11 Effects of Inflammation and Autoimmune Issues on Mental Health

Foreign. I'd like to welcome everybody to today's presentation on autoimmune issues and mood disorders. I am your host, Dr. Donnelly Snipes. We have got a lot of stuff going on right now. You know, there is a lot of stress. There are a lot of people who are experiencing increases or onset of mood disorders. There are also a lot of people who are experiencing exacerbations or even onset of some autoimmune diseases. So I thought, you know, why don't we talk about that? What is the relationship? Because there actually are a lot of commonalities, relationships, symbiotic sort of things between physical health, autoimmune issues in inflammation, and mood disorders. So we're going to talk about some of that. There are more than 80 types of autoimmune diseases, and obviously in this hour, we don't have time to go through all of those. But some of the more common ones that our patients may have include rheumatoid arthritis, lupus, inflammatory bowel disease, celiac disease, type 1 diabetes, psoriasis, graves disease, and multiple sclerosis. Interestingly, Graves disease was one of the most common autoimmune issues, and that has to do with the thyroid. Autoimmune diseases are conditions in which the body's immune system attacks healthy tissues. Now, we've been hearing a lot lately with COVID about T cells and immune systems and, you know, all of those sort of things. But it gets really complicated because there are multiple kinds of T cells, and there's also beta cells and other kinds of cells that are responsible in the immune process. The other thing that we've heard a lot about, and we're going to talk a lot about today, are some cytokines. And these cytokine storms are what end up causing people or part of what end up causing people to have a lot of trouble in recovery from COVID But cytokine storms can occur, you know, for a variety of reasons. Cytokines are basically a subset of inflammatory molecules we have in our body. We, when our HPA axis is activated, y' all know that I'm very fond of our HPA axis. It's our threat response system. When that's activated, the body releases glutamate and adrenaline and all of our excitatory neurochemicals so we can fight or flee. It also releases cortisol. Cortisol causes the release of blood glucose, so we have energy for fight or flee. It causes a lot of other changes in order to prepare us for fight or flee. Well, what happens when we Fight or, you know, if you've exercised, you know, when you flee for too long, you also have tissue damage sometimes, you know, sore muscles, those sorts of things. A result of the HPA axis activation is, even if you're not actually fighting, is the release of inflammatory cytokines. The body sends these cytokines out to go on a mission, sort of an exploratory mission, to figure out if there's damage and if so, to cause inflammation. And that sounds awful, but it's. It's very protective because when the body has inflammation, you know, it's got heat, it's bringing blood and bringing, you know, cells that need to be brought there to repair that tissue. So in theory, cytokines are really helpful. The they are supposed to temporarily increase inflammation in order to promote healing. Unfortunately, when we're stressed, especially chronically stressed, or experiencing anything else, physical or psychological, that stresses the body, that keeps that HPA axis activated, which keeps at least a low level of cytokines potentially circulating in our blood system. What that means is potentially there is when we have ongoing stress, we're going to have, or likely to have ongoing levels of systemic inflammation. And we're going to talk about what that means as we go through it. Hallmark symptoms of autoimmune diseases are systemic inflammation. No inflammation means it's not an autoimmune disease. So bada bing, fatigue, sometimes muscle aches, and psychomotor retardation are also common symptoms of autoimmune diseases. Psychomotor retardation is not always there. Inflammation always there. These others, not necessarily always there. Think about if you've got rheumatoid arthritis, for example, you know that it hurts to move, which means you're probably going to move a little bit more slowly, probably not going to be as excited to get up and move. And what do we know? If you've ever had your arm in a sling, for example, you know that if you don't move your body, your joint spirit start to stiffen up, and then it becomes harder and even more painful to move. So one of the interventions that we're going to talk about, obviously the patient wants to work with their doctor and physical therapist and what have you. But we do need to reinforce the importance of them following their physical rehabilitation guidelines in order to minimize or, you know, help them empower themselves to feel like they've got some level of control over their. Over their pain. Fibromyalgia is not considered an autoimmune disease because it does not cause inflammation. A main goal of treatment is to reduce inflammation. So we really want to encourage patients to identify number one things they do that may increase inflammation. You know, I know there are certain things I do like overuse that increase inflammation. If I spend five or six hours out in the garden, you know, my, my hands swell up. I know this. So there are certain things like just pacing yourself that they may be able to do. Some microorganisms, like bacteria or viruses, Covid, for example, or drugs may trigger the change in which the auto, in. In which the immune system kind of goes haywire. This is a spirit especially true in people whose genes make them more susceptible to autoimmune disorders. Now there are certain markers on the DNA sequence that may indicate that someone is more at risk for certain autoimmune diseases like multiple sclerosis or graves disease or rheumatoid arthritis, or, you know, any of those 80 disorders that are out there. And generally it requires a trigger. You know, if you think about it, people with rheumatoid arthritis, you know, many of them did not have arthritis of any sort when they were juveniles. Now, some of them did have juvenile onset arthritis, but some of them did not. So there is somewhere in there that this gene has to be activated. Think of it like a light switch. It has to be turned on. And what they're finding is there are a variety of things that can turn this gene on. Autoimmune diseases, unfortunately, are far more common in females. It's not just a psychosomatic thing. It is far more common in females. They're not sure why. We need to recognize this. We do need to recognize that some of our patients may have autoimmune diseases that haven't gotten diagnosed yet. So we do, we want to listen for some of that when we're talking to our patients. They may be downplaying, you know, the arthritis in their hands or something. But if they're having chronic pain that is bothersome to them, we need to empower them and encourage them to talk to their doctor and see if, see if there's something that can be done. There are simple tests that can identify, for example, whether there are increased levels of cytokines, the inflammatory markers in the person's blood system. And this is one of those first steps that a lot of doctors take to identify if there might be an autoimmune issue. Autoimmune diseases are characterized by flare ups and remissions, though. And this is really important when people are diagnosed. We want to help them recognize that with appropriate care and mindfulness, they are able to self manage their condition, self manage their disease a little bit, you know, and some of them may have a lot of control. You know, some of their symptoms may be really strongly tied to their mood or their sleep levels or, or things. Some people may not be able to affect as much of a change, but we do want to encourage them to be aware of the fact that they can. There are things they can do to help themselves feel better. Put out that empowerment there. Mood disorders and autoimmune diseases have overlapping concurrent symptoms. Fatigue is one of the biggies. And on one of these slides I read a study that I think it was 90%, some really high percent, 90, 95% of people with rheumatoid arthritis identified fatigue as being their most prominent and debilitating symptom. Now you think rheumatoid arthritis, or at least when I do, I think pain. But for them it was fatigue. Think about when you're in pain, you know, rheumatoid arthritis or any kind of arthritis. When you're in pain, a lot of the time, you know, a lot of the hours of the day, how does that impact your sleep? How much more effort does it require to do your daily chores like, you know, mopping or vacuuming, dusting, laundry, whatever, when you're in pain? I know for me, when my hands hurt or, or when my back hurts, it feels a lot more arduous just to do laundry. I mean, I think about trying to get the clothes in and out of the washer, which I'm short, so I almost have to dive into the thing and then into the front loading dryer and holding and moving and gripping. I just think about it and I'm like, okay, this is going to hurt. And I dread it. And that dread can lead to fatigue. And I've just got regular old run of the mill arthritis. I can't speak for people with rheumatoid arthritis, but I want you to recognize the impact that pain can have on our body, the impact that inflammation can have on our body. Because you know what, when our body is sending out cytokines, when there's inflammation, our body is saying, you know what? I need to put energy into repair. Well, where does that energy come from? They got to pull it from somewhere. So it's diverting energy that you could be using for other things to try to repair itself. Increased pain is common in autoimmune diseases, obviously, but also in mood disorders. We know that as certain types of serotonin are suppressed, pain perception goes up or our pain threshold Goes down. However you want to think about it. Serotonin is one of those modulating chemicals that is helpful in pain, in pain management. So when certain types of serotonin are low, remember there are like 17 different receptors people may experience, have a lower pain threshold, sleep changes. You know, we know that's one of those DSM symptoms for depression and even anxiety. It's also a very common symptom of autoimmune diseases and that psychomotor retardation we already talked about. Now, guilt and depression, anhedonia are overlapping concurrent symptoms. You know, autoimmune diseases don't cause guilt, but people a lot of times have guilt when they have an autoimmune issue that's preventing them from do the doing the things that they feel like they, quote, should be doing. Anhedonia, on the other hand, you know, there can be depression because they feel powerless over controlling their symptoms of their autoimmune issues because they're exhausted. But the anhedonia actually can be caused in part or triggered caused by inflammation. There have been multiple studies that have shown that as systemic inflammation goes up, depression symptoms go up. They are, you know, really strongly tied together. Significant infections in people with autoimmune diseases may cause mood disorders. So if we have somebody with an autoimmune disease and they get a significant infection, we want to be on alert for mood symptoms. Mood symptoms can create a vulnerability to infection. So, okay, think about this. Right now. We are, as a culture, for the most part, stressed the heck out right now. You know, the level number of mood disorders has just skyrocketed since all this Covid stuff and everything else politic, politics and everything else started. I think the majority of people are struggling with mood symptoms now, whether it rises to the level of a DSM diagnosis. You know, that's not necessarily the case for everybody, but a lot of people are experiencing significant mood symptoms that when. When we're stressed out, when we're depressed, it actually reduces our immunity, which makes us more vulnerable to all types of infections, including Covid. It also creates a vulnerability to autoimmune issues when we're stressed out. Remember, stress, HPA axis activation, cytokines circulating, increased systemic inflammation. Well, if you've got systemic inflammation, the. The immune system can go haywire. So that's what they're finding. Mood disorders, ineffective immune responses, generally related to the action of the different types of T cells. But an ineffective immune response leading to severe infection and autoimmune disorders may all share common triggers. Now, I do want to emphasize that the research indicates that for infection to trigger an autoimmune disorder, it has to be a, quote, severe infection. So if you get a cold, if you get, you know, the flu, probably not going to be severe enough to trigger an autoimmune response. What, what they're really looking at is to put it, you know, bluntly, if you're, in fact, if your infection is bad enough that you're hospitalized, then that could be a significant enough infection to trigger, to trigger an autoimmune issue that may be persistent after that. Sepsis is one of those things. Depression and anxiety can be related to autoimmune issues either because of biological and cytokine related mechanisms. So when we're depressed, there are that increase in cytokines actually can cause symptoms of depression and anxiety or because of the physiological impact of the disorder, which means when people have autoimmune issues, the pain, the fatigue, the lethargy, those sorts of symptoms which are very common when you look at the DSM criteria for depression, those source sorts of symptoms can cause people to feel frustrated, to cause them to feel helpless and hopeless or anxious. They may feel these symptoms and start getting anxious, that it's going to get worse. And those are all targets for intervention from a, from a mental health perspective. And I was right, it was 90% of patients with rheumatoid arthritis reported fatigue as the main factor causing their low mood and depression. This is a intervention point for our clients. When we're working with somebody with an autoimmune disorder or even a mood disorder, we want to ask them, you know, what are your symptoms and which ones are the most problematic for you? And then we need to work backwards from there and say, okay, what, what's causing this? And it can be cognitions, it can be lifestyle factors, it can be a lot of things. But this can serve as a starting point to figure out effective interventions. During autoimmune disease flareups, cytokines circulate in the blood, they reach the brain and cause depression, anxiety and hedonia, social withdrawal, fatigue and sleep disturbances. And that came directly from another study. I wouldn't have thought that cyto kindes would cause social withdrawal, but apparently it does. Let's think about that. You know, as cyto kindes are circulating or as people are demonstrating symptoms of depression, anxiety, anhedonia, fatigue and sleep disturbances, we'll put social withdrawal on the back burner. That tells us that they probably have increased levels of cytokines going through their system. Now think about, well, everybody you know right now, how Many of those people don't have at least one of those symptoms. Some of the things that we can, well, I'll get there, I'll get to interventions. I'm trying to put the cart before the horse. Likewise, depression, anxiety and just general stress can trigger autoimmune flare ups. When we trigger that HPA axis there is a strong chance that we're also going to trigger an autoimmune flare up in someone who has autoimmune issues. So if we're working with a patient who has depression or anxiety and, and an autoimmune issue, one of the ways to help them control the symptoms of the autoimmune disease is to help them address their mood issues so they can keep that HPA axis from getting becoming overactive. Chronic inflammation impairs physiological responses to stress. When we've been had this inflammation going for so long, there's actually something called, I think it was T cell fatigue that they start seeing. The immune system starts saying I give up. You know, I've been trying and I'm not winning, so I give up. And obviously they don't speak but that's basically what we see and they've seen some of this T cell fatigue in people with COVID who progress and get, you know, significant severe disease. It's important to recognize that our body has this sort of self limiting thing. HPA axis is the same way we've talked about hypocortisolism in the past. When the body perceives that it is continuing to exert effort is not going to have any benefit, then it starts backing off basically. And we see that in with cortisol with the HPA axis and interestingly enough we see that in the immune system. Sometimes when the immune system just gets fatigued, it just, it doesn't have any more to give. So chronic inflammation impairs the physiological responses to stress. When we're, when we've got chronic inflammation then our body is, has already said I, I'm exhausted, I don't have any other resources, I'm trying to fix whatever's going on over here that's causing the inflammation. So I don't have any energy to give you to respond to stress. Think about when you are in pain, when you've got this chronic inflammation, how well do you respond to stress? I know I don't respond very well. These impaired physiological responses include effective coping behaviors or lack thereof which result in depression which lead to a poorer prognosis for autoimmune issues. So if they've got chronic inflammation you know, they're already experiencing some level of inflammation in their body. Then they are hit with some sort of stressor. They're not able to effectively cope with it. They that increases inflammation, which increases depression, which also increases autoimmune symptoms. Other, you know, interesting little tidbits that I picked up. Vitamin D deficiency. We know that in inadequate vitamin D is related to seasonal affective disorder. We've started to see how vitamin D deficiency is also related to just run of the mill depression. It's also related. Vitamin D deficiency is also related to the development of cancer, cardiovascular disease, diabetes, autoimmune diseases and depression. So vitamin D is one of those really important things. Now, there is a caveat. We don't want to tell people this and, you know, give them the idea that they should go out and start taking mega doses of vitamin D. No, no, no, no, no, no. That's not generally safe or recommended. They need to talk to their doctor. They can get a blood test to see what their vitamin D levels are. Vitamin D is most efficiently used when the vitamin D is made by our skin, by our body as a result of sunlight. What are a lot of people doing right now with COVID Staying inside? People need to get outside, get that sunshine. I was driving to work today and I just happened to be paying attention to the fact of how sunny it was and how much time I spent in the car from the time I left my house to drive to the gym, to walk into the gym, walk out of the gym, walk to the. You drive to my office, walk in and walk out. I actually spent quite a bit of time outside this morning. And, you know, people don't recognize how much of that they're not getting because they're not leaving their houses. Vitamin D, super important. We can get it by just getting 10 to 15 minutes of sunlight a day. The gut microbiota, and this goes to what, you know, one of you was asking about before class. It's involved in many basic biological processes, including the stimulation of innate immunity. Now, the microbiome, the bacteria, for lack of a, you know, more descriptive term, the bacteria in our gut are super important. You know, we have things like E. Coli in our gut and they're supposed to be there. These bacteria in our gut, in our intestines, actually are responsible for helping to break down the foods that we eat to make neurotransmitters, to make hormones. You know, we need them and we need a balance. We need, you know, the millions of different strains there are in our gut in order to function Properly in order to do what they need to do. People's genes, you know, unfortunately there's, you can't change those. But also their lifestyle, the foods they eat and the drugs they consume, from, you know, alcohol to antibiotics have an impact on the bacteria in their gut. That affects the physiological systems like the immune system and the endocrine system. It's called the gut brain axis. And you can read more about that if you want. You can read about leaky gut. We're going to talk a little bit about that in a minute. But it is mind boggling to me as, as I do more research, how much, what we eat, how much sleep we get and the other things that we put into our body, how, how much that affects our mood, you know, basic lifestyle behaviors. When we take antibiotics, for example, what does that do? Well, antibiotics are not selective. They don't say, well, we need to kill this one little bacteria here. They go in and they just wipe it out. You know, you have gram negative and gram positive antibiotics, antibiotics that kill either gram negative or gram positive bacteria. But a lot of times we're prescribed broad spectrum antibiotics. So what does that do? It just goes in and wipes them all out. Which is why a lot of people, when they take antibiotics, especially strong antibiotics, develop to be polite GI symptoms, because all of a sudden that microbiome has gotten all out of whack. Well, when that happens, guess what? Not only does it cause unpleasant GI symptoms, but it also means that the body is less able to efficiently and effectively produce things, make things like serotonin, dopamine, norepinephrine, estrogen, testosterone. You know, the list goes on a lot of that stuff. 90% of our serotonin is actually made in our gut. And if our gut is on the, on the fritz, then guess what? Serotonin levels probably not going to be optimal. Lack of microbiota diversity leads to many diseases like autoimmune diseases and the development of problems such as memory disorders, diseases, depression, stress, autism, and even it's been linked to Alzheimer's disease. We need to have, and I can't remember the exact number, it's like 108 million different types of microbes in our gut in order to function effectively. And each one has its own part that it plays in keeping us healthy and, you know, fighting off bad things. One of the ways, and we'll talk about it more in nutrition. One of the ways that we can maximize microbiota diversity is to eat a healthy diet. Multiple colors of foods, each different type of food may feed A different type of bacteria. So it's important to recognize that it's important to increase, increase and include probiotics, which often have fibers in them or inulin and they're prebiotics, I'm sorry, and probiotics as well, which are the things that you get in your yogurts and your fermented foods. We need to have an array of different types of foods in our diet to meet the taste buds, if you want to put it that way. Of all of the different microbes in our gut, in the intestine there is synergy between mucus, the microbiome and immune cells, which plays an important role in preventing pathogens from crossing into the bloodstream and stimulating inflammation. When the microbiome is out of whack, that mucus can become thinned, which makes it easier for pathogens, you know, all the junk that's in our intestines to actually seep through the intestines and into the bloodstream. That's, you know, the very non clinical explanation for it. We want to keep our gut healthy because when our gut is unhealthy, you know, it increases the rate and likelihood of pathogens leaking into the bloodstream. Well, what do we know happens when bad things, pathogens get into the bloodstream? It excites or activates the immune system, which means, guess what, we're going to see more inflammation because activated immune system is associated with increased inflammation. Medications for autoimmune disorders I talk a lot of times about, you know, wanting to make sure that not only do we think as clinicians when we're doing our assessment about cognitions, but we also want to look at what are people putting in their bodies that might be contributing to their symptoms. Anti inflammatories. And this can be, you know, a lot of times we're thinking non, nonsteroidal anti inflammatories, your, your over the counter medications. Unfortunately for a lot of people, anti inflammatories can cause stomach pain and interestingly enough, difficulty concentrating. That was one I didn't know about, but it can now. A positive effect of anti inflammatories they have found is that in some circumstances the anti inflammatory mechanism actually serves as a partial antidepressant. Now it's not a replacement for, you know, Prozac or something, but they have found that certain anti inflammatory medications have significant effects on people's mood. You know, as inflammation goes down, mood goes up. You know, that's just the way it is. Antidepressants, you know, you think that's a panacea right there. It's not. Antidepressants can contribute to difficulty concentrating, fatigue, anxiety, and restlessness. Well, antidepressants can help a little bit with mood. And if people are less anxious and less depressed, then theoretically their HPA axis is less active, and so they've got fewer cytokines circulating in their body. But antidepressants do nothing or virtually nothing for addressing inflammation. They're antidepressants. So if the depression is being caused by inflammation, you know, you're, You're. You're barking up the wrong tree, you know, unless you also are concurrently addressing the inflammation and the antidepressant can only do so much. Another type of medicine that people often take with autoimmune disorders can be substances that the body can no longer make or regulate on its own. The two main ones are thyroid hormones and insulin. Now, thyroid hormones, you know, there's a fine line here. You think, hi, hypothyroid people who don't have enough thyroid hormone tend to have symptoms of depression. People with hyperthyroid or too much thyroid hormone often have symptoms that are more similar to anxiety. If people's levels of thyroid hormones are not correct, you know, if the doctor prescribed them something and it's too high or too low, that can be contributing to depression, fatigue, irritability, problems with concentrating or anxiety. The same thing with insulin. Too high or too low insulin can also cause or trigger these same symptoms. We want to make sure that people recognize that the medications they're taking, if they're not at the right levels, can contribute to their mood issues. So they need. If their doctor adjusts their medication, they need to keep a log. I suggest, I recommend that people keep a log anyway every day so they can notice things that may be changing. And, you know, there are times, you know, especially with thyroid medication, that's one that I'm super familiar with, that, you know, because you put on some weight or you take off some weight or something else changes that your thyroid medication dose needs to be adjusted. If people are being mindful and just keeping a log, it, you know, scale of one to five, how do I feel today? One being I feel like crap. Three being I feel okay. Five being, you know, I feel wonderful. Where are you on that scale? And have people keep that each day? And then if they see themselves, you know, backsliding, then they know they may need to do something different. Immunosuppressants are the final type of medication that people with autoimmune disorders may be taking. Unfortunately, immunosuppressants are well known for their neuropsychiatric side effects. Wow. Okay. Depression, fatigue, lethargy, anxiety, restlessness, anxiety, insomnia, and in 20 to 32% of people, even delirium. For people who are taking various immunosuppress. Immunosuppress suppressants. Now, let's think about this for a second. When we're taking something that is suppressing our immune system, what else does that do? It makes us more vulnerable to infection. When we get infections, we have inflammation. When we have inflammation, we have increased mood symptoms. So we do want to pay attention to some of the other things the person may need to do if they're on immunosuppressants to stay as healthy as possible. Immunosuppressants are metabolized by cytochrome P45, O3A4, which is inhibited by many psychotropic medications. So if somebody is on a psychotropic, let's say sertraline, and they are also taking an immunosuppressant, they may have poor response. Why? If the sertraline, if the psychotropic medication inhibits cytochrome, we'll just call it Cytochrome P45 for short. If it inhibits Cytochrome P45, then the body doesn't have that mechanism to metabolize the immunosuppressant medication, you know, so it can't break it down, it can't use it. That's important to recognize. That doesn't mean that you're not going to have people on both immunosuppressants and mood psychotropic medications, but it is important to recognize the interplay because they work against each other. Interventions. You thought you we'd never get here, huh? Reduce stress and depression to reduce HPA axis up regulation. And some of those things that we can do include just very basic cognitive behavioral stuff. Teach distress tolerance skills. In today's environment, there are a lot of things that we cannot change. And I, you know, I regularly say the serenity prayer. Even if you're not a religious sort of person, remember, or if you haven't heard it, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. Wow. Just let that sink in for a second. How much less overwhelming would our life be if we were able to accept the things we could not change and we knew the difference? Too often we spend inordinate amounts of energy and stress trying to change things that we have no control over. Getting Upset over what somebody says on tv, Getting upset over what somebody posts on Facebook. Getting upset over what we can or cannot do right now. Some of that stuff or most of it we have no control over. Well, to a certain extent with the tv, if I don't like what I'm hearing, I turn it off. You know, thinking about what parts of the situation do you have control over? That's going to be important. Also just having a list of those. Distress tolerance skills. When you feel distressed, when that HPA axis is activated, you are in fight or flight mode, which often means you've got sort of tunnel vision and you're in what, what Linehan refers to as your emotional mind. You're probably not going to make your best decisions when you are in that reactive emotional mind. Distress tolerance doesn't mean suppressing things forever. It means taking a break from it until you can get calm down so you can look at it logically and factually and make informed decisions. Activities, what can you do? I garden. You know, activities that you can do. Do things that make you happy. Anything that can trigger the opposite emotion. You can also use sensations, hold ice cubes, go on a run, do 50 push ups, whatever it is. Factual, likely and distortion free. Thinking is also important. Too often our thoughts are emotion based. If I feel afraid of something, then I may assume that it is threatening. You know, snakes are a perfect example. If I see a snake, you know, I may assume using that emotion based reasoning that it is a dangerous situation. When I look at the facts, you know, it's this cute little green snake that's just trying to get some sun, you know, probably not an issue. So we want to encourage people, when they have a distressful feeling, to examine the facts. You know, what are the facts for? For and against my belief right now. Once you have the facts, then you need to look at the likelihood. You know, let's take autoimmune disorders. Maybe somebody wakes up and they're in a lot of pain and they've been in pain for a week and they're thinking that maybe their condition is worsening and it's going to continue to get worse until they can't, you know, walk on their own and they're going to be, you know, in a wheelchair. You know, people can catastrophize really quickly. Let's look at the facts for and against your thought that your condition is getting significantly worse and it's going to continue to spiral out of control. All right. Is there a possibility that that can happen? Well, yeah, but so that's one of those facts that is a possibility. But how likely is it? What is the probability that that is what's going on and what's going to happen versus you overdid it and you know your body's taking a little bit longer to repair or there's a cold front coming in and you're just going to have to wait till it passes whatever. What is the probability that your, your fears are going to come true and then distortion free? And that's looking at what we're telling ourselves, what we're thinking and removing that all or none thinking, removing that, catastrophizing and focusing again on what's factual and probable. We can teach psychological flexibility and one of the tools that I like most with people with autoimmune issues as well as mood issues is living in the and I can have an autoimmune disease, whatever it is, and a rich and meaningful life. They it's not either or I don't have to get rid of one the, the disease in order to have a rich and meaningful life. I can have both. Living in the and psychological flexibility encourages people to use mindfulness, being aware of how they're feeling in the moment and then making a choice at that point and say, okay, you know, maybe I'm scared, maybe I'm angry, depressed, whatever it is, this is how I feel right now and that's okay. It's how I feel now. What are my options in order to help me improve the next moment and move into a place where I am having a rich and meaningful life? Dialectics encourages people to focus on the parts of the situation that they can control. Like I mentioned earlier, a lot of times the news, the mainstream media just stresses me the heck out because they repeat the same thing over and over again and it's just depressing. So what parts that can I control? Well, I'm not going to get them to change their programming. That's not going to happen. So I can change the channel or I can turn it off completely and then empowerment is also super important to help people feel like they've got a sense of control over their lives. And empowerment can be really easy. We can encourage them to do daily monitoring, you know, just logs of how am I feeling, what's going on today. So they can track and identify patterns maybe in what may affect their, their condition and disease management. That means educating them about all of their options so they know what they can do. So they have a menu of options to choose from and they feel empowered. They don't Feel like, well, I, okay, I'm hurting today. I'm stuck with it until I go to the doctor. They know steps that they can actively take to help themselves feel better. We talked earlier about reducing pain as being a primary goal. We are not doctors, we are not going to prescribe that they do anything. But there are options that we want to make sure that they educate themselves about different non pharmacological interventions that they can discuss with their doctor or physical therapist, including tens Transcutaneous Electronic Nerve Stimulation. This is awesome because TENS units, back when I was, you know, little, you had to have a prescription and they were super expensive and that's a problem. Now you can buy them offline, you can buy them from Walmart or Amazon or wherever. All you do, it's like little electrodes that you attach and, and it's battery operated. You turn it on and it sends out little nerve, little electric impulses that basically bombard the nerves and keep the nerves from receiving pain signals. Not clinical, but you know, basically that's what it's like. And when you turn it on the right level, it just kind of feels like somebody just gently tapping you. Now if you turn it up too much, it'll make the muscles contract, but you don't want to do that. But you can. But turning it on so it just bombards those nerves, gives the nerves a break, gives the muscles a break. So it's not, they're not constantly sending out that, you know, I'm in pain, I'm in pain sort of thing. A lot of times after a TENS treatment, people feel the muscles in that area have relaxed quite a bit. Hot and cold therapy, those can be great guided imagery. Now this is something that we can practice with our clients. It's not medical, so it's one of those things that's within our scope of practice. When people have pain, have them imagine that pain as a color. You know, maybe if you have pain in your hand, imagine your hand being surrounded by red, deep, deep red. And then visualize that, that color changing from red to purple to blue as the pain goes away. Another technique that some people find helpful is to envision their, think of their pain like, you know, a stereo, their pain. They've got a knob and they can turn the knob down on their pain. Some people like envisioning a destroyer, some sort of superhero. This obviously works better with kids. Some sort of imaginary character that comes and takes that pain away. Other people will envision a healer, you know, some sort of person, angel, spirit, whatever that comes and, and fixes it maybe lays hands on whatever they do, just envisioning that happening and noticing it. And a final type of guided imagery is just simply alternate focus. When you focus on how much your ears hurting or how much your hands are hurting, then you're going to notice it a lot more. So when you have a pain somewhere, turning your focus to something else. And this is one of those places where distress tolerance techniques of sensations can come in helpful. Um, if you put your hands in, you know, cool water, I'm not a big one for ice baths, you're going to notice that you want to focus on what the cool water feels like on your hands. If your knees hurting or something, you want to turn your attention totally away from whatever it is that's hurting right then and focus on something else that is not distressful, that's not painful, which is again, why I say don't use. Don't use ice baths. You want to have it be something that feels. Feels pleasant that you can focus on. Stretching is another thing that helps keep mobility, helps keep range of motion going in. People who have autoimmune issues, even if you've got something like Crohn's disease that you know doesn't affect the joint, if you are not moving, if, when you have Crohn's disease, you're laying in bed, you know, for hours at a time, you're still going to start developing stiffness and it's going to be harder to move. You're going to feel more fatigued. So even getting up and stretching with doctor's permission can be helpful for, you know, reducing some secondary symptoms. Exercise can also help reduce pain because it keeps those joints lubricated, it keeps them mobile, keeps your muscles moving, and it prevents muscle imbalances. Think about if you've ever awakened and you slept wrong and you've got a kink in your neck. Well, that happens a lot if people are not overly mobile, if they are spending a lot of time on the couch or in the bed or something. So encouraging some level of exercise. And we're going to talk about a little more about exercise in a minute. Social support is also vitally important. It is super helpful, even if it's an online support group for people to engage with others who have similar conditions, who can talk about the trajectory, who can talk about what works for them in order to address their symptoms. Because obviously, you know, we don't know everything. The doctor doesn't know everything that might help people mitigate their symptoms. The people who know best are the people who are living it. So if they can connect in support groups, that can be super helpful. We also want to make sure that people are not isolated, including those with limited mobility or who are, you know, on quarantine or whatever. Isolation contributes to depression. Isolation gives people a lot of time to sit home or sit there and think about the negative stuff. So reducing isolation, improving social support, having somebody that is encouraging in your corner, all of those things can help reduce anxiety and depression and serve as a buffer when people start having flare ups. And finally, lifestyle management. And this is kind of, you know, an all encompassing term, noise. They have done multiple studies that have on people that live in cities as well as people who live near turbine wind farms. And they found that increased levels of noise above 45 decibels I believe is associated with increases in depression, anxiety, reduced quality sleep, and increases in the rate of taking antidepressants. So noise is really important. There are some noises that are pleasant. You know, I like hearing the birds, I don't like hearing the cicadas. Making sure that people add in noise if they want it, that they like white noise, you know, the sound of babbling brooks, whatever makes them happy. But they do as much as they can to address what I call noxious noise. Noise that causes them stress. It can be the dogs barking, it can be the neighbor's car alarm going off or whatever it is. You know, how can they address that? Especially number one when they're sleeping so it doesn't disturb their sleep and also when they're trying to relax. And sometimes this means earplugs, sometimes this means noise canceling headphones, sometimes it can be white noise. But we want to help people figure out how to mitigate that noxious noise. We want to help people improve their nutrition. You know, get those three colors on your plate at every meal can be super helpful. Reduce alcohol, because alcohol, especially significant alcohol use, is associated with inflammation. Now, light drinking may have some limited benefits, but they describe light drinking as one drink or less per day. And most people that I know don't just have one drink per day. So that, that is an important caveat to put out there. And if you look at a lot of the research on the benefits of alcohol, there's usually a note in there that says, you know, yes, there's a potential that alcohol could have some benefits, but if you don't drink now, the risks far outweigh the benefits. So, so don't start drinking just because this study came out. And, and, and again, we're talking about light drinking. One drink or less per day. And during COVID alcohol consumption has just gone through the roof. And that is increasing inflammation, which is increasing mood symptoms, which is reducing immunity, which is making people more susceptible to illness. Hydration is another thing that we can do to improve people's mood. Our body sends signals through fluid, so we need to be hydrated in order for our nervous system to work as efficiently as it's supposed to. But hydration also helps clean out those toxins, you know, the ones we don't want to get into our bloodstream. So if our liver and our kidneys are functioning well, then we're going to have less sluggishness, less foggy headedness, and potentially less mood symptoms. And part of that can be achieved by making sure that we're periodically rinsing out those organs. Get enough sleep. Sleep is important to sleep deprivation. Increases the HPA axis activation. Body thinks that's a threat, so that's number one. But when we don't get enough sleep, it contributes to fatigue, it contributes to lethargy, and it contributes to difficulty concentrating and foggy headedness. Sleep is super important. Exercise, even light exercise. I'm not saying you got to go out and run a 5K. Exercise modulates the gut microbiota. Who knew? Well, evidently certain researchers did. Exercise actually helps keep your gut healthy, which and increases serotonin and impairs inflammatory signaling. So light exercise, you know, I'm not talking about doing it until you're causing inflammation because you've, you know, gotten micro tears. I'm talking about just light exercise helps modulate your gut, makes that more healthy, so it can do its job to help keep you healthy and keep those neurotransmitters balanced. And it impairs inflammatory signaling. Maintain a healthy weight. Because obesity is actually associated with inflammation, People who are obese have higher levels of cytokines and other inflammatory markers in their. In their system. And encourage people to pay attention to ergonomics at their desk, in their car, wherever they watch tv, and at in their bed in order to make sure that their body positioning isn't contributing to additional pain. Mental health issues that we may need to address. Grief, anger, and depression that can occur as a result of physiological limitations, as a result of a diagnosis, or as a result of inflammation. Help people write a new narrative. You know, okay, I have this autoimmune disorder now. That doesn't mean that my life's over. Let's close this chapter. And what does the next chapter look like with me, the protagonist, living with living a rich and meaningful Life with an Autoimmune Disorder Encourage people to focus on gratitude. And I've talked about the gratitude tree before. Get any old vase, get some sticks from outside and get some of those package tags from, you know, the store and each day add a new tag which serves as a leaf and on that tag write something that you're grateful for. This is a great activity to do as a family. Positive journaling has been found to reduce depressive symptoms and anxiety after a month and increase resilience after the first and second month relative to usual care. All that means is spending 10 minutes a day or writing down all the good things that happen that day. It's 10 minutes a day where you're just focusing on the positive. We may need to help people address guilt anxiety about worse, whether their condition may be worsening, which we can do by improving their health literacy, improving their awareness of the disease, and encouraging charting. They may have anxiety that people are going to reject them them because they can't do the things they used to do. So we want to work with them on that. They may also have anxiety that they're going to lose their job or not be able to pay bills because they can't do the things they used to. And there are changes that take place as a result of autoimmune issues as well as depression. And we want to help people, you know, really enhance their self esteem so they see themselves as an awesome person who happens to have an autoimmune issue. They don't see themselves as being broken or faulty or not worthy. Obesity, poor nutrition, stress, depression, poor sleep and other lifestyle factors can worsen autoimmune issues. Autoimmune issues and treatments for them can also contribute to neuropsychiatric symptoms. So so we do need to be aware when we're doing our assessments to screen for both mood disorders, which we're doing, as well as autoimmune issues. Because if we don't address the biological causes or contributors to the mood issues, then the person is probably not going to have optimal levels of recovery. If this podcast helps you help your clients or yourself, please support us by purchasing your CEUs at allce.com, or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allce.com podcastceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce.com Sponsor thank you.