Autoimmune Issues and Mood Disorders | Counselor Continuing Education

Hey there, everybody, and welcome to today's presentation on autoimmune issues and mood disorders. I'm your host, Dr. Donnelly Snipes. In today's presentation, we're going to discuss what autoimmune issues are and what they aren't, how they interact with mood disorders, and what clinicians need to consider when creating treatment plans for people who have both mood disorders as well as autoimmune issues. Autoimmune issues in their most general nature is a group of more than 80 different types of disorders, including rheumatoid arthritis, lupus, inflam, inflammatory bowel disease, celiac disease, type 1 diabetes, psoriasis, graves disease, multiple sclerosis, and obviously a whole lot more. The key feature of autoimmune disorders is inflammation. When people have autoimmune diseases or disorders, the body's immune system attacks healthy tissue. The hallmark symptoms, again, of autoimmune issues are systemic inflammation, fatigue, and sometimes muscle aches, and what we call psychomotor retardation, which is a slowing. It feels like you're walking through into an 80 mph wind. You know, everything you do feels like it's 10, 20, 30 times harder to do than if you didn't have that condition. Systemic inflammation, we're going to talk about this a lot today. Remember, is also associated with a whole bunch of other issues, not the least of which being depression and anxiety. Now, it is important to note that fibromyalgia is not considered an autoimmune disease because it does not necessarily cause inflammation. It doesn't mean it doesn't cause pain. And I have other videos on pain and mood disorders, but today we're really talking about those disorders that have, as one of their foundational characteristics, systemic inflammation. A main goal of treatment for autoimmune issues is to reduce inflammation. And you'll find as we go through this, some of the things that reduce inflammation also improve mood. So a target that we may look at for, for improving mood in people even without autoimmune disorders may be reduction of inflammation. Now, when it comes to inflammation reduction, that is a physiological issue that a doctor will have to address. But it is something that we can certainly consider and certainly do more research on to identify the correlation between bodily inflammation and mood disorders. Some microorganisms, such as bacteria or viruses or even drugs, may trigger the change where the immune system goes from being healthy to attacking healthy tissues. This is especially true in people whose genes make them more susceptible to autoimmune disorders. So. So there are some people out there who have a family history, who have a genetic predisposition to autoimmune issues, which means that they are going to be more likely to develop these conditions in response to assaults, if you will, on the immune system. Unfortunately, they have found that autoimmune disorders are far more common in females. And interestingly, I did see some research that has connected some of the autoimmune pathology actually to dysfunction in the estrogenic system. So just kind of one of the, another one of those things that they're exploring. And autoimmune diseases like mood disorders are characterized by flare ups and remissions. The person with an autoimmune disorder likely will not be in pain at max pain all the time. They may never be completely pain free, but the pain intensity and the amount of disability may wax and wane. And one of the things that we, we found is that it often tends to wax and wane, at least in part based on the amount of stress the person is under, Emotional stress, cognitive stress, environmental stress, and physical stress. So if they're sick from, for example, that's more like more likely going to trigger an autoimmune flare because when they're sick, their body's under stress and getting that immune system all hyped up anyway. Mood disorders and autoimmune diseases have overlapping or concurrent symptoms. Both have the symptom of fatigue. Well, think about it. When you've got systemic inflammation, when you've got inflammation throughout your body, it can be exhausting. You can be in pain from that. The same thing is true when people are experiencing depression or anxiety. One of the, well, several of the neurotransmitters in our brain are involved in pain perception and pain processing, not the least of which are gaba, dopamine and serotonin. And when people are experiencing mood issues, their gaba, dopamine and or serotonin are probably at a whack to, you know, oversimplify it. So people often experience, when they have mood issues, experience increased perceptions of pain or a reduced pain threshold. People with autoimmune diseases and mood disorders have sleep changes. They may sleep a lot, but it is not restorative sleep. So they just can't sleep, seem to wake up going back up to that fatigue thing and they may end up staying in bed too much, trying to catch up or get refreshed and it just ain't going to happen. And as they do that, you know, trying to get better in, you know, the best way they know how, a lot of times that disrupts their circadian rhythms, which throws the entire body factory out of whack. Nobody knows. None of the microbes and systems know when they're supposed to come online and or go offline. We see psychomotor retardation and I already talked about that. When you sl, everything seems to be a lot slower. It takes a lot more energy, a lot more effort to think, to move, to do activities of daily living. In both of them, we also tend to see increased guilt when people are not on their aame, let's just put it that way. Whether it's because of the autoimmune disorder or because of the mood disorder, when people are not on their aame, when they are not feeling, acting, reacting the way they think they quote, should. A lot of times that contributes to feelings of guilt. If I only didn't have this problem, I'd be able to do the things I want to do. People are going to be angry at me and I'm angry at myself because I can't do these things. So guilt is something we really need to address. Both the fear that others are judging them as well as the self anger and self hatred for and, and self guilt for not being able to do what they want to do. So we need to help them figure out is guilt warranted or is this something that is just the way it is right now and it's going to be important to figure out how to live your rich and meaningful life and have these things going on. Not every day is going to be an a day. And depression or anhedonia is another common symptom. As I mentioned earlier, we know that people who experience major depressive disorder also have increased levels of inflammatory cytokines. They have systemic inflammation. We know that people with autoimmune issues have increased levels of systemic inflammation. Therefore, it's not surprising that when autoimmune issues flare, that surge in inflammation also may trigger depression. Additionally, depression is the the sense of feeling helpless and hopeless. When you have a chronic condition, when your body is actually working against you, it can be exasperating and you can feel helpless and hopeless. A lot of times when you wake up and you know, you think you've been doing everything right and you're still having a bad day today. As clinicians, we can help people recognize what they can and cannot control. We can help them do some backward chaining to identify anything that may have triggered a flare. We can help them identify things that are out of control, like weather and changes in barometric pressure that may be out of their control, that may Be triggering their flare and help them figure out how can I deal with this and have my rich and meaningful life to the best that I can do. And, and it's important to recognize that not every day is going to be an a day and encourage people to embrace the days that are good and accept the days that are bad. Be compassionate with your themselves not getting into dirty discomfort where they get angry about the fact that they're in pain and they get depressed about the fact that they're in pain. So not only are they in pain physically, but now they're also emotionally in distress. So they're just really ramping up that stress response system, that HPA axis. And we know when that HPA axis is ramped up, what happens? Well, if it stays ramped up for too long, we see increased inflammation. So stress is only going to make it worse. Identified relationships between mood disorders and autoimmune disorders. There's significant infection in people with autoimmune disease, which may also cause mood disorders. Thought that was interesting. And mood disorders may create a vulnerability to infection and autoimmune disease. We've talked about this a little bit in other videos. When we are experiencing anxiety or depression or some other psychiatric issue, but especially anxiety, depression, anger, those mood issues and that HPA axis is just wide open and chronically wide open. Then cortisol, our stress hormone, which is actually sort of a steroid, it loses its ability to suppress inflammation and we start seeing increased systemic inflammation, increased activity of the immune system and reduced actual immunity to things. So basically the immune system goes haywire. If you want to simplify it and think about it, think back to times when you were stressed. Did you get sick easier? I think we all know the answer to that. Mood disorders and in ineffective immune responses, reduced cytotoxic killer T cells and T helper cell responses can lead to severe infection. And autoimm disorders may share common triggers. So we recognize that when people have mood disorders, as I, as I just mentioned, the immune system goes wonky. You see an ineffective response. The immune system's like, yeah, you know, I don't know what to do. I'm pulled so many different directions. So the immune system may not mount a response against a particular virus or bacteria. Depression and anxiety can be related to autoimmune issues either because of a biological and cytokine related mechanism. Now remember, cytokines as we're talking about them in today's presentation, are generally the inflammatory kind that we're talking about or because of the psychological impact of the Disorder. So what this is basically saying is that depression and anxiety can occur with autoimmune issues as a result of the physiological dysfunction, the inflammation that's going on. But we also can see people develop depression and anxiety because of cognitive, relational, interpersonal issues that happen as a result of the disorder. People start feeling helpless, hopeless. They start fearing rejection. They start fearing that they won't be able to accomplish their goals or live a rich and meaningful life. As clinicians, we can help them address these cognitions. We can help them keep daily journals. Not super detailed, intense. You know, a lot of people aren't, don't have the time for that, but keep basic daily journals of how did I feel today? So when they start saying things like, I always am in pain, I'm always in excruciating pain, we can go back and look and see is that accurate? And if so, sounds like they need to go back and talk to their physician. Because there is. There are a lot of different things we can do to help people mitigate their pain. Again. They may not be able to make it go away completely, but they should be able to have some good days in there. So we need to look at why is this pain remaining at such a high intensity for so long? What else is going on here? However, a lot of times we'll look back over the journal and we'll find that it's not going from max pain every day to no pain any day. You know, that's not reasonable. But the pain is decreasing in frequency, intensity, or duration, or all of the above gradually. So instead of seven days with pain on. At a level four, on a scale of one to five, they have six days with pain at a level four, and then one day not, and then the next week it gets a little bit better, or the intensity or the. The duration of the pain doesn't last as long. Instead of being all day, it's just the first two hours when they wake up in the morning, or the last two hours of the day when their body's just. It's. They've been to work and they've been moving around and their body's just screaming, I need a break. So we do want to look at that. We want to help people see gradual pro. Progress baby steps. 90% of patients with rheumatoid arthritis reported fatigue as the main factor causing low mood and depression. We don't want to focus exclusively on pain. We want to focus on functional distress. What does the disorder, whether it's the mood disorder or the autoimmune Disorder, what is it keep them from doing that they want to be able to do? What kind of functional impairment are they experiencing? And is there a way we can make accommodations in order to help them get as close to their rich and meaningful life as possible? What is it that we can do? But we also want to recognize that again, it's not just pain, it may be fatigue. And that fatigue can be extremely debilitating. When you are in pain, when there is systemic inflammation, your body's working hard to try to fix something that may not actually be broke. But that aside, it can contribute to fatigue and exhaustion. It contributes to HPA axis dysregulation. We want to help people figure out how they can mitigate their fatigue. Now they may not be able to make it go away completely. I hear that. Are there times of day that are better for them? Are they able to be a little bit more spontaneous? So those days they wake up and they have energy, they can do things they want to do. And then the days they wake up and they don't have energy, they're just dragging. They can do other things that don't require as much energy. Now not everybody can do that. But if they can, encourage them to take advantage of the bursts of energy that they may have. Addiction maybe may result as a way of medicating autoimmune systems or pain symptoms. And autoimmune flare ups may worsen as a result of systemic inflammation caused by addiction. When people are abusing substances and they start to develop, well, when they're abusing substances, when they're using them heavily, they're ingesting toxins in most cases, and those toxins are, are not supposed to be there. So it triggers the body to go, warning, you know, bad stuff is here. And that can trigger the audio, auto, trigger the immune system to, to kind of go into overdrive. When people are abusing substances and they start developing tolerance. Then when the substances start to clear out of their body and they start to experience detoxification or withdrawal symptoms, then that HPA axis, that threat response system, again, it's going to go off and it's going to say, hey, we need that now. We got used to having that. We need that in order to function. So again, we start to see increased levels of cortisol, increased levels of stress hormones, and a tendency for autoimmune issues to increase. Increased stress, increased inflammation, adverse childhood experiences. We know that they are directly correlated to a whole host of, of physical as well as mental health, emotional cognitive disorders. Research has even proven over and over again that adverse childhood experiences are significantly associated with the development of. Drumroll please. HPA axis dysfunction and inflammatory and autoimmune diseases. When that HPA axis becomes dysfunctional, when that stress response becomes hyperactive, if you will, then we start to see increased inflammation and an increased risk for autoimmune disorders. PTSD is common in people with mood disorders as well as people with autoimmune issues. They can a trauma, a particular trauma may trigger concurrent mood disorders with the ptsd. It can also trigger autoimmune issues. Untreated ptsd, symptoms of hyper vigilance and feeling unsafe in wherever they're at and disempowered. That's one of those core symptoms of ptsd. When that is ongoing, guess what? That HPA axis stays active. When that HPA axis stays active, we again see increases in inflammation and autoimmune issues. People need to feel safe, they need to feel empowered, they need to be able to rest. The HPA axis is a wonderful part of the body factory. When it is working properly. It is supposed to be there to help you in the event of a threat. It's supposed to be there to help you mobilize energy to do things that you want to do. But it also just like a factory needs to shut down so the machines can be recalibrated and all the floors can be cleaned and everything. Your body needs to be able to rest. If it doesn't, if it's not able to rest, then you start to see inflammation and dysfunction. Interestingly, bipolar disorder is also correlated with autoimmune issues. Now bipolar disorder definitely has a physiological component to it that is different than unipolar depression or anxiety. Research has found that autoimmune processes often precede come before the onset of schizophrenia and non affective psychosis and bipolar disorder. So that's really interesting that we see autoimmune disorders and systemic inflammation may contribute to triggering the genes or whatever you want to think of it as. That may trigger the onset, may trigger the first psychotic break or bipolar disorder. During autoimmune disease, flare ups cytokines. Inflammatory cytokines circulate in the blood. Now don't think of these as bad, they're not all bad. Inflammatory cytokines are kind of like the emergency response system. When the system is working correctly they go out kind of like the ambulance or the, the power crew after the power goes out in order to find out where the damage is and repair it so that inflammation, the cytokines are bringing inflammation to the area which brings Nutrients and oxygen and everything else to the area to help it heal. So when they're working, they are good, but when they go rogue, it's a problem. So during autoimmune disease flare up, cytokines circulate in the blood, reach the brain, and can cause depression, anxiety, anhedonia, or just kind of feeling flat, unmotivated, social withdrawal, fatigue, and sleep disturbances. So these inflammatory cytokines, when you start seeing inflammation throughout the body, it can be a big problem. Likewise, depression, anxiety and stress can trigger autoimmune flare ups. Chronic inflammation also impairs psychological responses to stress, including effective coping behaviors which result in depression and lead to a poorer prognosis for the autoimmune issues. So let's unpack all this a little bit. So I mentioned a couple times that your body's like a factory, okay. And, and I think it's really important that we kind of wrap our head around this metaphor, if we can. When your body is functioning properly, the gut microbiome takes the food you eat, breaks it down, sends it out to the other departments where it's needed in order to make hormones and neurotransmitters and repair those, the body and do all that kind of stuff. Now, as your body works during the day, just like in a factory, as the factory works, stuff builds up, trash builds up. You know, there are byproducts of whatever they're making. And if that doesn't get cleared away at the end of every shift or at the end of every day, it starts becoming a hazard. It starts getting more difficult to move around the factory. If the machines aren't shut down and recalibrated at the end of every day or at the end of every shift, or however often, then they start becoming less efficient and effective and they may start breaking down. Your body's the same way. During the day, when you're doing your normal things, thinking, talking, breathing, digesting all that stuff, you're producing free radicals. And normally your body can clear those free radicals just fine. You know, the funk, the, the factory is working just fine. But if you don't rest, if you don't sleep, if you don't take a break, then those free radicals can build up faster than your body can get them out. So it's kind of like that trash building up on the production floor and all the workers start having a hard time moving around and doing their job. So you can see how when our body, one system goes offline, when our body starts to have increased inflammation, increased amounts of trash around the around the factory, everything else has a hard time working effectively. When the HPA axis is activated because of chronic inflammation, because of pain, because of anxiety, for whatever reason, trauma, the brain is in fight or flight. The brain is not in higher order, processing. Let's think about it and figure out the best way to cope. The brain is in fight or flight. Make it stop. So chronic inflammation, chronic stress impairs your psychological responses. Linehan would say you're not in your wise mind, you're in your emotional mind. You're in your autopilot mind that just wants to get away from that hungry lion that's chasing you. You're not thinking about, okay, what's the best path? And, you know, what else could I do? You're just, you're running. So we need to recognize this. But as a result, chronic inflammation impairs our ability to problem solve, which means that we're more likely to maintain that stress, which means that we're more likely to maintain those autoimmune issues, because as stress increases or fails to decrease, those autoimmune issues get worse. So you can see how all this is folding in on itself. Other commonalities that are interesting, there is an association between vitamin D deficiency and cancer, cardiovascular disease, diabetes, type 1 and 2. Remember, type 1 is autoimmune. Type 2. They're on the fence. They're finding some research that may indicate there's an autoimmune component to type 2 as well. But I digress. But there's also an association between vitamin D deficiency and depression. We're not going to prescribe vitamin D. We're not even going to prescribe sunbathing because that can be taken too far, too. However, it is important, and this is one of those things that the doctor is probably testing for if the person is going in for their annual physical evaluation. This is one of those standard things they look for in blood work. So if the person is struggling with depression, you know, they're in your clinical office, which means they're probably presenting with some sort of a mood symptom, that this is one of those things that we can have them screen for, especially if we know they already have an autoimmune condition. And here's our friend, the gut microbiome. Again, the gut microbiota is involved in many basic biological processes, including the stimulation of innate immunity. When we get stressed, what happens? The stress response team, if you will, the stress response microbes show up in order to prepare what's needed for the fight or flight response. We have different microbes in our gut when we're stressed versus when we're relaxed, when we're awake versus when we're asleep. You didn't realize that they change shifts, did you? And that is oversimplified. But we know that the gut microbiome changes under stress and we know that these chain, these stress related changes also can impair our innate immunity. People's genes, your genetics, there's no way around it. Their lifestyle, food and drugs consumed, including alcohol and all the way through antibiotics. You know, the, the good, the bad and the ugly have an impact on the microbiome, which affects psychological systems and physiological systems like the immune system and the endocrine system. They found, and if you go back and watch my video on the gut microbiome, that there is a direct correlation between the makeup of the gut microbiome and mood. So we're finding a lot of these connections. We what happens when you take an antibiotic, for example? Well, if it's gram positive, it goes in and wipes out a whole family of microbes. If it's gram negative, goes in and wipes out a whole different family, if it is broad spectrum, it just goes in and wipes out a lot of them. Now obviously it doesn't kill everything because you have to have microbes in your gut in order to survive, but it creates a microbial imbalance. It's kind of like if you had, you know, 2/3 of your staff at the factory go on strike, you know, not good. Lack of microbe diversity leads to many diseases like autoimmune diseases and the development of problems such as memory disorders, depression, stress, autism and Alzheimer's disease. They obviously, I'm not saying an imbalance in the gut microbiome is the only cause. Okay, I'm not saying that, I'm not saying that it necessarily is a direct cause. But we do know that there is a very strong correlation between the microbe diversity in somebody's gut and intestinal tract and their mood, their memory, their cognition and, and they have found, doing certain studies that there are certain types of bacteria that are, are more prone to prompt or be associated with the display of certain symptoms of autism. So that's interesting. In the intestine, there's a synergy between mucus, the microbiome and immune cells, which plays an important role in preventing pathogens from crossing into the bloodstream and stimulating inflamma. Now that mucus is made up in large part of 5ht, which is a precursor to serotonin. So that's kind of interesting. There, but it lines the intestinal tract and keeps anything from leaking out. When people serotonin is low, they found that that mucus tends to be thinner and there tends to be more leaky gut. Toxins leak out, inflammation goes up, immune system kicks into overdrive, depression kicks up. We see problems, we see the relationship now. There are a lot of medications out there for autoimmune disorders and sometimes they are really helpful. But like most medications, they tend to have side effects. Anti inflammatories. All right, well, we know those NSAIDs that you can get over the counter or even by prescription sometimes cause stomach pain. And that's not good when you're in pain. When you've got inflammation, whether it's from the autoimmune disorder or from the anti inflammatory, it's going to be hard to concentrate. They have found though in some studies that NSAIDs may have a mild antidepressant effect. This is by no means a recommendation to self medicate with anti inflammatories because they have their own side effects. But it is interesting to note that as inflammation goes down, depression tends to go down or mood tends to improve. However you want to look at it. Antidepressants, your SSRIs, SNRIs, SNDRIs. When people take those, sometimes a side effect is difficulty concentrating. When you monkey with one neurotransmitter, you monkey with all his buddies. So when you increase serotonin, you're going to alter the levels of norepinephrine, acetylcholine, dopamine, you know, the whole group in there. So difficulty concentrating may be associated with alterations in neurotransmitters as a result of taking antidepressants. Some antidepressants may promote fatigue and it seems to be it promotes fatigue or anxiety in my clinical experience with people. But some people may experience them both. I'm not saying you won't. Some antidepressants cause a feeling of anxiety. Why is that? Well, because as you're increasing one, you're increasing like if you increase serotonin, you're also likely increasing norepinephrine. The interesting thing to note too is our neurotransmitters operate on what's called the Goldilocks principle, if you will. Too little, no good, too much, no good serotonin, they believe too little depression, too much anxiety. Therefore, when somebody's taking antidepressants, especially when they first start taking them, you know, their, their body's like, whoa, definite, definite shift in the, in the chemical makeup. So they may experience Initial anxiety or if low serotonin was not their problem. They had plenty of serotonin, thank you very much, but it was low dopamine. Then certain antidepressants may make them feel anxious all the time because low serotonin just wasn't their problem. But that's a whole different video. Antidepressants can also make people feel a little bit restless. And but they also have found that it can they, they can be anti inflammatory in nature. So that's another interesting feature that of. Of antidepressant medications that in and of themselves they may be antidepressant in nature. It's also important for treating autoimmune disorders to make sure that people I know, I sound like a broken record are communicating with their physician and they're regulating substances the body cannot effectively make on its own or regulate for some reason, whether it's because it's already been attacked by autoimmune issues and destroyed or whatever. Thyroid hormones. There is autoimmune thyroiditis that people are very commonly develop problems with insulin regulation, that type 1 diabetes or alterations in gonadal hormones like estrogen or progesterone. Progesterone or testosterone, but primarily estrogen. It's important that all of these things are imbalanced because all of these things can contribute to depression, fatigue, irritability, difficulty concentrating and anxiety, stress. And that stress is going to exacerbate the autoimmune issues. Unfortunately, immunosuppressants have been found to be very helpful for people who have an overactive immune system. But they're also well known for their neuropsychiatric side effects. Depression, fatigue, lethargy, agitation, restlessness, anxiety and insomnia are not uncommon. And it depends on the type of immunosuppressant the person's taking. And in 20, in 20 to 32% of people that take immunosuppressants, particularly corticosteroids, they may experience delirium. Being aware of this, we're not prescribers, we're not going to try to freak people out. But if you notice a sudden change in your clients and they just started taking immunosuppressant medication or they're complaining about these symptoms that started six months ago when they started taking immunosuppressant medication, that's a clue, and that's a clue that they need to go back and talk to their doctor if the side effects are intolerable. Some people will take some mild depression to not have the inflammatory condition. So, you know, it's a Personal judgment call for, for the client. But we do want to recognize that no amount of talk therapy in the world is going to completely eliminate symptoms or side effects of medications. So they've either got to accept that there's going to be at least a certain level of this particular side effect they're experiencing or go back and talk to their physician. Now for my diatribe on Cytochrome P450. The Cytochrome P450 is a family of enzymes. However, the. And what, what cytochrome P450 enzymes do is break down drugs and help them clear out of the system. There's only so much to go around, and I'm grossly oversimplifying this again, but you know, we've only got so much time today. If somebody is taking a substance that is metabolized by cytochrome P450, then that may make that enzyme less available to other substances that also are broken down by cytochrome P450. So those substances may build up to toxic levels really, really fast in the, in the body. Likewise, you know, it can go the opposite direction. But it is important to recognize that depending on which enzyme in the family, the breaks down the drug and the other drug that they're taking, there could be drug drug interactions. Psychotropic medications, anti inflammatories, immunosuppressants, opioids, CBD cannabidiol, CBD oil and statins are all metabolized by cytochrome P450. A lot of people that I know that have autoimmune conditions or pain conditions, inflammatory conditions, are turning towards things like CBD oil. I'm not saying pro or con about that. What I'm saying is if you are taking any other medication and you start taking cbd, you need to run it by your doctor. Because those other medications may need to be adjusted. They may need to be adjusted so they are sufficiently effective or so they don't become too high, so they don't become toxic in your system. So what can somebody with mood disorders and autoimmune issues do? Well, we need to help them reduce stress and depression and reduce HPA axis up regulation. We need to help them heal that stress response system. We need to help them take charge of that body factory and get everything operating and in working order. So all the departments are working efficiently and effectively. And that is way easier said than done because there are so many things that trigger that HPA axis, from mental stress to physical stress, including like sleep deprivation and, and pain to even Even doing things that are super exciting and exhilarating, you know, that's still excitatory in nature. You go on a roller coaster ride, you go to the amusement park all day long, you're going to be exhausted afterwards. That stress response system, if you will, was responding to what we call eustress or good stress, but it's still stress. And the HPA axis, if it's dysregulated, needs downtime, needs time to heal and rest and recover and rebalance. We can help people develop distress tolerance skills like deep breathing and grounding and mindfulness in order to identify potential triggers and potential distress before it becomes a big issue and figure out tools to either cope with it or tolerate it. Recognizing that, yeah, it's unpleasant, but it will pass, it's unpleasant and they can survive it. We want to help them address their, their cognitions with facts and address any cognitive distortions that they are using, like all or nothing thinking or personalization or mind reading. We want to help them develop psychological flexibility and particularly what I, what Hayes calls living in the. And, and that's what I talk about a lot too. Defining their rich and meaningful life. What is important to them in a rich and meaningful life and how can they have that life and also have this or these conditions? Now there, there may be some compromises or modifications that have to be made, but how can they get as close as possible to that rich and meaningful life and have an autoimmune disorder and have depression or anxiety so they recognize that their current condition is not going to keep them, not going to prevent them from having a rich and meaningful life. We want to help them embrace the dialectics and identify the parts of the situation that they can control. They wake up in the morning and their, you know, in pain. They start out the morning and it's not a good day. All right, well, you can't control. That is what it is. Now what can you control? You can control whether you get angry about the fact that you woke up and you're in pain and you stay angry and just dwell on that anger all day, or if you embrace it and say, okay, this is not going to be an A day, so how can I best use my energy today to move toward my rich and meaningful life? We can help them develop what I call empowerment skills. As I mentioned earlier, monitoring through journaling the intensity, frequency and duration of their pain, their depression, their anxiety, whatever their presenting issues are, how often is that happening and is it getting better and look for baby steps really encourage. I, I love the Likert scale, because you can look over time. Was it a two, a three, a four, a five? And how many fives did we have this week versus last week? Is it getting better? Is it getting worse? If it's getting worse, let's take a look at why. Let's get curious. Let's not get upset about it, let's not get angry about it. Let's say, all right, well, crap. What did we miss? Or what changed? And how do we need to change the treatment plan in order to adapt? Help people reduce pain. We are not physicians. We are not going to prescribe any of these. However, we can educate people about TENS units transcutaneous electronic nerve stimulation. They're all over the place now. People are even using TENS units for vagus nerve stimulation. But talking with their doctor about the use of a TENS unit for pain management. It's not going to work on everything. You know, it probably doesn't do anything for irritable bowel syndrome. Probably doesn't do anything for ulcerative colitis, but it may help with other types of inflammation and pain. Hot and cold therapy can be helpful. Guided imagery. Now, this one we can help with. We don't want people to ignore their pain to the point that something is wrong and it's getting worse. But if they feel their pain and they go, yep, this is my normal pain. It's a bad day, not really worried about it, but it's unpleasant, don't want to experience it. Guided imagery can be really helpful. Envisioning their pain as a color. Like, I've got really bad tennis elbow. Envisioning that elbow as bright red. And then seeing the color become more and more transparent until it disappears. Or seeing the color turn from red to blue as the pain eases. Envisioning pain. Maybe they've got pain in their gut. Envisioning it like a knob, like a volume knob on. On your car stereo. Turning down the. Not the knob on the pain. Seeing a destroyer of the pain. You know, if you want to get into the superhero thing or alternate focus, sometimes when we're really uncomfortable, think about a time, you know, forgive me if this is offensive, that you really had to pee really bad. If you sit there and you think about how bad you got a pee, it's going to get worse. You know, you're going to be, er, this is uncomfortable. If you focus on something else, the song that's on the radio or just about anything else, it tends to not bother you as much. Yeah, you still got to do it. But you can wait until the next rest stop, you're not going to, you know, have a problem. And pain can be the same way. You know, it is a sensory response to something that's going on. So instead of focusing on it, think of, focus on something else. Focus on something that you want to do. Focus on a song, focused on anything so you're not thinking about the pain, you're not feeding the pain. And stretching and exercise can be helpful when done appropriately for that person's particular condition. Social support, always helpful when it's helpful. What do I mean by that? Well, not all social support is helpful. Some people are going to give you advice. Some people are going to get in your way. Some people not so helpful, even if they're trying to be. But support groups can be very helpful. People who are going through the same thing who, who get it can be really helpful. People who've already been dealing with it for a while who can say, okay, you know, the first year is the worst, or, you know, when this happens, it tends to be bad, but it passes, or, this is how I dealt with it. There's a lot of great information that comes from lived experience. There's only so much you can get from clinical research papers. I learn a lot from my patients that I didn't learn directly from the research studies. Now, a lot of it I can go back and, you know, find supporting evidence. But there wasn't a study that said if they feel this way, then have them do this. It was something that they figured out. So that can be really important to get support from people with lived experience. And it's important if somebody has limited mobility because of their autoimmune issues or limited functionality and I don't know what word I'm looking for here, they can't get out and do the things they want to do because of their mood or their autoimmune issues. We need to help them reduce isolation to the extent that they are comfortable. If they're introverts, they don't want to be going to group meetings every day or attending online group meetings every day. That. No, that's not what they want. However, most of us benefit from some sort of connection. Some people are going to reduce isolation with a emotional support animal. That can be super helpful for a lot of people, especially people who are experiencing depression as well as autoimmune issues, because the dog or cat or whatever the animal is isn't going to judge you if you just, you know, you couldn't, your arthritis was too bad that day. You couldn't do your hair, you couldn't do your face, as my grandma would say, but they're there and they're going to sit on your lap and they're going to, you know, be your best buddy. Lifestyle management is also important in reducing stress. Noise. Oh, the noise, Noise, noise, noise. As the Grinch would say, ongoing background noise can be really stressful for people, even if they don't realize it. They find that people that live in urban areas tend to have higher stress levels than those who live in rural areas, and they attribute part of that to the noise. Help people pay attention to their nutrition. Reduce alcohol. Although light drinking may have some limited benefits for some conditions, you know, there's always. There still is a lot of argument in the literature about the benefits of some of the antioxidants that are found, like in red wine. But we know that excessive alcohol consumption is going to contribute to inflammation, hydrate to promote kidney and liver function, and clear out those toxins and help get those free radicals out, help get all that trash from production out of the factory. Get enough quality sleep, and it needs to be quality sleep. Exercise has been found to modulate the gut microbiome, increase serotonin and impair inflammatory signaling. So interesting. Even though a lot of times you exercise in the day after, you're a little sore when you're exercising and shortly thereafter it impairs inflammatory signaling. Exercise is a stressor. Stress releases cortisol. Cortisol, when it's functioning properly, suppresses inflammation. So you can see how exercise could help. For most people who are coping with autoimmune disorders as well as mood disorders, light to moderate exercise is going to be the goal. Not really. Heavy, intense exercise that wipes them out and leaves them sore the day after. Maintain a healthy weight because obesity contributes to inflammation, increases in adipose tissue and increase estrogen. Estrogen increases inflammatory signaling. It is what it is. Pay attention to ergonomics. If you are sitting on a couch all kinked up in, you know, a very not ergonomic way, you're going to increase your pain. That pain is going to prevent you from sleeping. It's going to trigger your HPA axis. It's just a whole bad thing. Pay attention to your body position when you're sitting, when you're laying down, and when you're walking. Address mental health issues like grief, anger and depression. Sometimes I've had people do what I call write a new narrative. They are the author of their own TV series and the season is ending and they're getting ready to write the next season, what's going to happen? What's going to happen in that narrative? And you know, just like most writers do, they don't just plan for this particular season, they're thinking two, three, four seasons away. You know, eventually, where are these characters going? What's their rich and meaningful life? So have people actually write their new narrative? Encourage them to practice gratitude, maybe even making a gratitude tree with a branch from outside and little present tags each day writing down something that they're grateful for. Positive journaling. Reduce depressive symptoms and anxiety after one month and improve resilience after the first and second month relative to usual care. This doesn't mean toxic positivity all day, every day. This means 20 minutes a day focusing on the positive. And some of my clients, they're not real into journaling, but they agree, you know, I'll spend 20 minutes a day, like during dinner time, focusing on the positive. The other 23 hours and 40 minutes. Focus on whatever you want. But for 20 minutes, I'm just going to have this positive zone, positive bubble. Address the guilt, as I mentioned earlier, that may be associated with not being able to be the person that you think you quote, should be. Deal with anxiety about your pain, about your health, about your conditions. Whether, you know, whenever you get a cramp or something's a little bit different, maybe you worry that it's worsening. Help people identify the triggers for their health anxiety and strategies to deal with it by partly improving their health literacy so they understand the course of their disease and what makes it worse and what makes it better, but also doing that journaling and charting that I talked about. Help them address their anxiety about abandonment or rejection because they are not perfect. Help them explore resources to deal with job loss and finances. Sometimes with autoimmune issues, people need to have, you know, things changed around the house and it's not inexpensive to get grab bars and things added. So encourage them to work with the Department of Rehabilitative Services in your state in order to identify any resources that are available to help them with modifications or reasonable modifications at work as a result of their disability, and then work on self esteem. Obesity, poor nutrition, stress, depression, poor sleep and other lifestyle factors can worsen autoimmune issues. Autoimmune issues and treatments for them can contribute to mood and neuropsychiatric symptoms. So they're going to work together. Sometimes treatment must aim to maximize quality of life, enhance compliance with multidisciplinary treatment plans, provide health education and address underlying mental health issues.