damage. Diarrhea was believed to be the first and most important symptom.
In contrast, recent research shows that sensitivity to gliadin is fairly common, affecting 2% or so of the population, and a much higher proportion among people who are ill. This sensitivity can damage the brain, heart and other organs, even when there are no G.I. symptoms at all.
What We Might Do: Screen with a blood test to detect gluten sensitivity. Or, do a full elimination diet to look for a broader range of food sensitivities.
Low Blood Sugar/Hypoglycemia: Despite persisting skepticism among some physicians, there is strong evidence that too much sugar and simple carbohydrate can cause mood swings and other symptoms. Ironically, the immediate cause of symptoms is not low blood sugar per se, but the over-reaction of hormones that the body calls on to prevent blood sugar from falling too low. These include adrenalin, insulin and cortisone. These hormone surges increase vulnerability for mood instability, anxiety and/or depression. (See our hypoglycemia symptoms, hypoglycemia treatments pages)
What We Might Do: We can often judge from your history whether hypoglycemia is likely. Often, we try a few weeks of an anti-hypoglycemia to see if you improve. Proper exercise and stress management are also useful. The traditional 5 hour glucose tolerance test, however, is not usually worth doing.
System VIII: Integrative Medicine-Brain, Gut and Liver Connections
The Science: The gut is an active, not a passive, organ. It communicates intimately with the brain, the immune system and other organ systems. For example, many of the hormones made in the gut also act on the brain as key neurotransmitters. Serotonin is one example.
The microorganisms that live within the gut play a critical role as supports for the immune system. Imbalances and overgrowths of gut bacteria and yeast can damage the gut's lining allowing toxic products to enter. Known as the "leaky gut syndrome" this can affect distant parts of the body.
The liver acts as the body's main waste disposal and recycling plant. The liver has specific biochemical pathways for processing metabolic by-products, hormones, foreign chemicals and medication. Many of us have weaknesses within one or more of these detox pathways. That is one reason why people might react adversely to medicines or to environmental chemicals.
Identifying and supporting weak detox pathways can aid the healing process.
What We Might Do: We have a broad range of laboratory tests for evaluating gut and liver. These include:
- The Comprehensive Digestive Stool Analysis evaluates digestive enzymes, malabsorption, bacteria, yeast, and parasites.
- The leaky gut test measures how well the gut selects which molecules to admit and which to keep out.
- The bacterial overgrowth breath test detects the presence of excessive bacteria in the gut.
- A liver detoxification challenge test monitors the strength and weakness of specific liver detox pathways.
Unfortunately, standard liver function tests do not tell us much about the liver's detox pathways.
System IX: Sleep Medicine-The Healing Power of Sleep
The Science: Both physical and mental distress undermines the healing power of sleep. Specific sleep disorders such as sleep apnea and Periodic Leg Movement Disorder (PLMD) also damage sleep. Repairing sleep quality strengthens the body's healing systems overall.
What We May Do: We take a careful history to evaluate sleep patterns. We may ask you to have a friend observe you while asleep. A few people require an overnight sleep study.
Many behavioral, nutritional, herbal and pharmacological options are available. It may be difficult to predict in advance which will do best, but persistence and trial and error carries very low risk and is often effective.
System X: Metabolism Nutrition-How Mitochondria produce energy for the brain
The Science: The body's chemistry requires continuous energy every minute of our lives. We store this energy primarily within a small molecule called ATP. Mitochondria, tiny organs within cells, are where we make this ATP. The active brain requires a major share of this energy. Several neurological and metabolic diseases reflect damage to the mitochondria and their energy production.
Production of biochemical energy requires collaboration among a broad team of nutrients including Vitamins C, E and A, glutathione, Co-enzyme Q, L-Carnitine, lipoic acid, Riboflavin, and NADH (ENADA). Deficits in any of these can affect total energy output.
What We Might Do: We usually cannot measure the specific function of mitochondria, so we might cast a broad nutritional net to cover many of the elements that might need support.
Please see our discussion of chronic fatigue and fibromyalgia for more on improving mitochondrial energy.
System XI: Exercise, the best medicine, if done just right
Both too much and too little exercise can make mood disorders worse. In contrast, exercise that is tailored to each individual's abilities and needs almost always helps mood. We base our exercise advice on the Goldilocks Principle. Do the right amount, not too little and not too much.
Recent research suggests that CFS/FMS has different effects on aerobic versus anaerobic metabolism. Aerobic capacity (e.g. for sustained walking) is often moderately to severely reduced. However, anaerobic capacity (e.g. brief heavy-lifting) is usually fairly well preserved.
What We Might Do: We take a careful exercise history and tailor your starting program to your individual needs, abilities and interests. Often, we start at much lower intensities than you might expect. We then build slowly, but steadily, with the pace based on your tolerance. We help design separate programs for aerobic and anaerobic work. Beneficial effects on mood may require several months, but this approach to exercise is one of the most dependable of all therapies.
System XII: Positive Psychology-How To Feel In Control while coping with Illness
Coping with chronic illness can be very difficult. Positive change comes easier when you feel in control and optimistic. Traditional talk therapy works toward this goal, and we support its use. However, we also offer additional techniques that much psychotherapy tends to overlook.
Behavioral Medicine/Relaxation is not so much psychotherapy as training to use a set of skills. Like learning to ride a bicycle, it's awkward at first, but quickly becomes second nature. Mastering behavioral/relaxation skills improves control over your physical and mental response to stress. This helps you keep your emotional balance.
We offer a selection of behavioral tools including slow diaphragmatic breathing, guided visual imagery, and deep muscle relaxation. We also teach advance skills, one of which, called Freeze-Frame, has these great advantages. It reduces stress reactions within one minute and you can do it while you carry on with activities. No one around you need know that you are relaxing.
Cognitive behavioral therapy (CBT) is another educational skill. CBT helps you reframe issues and problems in ways that escape the trap of negative thinking, and also helps recognize opportunities for healthy change. Our basic CBT training requires only a few sessions.