Examining Medical Causes of Psychological Symptoms: An Orthomolecular and Functional Medicine Approach

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Examining Medical Causes of Psychological
Symptoms An Orthomolecular and Functional
Medicine Approach

• David Reinhardt Ph.D. ABMP
• National Alliance of Professional Psychology
  Providers
• 2010 NAPPP Practice Conference October 9-10 Las
  Vegas NV
• Askdrdave_at_gmail.com
• www.CenterforHealthScience.com

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Useful Links

• www.CenterforHealthScience.com
• Symptom Checker
• Discount lab service / Alternative treatment
  products
• Affiliate Program and Referral Service
• Power Point Presentation
• Drugs That Cause Psych Effects Excel file
• www.Epocrates.com
• Free and Fee Software for Desktop and Mobile
• Drug and natural medicine information
• Practice guidelines
• Many free tools
• www.orthomed.org Orthomolecular
  Medicine Online
• www.ohmsociety.com Orthomolecular Health
  Medicine Society
• functionalmedicine.org The Institute for
  Functional Medicine
• www.labtestsonline.org Complete information
  on lab tests
• www.apexseminars.com Lab Test courses

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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.
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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)
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Modern Mental Health Treatment IS NOT Modern
Mental Health Science
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Diagnostic Standards of Care are poorly written
and generally lacking for symptoms of mood,
cognition and behavior
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APA Practice Guideline for the Treatment of
Patients With Major Depressive Disorder May 2010  

• 152 Page Document states "...not intended to be
  construed or to serve as a standard of medical
  careCommunication with other clinicians who are
  providing treatment for general medical
  conditions is recommended."

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APA Differential Diagnosis of Depression

• Medications includingAnti-rejection Agents
• Chemotherapy Agents
• Interferon
• Steroids
• Some Antibiotics
• Tests
• No Recommendations

• Rule Outs
• Stroke
• Parkinson's
• Dementia
• Multiple Sclerosis
• Thyroid Disorders
• Hypercalcemia
• Malignancy
• Infectious Diseases

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The Merck Manual for Healthcare Professionals
does better
Merck Depression Chart
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Unfortunately, the Merck Manual is seldom
followedand offers little guidance on other
psychological symptoms
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Epocrates Inc. Software

• Clinical information and decision support tools
• Used by over 40 of US Physicians
• www.epocrates.com

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Offers reliable free and subscription
applications for handhelds and desktop
Epocrates Home Page
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Diagnostic Standard of Care for
Depression (Epocrates.com)

• Hypothyroidism
• Medication adverse effects
• Cushing disease
• Vitamin B12 deficiency
• Tests
• Symptom questionnaires
• CBC
• Thyroid function tests
• 24-hour free cortisol
• Vitamin B12
• Folic acid

• Differential
• Situational adjustment reaction with depressed
  mood
• Bipolar disorder
• Premenstrual dysphoric disorder (PMDD)
• Grief reaction
• Dementia
• Anxiety disorders
• Alcohol abuse
• Anorexia nervosa

Epocrates Page
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Diagnostic Standard of Care for Anxiety
(Epocrates.com)

• Differential
• Panic disorder
• Social phobia
• Post-traumatic stress disorder
• Obsessive-compulsive disorder
• Depression
• Substance-induced anxiety disorder
• Anorexia nervosa
• Situational anxiety (nonpathologic)
• Cardiac disease
• Pulmonary conditions (i.e., COPD, asthma)
• Hyperthyroidism
• Infections
• Crohn disease
• Irritable bowel disease
• Ulcerative colitis

• Asthma medications
• Corticosteroids
• Antidepressants
• Beta-blockers
• Peptic ulcer disease
• Tests
• Thyroid function tests
• Urine drug screen
• 24-hour urine for vanillylmandelic and
  metanephrines
• Pulmonary function tests
• Echocardiogram
• Electrocardiogram (EKG)
• Electroencephalogram (EEG)

Epocrates Page
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Diagnostic Standard of Care for Insomnia
(Epocrates.com)

• Differential
• Restless leg syndrome
• Periodic limb movement disorder
• Obstructive sleep apnea
• Circadian rhythm disorders

• Tests
• Symptom questionnaires
• Polysomnography
• Sleep Diary
• TSH

Epocrates Page
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Diagnostic Standard of Care for Schizophrenia
(Epocrates.com)

• Differential
• Substance-induced psychotic disorder
• Dementia with psychosis
• Malingering and factitious disorders
• Delusional disorder
• Brief psychotic disorder
• Pervasive developmental disorder
• Organic psychosis
• Carbon monoxide poisoning
• Heavy metal poisoning

• Medication-induced psychosis
• Liver disease
• Hyperthyroidism
• Hyperparathyroidism
• Tests
• CT/MRI head
• Serum HIV
• Serum rapid plasma regain
• CBC
• Urine drug screen
• Plasma drug level monitoring

Epocrates Page
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Diagnostic Standard of Care for Bipolar Disorder
(Epocrates.com)

• Tests
• Symptom questionnaires
• CBC
• Thyroid function tests
• Serum Vitamin D
• Toxicology screen
• Fasting lipids
• Fasting glucose
• MRI brain

• Differential
• Mood disorder due to general medical condition
• Substance induced mood disorder
• Major depressive disorder
• Dysthymic disorder
• Cyclothymic disorder
• Psychotic disorders
• Personality disorders
• Obsessive-compulsive disorder
• ADHD

Epocrates Page
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Diagnostic standard of care for OCD
(Epocrates.com)

• Differential
• Obsessive-compulsive personality disorder
• Body dysmorphic disorder
• Hypochondriasis
• Delusional disorders
• Severe social phobia
• Panic disorder
• Autism
• Asperger syndrome

• Tests
• Symptom questionnaires
• No lab tests recommended

Epocrates Page
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Diagnostic Standard of Care for Dementia
(Epocrates.com)

• Differential
• Mild cognitive impairment
• Delirium
• Depression
• Vascular dementia
• Dementia of Lewy body
• Frontotemporal dementia
• Parkinson disease
• Creutzfeld-Jacob disease

• Tests
• Cognitive testing
• CBC
• Erythrocyte sedimentation rate
• Metabolic panel
• Serum TSH
• Serum B12
• Serum VDRL

Epocrates Page
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All of these approaches, if followed, allow the
patient to be put into a diagnostic
boxTreatment consists of prescribing
psychotropics and, hopefully, psychotherapy
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Current practice guidelines have 2 things in
common...Treatments mostly suppress symptoms
Causes are seldom explored
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Modern Medical Treatment IS NOT Modern Health
Science
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A branch of healthcare has looked to treat CAUSES
since the days of Ancient Civilizations
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It has been MARGINALIZED by Modern MedicineIt
offers limited profit potential for drug
companies
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Psychology!
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Another branch of healthcare has been similarly
marginalized by Modern MedicineIt too has
limited profit potential for drug companies
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Orthomolecular Medicine
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Critics have described some aspects of
orthomolecular medicine as food faddism or
quackery. (Wikipedia)
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Orthomolecular Medicine draws on health knowledge
with roots in pre-history

• It reflects the most recent science, learning
  from the discoveries of genetic research and
  bioscience

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Orthomolecular medicine aims to restore the
optimum environment of the body by correcting
imbalances or deficiencies based on individual
biochemistry (Linus Pauling)
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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)
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Orthomolecular medicine uses substances natural
to the body such as vitamins, minerals, amino
acids, trace elements and fatty acids
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Orthomolecular Medicine has a Big Tent
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Orthomolecular Medicine uses

• Vitamins
• Minerals
• Amino acids
• Essential fatty acids
• Fiber enzymes
• Antibodies
• Antigens
• Cell therapy
• Acupuncture
• Massage
• Exercise
• Biofeedback

• Chelation therapy
• Dialysis
• Plasmapharesis
• Hydrotherapy
• Thermal therapy
• Phototherapy
• Electrotherapy
• Air ion therapy
• Light Therapy
• Solar therapy
• Hypnotherapy
• Psychotherapies

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7 Cardinal Rules of Orthomolecular Medicine

• 1. Nutrition comes first in medical diagnosis and
  treatment
• 2. Drug treatment is used only for specific
  indications and always with an eye to the
  potential dangers and adverse effects

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7 Cardinal Rules of Orthomolecular Medicine

• 3. Environmental pollution and food
  adulteration are an inescapable fact of modern
  life and are a medical priority
• 4. Biochemical individuality is the norm in
  medical practice therefore stereotyped RDA
  values are unreliable nutrient guides

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7 Cardinal Rules of Orthomolecular Medicine

• 5. Blood tests do not necessarily reflect tissue
  levels of nutrients
• 6. Nutrient diagnosis is always defensible
  because nutrient related disorders are usually
  treatment responsive or curable
• 7. Hope is an indispensable ally of the physician
  and an absolute right of the patient
  (Richard Kunin)

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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)

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Functional Medicine puts a fresh name to the core
concepts of Orthomolecular MedicineThe
Institute of Functional Medicine was founded by
Jeffrey Bland in 1991
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Orthomolecular/Functional Medicine identifies and
treats using a 3 prong approach

• Antecedents
• Triggers
• Mediators

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ANTECEDENTS

• Are things that happen before disorders starts

• Genetic Variations
• Genetic Regulation
• In-utero Exposure
• Early Life Exposure

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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
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Genetic variations can impair absorption of
sufficient nutrients, leading to mood, behavior
and physical symptoms
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TRIGGERS
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

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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.
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Example

• 5,10-methylenetetrahydrofolate reductase (MTHFR)
  polymorphisms impair conversion of folic acid to
  methionine, resulting in increased risk of
• Coronary Artery Disease
• Inflammatory bowel disease
• Depression
• Downs Syndrome
• Alzheimers disease (possibly)

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MTHFR variant C667T

• Occurs in
• 26.6 of Whites
• 12.4 of Blacks
• 41.5 of Hispanics

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Identification of MTHFR related risk can be made
by

• Genetic testing
• Nutrient testing
• Interpretation of subtle symptoms
• Best guess

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Typical Orthomolecular Intervention Supplemental
Folic Acid!

• Taking high dose supplemental folic acid pushes
  the metabolic pathway to create sufficient
  methionine. This is safe, and has no adverse
  effects.

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Are those things your body does to try to rectify
the consequences of the antecedents and
triggersFeedback loops are Mediators that
attempt to compensate for imbalances in an
attempt to reach homeostasis
MEDIATORS
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Mediators are very effective at rectifying
imbalances due to drugs
These feedback loops are the Achilles heel of
Modern Medicine
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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
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A Proposed Diagnostic Protocol for Assessment of
Mental Health Symptoms
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Diagnostic InterviewSymptom Questionnaire
Symptom Checker
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2. Medication Review

• Appropriateness of Dosage
• Adverse Effects
• Interactions Checker
• Consult when beyond your level of expertise

Abilify
Drugs Excel
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3. Consider Possible Alternate Explanations

• Consult!
• www.wrongdiagnosis.com
• www.CenterforHealthScience.com

CHS depression
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Recommend or Obtain Medical Labs to rule out
physical causes

• For Information on Lab Testing
• labtestsonline.org
• CenterforHealthScience.com
• Apexseminars.com

Depression Labs
Apex
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5. Refer for Treatment!

• Allopathic Physician
• Naturopathic Physician
• Doctor of Oriental Medicine
• Ayurvedic Physician
• Medical Psychologist
• Nutritionist
• Other Professionals

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Qualified Referral Sources

• Institute of Functional Medicine members
  www.functionalmedicine.org
• Orthomolecular Health Medicine members
  www.ohmsociety.com
• ISOM Members
• www.orthomed.org
• Center for Health Science
• www.centerforhealthscience.com