The Mind-Body Interaction: Holistic Approach to Mental Health

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allceus.com counselortoolbox I want to thank everybody for being with me on this Memorial Day. In the. In the US it is Memorial Day and thank you for being with me so early in the morning. For you, Helen, I appreciate you being here and we're going to go ahead and get started. I'd like to welcome you all to today's presentation on holistic or biopsychosocial approach to diagnosis and treatment. And treatment of what you say? Well, kind of treatment of everything. And you're going to understand that a little bit more as we get into it. I really wish that all practitioners would embrace a biopsychosocial approach. We're going to identify the common physical, cognitive, interpersonal and environmental causes of mood disorders, particularly today. But you're going to see how they interact with everything else. We'll describe the impact of these on neurotransmitters in the HPA axis and develop treatment interventions that address the whole person, not just a single cause of a single symptom. What kills me is when I see people go in for depression or anxiety or they go to the doctor and they're fatigued and the treating clinician takes whatever is most handy as a diagnosis in mental health, we call it depression in medical. They may look at sleep or start looking at thyroid or whatever, but instead of looking at the whole person and going, hmm, what could be causing this malfunction in the symptom, in the system? Because every symptom we have indicates that our body system, our body machine is malfunctioning somehow for some reason. And we want to find out what that underlying cause is. If you have a car and you take it into the shop because you're getting bad gas mileage, you know, you don't want to just change the oil, maybe that'll help some. But you also want to get the two 50 pound bags of dog food out of the trunk. You also want to inflate your tires so they're the right tire pressure to get the best gas mileage and, you know, maybe have them clean all this stuff so the gunk in the engine isn't also slowing things down. You see, I'm real technical there, but my point is you're going to look at more than just the fluids. You're going to look at the whole car and go, what could be causing my gas mileage to be Low. And with the person, we're going to say, what could be causing distress in this person. Why holistic? Well, 30 to 40% of patients with major depressive disorder do not respond sufficiently to usual antidepressant treatment. That's a lot of people. Even under optimal treatment conditions, only one third of patients achieve remission. So that means 2/3, 66% of patients don't achieve remission, and they're still struggling with symptoms. And that's a travesty. And one of the reasons I hypothesize is because we're not addressing the cause. And research has shown that it's not just when you're looking at a person and say they have depression. It's not necessarily just a serotonin deficit. They may be making plenty of serotonin, but there's a breakdown in the serotonin transmission. Or maybe it's not serotonin at all. Maybe it's dopamine or norepinephrine. So when the first thing we do is start encouraging them to take antidepressants, SSRIs, they're gonna get frustrated. Cause they think, oh, my gosh, I saw on TV that this serious selective serotonin reuptake inhibitor, the ssri, is supposed to make me feel better. So I'm going to take that and I'm going to feel great. And then when they don't, the 66% that don't, they get frustrated and they start feeling hopeless, and they're like, what's going on? Well, we're going to talk about some other causes for depressive symptoms. Among patients who fail to respond to two pharmacologic interventions, remission rates with the next antidepressant are as low as 12%. Every pharmacological treatment they try theoretically lowers people's likelihood of response. And, you know, we could hypothesize about all the reasons that might be. Part of the reason is. And again, my belief is that we may not be addressing the root cause of the imbalance. It may be a problem in the system transmission. Not that there's a lack of a particular neurotransmitter. Why holistic? We're still on this. The cause may not be the obvious reason. You know, we look at somebody, they come in, they're depressed. In mental health counseling, we often say it's probably because of their thoughts or their trauma that is causing their depression. So we need to help them identify and address those. Well, that could be true. And likely, if they have been feeling bad for a while, then they've got some unhelpful cognitions, and they may have some trauma or grief or other stuff going on. That's true, but that may not be the root cause of their symptoms. Positive changes in any symptom will positively impact the rest of the symptoms, the system. And I want you to think about a blanket, a big woven blanket, and pull that blanket over your head. And it's heavy and it's hot and it's stuffy, and that's how people feel, you know, using this analogy, when they are experiencing distress, when they're experiencing depression or PTSD or whatever, when they're experiencing symptoms, it's oppressive. The good thing is with a woven blanket, you can start in the middle, you can start at the end. It doesn't matter. You start pulling a string and that blanket is going to start getting lighter and more air is going to start getting in, and you're going to start seeing the light. The same thing is true with holistic treatment. There are a lot of things that we can try or encourage patients to take a look at, because any positive change is probably going to help them start unraveling that blanket. When they get depressed. For example, a lot of people with major depressive disorder, they get their circadian rhythms out of whack. They can't sleep, they wake up at all hours, so they start getting exhausted, and that just compounds their depression. Well, if we can help them even address that sleep, I know that's not cognitive, but if we can help them, it may help them feel better. For people to feel happy and healthy. The body machine, the. The body system needs to be running efficiently. Not only does it need to have all the right fluids and parts and everything, but those fluids and parts need to be in the right place. And all of the systems need to be communicating properly. It would be. We'll stick with the car analogy. If your fuel system is working great, but your electrical system ain't, then your car is not going to go. We need to make sure that everything is communicating as it needs to be. Let's just take a look at this for a second. And the things we're going to talk about are general health, pain, mood, thoughts, nutrition, and sleep. So that kind of runs the gamut. And yes, you've got social relationships and environment and stuff out there. I couldn't cover that in a full hour, but I want you to think about it. Most mental health and addiction issues have symptoms in each category. So when we're talking about depression, we're talking about changes in sleep habits. We're talking about changes in nutrition habits. We're talking about thoughts of hopelessness and helplessness. Apathy, low mood, difficulty experiencing pleasure. We know when people are depressed they tend to have a lower pain threshold, so they experience more pain in their general health. We know that people who are depressed tend to experience more health conditions. So, okay, we can see how depression has symptoms everywhere. Let's look at low thyroid. If somebody has hypothyroid, they're going to want to sleep more, they're going to feel fatigued, they may not have the appetite that they need to have. They may have slow thoughts and difficulty concentrating. Their mood may be flat and apathetic, and they may or may not be experiencing additional pain. Those two things, depression and hypothyroid, look very, very similar on the outside, which is why we need to get down and dirty and figure out what's the underlying cause. We're going to start out with the medical causes of mood symptoms because typically too often clients will come into clinicians offices and we don't consider the fact that there may be a underlying biological issue going on. And you're going to learn about sort of the breadth of those issues. Today, the HPA and the gut brain axis are both involved physical symptoms in systems. I'm having a hard time with those words today. Physical symptom systems that are involved in our mood. The HPA axis is what I call our threat response system. And when we experience stress, when we experience a threat, the hypothalamus kicks off a whole set of reactions in the body to trigger the fight or flight response. And I use the acronym CHALET because that's the only word I could come up with that fit all of these. But the hypothalamus is really interesting because when it is hyper functioning, when it's functioning in overdrive, or when it is not functioning well, it's going to affect your circadian rhythms, your hormones, including your thyroid hormones, your appetite, your libido and your sex hormones. Your emotions and thoughts are going to be affected because the hypothalamus is part of that limbic system and your body temperature is going to be affected. When you're in fight or flight, your body temperature goes up. When you are in rest and relax, your body temperature goes down. And the hypothalamus is one of the main coordinators of that whole system. So if the hypothalamus, which is the main part of the HPA axis, if the hypothalamus is in overdrive, then you're going to have dysfunction in all of these things. And you're going to see how circadian rhythm dysfunction can cause symptoms of anxiety or depression or other problems. The hypothalamus also connects the nervous and the endocrine system. So the nervous system takes in information about what's going on and says there's a threat or, or it's all clear. And the hypothalamus takes that information and relays it to the endocrine system and says, we, if there's a threat, we need to start secreting all these hormones for fight or flight. Or if there's an all clear, then it says we need to secrete all the hormones for calming down. But if that system breaks down, if the hypothalamus isn't directing the endocrine system correctly, then the person may experience distress. The peripheral nervous system. We're going to stay over here on the left side right now. Those are your eyes, ears, nose, skin, you know, all of your senses. That's where this information comes from. The nervous system gets information from your senses about whether there's danger or whether it's all clear. People who live in an environment where they are not environmentally safe, when they feel threatened for their safety, are going to experience heightened HPA axis. People who are in an environment and they smell something that reminds them of a time they weren't safe, it's going to trigger that HPA axis. Or they hear something that triggers a memory. So it can be their environment can be currently unsafe or threatening. Or something in their environment could be triggering a memory that's still stored in the amygdala and hasn't been integrated, which triggers a memory that's traumatic, that can trigger that HPA axis. Think about your clients. I mean, and maybe even just everyday people. We have things we experience, things that remind us of distressful times. We which trigger that HPA axis. Depending on the person, some people react well, if, if you want to use that term, and are able to modulate their emotions. Other people become emotionally dysregulated. The other system that we want to talk about is the gut brain axis. And I talk a lot about this axis in the class on gut health. But basically your gut manufactures up to 90% of neurotransmitters and hormones. You thought it was in your brain, didn't you? Well, it isn't. It's in your gut, which kind of makes sense because you eat foods. The foods are broken down into building blocks. Those building blocks are made used to make neurotransmitters. So it kind of makes sense that neurotransmitters would be made in your gut. But, you know, who would have thunk it? Anyhow, the vagus nerve connects the gut to the brain. And when there's an imbalance in the microbiome, in the bacteria in the gut, or there's an imbalance in the neurotransmitters in the gut, then that is transmitted via the vagus nerve to the brain, which ends up causing people to experience mood symptoms. And again, if you want to learn more about that, you can review the gut health video that is on the YouTube channel@allce.com YouTube or, you know, you can just read about gut health. But basically, the take home is anything that causes stress, even a lack of sleep, exercise, or hypoglycemia, will activate the HPA axis. And anytime your gut gets out of whack because it doesn't have the right building blocks or because they're stressed or because you're sick, then the vagus nerve may send a signal to the brain that all is not okay in, in the person's body. So, medical conditions. Now we know about these two main axes that are communicating the body between the body and the brain. Let's talk about medical conditions. Medical conditions that alter sex or thyroid hormone levels, blood sugar regulation or oxygenation can cause symptoms of anxiety, irritability, hypomania, and depression. Okay, well, we don't want to assume, if somebody comes in and they are anxious and hyper and irritable, we don't want to assume that they're hypomanic. We don't necessarily want to assume that they're under the influence of some sort of stimulant medication. That may not be true diabetes. For example, when there's blood sugar dysregulation, it activates the HPA axis, which can cause irritability and difficulty concentrating. When your blood sugar gets low, your HPA axis kicks into high gear and tells your body, dump blood glucose, dump blood glucose, which happens, but that also triggers the fight or flee response. It can make people sort of shaky. It can make them a little bit dizzy, obviously. It can also cause irritability, difficulty concentrating, and if there's too much insulin, then blood sugar is going to be too low. So you can see how diabetes, if it's uncontrolled, can, can impact mood. Autoimmune disorders such as cystic fibrosis, chronic fatigue, not cystic fibrosis, but chronic fatigue, fibromyalgia, Crohn's disease, rheumatoid arthritis are often triggered by stress. And all of those that I mentioned trigger inflammation. And inflammation is a threat to the body, which does what triggers the HPA axis? Because the body says, oh, we're vulnerable right now, we need to be on high alert. Cardiac disorders, congestive heart failure, anything that keeps the heart from working as well as it should can prevent adequate oxygenation or resemble panic attacks. We don't want to assume that somebody's just having a panic attack. If they are having panic attack symptoms, especially if they've got tightness in their chest, their heart's beating really rapidly. Thyroid imbalances can be caused by autoimmune diseases, genetics, nutritional imbalances or hormone imbalances. And you can learn more about the different nutritional imbalances if you download the PDF and you can click on that hyperlink later. But it's important to recognize that if somebody has poor nutrition, it actually can affect their thyroid, which actually can cause depressive symptoms. Who knew? So we might need, if we're following that chain backwards when we're talking to the client, we might find out that, yes, they went to the doctor, they got a test, they've got low, low thyroid. What's causing that? Well, poor nutrition or something else. Anxiety symptoms, this is important to recognize, can precede an official diagnosis of hyperthyroid by up to five years. So if somebody has anxiety symptoms and we keep trying to treat them with cognitive behavioral therapy or, you know, psychotropics, it may not work because what they may have is sub threshold hyperthyroid. And, you know, at least in the US doctors tend to be very rigid with their parameters. You know, if, if your thyroid is within this range, it, it doesn't matter if you're more sensitive to thyroid changes or not. If your thyroid's within this range, you're normal and they're not going to pay attention to it. But they found in looking at people who have a diagnosis of hyperthyroid later in life, they look back and a lot of times they were experiencing anxiety and or panic symptoms for up to five years before their thyroid finally got far enough out of that band of normal, quote, unquote, that the medical community would take it seriously. We want to advocate for patients there. Thyroid hormones impact the availability of serotonin, which impacts mood. So if your thyroid levels are low, your serotonin levels are going to be low. Good to know. Cortisol from chronic stress reduces thyroid levels. So if you have chronic stress, it's going to reduce your thyroid levels. If your thyroid levels are low, Then it's going to reduce your serotonin levels, which can contribute to depression and anxiety. The other side of that is generalized anxiety disorder can be a source of chronic stress. So you see how we're in this unfortunate loop where the stress causes reductions in thyroid, which increases the stress, which causes a reduction in thyroid levels. Hypothyroid has a prevalence of 10% in women and 2% in men. So if you're in a room with 10 co workers, it's likely that, and 10 female co workers, it's likely that one, at least one person in that room has hypothyroid to some degree. Well, that's important because that's really not treated. Hypothyroid they're finding is very under diagnosed. And again, there are a lot of causes for hypothyroid. A lot of them are easily treatable. They're lifestyle factors. So it's not that people have to go on some sort of thyroid medication for the rest of their life. They may have to reduce their cortisol by reducing their stress in order to get their thyroid levels up. That's going to be a team decision. You know, obviously they need to see their doctor and their doctor is going to decide what needs to happen with their thyroid in the short term. But it's going to be important to figure out what's causing that hypothyroid. Is it stress, is it genetics, Is it some other hormone? What's going on? The risk of hypothyroidism increases during pregnancy, after delivery and around menopause. And my guess would be after the cessation of breastfeeding as well, because all four of those times are huge hormone swings. And they found that hypothyroid may be first diagnosed in women during those periods of time. Sex hormone imbalances can be caused by diabetes, testicular injury. Obviously we're talking about testosterone. There drug use, including oral corticosteroids or long term use of inhaled corticosteroids. And you're like, well, what are those? Obviously drug use, we're talking about steroids or illicit drugs. Um, oral corticosteroids are like prednisone, which some people have to take for different medical conditions, especially inflammatory medical conditions. And inhaled corticosteroids are actually one of the most common forms of them are the inhaled allergy medications, which is why they say you shouldn't take the inhaled allergy medications for more than three to six months without doctor's clearance or yada yada. Birth control can obviously alter sex Hormone balance, menopause polycystic ovarian syndrome. If you have clients who have excessive facial hair, who have thinning hair, especially oily thinning hair, who have weight problems and are depressed, you really want to make sure that they get their sex hormone levels assessed. They may have too much testosterone and or polycystic ovarian syndrome. Too little estrogen. There's a variety of things, but polycystic ovarian syndrome is one of the leading causes of treatment resistant depression. If it's not, if the hormones aren't treated, hysterectomy can cause sex hormone imbalances because once you lose the ovaries, you know, that's a problem. Childbirth and cessation of breastfeeding. So we do want to be aware of what changes sex hormone levels because that alters the levels of serotonin, norepinephrine and dopamine in the brain, which obviously is going to impact people's mood. Estrogen and testosterone both impact serotonin availability. Too much or too little of either can produce anxiety or depressive symptoms. So it's not, you know, let's, this person is depressed, so let's increase their testosterone levels. That may not be it. That may be they may have too much testosterone, which is causing anxiety, which is wearing them down and causing excess cortisol, which is reducing their thyroid hormones and causing depressive symptoms. High levels of estrogen affect our ability to deal with stress. That's not news to a lot of us. But it's important to recognize that if estrogen is high, we, we have more difficulty dealing with stress, which means our cortisol levels will probably be higher. The production of cortisol affects the concentration of all sex hormones. The more stressed somebody is, the less or the more imbalanced the testosterone, estrogen, progesterone, and other sex hormones are going to be. Both men and women produce luteinizing hormone. Testosterone and estrogen. Okay, so guys have estrogen and women, we've got testosterone. We have it. It's just in differing amounts. One of the interesting things is when the body's under stress, it shuts down libido so we can deal with our survival needs. You know, your body's HPA axis goes off, it says there's a threat. You don't need to worry about reproducing right now. You need to worry about surviving. Testosterone is suppressed under chronic stress or exposure to chronic high levels of cortisol for whatever reason, which lowers libido and contributes to feelings of depression and apathy. Now, as an Aside, just like estrogen levels go down for women, testosterone levels go down for men as they age. We do want to be aware of age induced hormone imbalances as well. Under stress, estrogen is often elevated, but luteinizing hormone is reduced. When these three hormones are not in the right formula, people are going to experience mood symptoms. So medical problems, how does it affect mood? Well, medical problems can change the availability of neurotransmitters. Medical problems can affect mood because of a lack of adequate oxygenation from heart problems. It can affect mood because medical problems can cause thyroid imbalances. And people may just have increased stress due to their medical conditions. They may be frustrated that their diabetes is more difficult to control. They may be struggling with accepting that they've got rheumatoid arthritis or something, and they have to deal with the distressful emotions surrounding their medical diagnosis. Medical problems can also impact mood because it can impact sleep, it can cause sleep apnea. Certain medical conditions cause sleep apnea, which prevent good sleep. If you don't have good sleep, then your circadian rhythms are going to be out of whack. Appetite and sleep, our systems are going to be out of whack and mood is going to be impacted. Medical problems can contribute to exhaustion because of low thyroid or low oxygen. And when people are exhausted, they want to sleep all the time. When they want to sleep all the time, then they often are taking naps and messing up their circadian rhythm. So the sleep they do get is poor quality and they wake up and they don't feel refreshed. Circadian rhythm imbalances can be caused by a variety of other things. Medical problems can also cause pain, which keep people from sleeping. And again, anything that prevents us from getting quality sleep is going to impact mood as well as our stress hormones, which is going to create a cascade effect and affect all of our other hormones and stuff. Too little or too much testosterone may also affect overall sleep quality. And I know there are a lot of people out there taking testosterone supplements. It's important to recognize that supplements can also cause changes in the body that will impair sleep and can contribute to mood disorders, nutrition issues from medical conditions. If people aren't getting the building blocks they need to make the neurotransmitters and the hormones for health, then that's going to be a problem. Sometimes they're just not hungry, they're not eating. Other times because of malabsorption syndromes, you know, Crohn's disease, et cetera, they may not be absorbing the nutrients that they Need. The gut brain axis is also, as we talked about earlier, involved. So if they're under, when you're under stress, you know how sometimes that HPA axis kicks off, speeds everything up and food goes flying through your digestive system. Your gut brain axis is going to be telling your brain, there is not happiness in my belly right now. So there is distress. There's an imbalance in neurochemicals because I don't have. The gut doesn't have the building blocks or the time to make the neurotransmitters it needs and substances. And this is going to come up a lot. Substances including caffeine and nicotine can impact people. And when people have medical issues, if they're taking opiates, for example, they may feel tired. When they feel tired, they may compensate by drinking a lot of caffeine. Well, that's going to rev up the system and activate that HPA axis. So is nicotine. So caffeine and nicotine can both stimulate cortisol. The HPA axis can be activated because of high thyroid imbalances, sex hormone imbalances, pain or insufficient sleep. That one's not even on there. When you look at the medical condition some somebody has, even if it's something you know, you're not thinking is life threatening, you do want to look at the impact of that and pain. Pain causes reduced serotonin, which leads to reduced pain tolerance and too little movement from pain. A lot of times when people are in pain, they baby it or they don't want to move. Especially if it's like a back pain or something or a migraine, you know, it just, it hurts to move. They're feeling nauseous, they don't want to do anything, so they become very sedentary. And when they're very sedentary, it can make other things start to hurt. It can contribute to stiffness and more pain, more fatigue, more psychomotor retardation, as the DSM 5 says, which can look a lot like depression. Pain can be caused by a variety of things, including aging, autoimmune issues, medication side effects, musculoskeletal or neurological problems, and when I say medication side effects. There are two ways that medication can cause pain, if you will. Number one, if you take something like an anti inflammatory and it upsets your stomach. And a lot of people have reactions to medications that cause them, especially GI pain. That's one kind of pain that can be caused by medication. But you may be needing to take that because you just broke your arm or something. And the Doctor said you got to take it. It's important to talk to the, encourage patients to talk to the doctor to mitigate any pain that might be happening. Because pain is the body's signal that something's wrong and you don't want them to end up with, you know, problems in their digestive tract because of the medication. The other way medication can increase pain is if people are taking opiates. The brain registers that influx of artificial opiates as a signal that it doesn't need to produce its own anymore. Basically that's very oversimplified. But when people quit taking opiate medication or opioid medication, if they've been taking it for more than a few days, it takes the body a little while to get the message that, oh, we're not getting that stuff anymore. We need to start producing our own natural opioids. Which means in that interim, people may have a lower pain threshold and feel more achy and more pain. It's important to educate them so they're not going back and going, doc, I really need more of that opioid medication because I'm still hurting a lot. Maybe weaning them off of it. The doctor will figure out how to work with them. But that's why a lot of patients who have been on opioids for a while because of a surgery or because of cancer or something else may wean off the pain medication. Pain can impact our mood and our thoughts because it increases anxiety. We may have thoughts that things are going to get worse. We may be wondering about our own mortality. If you're having it pain and you don't know what's causing it, you may think it's cancer. And pretty much if you've gone online and you've gone on WebMD, any symptom you have is gonna kill you. According to that website. It seems so a lot of physicians will say, please don't go online, please do not try to self diagnose because you see the worst case scenarios online and then you start freaking out. People may have increases in anxiety around their pain because they fear rejection. They fear people are not going to want to hang out with them anymore because they can't rock climb anymore or they can't do things like they used to or maybe, you know, for a while they won't be able to go to their kids soccer games and they feel guilty about that and they're afraid their kid is going to be mad at them because they can't leave the house until they're healthier. Pain can Also increase depression because people feel and start thinking thoughts of hopelessness and helplessness. They wake up in the morning and they hurt. They are going through the day and they hurt. They go to sleep at night and they're wondering if they're going to even be able to sleep because their body hurts and it's frustrating and exhausting and they feel like they don't have any option. They can't just pull out the pain and make it go away. And sometimes they can't take find the right medical treatments to make the pain completely go away. We want to help people figure out, especially with chronic pain conditions, help people feel empowered in addressing their pain conditions and empowered in taking charge of their life. People may also have increases in depression due to feelings of guilt, envy, resentment and anger. Those are exhausting emotions, having those repeatedly day in and day out. If you resent other people for being able to do things you used to do, if you feel guilty because you can't do the things you used to be able to, if you envy other people because they're healthy, or if you're angry at yourself, at your higher power, at your body, at whomever, because you hurt, if you're angry at the doctors because they're not fixing you, you know, all of those feelings, those dysphoric feelings can occur because of pain and they drain, they exhaust people's energy and they keep their cortisol levels high, which reduces their thyroid, which reduces their serotonin, which reduces their pain threshold, which causes symptoms of depression. So by holding on to these dysphoric emotions, people are actually increasing their dysphoria. Now don't get me wrong, emotions are natural and people have them and they feel them. And that's your body's way of telling you what's going good and what's not going so good. And that's cool what you do with those emotions, whether you hold them and nurture them and keep them real close or you figure out what to do with them, that's in your best interest. Pain activates the HPA axis, which increases stress. And because of your brain's perception of vulnerability, the brain's going, okay, this hurts. That means the primitive part of your brain is going to. That means we're more vulnerable to the lion that may be coming up to eat us. Nutrition, especially substances and medications, including NSAIDs, nonsteroid non steroidal anti inflammatory drugs can upset your stomach and cause dysfunction in the endogenous opioid system. Now we talked about that earlier. The opiates, opioid medications may cause dysfunction in the endogenous opioid system, which can lead to feelings of depression. Pain also impacts sleep because it causes discomfort keeping you from sleeping, and the medication can make you feel groggy and the person wants to sleep all the time. Or the medication may not be enough, or it may be causing pain. There are a lot of reasons that sleep can be impacted. So when we hear somebody's having sleep difficulties, again, let's get to the root of it. Just keep going backwards in that assessment to find out, okay, what caused that? All right, what caused that? So they come in with depressive symptoms and fatigue. Okay, what do you think is causing your fatigue? Well, I'm not sleeping well. Okay, tell me more about that. When did that start? What do you think is causing that? Let's go backwards from there. Have you had a physical recently? Do you know? You know, there are all these things that can be contributing to sleep changes if they can't pinpoint. Well, I sprained my wrist, you know, six weeks ago, and I haven't slept through the night since because I always roll over on it or something. Well, that's an obvious cause. But if there's not an obvious cause, then we really do want to start looking at some of the internal stuff by having them get a physical. Nutrition. Tryptophan, tyrosine, and phenylalanine are building blocks for neurotransmitters. Those are all amino acids, proteins. Tryptophan is converted to serotonin, which contributes to reduced depression and pain sensation, improved gut mobility, and increased relaxation. Eating carbohydrates can trigger a release of brain tryptophan. So if you're talking to somebody who's on a high protein, low carb, no carb diet, you know, and they're starting to experience depressive symptoms, we may want to look at whether they have all the nutrients their body needs to break down tryptophan in order to make serotonin. Tyrosine and its precursor, phenylalanine are converted into dopamine and norepinephrine. If you don't have dopamine, you don't have your drive, your motivation chemical. You don't have norepinephrine, you don't have arousal and alertness. Dopamine is made from tyrosine, and the neurotransmitter serotonin is made from tryptophan. So just kind of remember that. And autoimmune issues and stress contribute to gut permeability and malabsorption. Why do we care well, because if we eat the food and it goes down into our gut and that gut is just leaking like crazy and it can't hold on to the amino acids and everything it needs to long enough in order to make the neurotransmitters it needs to, then people are going to start experiencing mood issues. Autoimmune issues and stress contribute to a lot of problems in and stress actually exacerbates autoimmune issues. Caffeine is a stimulant with a six to eight hour half life. So what you drink at noon very likely is still in your system up until midnight. Nicotine is a stimulant with a two hour half life. So people who are smoking up until they go to bed still have stimulant in their system for four hours after they're trying to get quality sleep. Decongestants also have a two hour half life. Antihistamines can make you drowsy, but contribute to poor quality sleep. Alcohol blocks REM sleep and the body can only use food to create certain amino acids necessary for neurotransmitters. Your body can produce a fair amount of the amino acids it needs, but there are certain, what they call essential amino acids that you have to get from food, nutrient deficiency syndromes. And we're not going to go through all of these. But basically, if people do not have enough tryptophan to make serotonin, they'll have insomnia, depression, pain and obesity. If they don't have enough glutamine to make gaba, they'll have muscle spasms, pain and anxiety. And if they don't have enough tyrosine to make epinephrine or norepinephrine, they will have fatigue, depression, pain and apathy. You see, pain and apathy is common to all three of these things. We're not registered dietitians, but if somebody is not eating what seems to be a healthy diet, you know, it's important to encourage them to keep a food diary and consult with a registered dietitian and educate them about why it may be important and how they're. What they're eating could be contributing to their mood issues. So nutrition impacts people's mood and their health because it affects the availability of neurotransmitters. It can affect the body's ability to oxygenate. Not only does the heart do it, but if you're anemic, then your blood cells are not carrying the oxygen around like it needs to, and that contributes to fatigue. And people can have excitation or retardation of their psychomotor activities due to thyroid imbalances. The HPA axis can be affected by nutrition because low blood sugar will trigger the HPA axis and the availability of neurotransmitters and hormones can also trigger dysfunction in the HPA axis. Nutrition impacts sleep because if people don't have enough tryptophan, they can't make serotonin. They can't make serotonin, they can't make melatonin and people need melatonin to help them drift off to sleep or if they're having too many stimulants, then that's also going to impact sleep. Nutrition impacts pain because if people are not able to make serotonin and you know, some of their other chemicals, the endogenous opioids, because they have poor nutrition, then they're going to have reduced pain tolerance and their health. If they don't have the building blocks they need to repair their body, then they may feel pain. People heal a lot faster if they're eating a healthy diet. Additionally, nutrition can contribute to problems and pain and mood issues because some substances can trigger oncogenes or the cancer causing genes in your body, which will contribute to pain and will likely add to mood issues. Ensure people keep a food diary to ensure they're eating sufficient quality proteins and getting plenty of water and getting enough vitamins like selenium, vitamin D, calcium, vitamin A, magnesium and zinc, which are all necessary to break down tryptophan to make serotonin. Sleep problems. Maybe the person's problems stemmed from insufficient sleep because they're on shift work or they've got a new baby in the house or whatever it is. Sleep is a time to rest and restore. Adequate sleep improves memory and learning, increases attention and creativity, and aids in concentration and decision making. Toxins that accumulate in the brain, adenosine, are thought to be cleared out during sleep. Muscle growth, tissue repair, protein synthesis and growth hormone release occur mostly or in some cases only during sleep. So protein synthesis is taking those proteins and turning them into the neurotransmitters. If this happens mostly during sleep and you're not sleeping, guess what? You're probably going to have some hormone imbalances. Sleep helps to maintain the balance of hormones in the body. Specifically ghrelin and leptin regulate feelings of hunger and fullness. So when people's circadian rhythms get out of whack, their ghrelin and leptin get out of whack and they're not sure if they're when they're Awake, they're not sure if they're sleepy or they're hungry or they don't know what to do, which is why a lot of shift workers end up having problems with weight and nutrition. Sleep also helps regulate insulin levels, which regulates the glucose in the blood. When people are getting insufficient sleep, their insulin levels are going to be wonky, for lack of a better term, and can contribute to triggering that HPA axis, increasing cortisol and increasing mood symptoms. Other rejuvenating sleep aspects of sleep are specific to the brain and cognitive function. While we're awake, our neurons in our brain are producing adenosine. The buildup of adenosine in the brain leads to the perception of being tired. When it builds up too much, the body says, okay, we need to go to sleep, so this can clear out. If you don't go to sleep, then that persistent fatigue goes on. And it's not any old sleep. You have to get that good, deep restorative sleep because the brain doesn't clear out, and a lot of that stuff doesn't happen during light sleep. Circadian rhythm disorders can be caused by many factors, including shift work, pregnancy, time zone changes, medications, including some of your psychotropic medications like your atypical antipsychotics, and even some of your SSRIs. Changes in routine, such as staying up late or sleeping in, or if you get called in to cover the midnight shift, medical problems, including Alzheimer's or Parkinson's disease, and mental health problems. If you've got a client with major depressive disorder, for example, or generalized anxiety, who is having difficulty sleep, we want to look and figure out again what's causing that difficulty sleeping. And did the lack of sleep cause the depressive features, or did the depressive symptoms start for some other reason which contributed to sleep problems? So sleep contributes to mood problems because of the buildup of toxins, which leads to difficulty concentrating and irritability, fatigue and loss of energy, increased stress due to difficulty concentrating and lethargy. Poor sleep activates the HPA axis because the person is experiencing more stress. You know, when you're exhausted, it feels like it's just 10 times harder to do the stuff that you normally do. Sleep can impact nutrition because when the circadian rhythms are out of whack, people tend to have appetite disturbances, and a lot of times they tend to gravitate towards comfort foods, which tend to be more highly processed and lower in nutrients. And when people are having problems sleeping, they may tend to overdo it on stimulants which can impact their sleep at night, which can worsen the sleep problem, which can worsen their mood. And same old thing with pain. When sleep is impaired, when the HPA axis is activated, people are going to have reduced serotonin, leading to reduced pain tolerance. And if they're getting too much sleep, they may have more stiffness and pain and just achiness all over. I was on bed rest for a while with my daughter, and I can tell you, being still for a while, yeah, it can get really uncomfortable. And lack of sleep is actually associated with an increased risk of cardiovascular disease, stroke, diabetes, and kidney disease. Physical interventions, assessment, education and intervention. We want to find out what's causing it. We want to educate clients about why it's important to address these things because they may be going, you know, I came to you because I'm depressed. Why are you sending me to the doctor for a blood test or the nutritionist to evaluate my. My diet? We want to educate them, and then we want to apply or come up with an intervention to help them address those areas, those threads in their blanket that they can start pulling in order to start feeling better. Ensure they get a complete physical that addresses their thyroid function, their sex hormone levels, vitamin D levels, their iron, their pain levels, causes, threshold their thiamine levels. People who are alcoholic, anorexic, or who have had bariatric surgery are at high risk for a thiamine deficiency, which can lead to something called Korsakoff syndrome, which vaguely resembles dementia. Once the thiamine levels are corrected, a lot of times their memory will improve again. The physical also needs to address underlying conditions that may be causing a dysfunction in this body system. We want to have a nutritional assessment and improvement plan if needed. We want to have them get an ergonomic assessment for both where they work and where they sleep. That's, you know, a significant portion of their day to remove any causes or preventable causes of pain. If they're having difficulty sleeping, you may have them go for a sleep study. You know, all of these assessments can get expensive. People may want to just chart how well they slept. If they have a fitness tracker, A lot of them monitor sleep now so they can start keeping track of that to at least get an idea about how well they're sleeping. Develop a sleep hygiene improvement plan. Most people have really crappy sleep hygiene. They sleep with the television on or in hot rooms or with the dog in the bed. I'm guilty. Encourage them to learn about sleep hygiene and figure out how they can maximize the quality of their sleep because it will go a long way to helping them with their mood and help them address pain issues, whether that's referring to their gp, who can refer for massage therapy or physical therapy or whatever. But we know that pain is going to have systemic effects on their mood, their energy, their sleep, et cetera. Mood impacts perception, perception impacts stress levels, and stress levels impact, well, everything else. And when we're talking about mood, I'm just talking about emotions here. And one of the things I want you to recognize is that we can eliminate and eliminate and eliminate, you know, in this box over here, eliminate distress over, you know, the bad weather, eliminate whatever's making you sad, address the grief, address the noise in your environment, address the traffic, address the things that are making you angry. You can start eliminating all those things that are distressful in your life, but if you don't add in the good stuff, then all you're left with is an empty box. We need to make sure that people add in some happy instead of just eliminating the unpleasant. No, that's not going to make them just giddy from get go, but it does help them to start adding in things that make them at least mildly amused. If they're clinically depressed, they're not going to be rolling with laughter, but if we can help them experience some relief and help them see a glimmer of hope, a glimmer of happiness, then they can start building on that and adding the happy into their box. Some clients I even have make two different boxes and one is their distress box and that's the stuff we want to empty out. But I have them make a happy box and it's just ideas of things that they want to do or sometimes just things that make them happy. Pictures, whatever. Mood impacts the HPA axis, because stress revs up the HPA axis, it can cause appetite disturbance, it can cause because of circadian rhythm disruptions, it can cause poor nutrition because people tend to go for comfort foods, which causes lack of building blocks. And then the body's going, I can't make the neurotransmitters, I need to. Stress increases gut permeability, which increases inflammation throughout the body, which has been associated time and time again with depressive symptoms. And poor mood is also associated with overuse of substances to feel better, whether that's to increase energy with caffeine or or to reduce dysphoria with alcohol. Mood impacts sleep, because sometimes people just want to avoid the world and sleep all the time. Mood impacts thoughts because when we're in a bad mood, we tend to perceive the world through a negative Lens and mood. Low mood tends to increase pain. Low mood and anxiety can actually also increase muscle tension. You know, when you're stressed out, you tend to hold that muscle tension, which can get painful, cause kinks in your neck, or even cause you to grind your teeth. And mood also impacts health by causing hypertension and other stress related illnesses. And finally, thoughts. Unpleasant thoughts and unresolved traumatic memories increase feelings of hopelessness, helplessness, anger, resentment, anxiety, guilt, grief, yada yada. Unpleasant thoughts and memories and dysphoric emotions encourage people to interpret the world through a stressful lens. When you're in that mindset, your brain is programmed for survival. So if you're thinking about things that have been threatening or dangerous before, your brain's going, don't forget those, because we don't want to go back there. Interventions encourage people to focus for five minutes three times a day, and I say at meals, five minutes, three times a day on what's going well and what is making them happy that day. They can address the negative stuff, the unpleasant stuff later, but for five minutes three times a day, just take a break and have a happy time out. Teach them how to address cognitive distortions, help them address trauma from the past, and educate clients about dialectics. That means accepting the good with the bad and, and living in the and. If it's raining, okay, you know, you wanted to go hiking today, you're not going to get to do that, but hey, at least you're getting your car washed for free. You know, try to encourage them to look at the good and the bad and accept the fact that generally everything has a good and a bad with it, but they can experience some level of distress and still have a rich and meaningful life. Thoughts impact mood because it encourages people to focus on the negative and it increases dysphoria through HPA axis activation. Negative thoughts trigger that HPA axis like crazy because it increases your perception of threat, your sense of helpless and sense of helplessness. And if that HPA axis stays activated for too long, levels of cortisol will actually drop because the body, it's learned helplessness. The body goes, I can't defeat this stressor, so I'm going to conserve energy for a time when I might be able to sleep. Is affected by thoughts because people will ruminate. Whether it's anxiety or grief or whatever it is, when people are in pain, they may have thoughts that focus on the pain and they're wondering what it is or what can make it go away, or just focusing on the fact that, oh, this really hurts and this really is awful. Thoughts can contribute to poor nutrition again because people often look to food to help distract themselves, especially comfort food. And it can contribute to malabsorption because these stressful thoughts upset your tummy and trigger that HPA axis. So the system is going faster and it contributes to health problems through hypertension and other stress related illnesses. Many people with addictions or mental health issues have concurrent physical health issues. Many people who don't respond to antidepressants may have dysfunction in one of the other systems that supports neurotransmitter availability. A positive change in any aspect of the system will often have positive effects throughout the whole system, but a problem in any aspect of the system can also cause problems throughout the system. It's important to recognize that addictions and mood disorders may have developed as a result of dysfunction in some other system, like your thyroid hormones or your sex hormones, or due to poor nutrition or sleep deprivation. In addiction, we talk about the acronym Hungry, Angry, Lonely and Tired as relapse warning signs. If we're not taking care of our body, then likely our mood may follow and our behaviors may become more impulsive and reactive after that. On the PowerPoint, you know, when you get time, I just kind of gave you a visual representation of the symptoms that we often see in mental health diagnoses and how they're present in some of these common diagnoses that we see. So, you know, depression and thyroid often look very similar. Depression has a lot of symptoms in common with chronic pain, so we really want to ferret out what is the root cause of the body system dysfunction in order to help people address their mood and their physical health issues. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@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 podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. 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