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Holistic (Biopsychosocial) Approach to Diagnosis and Treatment
Why Holistic?
~ 30% to 40% of patients with major depressive disorder (MDD) do not respond sufficiently to usual antidepressant treatment
~ Even under optimal treatment conditions, only one-third of patients achieve remission
~ Among patients who fail to respond to two pharmacologic interventions, remission rates with the next antidepressant are as low as 12%
~ A patient becomes less likely to respond clinically with each additional nonresponse to antidepressant treatment
Why Holistic
~ 1. The cause may not be the “obvious” reason
~ 2. Positive changes in any symptom will positively impact the rest of the system
~ 3. For people to feel happy and healthy, the system (body machine) needs to be running efficiently
Why Holistic
HPA & Gut-Brain-Axis
~ Medical conditions that alter sex or thyroid hormone levels, blood sugar regulation or oxygenation can cause symptoms of anxiety, irritability, hypomania, depression
~ Diabetes
~ Blood sugar dysregulation activates the HPA-Axis which can cause irritability, difficulty concentrating
~ Autoimmune Disorders (CF, Fibro, Chron’s, Rheumatoid arthritis) are triggered by stress and trigger inflammation and additional HPA-Axis Activation
~ Cardiac Disorders can prevent adequate oxygenation or resemble panic attacks
Medical- Thyroid
~ Thyroid imbalances can be caused by autoimmune disease, genetics, nutritional imbalances, hormone imbalances
~ Anxiety symptoms can precede an official diagnosis of hyperthyroid by up to 5 years
~ Thyroid hormones impact the availability of serotonin which impacts mood
~ Cortisol from chronic “stress” reduces thyroid levels, ergo anxiety, PTSD and even depression can impact thyroid levels
~ Hypothyroid has a prevalence of ~10% in women and 2% in men
~ The risk of hypothyroidism increases during pregnancy, after delivery and around menopause.

Medical- Sex Hormones
~ Sex hormone imbalances can be caused by diabetes, testicular injury, drug use including, oral corticosteroids, inhaled corticosteroids (LTU) or birth control, menopause, polycystic ovarian syndrome, hysterectomy, child birth, cessation of breast feeding…
~ Estrogen and testosterone impact serotonin availability.
~ Too much or too little of either can produce anxiety or depressive symptoms
~ High levels of the estrogen affect our ability to deal with stress
~ The production of cortisol affects the concentration of all sex hormones.
Medical- Sex Hormones
~ Both men and women produce luteinizing hormone, testosterone, and estrogen.
~ Under stress the body shuts down libido so that we can deal with more urgent, survival needs.
~ Testosterone is suppressed under chronic stress/cortisol
~ Estrogen is often elevated but luteinizing hormone is reduced under chronic stress/cortisol
~ Mood
~ Changes in availability of neurotransmitters
~ Lack of adequate oxygenation
~ Thyroid imbalances
~ Increased “stress” due to medical conditions
~ Sleep
~ Apnea
~ Exhaustion (thyroid or low oxygen)
~ Pain
~ Circadian rhythm imbalance
~ Too little or too much testosterone may affect overall sleep quality

~ Nutrition / Malabsorption
~ Building Blocks
~ Gut-Brain Axis
~ Substances (including caffeine and nicotine)
~ HPA-Axis
~ Thyroid Imbalances
~ Sex Hormones Imbalances
~ Pain
~ Pain
~ Reduced serotonin  Reduced pain tolerance
~ Too little movement  Stiffness and pain

~ Pain can be caused by a variety of things including aging, autoimmune issues, medication side effects, musculoskeletal or neurological problems
~ Mood and Thoughts
~ Increase anxiety
~ Cognitions
~ Things will get worse
~ Mortality
~ Rejection
~ Increase depression
~ Cognitions: Hopelessness and helplessness
~ Feelings of guilt, envy, resentment, anger
~ Activates the HPA-Axis
~ Increased stress
~ Perception of pain/vulnerability
~ Nutrition
~ Especially substances and medications including NSAIDs which can upset stomach and cause dysfunction in the endogenous opioid system (pleasure system)
~ Sleep
~ Discomfort
~ Medication
~ Tryptophan, tyrosine, phenylalanine are building blocks for neurotransmitters
~ Tryptophan is converted to serotonin (reduced depression & pain sensation, improved gut motility, increased relaxation)
~ Eating carbohydrates can trigger a release of brain tryptophan
~ Tyrosine and its precursor phenylalanine are converted into dopamine and norepinephrine  arousal, alertness
~ The neurotransmitter dopamine is made from the essential* amino acid tyrosine and the neurotransmitter serotonin is made from the tryptophan
~ Autoimmune issues and stress contribute to gut permeability and malabsorption

~ Caffeine is a stimulant with a 6-hour half life
~ Nicotine is a stimulant with a 2-hour half life
~ Decongestants are stimulants with a 2 hour half life
~ Antihistamines make you drowsy but contribute to poor quality sleep
~ Alcohol blocks REM sleep and can cause sleep apnea
~ The body can only use food to create certain amino acids necessary for neurotransmitters

Nutrient Deficiency Symptoms
~ Tryptophan -> 5 HTP ->Serotonin -> Melatonin
~ (Phenylalanine ->)Tyrosine ->Thyroid hormones
~ Tyrosine -> Dopamine -> Norepinephrine (Neurotransmitter) -> Epinephrine/Adrenaline (hormone)
~ Glutamine -> Glutamate -> GABA
~ Mood
~ Changes in availability of neurotransmitters
~ Lack of adequate oxygenation (anemia)
~ Excitation or retardation due to thyroid imbalances
~ HPA-Axis
~ Blood sugar
~ Availability of neurotransmitters and hormones

~ Sleep
~ Insufficient Tryptophan to make melatonin
~ Too many stimulants
~ Pain
~ Reduced serotonin  Reduced pain tolerance
~ Too little movement  Stiffness and pain
~ Health
~ Lack of building blocks for repair
~ Addition of substance that trigger oncogenes
Nutrition cont…
~ Keep a food diary to ensure that you
~ Eat sufficient quality complete proteins
~ Drink plenty of water
~ Get enough
~ Selenium
~ Vitamin D
~ Calcium
~ Vitamin A
~ Magnesium
~ Zinc

What is the Function of Sleep
~ Sleep is time to rest and restore
~ Adequate sleep improves memory and learning, increases attention and creativity, and aids in concentration and decision making.
~ Toxins that accumulate in the brain are thought to be cleared out during sleep
~ Muscle growth, tissue repair, protein synthesis, and growth hormone release occur mostly, or in some cases only, during sleep.
~ Healing and repair of cells takes place during sleep

Function of Sleep
~ Sleep helps to maintain the balance of hormones in the body:
~ Ghrelin and leptin, which regulate feelings of hunger and fullness
~ Insulin, which is responsible for the regulation of glucose in the blood
~ Other rejuvenating aspects of sleep are specific to the brain and cognitive function.
~ While we are awake, neurons in the brain produce adenosine.
~ The build-up of adenosine in the brain may lead to our perception of being tired.

Circadian Rhythms
~ Circadian rhythm disorders can be caused by many factors, including:
~ Shift work
~ Pregnancy
~ Time zone changes
~ Medications
~ Changes in routine such as staying up late or sleeping in
~ Medical problems including Alzheimer's or Parkinson disease
~ Mental health problems

Physical Interventions
~ Interventions
~ Complete physical to assess:
~ Thyroid
~ Sex hormone
~ Vitamin D
~ Iron
~ Pain
~ Thiamine (alcoholism, anorexia or bariatric surgery)
~ Nutritional assessment
~ Ergonomic assessment (Work, sleep)
~ Sleep study (or at least recording)
~ Develop a sleep hygiene improvement plan
~ Address pain issues (nonpharmacologically when possible)

~ Mood
~ Buildup of toxins ->Difficulty concentrating and irritability
~ Fatigue/Loss of energy
~ Increased “stress” due to difficulty concentrating and lethargy
~ HPA-Axis
~ Stress increase
~ Nutrition / Malabsorption
~ Circadian rhythms are out of whack -> appetite disturbances
~ Substances (including caffeine and nicotine)

~ Pain
~ Reduced serotonin  Reduced pain tolerance
~ Too much sleep Stiffness and pain
~ Health
~ Cardiovascular disease
~ Stroke
~ Diabetes
~ Kidney disease

~ Mood impacts perception
~ Perception impacts stress levels
~ Stress levels impact…everything else
~ Interventions
~ Help people focus on what they have control over, what they are grateful for
~ Have clients do things that make them happy.

~ HPA-Axis
~ Increases “stress”
~ Nutrition
~ Appetite disturbances from CR disruption
~ Poor nutrition -> Lack of building blocks
~ Stress increases gut permeability, malabsorption and inflammation
~ Substances (including caffeine and nicotine)
~ Sleep
~ Wanting to avoid the world and sleep all the time
~ Thoughts
~ Negative perceptions
~ Pain
~ Reduced serotonin  Reduced pain tolerance
~ Bruxism
~ Muscle tension
~ Health
~ Obesity
~ Hypertension and other “stress related illnesses”

~ Unpleasant thoughts and unresolved traumatic memories increase feelings of hopelessness, helplessness, anger, resentment, anxiety, guilt, grief…
~ Unpleasant thoughts and memories and dysphoric emotions encourage people to interpret the world through a stressful lens
~ Interventions
~ Encourage focusing for 5 minutes 3 times a day on what is going well and making them happy
~ Address cognitive distortions
~ Address trauma from the past
~ Educate about dialectics and living in the “And”

~ Mood
~ Focus on the negative
~ Increase dysphoria through HPA Axis Activation
~ HPA-Axis
~ Perception of threat
~ Sense of helplessness
~ Hypocortisolism
~ Sleep
~ Ruminations
~ Pain
~ Focus on the pain
~ Nutrition
~ Poor nutrition
~ Malabsorbtion due to stress caused from thoughts
~ Substances (including caffeine and nicotine)
~ Health
~ Hypertension and other “stress related illnesses”
~ Many people with addictions or mental health issues have concurrent physical health issues
~ Many people who do not respond to antidepressants may have dysfunction in one of the other systems that supports neurotransmitter availability.
~ A positive change in any aspect of the system will often have positive effects throughout the system, but a problem in any aspect of the system can also cause problems throughout the system.
~ If is important to recognize that addictions and mood disorders may have developed as a result of dysfunction in another system (thyroid, sex hormones) or due to poor nutrition or sleep deprivation (Think HALT)
Differential Diagnosis