Post on 25-Dec-2015
Examining Medical Causes of Psychological Symptoms: An Orthomolecular and Functional
Medicine Approach
David Reinhardt Ph.D. ABMPDavid Reinhardt Ph.D. ABMPNational Alliance of Professional Psychology ProvidersNational Alliance of Professional Psychology Providers2010 NAPPP Practice Conference October 9-10 Las Vegas NV2010 NAPPP Practice Conference October 9-10 Las Vegas NV
Askdrdave@gmail.comAskdrdave@gmail.com
www.CenterforHealthScience.comwww.CenterforHealthScience.com
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Symptom CheckerSymptom Checker Discount lab service / Alternative treatment products Discount lab service / Alternative treatment products Affiliate Program and Referral ServiceAffiliate Program and Referral Service Power Point PresentationPower Point Presentation ““Drugs That Cause Psych Effects” Excel file Drugs That Cause Psych Effects” Excel file
www.Epocrates.comwww.Epocrates.comFree and Fee Software for Desktop and MobileFree and Fee Software for Desktop and MobileDrug and natural medicine informationDrug and natural medicine informationPractice guidelinesPractice guidelinesMany free toolsMany free tools
www.orthomed.orgwww.orthomed.org Orthomolecular Medicine Online Orthomolecular Medicine Online
www.ohmsociety.comwww.ohmsociety.com Orthomolecular Health Medicine Society Orthomolecular Health Medicine Society
functionalmedicine.orgfunctionalmedicine.org The Institute for Functional Medicine The Institute for Functional Medicine
www.labtestsonline.orgwww.labtestsonline.org Complete information on lab tests Complete information on lab tests
www.apexseminars.comwww.apexseminars.com Lab Test courses Lab Test courses
The Doctor of the Future“The doctor of the future will be an integrative healer whose practice differs in many ways from that of today's typical physician. The doctor of the future will provide care that is patient-centered and comprehensive (body, mind, and spirit), and care that is both high-tech (using genomic prediction tools, systems biology, and functional medicine, for example) and high-touch.”
“Care will focus more extensively on preventing disease and injury. The practice of the future will be provided by smoothly working teams that will include primary care physicians, complementary and alternative health practitioners, health coaches, and wellness mentors, as well as medical specialists, allied health and nursing practitioners.” (Foundation for Alternative and Integrative Medicine)
“Modern” Mental Health Treatment
IS NOT
Modern Mental Health Science
“Diagnostic Standards of Care”
are poorly written and generally
lacking for symptoms of mood,
cognition and behavior
APA Practice Guideline for the Treatment of Patients With Major
Depressive Disorder May 2010
152 Page Document states "...not 152 Page Document states "...not intended to be construed or to intended to be construed or to serve as a standard of medical serve as a standard of medical care…care…Communication with Communication with other other clinicians who are providing clinicians who are providing
treatment for general medical treatment for general medical conditions is recommended."conditions is recommended."
APA Differential Diagnosis of Depression:
Rule Outs:Rule Outs: StrokeStroke Parkinson'sParkinson's DementiaDementia Multiple SclerosisMultiple Sclerosis Thyroid DisordersThyroid Disorders HypercalcemiaHypercalcemia MalignancyMalignancy Infectious DiseasesInfectious Diseases
Medications Medications including:Anti-rejection including:Anti-rejection AgentsAgents
Chemotherapy Agents Chemotherapy Agents InterferonInterferon SteroidsSteroids Some AntibioticsSome Antibiotics
Tests:Tests: No RecommendationsNo Recommendations
The Merck Manual for
Healthcare Professionals
does better
Merck Depression Chart
Unfortunately, the Merck
Manual is seldom followed
and offers little guidance on
other psychological symptoms
Epocrates Inc. Software
Clinical information and decision Clinical information and decision support toolssupport tools
Used by “over 40% of US Used by “over 40% of US Physicians”Physicians”
www.epocrates.comwww.epocrates.com
Offers reliable free and
subscription applications for
handhelds and desktop
Epocrates Home Page
Diagnostic Standard of Care for Depression (Epocrates.com)
DifferentialDifferential Situational adjustment Situational adjustment
reaction with depressed moodreaction with depressed mood Bipolar disorderBipolar disorder Premenstrual dysphoric Premenstrual dysphoric
disorder (PMDD)disorder (PMDD) Grief reactionGrief reaction DementiaDementia Anxiety disordersAnxiety disorders Alcohol abuseAlcohol abuse Anorexia nervosaAnorexia nervosa
HypothyroidismHypothyroidism Medication adverse effectsMedication adverse effects Cushing diseaseCushing disease Vitamin B12 deficiencyVitamin B12 deficiency
TestsTests Symptom questionnairesSymptom questionnaires CBCCBC Thyroid function testsThyroid function tests 24-hour free cortisol24-hour free cortisol Vitamin B12Vitamin B12 Folic acidFolic acid
Epocrates Page
Diagnostic Standard of Care for Anxiety (Epocrates.com)
DifferentialDifferential Panic disorderPanic disorder Social phobiaSocial phobia Post-traumatic stress disorderPost-traumatic stress disorder Obsessive-compulsive disorderObsessive-compulsive disorder DepressionDepression Substance-induced anxiety disorderSubstance-induced anxiety disorder Anorexia nervosaAnorexia nervosa Situational anxiety (nonpathologic)Situational anxiety (nonpathologic) Cardiac diseaseCardiac disease Pulmonary conditions (i.e., COPD, Pulmonary conditions (i.e., COPD,
asthma)asthma) HyperthyroidismHyperthyroidism InfectionsInfections Crohn diseaseCrohn disease Irritable bowel diseaseIrritable bowel disease Ulcerative colitisUlcerative colitis
Asthma medicationsAsthma medications CorticosteroidsCorticosteroids AntidepressantsAntidepressants Beta-blockersBeta-blockers Peptic ulcer diseasePeptic ulcer disease
TestsTests Thyroid function testsThyroid function tests Urine drug screenUrine drug screen 24-hour urine for vanillylmandelic and 24-hour urine for vanillylmandelic and
metanephrinesmetanephrines Pulmonary function testsPulmonary function tests EchocardiogramEchocardiogram Electrocardiogram (EKG)Electrocardiogram (EKG) Electroencephalogram (EEG)Electroencephalogram (EEG)
Epocrates Page
Diagnostic Standard of Care for Insomnia (Epocrates.com)
DifferentialDifferential Restless leg syndromeRestless leg syndrome Periodic limb movement Periodic limb movement
disorderdisorder Obstructive sleep apneaObstructive sleep apnea Circadian rhythm Circadian rhythm
disordersdisorders
TestsTests Symptom questionnairesSymptom questionnaires
PolysomnographyPolysomnography Sleep DiarySleep Diary TSHTSH
Epocrates Page
Diagnostic Standard of Care for Schizophrenia (Epocrates.com)
DifferentialDifferential Substance-induced psychotic Substance-induced psychotic
disorderdisorder Dementia with psychosisDementia with psychosis Malingering and factitious Malingering and factitious
disordersdisorders Delusional disorderDelusional disorder Brief psychotic disorderBrief psychotic disorder Pervasive developmental Pervasive developmental
disorderdisorder Organic psychosisOrganic psychosis Carbon monoxide poisoningCarbon monoxide poisoning Heavy metal poisoningHeavy metal poisoning
Medication-induced psychosisMedication-induced psychosis Liver diseaseLiver disease HyperthyroidismHyperthyroidism HyperparathyroidismHyperparathyroidism
TestsTests CT/MRI headCT/MRI head Serum HIVSerum HIV Serum rapid plasma regainSerum rapid plasma regain CBCCBC Urine drug screenUrine drug screen Plasma drug level monitoringPlasma drug level monitoring
Epocrates Page
Diagnostic Standard of Care for Bipolar Disorder (Epocrates.com)
DifferentialDifferential Mood disorder due to Mood disorder due to
general medical conditiongeneral medical condition Substance induced mood Substance induced mood
disorderdisorder Major depressive disorderMajor depressive disorder Dysthymic disorderDysthymic disorder Cyclothymic disorderCyclothymic disorder Psychotic disordersPsychotic disorders Personality disordersPersonality disorders Obsessive-compulsive Obsessive-compulsive
disorderdisorder ADHDADHD
TestsTests Symptom questionnairesSymptom questionnaires CBCCBC Thyroid function testsThyroid function tests Serum Vitamin DSerum Vitamin D Toxicology screenToxicology screen Fasting lipidsFasting lipids Fasting glucoseFasting glucose MRI brainMRI brain
Epocrates Page
Diagnostic standard of care for OCD (Epocrates.com)
DifferentialDifferential Obsessive-compulsive Obsessive-compulsive
personality disorderpersonality disorder Body dysmorphic disorderBody dysmorphic disorder HypochondriasisHypochondriasis Delusional disordersDelusional disorders Severe social phobiaSevere social phobia Panic disorderPanic disorder AutismAutism Asperger syndromeAsperger syndrome
TestsTests Symptom questionnairesSymptom questionnaires No lab tests recommendedNo lab tests recommended
Epocrates Page
Diagnostic Standard of Care for Dementia (Epocrates.com)
DifferentialDifferential Mild cognitive impairmentMild cognitive impairment DeliriumDelirium DepressionDepression Vascular dementiaVascular dementia Dementia of Lewy bodyDementia of Lewy body Frontotemporal dementiaFrontotemporal dementia Parkinson diseaseParkinson disease Creutzfeld-Jacob diseaseCreutzfeld-Jacob disease
TestsTests Cognitive testingCognitive testing CBCCBC Erythrocyte sedimentation Erythrocyte sedimentation
raterate Metabolic panelMetabolic panel Serum TSHSerum TSH Serum B12Serum B12 Serum VDRLSerum VDRL
Epocrates Page
All of these approaches, if followed, allow the patient to be
put into a diagnostic box
Treatment consists of prescribing psychotropics and, hopefully,
psychotherapy
Current practice guidelines have 2 things
in common...
Treatments mostly suppress
symptoms
Causes are seldom explored
“Modern” Medical Treatment
IS NOT
Modern Health Science
A branch of healthcare has
looked to treat CAUSES since
the days of Ancient Civilizations
It has been MARGINALIZED
by “Modern Medicine”
It offers limited profit potential
for drug companies
Psychology!
Another branch of healthcare has been similarly marginalized by
Modern Medicine
It too has limited profit potential for drug companies
Orthomolecular Medicine
“Critics have described some
aspects of orthomolecular
medicine as food faddism or
quackery.” (Wikipedia)
Orthomolecular Medicine draws on health knowledge with roots
in pre-history
It reflects the most recent It reflects the most recent science, learning from the science, learning from the
discoveries of genetic discoveries of genetic research and bioscienceresearch and bioscience
“Orthomolecular medicine aims to
restore the optimum environment of
the body by correcting imbalances or
deficiencies based on individual
biochemistry” (Linus Pauling)
“Orthomolecular practice rests on a
foundation of basic science advances in
biochemistry, biophysics, genetics,
physiology, psychophysiology and
ecology. We do not eschew drug therapy
or pharmacology; but we do recognize
their limitations and their potential for
toxicity.” (Richard Kunin)
Orthomolecular medicine uses substances natural to the body
such as vitamins, minerals, amino acids, trace elements and
fatty acids
Orthomolecular Medicine has a Big Tent
Orthomolecular Medicine uses: VitaminsVitamins MineralsMinerals Amino acidsAmino acids Essential fatty acidsEssential fatty acids Fiber enzymesFiber enzymes AntibodiesAntibodies AntigensAntigens Cell therapyCell therapy AcupunctureAcupuncture MassageMassage ExerciseExercise BiofeedbackBiofeedback
Chelation therapyChelation therapy DialysisDialysis PlasmapharesisPlasmapharesis HydrotherapyHydrotherapy Thermal therapyThermal therapy PhototherapyPhototherapy ElectrotherapyElectrotherapy Air ion therapyAir ion therapy Light TherapyLight Therapy Solar therapySolar therapy HypnotherapyHypnotherapy PsychotherapiesPsychotherapies
7 Cardinal Rules of Orthomolecular Medicine
1. Nutrition comes first in medical 1. Nutrition comes first in medical diagnosis and treatment diagnosis and treatment
2. Drug treatment is used only for 2. Drug treatment is used only for specific indications and always with specific indications and always with an eye to the potential dangers and an eye to the potential dangers and adverse effectsadverse effects
7 Cardinal Rules of Orthomolecular Medicine
3. 3. Environmental pollution and food Environmental pollution and food adulteration are an inescapable fact adulteration are an inescapable fact of modern life and are a medical of modern life and are a medical prioritypriority
4. 4. Biochemical individuality is the Biochemical individuality is the norm in medical practice; therefore norm in medical practice; therefore stereotyped RDA values are stereotyped RDA values are unreliable nutrient guidesunreliable nutrient guides
7 Cardinal Rules of Orthomolecular Medicine
5. Blood tests do not necessarily reflect tissue 5. Blood tests do not necessarily reflect tissue levels of nutrientslevels of nutrients
6. Nutrient diagnosis is always defensible 6. Nutrient diagnosis is always defensible because nutrient related disorders are because nutrient related disorders are usually treatment responsive or curableusually treatment responsive or curable
7. Hope is an indispensable ally of the 7. Hope is an indispensable ally of the physician and an absolute right of the physician and an absolute right of the patientpatient (Richard (Richard Kunin)Kunin)
Orthomolecular medicine does not purport to treat all diseases, nor is it "a replacement for standard treatment. A proportion of patients will require orthodox treatment, a proportion will do much better on orthomolecular treatment, and the rest will need a skillful blend of both”
(Abram Hoffer)(Abram Hoffer)
Functional Medicine puts a fresh name to the core concepts of Orthomolecular Medicine
The Institute of Functional Medicine was founded by Jeffrey Bland in 1991
Orthomolecular/Functional Medicine identifies and treats using a 3 prong approach:
AntecedentsAntecedents TriggersTriggers MediatorsMediators
ANTECEDENTS
Are things that happen before Are things that happen before disorders startsdisorders starts
• Genetic Variations
• Genetic Regulation
• In-utero Exposure
• Early Life Exposure
Genes control the formation and structure of nutrient and
neurotransmitter receptors
Genetic variations influence metabolic pathways and lead to the
“Neurotransmitter Imbalances” claimed by the drug makers
Genetic variations can impair absorption of sufficient nutrients,
leading to mood, behavior and physical symptoms
Things that unmask your antecedents
They are involved in REGULATION and EXPRESSION of particular genes
Early life events may alter gene expression through:
•Viral Exposure•Radiation Exposure•Drugs•Environmental Pollutants
TRIGGERS
Orthomolecular Scientists counsel to avoid disorders caused by antecedents through appropriate lifestyle, nutritional supplementation, diet, and shunning of additives and industrial pollutants.
Nutrients may be used as a “work-around” to impaired metabolic pathways at the Trigger level.
Example
5,10-methylenetetrahydrofolate reductase 5,10-methylenetetrahydrofolate reductase (MTHFR) polymorphisms impair (MTHFR) polymorphisms impair conversion of folic acid to methionine, conversion of folic acid to methionine, resulting in increased risk of:resulting in increased risk of: Coronary Artery DiseaseCoronary Artery Disease Inflammatory bowel diseaseInflammatory bowel disease DepressionDepression Down’s SyndromeDown’s Syndrome Alzheimer’s disease (possibly) Alzheimer’s disease (possibly)
MTHFR variant C667T
Occurs in:Occurs in:
26.6% of Whites26.6% of Whites
12.4% of Blacks12.4% of Blacks
41.5% of Hispanics41.5% of Hispanics
Identification of MTHFR related risk can be made by:
Genetic testingGenetic testing Nutrient testingNutrient testing Interpretation of subtle symptomsInterpretation of subtle symptoms Best guessBest guess
Typical Orthomolecular Intervention: Supplemental Folic
Acid!
Taking high dose supplemental folic acid Taking high dose supplemental folic acid “pushes” the metabolic pathway to create “pushes” the metabolic pathway to create
sufficient methionine. This is safe, and has sufficient methionine. This is safe, and has no adverse effects.no adverse effects.
Are those things your body does to try to rectify the consequences of the antecedents and triggers
Feedback loops are Mediators that attempt to compensate for imbalances in an attempt to reach homeostasis
MEDIATORS
Mediators are very effective at rectifying imbalances due to
drugs
These feedback loops are the Achilles’ heel of Modern
Medicine
Orthomolecular/Functional medicine tries to understand antecendents and intervene at the
trigger level.
Modern Medicine understands mediators and intervenes at the symptom level.
That is one of the fundamental differences
between the two disciplines
A Proposed Diagnostic Protocol
for Assessment of Mental Health
Symptoms
1. Diagnostic Interview
Symptom Questionnaire
Symptom Checker
2. Medication Review
Appropriateness of DosageAppropriateness of Dosage Adverse EffectsAdverse Effects Interactions CheckerInteractions Checker Consult when beyond your level of Consult when beyond your level of
expertiseexpertise
Abilify
Drugs Excel
3. Consider Possible Alternate Explanations
Consult!Consult! www.wrongdiagnosis.comwww.wrongdiagnosis.com www.CenterforHealthScience.comwww.CenterforHealthScience.com
CHS depression
For Information on Lab Testing:For Information on Lab Testing: labtestsonline.orglabtestsonline.org CenterforHealthScience.comCenterforHealthScience.com Apexseminars.comApexseminars.com
4. Recommend or Obtain Medical Labs
to rule out physical causes
Depression Labs
Apex
5. Refer for Treatment!
Allopathic PhysicianAllopathic Physician Naturopathic PhysicianNaturopathic Physician Doctor of Oriental MedicineDoctor of Oriental Medicine Ayurvedic PhysicianAyurvedic Physician Medical PsychologistMedical Psychologist NutritionistNutritionist Other ProfessionalsOther Professionals
Qualified Referral Sources Institute of Functional Medicine members: Institute of Functional Medicine members:
www.functionalmedicine.orgwww.functionalmedicine.org Orthomolecular Health Medicine members: Orthomolecular Health Medicine members:
www.ohmsociety.comwww.ohmsociety.com ISOM Members:ISOM Members:
www.orthomed.orgwww.orthomed.org Center for Health Science:Center for Health Science:
www.centerforhealthscience.comwww.centerforhealthscience.com