Important Physiological Systems in Behavioral Health: PACER Integrative Behavioral Health

Hey there, everybody, and welcome to this presentation on important physiological systems in behavioral health. I'm your host, Dr. Donnellice Snipes, and this is part of the PACER Integrative Behavioral Health series. In this video, we're going to review the functions of the hpa, HPG and HPT axes as well as the gut brain axis. Now, in prior videos we have talked about these things in, in parts. So this, the, the goal of this video is to kind of pull it all together so you can understand why these systems are so important. The HPA axis involves the hypothalamus, the pituitary gland and the adrenals. It regulates cortisol levels, norepinephrine, glutamate, dopamine, blood sugar, serotonin levels, inflammatory cytokines, and it also directly influences the hpt, the thyroid axis, and the hpg, the gonadal hormone axis. So the HPA axis you can kind of think of as the main control center, if you will. It's important to recognize that in mood disorders, for example, when people have anxiety, their levels of quantity, cortisol, norepa, norepinephrine and glutamate are probably going to be high, maybe even too high, where it's becoming excitotoxic. Their blood sugar is probably going to be high because their HPA axis is telling their system to dump adrenaline, which is telling their system to drum, dump blood sugar for the fight or flight process. Serotonin levels, the happy serotonin levels typically are low when the HPA axis is overactive, when the HPA axis is resting. If you want to think about it that way, when it's downregulated, serotonin levels go up. The HPA axis is responsible for fight or flight. So I want you to just think about it in terms of the brain saying, okay, you need to do this. You need all the energy you can and all the focus you can to survive this threat. So now is not the time for relaxation. Now's not the time for sleep. Now's not the time for procreation or libido. Now's not the time for digestion. Now is the time to fight or flee. So when the HPA axis is hyperactive, all those other things get, get, be, get pro start to develop problems. What can disrupt the HPA axis? Well, we know, quote stress, but what does that look like? Well, there are a lot of different things that cause stress on the body, including sleep deprivation, inflammation and pain. It can be from an injury, from an illness, from an autoimmune Disease, toxins in the environment are stressful on the body and poor nutrition. If the body doesn't have the nutrients it needs to complete the chemical processes necessary to make the hormones and neurotransmitters, the brain perceives that as a threat because the body is, the body factory is not in optimal functioning form affectively any of our dysphoric emotions. Stress, anxiety, anger, negativity, grief, depression can disrupt the HPA axis. They can cause it to become overactive, hyperactive, cognitively poor problem solving, inaccurate schema, cognitive distortions, all of those things. And anything that causes us to have stressful thoughts or to perceive the world as negative or threatening will increase our anxiety and increase that HPA axis activation. Now, interestingly, one thing people don't think about very much is the environment. But there have been a multitude of studies that have shown that things like noise, light and smells can be perceived as stressful to the body. People who live within three miles, I believe, of a wind farm often have much higher levels of rates of antidepressant prescriptions. So that's something to take into consideration. Even a constant low grade noise can be irritating to the sensory organs and can contribute to HPA axis activation. People who live in a flight path where airplanes are coming over their house all the time, or they live in the city where there's regularly noise, traffic and sirens and stuff, and even people who live in a household where there is lots of discordant, constant noise, people screaming, yelling, whatever. If you live in a apartment complex, so sometimes you can hear your neighbors, but if you live with a lot of family, sometimes it can be your family. And that noise can be very stressful on the body. That noise can trigger a, a sense of a lack of safety and it can keep the person from being able to relax and get good quality sleep. Light can also be an HPA axis disruptor because light is important for circadian rhythm regulation. When circadian rhythms get out of balance, HPA axis becomes more active. We start seeing things like seasonal effective disorder, but also harsh lights that have glare or that have strong blue light components to it can be very hard on the eyes and actually very stressful to the body. If you, you take some of those old fashioned fluorescent lights and when the ballast starts to go out, not only does it flicker, which is very stressful to the body and the brain, but there's also usually a very annoying hum that goes along with it. And that also can contribute to HPA axis activation, the stress response and anything in the environment that constitutes a sense of lack of personal safety. If you're, if you are afraid for your personal safety, then that HPA axis is going to be activated. And it could be that your memories based on prior trauma keep you from feeling safe wherever you are. And it's important for us to recognize that and help people figure out, okay, how can I create safety in this context at this time? Interpersonally, there are things, Relationally, there are things that can also activate that HPA axis, including a lack of healthy relationships. As humans, we are sort of programmed to want to be with others. That's why we have bonding hormones like oxytocin and vasopressin. Lack of healthy relationships can contribute to HPA axis activation and a sense of isolation and unsafeness. And interpersonal trauma can also make people feel unsafe, Whether it was from a stranger or from a known person. Fights, arguments, or traumatic events, victimization from another person can make it hard to trust and can upend people's concept of the world being a safe, beneficent place. Those are all targets that we can work on with people in order to help them down regulate their HPA axis. The HPG axis, or the hypothalamic pituitary gonadal axis, is also important because it regulates our gonadal hormones. And you remember from the last presentation that gonadal hormones are involved in bone density and energy and mood and a lot of other things. It's not just libido and sex characteristics. So disruption of the hypothalamic pituitary gonadal axis can be caused by aging. As we age, unfortunately, our body produces less human growth hormone, less dhea, less estrogen, less testosterone. So there can be problems related directly to aging. Surgical removal through a hysterectomy or, you know, removal of the testes can also. Obviously, if you take away the places, the parts of the body that produce these hormones, you're going to have a decrease in the hormones. Nutritional deficiencies can contribute to HPG axis disruption. The body needs cholesterol in order to make a lot of your gonadal hormones, and it also needs other vitamins and minerals to make that process work. So if people are not eating a healthy diet, they may be contributing to deficiencies in the HPG axis. Synthetic hormones that people take through hormone replacement, birth control, and even replacement testosterone can cause disruption of the HPG axis if they are not in the right balance for that person at that point in time. And our hormone levels are partially dependent upon our stress levels as well as our. As well as our weight. So as your weight changes, you may need alterations as you age. If you're replacing something like testosterone, as you age, testosterone goes down. So as you age, your testosterone supplementation may need to go up. Medication side effects can alter the availability of the gonadal hormones or the activity of the gonadal hormones. Certain medications will suppress libido, for example, certain antidepressants. Stress can also do that as well as hormone disruptors. And we're, there's going to be a whole class on hormone disruptors later. But basically these are chemicals in the environment like BPA that are known to actually interfere with the HPG axis and finally, inadequate connection and social interaction. If you don't have healthy relationships, it can affect the HPG axis, which, you know, part of the HPG axis is designed to increase bonding and increase procreation. So if you don't, if you feel isolated, if you don't have healthy interactions, it will increase stress and it will blunt the HPG axis, which can result in blunting of mood, blunting of energy, difficulty with concentrating, and even things like more brittle bones because of reduced bone density. The HPT axis is your hypothalamic pituitary thyroid axis. It's involved in regulation. The hypothalamic thyrotropin releasing hormone, or trh, comes from the hypothalamus, obviously stimulates the synthesis and secretion of pituitary thyrotropin, which is a and thyroid stimulating hormone, which acts at the thyroid to stimulate the synthesis and the release of thyroid hormones. So the hypothalamus stimulates the pituitary to, to tell the thyroid to make thyroid hormones, fasting infection and other acute and chronic physical and mood disorders. So anything that's, you know, getting that HPA axis to be overactive, keeping the person in fight orf flight mode, can lead to inhibition, dampening, blunting of the HPT axis and the development of symptoms of hypertension, hypothyroid. So people who are under chronic stress, it's not uncommon for them to start to develop symptoms of hypothyroid because cortisol can block the ability of the thyroid hormones to do their job. High fat diets, interestingly enough, and I just kind of threw this in here as a interesting point, high fat diets actually stimulate the HPT axis by altering leptin levels. Now, ghrelin and leptin are hunger and satiation hormones and they are generally regulated by the circadian rhythms. But they have found that independent of circadian rhythms, high fat diets may actually increase leptin levels and the gut brain axis. You know, this is one of my favorite. The gut brain axis consists of bi directional communication. So the brain talks to the gut and the gut talks to the brain, linking emotional and cognitive centers of the brain with peripheral intestinal functions. So when the HPA axis is activated, for example, the brain sends a signal to the gut via the vagus nerve that says, hey, we have a threat out here. Stop digesting, get the food out of there. You know, speed up the gut motility because we really need to be able to focus on addressing this threat. The microbiota in the, in the, in the gut, and that's in your, in your stomach as well as in your intestines, communicate with the brain via the vagus nerve. They found in multiple studies that gut health is directly related to mood regulation. Now, part of this is because of the communication with, by the vagus nerve, but another huge part of it is the fact that the microbiota, the bacteria in the gut, actually synthesize hormones and neurotransmitters. And when you get to the class on gut health, you'll learn about a lot of really interesting things like E. Coli and streptococcus that exist in your gut that are actually essential for producing certain hormones and neurochemicals. The majority of neurotransmitters and hormones are created in the gut. This is where nutrients are. When nutrients are consumed, they're broken down into usable components. An unhealthy gut, one that doesn't have the right balance of bacteria, is unable to effectively create the neurotransmitters and hormones it needs to. Unfortunately, most Americans have an unhealthy gut. Now, stress can make your gut unhealthy, and an unhealthy gut can cause stress. So this is a place that we really need to start considering for intervention. Since most of you probably are not registered dietitians, it's important to remember that we cannot prescribe meal plans, but we can educate people about the importance of good nutrition to make sure that the body has all of the nutrients it needs to complete the chemical reactions that are necessary to keep the gut healthy, as well as to make the neurotransmitters and hormones. The gut brain acts as bidirectionality, and this image was from one of the studies. So I just figured I'd share it with you. The gut communicates to the brain and tells it about the production, expression and turnover of neurotransmitters. So if the gut is unhealthy and effectively make serotonin for example, it sends that signal to the brain and it says, you got to slow down using that serotonin because I can't make enough of it, which we know may end up in with symptoms of depression. The gut tells the brain about the health of the intestinal barrier and the junction integrity, how tightly knit together or how tightly compacted the cells of the intestine are. When they become loose and not tightly packed, then toxins can seep out from the gut and they call this leaky gut. When the intestinal barrier becomes permeable, that becomes a problem that leads to systemic inflammation and often is associated also with an increase in depressive symptoms. So if the vagus nerve is regularly telling the brain about how well the fortress is being protected, so to speak, it modulates enteric sensory afference. So basically it modulates gut sensory organs. It tells the brain about bacterial metabolites, it tells it if it's getting too toxic, there's too much building up of a certain bacteria. And it also tells the brain about the status of the mucosa and the immune system in the gut. There's actually an immune system in your gut. The brain tells the gut about alterations in, or the need for alteration in mucus and biofilm production, about the need for alterations in motility. Like I said, when it's time to fight, it's not time to digest. So that's why a lot of times when people get stressed, they get diarrhea, alterations of intestinal permeability, and alterations in immune functioning. So when the brain is under stress, it tells the gut how to react in order to prepare the system to fight or flee. When the brain is not, Excuse me, when the brain is not under stress, then it tells the gut, hey, we can relax, we can rest and digest until the cows come home. General interventions that we want to consider include the. Sleep hygiene. We know that sleep deprivation is directly correlated to hyperactivation of the HPA axis, circadian rhythm regulation, helping people make sure that they are keeping their circadian rhythms in balance. With bright light during the day and dim light at night. With keeping a sleep routine, for example, nutrition improvement can be helpful. Again, we're not prescribing diets, but we are educating people about what healthy nutrition looks like. Non pharmacological pain management. Obviously we're not prescribers, so we can't work with pharmacological pain management, but we can help people with things like guided imagery and exploring, for example, aromatherapy, which has been shown to be helpful with reduction of pain. And inflammation. We can focus on health maintenance, behavior improvement. So what things are they doing to maintain their health and keep their body factory optimally functioning? Emotion regulation, that's right up your alley with distress tolerance skills and coping skills to to prevent the HPA axis from being unduly activated. We also want to encourage people to engage in activities to promote happiness. Let's do things to increase dopamine, increase serotonin. Mindfulness is another intervention that can help people notice when something is going astray early, before it becomes a big issue, before it triggers that HPA axis. If they're mindful and they notice that they haven't gotten enough sleep on one night, then they can take steps to make sure the next night that they remedy that so they don't start creating stress on their body. We can help them address cognitive distortions and develop cognitive flexibility and attitude of positivity and radical acceptance. We can educate them about toxins and hormone disruptors in the environment like BPA and PofAs that they can easily stay away from if they choose to. We want to help them figure out how to enhance their perception of safety. How can we help them feel safe and loved at this time? In this context, we want to help them create that the environment that supports that safety and enhance interpersonal skills so they feel like they've got social support, they don't feel like they're isolated and help them work on their self esteem so they are. Well, they need social supports. They can also tolerate not being liked by everybody all of the time. When the hpa, the HPG axis, the HPT axis, or the gut brain axis become hyperactivated or dysfunctioning in some way, it impacts people's sleep, which we know that sleep changes are a symptom of depression and anxiety. We know that sleep changes are associated. Sleep deprivation is associated with reduced immunity and increased inflammation. So sleep impairment is something that we need to be concerned about as behavioral health practitioners. Energy level reduction because of a problem in any of those axes? Well, when people feel fatigued and flat and unmotivated, it's really hard for them to get excited about anything. So we do want to help them make sure that they're getting the nutrients they need, they're trying to eat a healthy diet and they're addressing anything that could be contributing to their low energy from, from circadian rhythm disruption all the way through negative affect. Impaired nutrient absorption happens especially under stress because if the body pushes food out before it's fully digested because it's too worried about fighting or fleeing Then you're not. It doesn't have time to absorb or break down the food in order to get all the nutrients. So we want to help them figure out ways that they can eat healthfully, but also make sure that their system has time to absorb those nutrients. Chewing thoroughly, practicing relaxation exercises before and or after eating. There are a lot of things that we can do to help people support their body in focusing on rest and digest at the right times. Immune system impairment also goes wonky when any of these systems get out of whack. And it's important for us to help people figure out what they can do to not stress their immune system. For example, washing their hands, wearing a mask, social distancing, the things that we keep hearing. But also again, eating a healthy diet, making sure they're getting enough vitamin D. All of those things can be helpful. Inflammation and pain are very common in people who have chronic stress or depression. And inflammation and pain can cause chronic stress and depression. So these are targets that we need to help people focus on as they reduce their stress levels. As they reduce that HPA axis activation, inflammation tends to go down some and pain perception or pain tolerance tends to go up. So those are all good things. It won't necessarily do everything for people. If they've got rheumatoid arthritis, you know, relaxation exercises may help. They may not do everything. So it's important to make sure they're talking with their doctor about other strategies to address inflammation and pain. Sexual dysfunction can take a toll on people's relationships as well as their self esteem. And when, especially when the HPG axis becomes dysfunctional or when the HPA axis is overactive and saying, hey, now's not the time to procreate, it can contribute to sexual dysfunction. We want to help people identify what they may be able to do to address the sexual dysfunction. One of them being talked to their doctor. Some others may be working on addressing sources of stress that may be contributing to HPA axis over activation and sexual dysfunction. Emotional distress can be caused. So we need to help people figure out how to cope with emotional distress as well as trying to figure out things that they can do to try to increase or try to create moments of happiness. Memory problems can be problematic and they can increase stress. If you're forgetting things, you know, I know I went to the gym this morning and I actually forgot my dress shoes. So I'm sitting here wearing my, my gym shoes in the office and but consistent memory problems can be frustrating to people and increase their stress levels, increase their negativity helping people figure out how to cope with those memory problems. People who have new babies in the house, they're not sleeping a lot, so they're sleep deprived, which means that HPA axis is activated. They may not be concentrating, they may be more foggy headed. So what can they do to cope with that, to prevent those memory problems or from worsening their stress. And likely as their stress goes down, memory will improve. Poor attention and concentration is another thing that we need to help people focus on. If people are stressed out sometimes it's hard to sit down and focus for an hour or an hour and a half, even for things like watching a movie. So help them figure out ways to chunk things, chunk things that they need to do into manageable time periods where they can take a break in between. Obsessions and compulsions can happen when these axes get out of whack. And it's important for us to help people really work with some cognitive tools to address those obsessions and compulsions. And finally, social withdrawal. A lot of times when we're stressed, when one of these axes is out of balance, we may not feel like interacting with others, we may feel overwhelmed. And social withdrawal actually often contributes to worsening of symptoms. So we do need to help people find healthy, supportive relationships to engage with. Even if it's not face to face, even if it's over a mobile device because they just don't have the energy to go out or something. It's still important to connect with others. Now everything we talked about really applies to people who are neurotypical and aren't ex experiencing major mental illnesses like schizophrenia or dementia or Alzheimer's. Those are very special case scenarios. What we're really talking about is the person who is, you know, overall not having any major neurocognitive issues and things we can do to help them improve their health, wellness and quality of life.