Although spring is trying to get a start, Colorado tends to be slow on the up take. This month’s newsletter has three information packed articles on anxiety, autism and massage cupping to help you get your spring moving! It is Autism awareness month and recently the CDC just revised their disease incidence figures from 1:80 > 1:50! Dr. Karen speaks on epigenetics and how we can treat, and successfully manage autism, but more importantly how we can PREVENT Autism through mom’s health. Dr. Ian speaks on the most common neuropsychiatric condition in the USA, anxiety. Many are unaware how complex anxiety can be but also how effective it can be treated through the functional medicine model and strategies like heart math training. Lastly, Erin Stanley, LMT, explains how cupping technique can effectively address dysfunction and pain to leave you relaxed and energized!
Anxiety and Heart Rate Variability
Anxiety is one of the most common neuropsychiatric disorders presenting to clinicians today, but its many manifestations and origins cause complexity in differential diagnosis. Anxiety disorders can either be categorized as exogenous or endogenous (Cameron, 1985). Phobic disorders (exogenous) are described as anxiety symptoms evoked from environmental stimuli. The stimulus that is provoking the symptom characterizes and determines the diagnosis. In comparison, panic attacks and generalized anxiety disorders (GAD (endogenous)) correlate to symptoms of anxiety not only associated with a specific eliciting stimulus. Panic disorders are differentially diagnosed from GAD by the onset of discrete attacks lasting 10-60 minutes, although both disorders usually have a level of persistent anxiety. Depression disorders are frequently associated with anxiety symptoms, but this is not necessary for the diagnosis of depression. The purpose of this review will look at GAD, its common diagnosis and treatment in western medicine and how complementary and alternative treatments like heart rate variability training and the functional medicine model can help co-manage with modern western treatments, or, potentially replace the standard pharmacotherapy model.
Diagnosis and treatment with the western model
GAD is one of the most common, under recognized and undertreated psychiatric conditions, which present to physicians (Davidson. et al, 2010). GAD is the most common anxiety related disorder to present to clinicians. In spite of this, its diagnosis may elude clinicians although it is responsive to therapies. According to the DSM-IV, 5-6% of the world’s population experiences anxiety, exogenous or endogenous in origin. GAD is mainly diagnosed through excessive worry that is difficult to control with at least 3 of a list of 6 symptoms: irritability, difficulty concentrating, restlessness, muscle tension, sleep disturbances and being easily fatigued. These listed symptoms must be distressing to the patients and or cause impairment and not explained by another organic disorder. The symptoms must also be present for at least 6 months. Unfortunately, although symptoms tend to fluctuate, chances are that complete recovery will not occur. Treatment typically consists of initial pharmacologic monotherapy with improvements in symptoms noted from serotonergic antidepressants, benzodiazepines, antihistamines, and newer therapies like the A2gamma ligand drug, pregabalin. If monotherapy fails the typical next step is to start polypharmacy or potentially include psychotherapy. Goals of treatment focus on not only the relief of symptoms but also restoration of a high functioning quality of life. This may be particularly challenging in the GAD sufferers who also experience problems with insomnia and that there are numerous reports that success with first line therapy may take 4-6 months into treatment (Allgulander, 2002)! With the potential side effects and black box suicide warnings for those under 25, it appears there is necessity to develop treatment protocols which emphasize the bodies natural ability to heal itself.
Functional medicine connections with GAD
Functional medicine is a systems based method of addressing the underlying causes of disease. By engaging both the clinician and patient in a therapeutic encounter it evolves the practice of medicine so that complex clinical conditions can be broken down and systematically addressed with lifestyle, dietary, structural and supplemental changes. Through this new paradigm we look at a condition in relation to numerous areas in a patient that may be contributing and interacting to create their clinical scenario. These areas are: defense and repair, energy, biotransformation and elimination, transport, communication, structural integrity, structural integrity and assimilation. All of these areas interact with each other and it is these interactions among antecedents, triggers and mediators that dictate how a patient may experience their disease. Numerous dietary factors are at play with anxiety, something rarely addressed by western medicine. Reactive hypoglycemia or an excessive fall in blood sugar will lead to an over activation of the sympathetic nervous system, which may facilitate the release of epinephrine and norepinephrine. This reaction helps to restore normal blood sugar levels at the expense of potentially creating anxiety, palpitations, sweating or irritability. Energy biotransformation is clearly altered in these reactions and unfortunately a vicious cycle where insulin is over secreted can begin leading towards insulin resistance and systemic inflammation. Many investigators indicate reactive hypoglycemia is a common contributing factor to chronic anxiety (Uhde T, 1984). Caffeine has also been implicated in anxiety disorders and symptoms like nervousness, irritability, tremors, insomnia and palpitations can be confused for GAD. GAD sufferers also appear to be more sensitive to caffeine and this may implicate single nucleotide polymorphisms (SNPs or single alterations to our genetic code that confer benefits and detrimental health effects) are present that slow caffeine clearance (detoxification stress) or create an exaggerated response to caffeine (Tiffin P. et al, 1995). Additionally, caffeine appears to heighten the biochemical responses noted in hypoglycemia, potentially worsening this condition and increasing cortisol, insulin, epinephrine and norepinephrine. In a study of 14 psychiatric patients who had been hospitalized, caffeine elimination for 3 weeks caused significant improvement in anxiety, irritability, hostility and suspiciousness (DeFreitas B, 1979). Improvements were nullified once caffeine consumption began again. Patients should be assessed for food allergies as multiple case reports indicated cessation of offending foods decreased or eliminated anxiety (Alvarez et al, 1946). Another common functional medicine condition linked to almost every core area is Candidiasis. Anxiety has been shown as one of the primary clinical presentations of chronic Candidiasis (Galland L, 1985). Therefore an anti-Candida program should be considered with patients suffering from anxiety, especially if they have post prandial gas and bloating, recurrent vaginitis, anti-biotic use history, oral contraceptives or history of steroid use. Since Candida is correlated to auto-immunity and leaky gut, it is also a potential mechanism behind the formation of GAD-65 antibodies, commonly associated with Type I diabetes, but also, treatment resistant anxiety (typically young females). GAD-65 is the enzyme that decarboxylates glutamate turning it into GABA. GABA is the main inhibitory neurotransmitter in the central nervous system. Anything that can perturb the normal effects of GABA can potentially worsen inflammation as GABA not only works as an inhibitory neurotransmitter, but also, specifically decreases immune based inflammation. Therefore, proper treatment may not necessarily be to increase GABA supplementaly, but to diminish GAD-65 antibodies by eradicating candida albicans!
Heart Rate Variability (HRV) and the Emwave-2
Heart rate Variability (HRV) is the physiological progression of variation in the time interval between multiple heartbeats. It is calculated by measuring variation in the heart’s beat-to-beat interval. HRV was originally studied in its relation to error variance, which complicated researchers efforts to distinguish accurate signals of cardiac activity (Lehrer, 2007). Later it was found that HRV was a marker of physiologic status and specifically a reliable measure of the ability to adapt to physiological changes. This has been used as a tool to show low HRV signifies susceptibility to disease and stress (Wheat, 2010). HRV is a mechanism that the body uses to maintain an adequate level of cardiovascular activity. When physiology is not performing at a high level, a person’s stress response may be larger and extended over time. Consequently, the person may experience more negative outcomes from stress that may lead to diseases such as cardiovascular, metabolic syndrome, anxiety and depression (McGrady, 2007). Therefore it is plausible that harmonizing HRV could train patients to increase their ability to adapt to stressors and reduce their risk of disease. Heart Math is a company that has incorporated specific research on HRV into hardware and software systems that harness the diagnostic and therapeutic abilities of HRV. Specifically, their Emwave-2 device can measure HRV and through guided imagery, relaxation techniques and breathing exercise, specifically tap into the relaxation response and treat conditions like GAD. The benefit of biofeedback and specifically the Emwave-2 is that it is a portable, easy to use device that requires little training to effectively use. The benefit of biofeedback is that it assesses the bodies’ response to its current situation and gives an objective assessment of color (blue-neutral green-coherence and red-sympathetic dominant) to represent its physiologic state. The practitioner and patient can quickly assess status and engage in therapeutic modalities like deep, paced belly breathing, visualization and meditation to decrease heightened arousal and erratic heart rate variability, which are connected to anxiety.
The science of Heart Rate Variability modulation in anxiety
The research for HRV impacting GAD is growing and to date there are numerous studies implicating poor HRV and GAD (Pittig A. et al, 2012, Cohen et al, 2000, Thayer et al, 1996). Most studies have focused on panic disorders, GAD disorders and some social anxiety disorder. Most studies have looked at HRV and heart rate as outcome measures of cardiovascular and autonomic activity. HRV can represent an index of sinus arrhythmia (RSA), which allows researchers to assess HRV fluctuations that are linked to the breathing cycle and parasympathetic modulation. Most research to date implicates close ties between low RSA and psychopathology, especially anxiety disorders (Pittig A. et al, 2012). The polyvagal theory by Porges connects autonomic regulation and RSA to a multitude of psychopathologic states and behaviors. Accordingly, the polyvagal theory links various phylogenetic systems of the autonomic nervous system to cardiac control that seem to be directly connected in GAD. These studies have demonstrated lower HRV at rest in GAD patients or in response to anxiety-related provocation, compared to non-anxious controls. PD patient’s demonstrated especially dramatic inhibition of HRV when subjected to panicogenic substances like yohimbe or sodium lactate (Yeragani et al, 1992). Overall the literature indicates a decrease plasticity in those affected by anxiety related disorders. Their rigidity to external stimuli is demonstrated via poor variability of their heart rate and an over-reactivity in heart rate to tasks and stimuli. Importantly, the clinician should then infer that this close relationship indicates HRV serves as an index for GAD and can be used for assessment and as a clinical outcome measure.
Protocols and implementation of HRV training for GAD
A functional medicine approach to GAD is to assess the patient’s objective labs, lifestyle factors, diet and overall willingness to adhere to a tailored plan. I approach GAD through Heart Math’s Emwave-2 HRV trainer and first assess their reaction to using the device and then begin with a session of education about locus of control and how to change this through visualization of gratitude and paced breathing as taught by Heart Math. I modulate their protocol eventually by sequentially increasing their ability to handle controlled thoughts and panic related stimuli. If a client has a specific phobia we first begin to think about that and then retrain them to think about the stimuli while practicing the biofeedback visualization and breathing. This is also encouraged at home if they are comfortable, twice daily for 20-30 minutes. I also gently coach the client on blood sugar stability and its importance as we can decrease the hormones cortisol and epinephrine. I also encourage clients to drink green tea or herbal tea so that caffeine is eliminated. Clients will also be put through an elimination, provocation diet over 28 days and if food allergies or if Candidiasis is suspected, plus, treated with anti-microbials and probiotics. There are many exogenous and endogenous causes of anxiety but functional medicine practitioners are clearly capable of assisting our society to control, contain and maybe even eliminate anxiety so that clients can thrive and live the life they never imagined possible!
If you suffer from anxiety or have loved ones who could benefit from a functional medicine perspective, call Dr. Autoimmune at 303-882-8447
References
Cameron OG, et al. The differential diagnosis of anxietry. Psychiatric and medical disorders. J Psychiatr Clin North Am. 1985. Mar 8(1): 3-23. Davidson J et al. Management of generalized anxiety disorder in primary care: Identifying the challenges and unmet needs. Prim Care Companion J CLin Psychiatry. 2010. 12(2). Allgulander C, Hirschfeld RM, Nutt DJ. Long-term treatment strategies in anxiety disorders. Psychopharmacol Bull. 2002;36 Uhde TW, et al. Glucose tolerance testing in panic disorder. Am J Psychiatry 1984; 141:1461-1463. Tiffin P. et al. Pharmacokinetic and pharmacodynamic responses to caffein in poor and normal sleepers. Psychopharmacology 1995; 121:494-502. DeFreitas B et al. Effects of caffeine in chronic psychiatric patients. Am J psychiatry. 1979; 136: 1337-1338. Alvarez et al. Puzzling “nervous storms” during food allergy. Gastroenterology 1946;7:241-242. Galland L, et al. Normocalcemic tetany and candidiasis. Magnesium. 1985; 4:339-340. Lehrer, P. (2007) Biofeedback training to increase heart rate variability. pp. 227-248. McGrady, A. (2007). Pscychophysiological mechanisms of stress: A foundation for the stress management therapies. p 16-37. Pittig et al. Heart rate and heart rate variability in panic, social anxiety, obsessive-compulsive and generalized anxiety disorder at baseline and in response to relaxation and hyperventilation. Intern J Psychophysiology. 2012. 87;19-27. Cohen et al. Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Res. 2000 Sep 25;96(1):1-13. Thayer et al. (1996). Autonomic characteristics of generalized anxiety disorder and worry. Biological Psychiatry, 39, 255-266. Yeragani et al. Effects of Yohimbine on heart rate variability in panic disorder patients and normal controls: a study of power spectral analysis of heart rate. J Cardio Pharma 1992. 20; 609.
Reversing the Autism Epidemic
Last month, a new Autism statistic hit the headlines. The incidence of Autism has increased from 1:88 to 1:50 children in the United States! The number of children with Autism is growing at a staggering rate. It’s not just more awareness or greater understanding of what Autism is. It is an increase in new cases that affect our children and families. How is it that Autism is now affecting 1:50 children whereas 30 years ago, most people did not know what Autism was? Most of us now know at least one child with autism. And as more children show autistic tendencies, more questions are raised. Why is it increasing? Why does it develop? How do you treat it? Can it be reversed? How is the diagnosis going to affect my child in school? How will it affect us financially- as a family and a nation? And the list of questions and uncertainties goes on. While there do not seem to be any cut and dry answers to these questions, there are patterns and hypotheses. One idea for why Autism is increasing is due to epigenetic changes. Our daily stresses, foods, and toxic environment cause our DNA to make changes which do not necessarily affect us, but rather show up in our children. Parental health seems to be a key to our children’s health. Hormone imbalances, especially in the mother, seem to affect the developing baby and make it more susceptible to Autism and other developmental disorders. This is not to say that the father’s health is not important, merely more research has been done on mothers. Thus addressing your health prior to conceiving can have a HUGE impact on the health of your child. There is no doubt that a child with Autism needs special care, but more importantly, they need proper care. The proper care improves the child’s condition, if not reverses it! By doing so, the child’s quality of life is improved, as is the family’s. And the family could pocket the averaged $3.2million spent over a lifetime for care of one child with Autism. There are many theories about how to treat Autism. Most of them look to the symptoms. They work on a Pavlovian treatment plan, rewarding good behavior. They look to food allergies since many children with Autism have digestive problems. They look to hormone imbalances since those are prevalent as well. But none of these actually look to the cause of the food allergies or the cause of the hormone imbalance, or why the children can’t learn concepts but rather have to do repetitive ” learning”. The missing link in most treatment ideas is the brain. The brain controls the entire body. It is necessary for proper digestion, language and skill development, hormone balance, body movement and development. So doesn’t it make sense to treat the brain to address the subsequent health issues? That is one of my favorite aspects of practicing, looking at and addressing brain imbalances. The brain has to be the cornerstone of any treatment plan that is going to truly treat and improve health. How amazing is it that there are techniques to help balance the brain, causing it to function better, and decrease autistic tendencies, permanently? The secret is looking at each case individually, addressing the brain as well as foods and hormones to create a truly life changing health plan. It is my dream to help as many children as I can with learning problems using the knowledge of the brain, neurology, nutrition, and chiropractic. I know what it is like to have a learning disability, struggle in school, and feel like the slowest and dumbest kid in class…that was me! And I know what it’s like to get the brain and nerve system functioning properly so that my dyslexia is almost non-existent.
By addressing parental health including brain balancing, hormones, allergies, etc. prior to conception, and children’s health from birth, it is possible that we can change the latest statistic on Autism. Start this change with your health or the health of your children. You will not regret it!
Contact the Dr. Autoimmune @ 303-882-8447 for more information.
Let Your Health Soar,
Dr. Karen
