110. When in Doubt, Check Your Gut

Welcome to the Holistic Inner Balance podcast with Dr. Nicole Cain and Happy healthy Hadley, your go to resource for natural mental health and wellness strategies so that you can become the expert of your own emotional and physical well being. Merging modern science with ancient wisdom. I'm so happy to be here. Thank you. I would love to start by doing a quick check in. How are you feeling right now and what emotions are coming up for you? Maybe cravings? What if I were to suggest that a big part of the feelings that you're experiencing and these cravings weren't really up to you at all, that the emotions that you experience, that that giant gooey pastry at the reception that you're dreaming about were actually messages from very extremely verbal and opinionated critters in your gut. And today we're going to talk about that. We're going to take a tiny peek into the great big world of your microbes, their home, and the channels they use to communicate throughout your body. And this is going to be a really especially important conversation if you're working with people who have anxiety and panic. And so we're going to jump into the gut brain access and so we have the abstract, which you can take a peek at, but essentially we're going to explore the research on the gut brain access and the ways that the gut communicates bidirectionally with the brain. There are four major systems for that which you'll get to introduce to today. So learning objectives, what are we going to learn about? We're going to learn about what is gut anxiety, the those four communication mechanisms. We're going to explore pharmacological interventions and ethical implications for gut anxiety. And then we're going to dive into functional testing to get to the root cause of why anxiety can show up in your gut. And then of course, the psychobiotics part, which is my favorite part, which are those little critters and how we can leverage that information to actually help people be truly free from anxiety and panic. So anxiety in the gut. Gut anxiety is anxiety that manifests in your digestive tract and it could be upper gut or lower gut. And gut anxiety is a term that I created. When we look at all of the symptoms in the literature of anxiety, we can generally break them down into eight categories. And those eight categories of which is one is gut psychology, which we're going to be focusing on today. And so if your patient comes in and they have reflux or heartburn, fullness in the throat, nausea, stomach ulcers, these things can be associated with your gut. And of Course, they could also be associated with your mental and emotional well being. And we'll talk about some cases of this later. And then lower digestive tract, we're a little bit more familiar with how someone can get anxiety and then it can cause diarrhea or maybe G gas and bloating. These are signs of lower digestive tract gut anxiety. And we know that your gut and your brain are intimately connected. And a lot of us have heard about the gut brain access. And so we're going to dive into the little nuanced details of how that works. And so on the left side of the slide, you see a gut anxiety checklist, which is a really useful screening that I put in my inpatient or my new patient paperwork that can just sort of help us zero in on if it seems like it may be an area to do a little bit deeper digging. Of course we'll talk about how to do that deeper digging. Or if really there's other areas in the body where the stress and anxiety is showing up maybe more strongly. And so you could take and screen captures that if you want a cleaner copy, feel free to message me and I can get that for you. And so where we're going to start is we're going to learn about the enteric nervous system. And the enteric nervous system is this huge circuit, a nervous system that surrounds your gastrointestinal tract, it surrounds your gut. And this is one of the big ways that your gut is able to send communications to the brain. And so then we have the microbes in your gut, and they release all sorts of chemicals like dopamine and serotonin and many, many other things. And then they go into that enteric nervous system and they go up to your brain and they affect it. What's a really fun little fact in here is that 95% of serotonin is made in the gut. And if you've either used an antidepressant or prescribed it for your patients, you may realize that one of the main side effects of antidepressants, particularly SSRIs and SNRIs, and is digestive upset, whether it's changes in appetite or nausea or diarrhea or constipation. And that's because you have so much serotonin in the gut. So the four primary mechanisms. So how are these critters communicating? And so we have your 100 trillion microbes, and those are represented over here by the number one. And so you have all these little microbes and they're releasing all sorts of different chemicals. Then the microbes will stimulate what's called a neuropod cell, which lives in the epithelium of your gastrointestinal tract. That's this little blue guy here. Then the neuropod is connected with your enteric nervous system, again the nervous system of the gut. And so then that will send a signal to your vagus nerve. And the vagus nerve will carry the signal to the brain, which in turn can communicate back down to your gut. And it could also, of course, send signals to the rest of your body, which we'll cover today, too. And so then we have number one is the gut, number two is the vagus nerve, and then we have number three is inflammation, which can also come from the gut. And the number four is your endocrine system. And so we're going to explore each of these channels in a lot more detail together. All right, so we're going to begin, though, we're going to be looking first at conventional approaches to gut anxiety. And there are four main ways that this is generally targeted, and this is with antibiotics, antihistamines, antidepressants, and benzodiazepines. And so we're going to go through each of these, and then we'll get into a little bit of the ethical implications. So antibiotics, this is what I see really commonly. If somebody shows up into my office, we're going through their history. Really often they have taken antibiotics either as a treatment for something else or as a treatment for symptoms of digestive upset that show up in the gut. And I see this really commonly with my SIBO patients. The go to treatment is antibiotics, generally speaking. And in sibo, as you know, the bacteria from the large intestine can move, migrate up where they do not belong into the small intestine, and then they can recapit fermenting carbs, producing gas. And then we get those symptoms of abdominal pain and diarrhea and bloating and constipation, which can look really similar to irritable bowel syndrome. And again, the target is often antibiotics, which I have listed here. The problem with this is that their antibiotics don't really work much better than chance. You know, chance is 50% improvement, and they're only at 67.7%. And there can be a lot of trade offs for antibiotic use. And we'll get to that in just a moment. But the second line, if the first antibiotics that we talked about aren't working, then they'll bring out the big guns. And so then we see things like doxy being prescribed and these have quite a high side effect profile and can contribute to antibiotic resistance. And so when you're thinking about the treatment of gut anxiety, if it isn't truly infectious in nature, then that wouldn't be the first place that you should start, is you want to get to the root cause and see if there's any way that we can do no harm or use risk mitigation, unless there's something that can't be treated without antibiotics. And then maybe that might be more appropriate, but we have the risk of antibiotic resistance, we destroy all the unwanted critters. But as also your good bugs, those ones that you have had in your body that you got from your ancestors. And a really cool fact about your gut bugs is that your gut microbiome is as unique to you as your fingerprint. And you inherit your gut microbiome from your mother, who inherited it from her mother, and onwards and onwards and onwards. And so you are affected by the guts of your relatives way back in time. And so when we carry that legacy of information and RNA and all sorts of information that are in these bacteria, and then when we take an antibiotic, we're essentially wiping that out. And so I think there's a lot of deeper exploration that we can do and the implications of what that is, because I imagine there's more to our gut microbiome than meets the eye, that maybe when we're here together in 10 years, that we'll be talking about these mind blowing facts that we didn't know, that we're discovering. Then of course there are psychiatric side effects from antibiotics. Antibiotics are associated with an increase in incidence of anxiety and depression and mood destabilization. And so if someone has gut anxiety and you give them an antibiotic, you are increasing their anxiety and their insomnia and all sorts of other things, right? And then of course, a post antibiotic recovery treatment isn't always available for patients. And so that is a definite limitation. The second approach that I see commonly is antihistamines, which is really interesting because of the nature of histamine and anxiety. And a really fun fact about histamine and is that it is as excitatory to your nervous system as adrenaline. So we think of adrenaline as that fight, flight, freeze neurotransmitter, but that neurotransmitter, histamine, that makes your eyes itchy and your nose watery and you have that post nasal drip and maybe a little itchiness in your lungs, that same neurochemical could also cause panic and anxiety and Insomnia and restlessness. Right. And so an approach for gut anxiety that we see in more conventional treatments is antihistamines. And there are different kinds of antihistamines. And we're going to talk about H1 and H2 histamine receptor blockers. Histamine H1 type receptors are associated with the allergies, inflammation that we were talking about, as well as nervous system activation. If you stimulate an H1 receptor, you're going to have those symptoms of allergic reactions or asthma, dermatitis. And we use in medicine first generation antihistamines to block that. And so that's why Benadryl, as an example, can make you feel less itchy, maybe less congested. If you're having an anaphylactic reaction, it can calm that, but it can also make people feel really sleepy and sedated. And so sometimes first generation antihistamines are prescribed for sleep. If someone is not able to go to sleep and they're anxious, these can be quite relaxing. And it's actually an awesome first step before prescribing a benzo, which we'll get to the newer generation H1 receptor blocking. Antihistamines like Zyrtec are a little bit less sedating. So if you have a patient and they have allergies, but they don't want to be zonked out, then maybe you would block histamine with Zyrtec. But of course, we could do better. Right? We can look at what are the causes of histamine, what's coming in. I think of it like a funnel. What's coming into your vase and causing histamine. What in your body is producing histamine? And are our three main histamine detoxification channels, are they working? So instead of just suppressing histamine, we can do a lot deeper digging. Right. And then we also see antihistamine working. Antihistamines working well with gut upset. And so These are the H2 receptor blockers. When H2 histamine receptors get stimulated, you're gonna see reflux ulcers. You could also see anxiety spike up. These receptors are found in both the gut and the brain. And histamine at the H2 receptors helps your stomach make stomach acid. So you need histamine. It's just a matter of finding the right balance in histamine. Right. So we don't wanna totally block it because then we end up with insufficient digestion. And then that changes the the gut and creates this domino effect that can affect gut brain access. And all those four Channels and everything downstream. And while it can combat digestive upset, it doesn't help the mood because these H2 blockers don't cross the blood brain barrier. So they're more for the gut part of gut anxiety, not the anxiety part. Of course, there are ethical concerns about antihistamine use. We want to make sure that the medication is, are we trying to treat the root cause and is this medication doing that? And is there a rebound potential if somebody's taking an antihistamine long term? What will happen if they discontinue it? Is there a risk of withdrawal? What are the side effects of antihistamine? So these are all things to take into consideration for our patients. And then we have antidepressants. I see this really commonly with gut anxiety. Often the first line of treatment if these other solutions don't work is we try an antidepressant. Initially they were using more the tricyclic antidepressants. These are the older generations. They're a little bit less expensive and they've been used to treat functional gastrointestinal disorders, especially those that co occurred with anxiety and insomnia. And so we have amitriptyline and some of the other ones, there's the SSRIs. And so sometimes doctors will recommend that as opposed to maybe taking something at nighttime like an amitriptyline or a trazodone. And so we see citalopram, Escitalopram, paroxetine, sertraline, fluoxetine. These are all SSRIs that can help in some patients with gut anxiety. And then of course, as you know, it doesn't help everyone with gut anxiety. It can create more digestive upset. Ethical considerations of antidepressant use is 1, is 1, what is the efficacy like for that person? Sometimes it's a little bit difficult to know until they try it. One hack is to do epigenetic testing like the nutraseq is a good genetic test that can look at that, but it doesn't tell you what epigenetics is. And so then we might look at methylation, DNA methylation, phosphorylation, acetylation, epigenetic test to see if there is a greater likelihood that it could be problematic. But often it's just clinically clinical trial and error. The other ethical concerns of using antidepressants is that the chemical imbalance theory was debunked. And we won't get into this in a lot of detail. It's a little bit out of the scope of today's talk. But if this is the first that you've heard about, that is essentially the chemical imbalance theory was based on serotonin. And the understanding that was established around the 1960s is that low serotonin caused depression and that increasing serotonin relieved depression. But this isn't at all what we see clinically. And so this huge meta analysis was performed and the researchers concluded that there is zero correlation between serotonin levels, manipulating serotonin levels and amelioration of depression symptoms. And so now we are back to square one, which is a good place to be, right? Because now we can be curious and we can start to dive a little bit deeper about. Well, serotonin does make a difference for some people. Some people feel way better on their antidepressant or their St. John's Wort or their 5 HTP. But now we have the opportunity to ask why? Well, what else is going on? Right? There's a whole lot more going on and the research is finding more and more things every single day. So it's pretty cool. Of course, there's a side effect black box warning of suicidality. We often see that as we increase serotonin, dopamine goes down. Dopamine is your feel good neurotransmitter. And so if we're crushing your feel good but giving you a little bit more motivation, this is when we see suicidal ideation kicking up in high risk patients. And then of course, there's a lot of concerns about antidepressant use in children and how that can affect neurotransmitters, genesis and growth and IQ and all sorts of things. So then we have benzodiazepines. It's another conventional approach to gut anxiety. And these medicines work by enhancing gaba and that's your relaxing neurotransmitter. We see short acting benzos are prescribed for gut anxiety, such as Xanax or Ativan. And then we also see longer acting like Klonopin or even Diazepam, which is an extremely long acting benzodiazepine. And these are extremely habit forming. In fact, after three consecutive days of taking a benzodiazepine, you should have your patient taper down. Withdrawal can be really severe and oftentimes the shorter acting benzodiazepines can be significantly more habit forming. We get this really quick, quick and heavy spike in gaba and then that really quickly goes away. And so then you have these people who are getting whiplash while the nervous system is trying to adjust these rapidly changing doses. So if you have somebody who's on a benzodiazepine, always taper them if you need to switch them from a shorter acting to a longer acting and then taper them. We could talk more about that in future sessions, if you're interested. And the other thing with benzodiazepines is they're not targeting the root cause of anxiety. They're very palliative and they can be very effective at helping with digestive upset, concomitant to mood disturbances. But they don't get to the root cause. And they can actually be quite damaging to the GABA receptors in the brain and in the nervous system. And they change your gut and they change your hormones. And some people develop protracted withdrawal. And some protracted withdrawal can last years to decades. So what else can we do? Gut anxiety, how can we approach it holistically? And so functional testing can make a huge impact in taking some of that guesswork out. So if you feel like you're throwing spaghetti at the wall and just kind of seeing what sticks is functional testing can be incredibly, incredibly helpful. And the thing with functional testing is, is that it's not always a perfect formula and it can be very rapidly impacted by what's happening in your client's day to day life. And so we want to definitely take that into consideration. In fact, with your gut microbes, they can actually change every single time that you eat something. And so if you're feeling in a particular mood and you're feeling maybe like sad or lethargic, and maybe you're listening to this conversation now and you're feeling a little restless, it is possible that you could eat something that could shift your gut microbes and then within 20 minutes you can be out of that state. And so when we have gut microbes that are shiftable like that, it's really cool because that means that you can work with the gut and the brain to get really quick results. But it could also kind of skew your data a little bit as you're trying to figure out what's going on. And so when you're using functional testing is use it in addition to maybe looking at what they're doing in their lifestyle, ask them to journal or track it and see if you can find other correlative measures that will kind of fill in some of the gaps and what's going on. So let's talk about stool testing. And so there are a lot of wonderful labs, a lot of wonderful companies. These screen captures in particular are from Genova. I have no affiliation with them. But I do appreciate the depth of information that they can provide. And so when we're looking at what. What is happening in the gut, you want to look at it from several different angles. You want to look at pcr, you want to look at culture, you want to look at microscopy. And so we have some examples of that here. And I like that this test gives us information about viruses as well as pathogenic bacteria, because your gut microbes can borrow hacks from viruses. And so if they're under assault and they need to adapt and they need to change your viruses that are chilling in that huge microbial stew, they can actually help the microbes be able to evolve and change based on whatever is happening in their ecosystem. Right. And so being able to have an idea of what's going on with viruses can be valuable, can be very valuable. And I also really like looking at parasitology, because sometimes you just never know what's going to show up. I found of them all, all sorts of things that were unexpected on patients, parasitologies, even though they're staying in the United States and drinking filtered water, it just can be kind of surprising. And these are things that you just wouldn't guess that are going on. And so testing can really help that. And then we can look at commensurate bacteria again. These are your fingerprint bacteria, right? The ones that you've had in your family lineage for many years. I love using organic acid testing to give information about what's going on with your gut bugs. And we'll talk about that in a little bit more detail in a minute. And then there's also swabs. So the nervous system. So your gut communicates to your nervous system, and your nervous system communicates back to your gut. And we see that microorganisms in the gut have a really important function. And not only does your nervous system affect your gut gut, but that nervous system affects your hormones, and your nervous system affects your immune system. And then your gut gets affected by it, and then that affects your hormones and your immune system. It's like this huge Venn diagram, and one affects the other. Right? So we want to look at the whole picture. And so we see that infants that have high levels of Bacteroides have better cognitive outcomes, but too many those bacteria can be really, really problematic. So it's all about balance. And microbes influence the development of the central nervous system. And so we are born, we receive this big glob of bacteria, and then those bacteria are kind of figuring they're getting their wiggles out if you will. They're just trying to figure out who belongs here, who doesn't belong here. And they're constantly adjusting to the environmental data. It's adjusting to trauma, adversity, environmental toxins, what you eat, what you don't eat, your level of activity, right? The gut microbes are evolving and adjusting to everything, and they really don't settle and hit cruise control in the composition until right around adolescence. And unfortunately, adolescence is often a time where. Where we're eating, like, the worst trash available, right? Like you have. You have teenagers, or if you were a teenager, which is all of us, some of us are still teenagers at heart, right? Is that we want to eat pizza and popcorn and candy. And I remember, like, I have this memory of this, like, huge lollipop, and all I wanted was this, like, giant lollipop, and I wasn't allowed to have it, so I would sneak behind the chair and lick my lollipop, right? And so we all have that kind of a. Of sort story. And so this is the time, though, where you have a huge impact on the developing gut and then setting a stage, setting a foundation for the rest of their life, the rest of their health. This is a huge time. And so those of you who are working with children and adolescents, get into the gut brain axis work, because that is where you are going to make the most profound decision impacts in your patients. When they're 80 and 90, they'll be. Their gut bugs will be thanking you for the work that you did when they were 10, 11, 12, right? And so we know microbes impact production and metabolism and the behavior of your neurotransmitters like serotonin and dopamine and all sorts of them. We know that microbes impact your blood brain barrier permeability. We know they regulate neuroimmunity. They're just so important, right? So looking at the nervous system is. I love the OAT test in particular. My favorite part of the OAT test is that it looks at clostridium markers. And clostridia can be a huge component behind gut anxiety and anger. Anxiety and anger. Anxiety is another one of the eight types of anxiety, and it's characterized by anxiety that comes out more in the fight of fight, flight, freeze, flop, fawn and fracture, right? That fight, that autonomic arousal that need to, like, get your way out of freedom, maybe with, like, aggression or irritability or frustration. We see clostridia in the gut often being behind that. And so knowing that, especially if someone is dealing with gut anxiety with an edge of irritability can be game changing because suddenly if we know it's clostridia and we get sensitivity testing, we know exactly as naturopaths how to target that. So clostridia can be problematic by releasing metabolites like for Crestol or hphpa and those interfere with dopamine hydroxylase. And so what that results in is then dopamine can't get converted into epinephrine. So then you have high dopamine and low epinephrine. The symptoms of high dopamine are anxiety, paranoia, a lot of hedonism or pleasure driven behaviors. Right. High dopamine, there's always too much of a good thing, right? Not dopamine, more isn't always better. And then if you have low epinephrine, you're going to feel lethargic and tired and have poor endurance when you have this kind of mix of symptoms that we can see clinically knowing, oh, there's something going on in the gut game. Changing my friends immune system. So the gut communicates with your immune system. And this is really fascinating actually I've been writing the book Panic Proof and the research behind the way the gut affects the immune system is just groundbreaking because your immune system is underneath everything. Your immune system influences inflammation. This like I could do probably 10 hours of talking about this. It's just so fascinating and so important and so looking at immune system health is really valuable, especially in anxiety and panic patients. I like to look at inflammatory markers like esr, crp, of course, your complete blood count, immune system testing like more specific specialized testing. But stool analysis is really great. And I highlighted in this article here, this section and in case you can't read the small font, it says that based on the current literature it appears that the gut microbiota composition differs between individuals and is contingent on a variety of factors like diet, genetics. And some individuals may have bacteria associated with pro inflammatory effects while others may harbor those with anti inflammatory effects. So your gut makes a huge difference in your tendency towards inflammation. So remember, inflammation is an effect and we want to know what the cause is. Right? So we can give anti inflammatories all day long, we give tons of amazing anti inflammatory tools. But the question we should be asking is why? Why are they inflamed? Okay, maybe their microbiota is off. Well, why is their microbiota off? Right. So it allows us to deactivate deeper and deeper and deeper. And so instead of the question being well, what do I give for anxiety? It's how is the body, the mind and the nervous system adapting to whatever's going on or has gone on in a way that is necessitating production of anxiety? Well, that's a big. A big reword, right? So again, how is the body, the body, mind and nervous system adapting? Why is this an adaptation? What are the symptoms telling you? Needs healing and how. And suddenly our relationship with symptoms is completely different. Right? Your symptoms are your messengers of what needs healing and how. Back to the immune system. So I like to do gut testing to look at what's happening with immune system in the gut. Your gut regulates your immune system. And so it makes sense, right, to test the gut. And so here's a test from Genova again. And it looks at digestion and it looks at inflammation. It looks at your gut microbial composition, metabolic imbalances and infection. And so one example that I pulled out here is that butyrate is a key inflammatory modulator in the gut, and certain bacteria make more butyrate. And so if you have inflammation and you test and you have a deficiency in these bacteria that produce butyrate, and you have low butyrate, it would make sense to replenish those bacteria, Right, as opposed to just giving butyrate. I mean, you can give butyrate, but why not give the person bacteria that make butyrate? Right? It's sort of like giving someone fish versus teaching them how to fish. Yeah, that makes sense. It's so good. So stool testing can enable us to. To test for the presence of these bacteria. And so the butyrate producers are the firm acutes. And we see all of their friends tested for here endocrine testing. So your gut has a lot to say to your endocrine system. We'll go into some of the specifics. Thyroid will be coming in a minute if you're a thyroid lover. And what I thought was really cool is that the microbiomes have a lot to say about sex hormones. And in fact, the microbiome in somebody, a cisgender female premenopausal, will be different than it will be when they are postmenopausal. The bacteria change. And postmenopausal cisgender females will have guts that look similar to men. And so that's kind of interesting. Like your guts will change, your bugs will change based on where you are hormonally. And we see that if we give antibiotics and we work on changing the gut, that the bacteria there will in turn change, and that can change your hormones, for example. A specific is that Clostridia, E. Coli, the Bacteroides species, they can increase estrogen. So if you're doing hormone replacement therapy and you're trying to create a dosage that's appropriate for them, is you want to know what's going on in the gut because that's going to impact how they metabolize that. And oftentimes we've seen estrogen dominant conditions that we have bacteria that are just going hog wild, making estrogen reabsorbed. They're reactivating it, reabsorbing it, then you have more estrogen. And so we use lots of wonderful estrogen herbs and we can work with things like Vitex and all these great plants. But also make sure that you don't forget the gut, because if you have gut bacteria in there that are reactivating est estrogen, you can feel like you're hitting your head against the wall or you're like Sisyphus pushing that boulder up the unending mountain. And so you deserve to get to the root cause and so does your patient. Thyroid and microbes. Your gut flora regulates your thyroid gland in three ways. One is via your immune system. And so we, many of us are familiar with the relationship between non celiac and celiac disease with autoimmune thyroid, Hashimoto's thyroiditis. And so we see that imbalances in your gut flora, which is dysbiosis, right? Dysbiosis is a lack of microbial diversity. So it's like you have a whole bunch of bugs that are quite similar. You don't have all of the diversity that you need. And we see that when we have dysbiosis that you have a higher risk of developing these immune system imbalances that show up as autoimmune disease or non autoimmune. We also see that your gut microbes are very involved in absorption and metabolism of nutrients and micronutrients such as iodine and iron and copper, all of which are important for thyroid. We know that these are needed to make thyroxine T4, and selenium and zinc are needed to convert T4 into active T3. And so if you have somebody who has high reverse T3, for example, it could mean that there's something going on in their gut that they're not absorbing those nutrients and then getting that conversion down that deiodinase pathway. Right. And so you want to make sure that instead of just giving enzymes or just giving bitters is really look at what's going on with the bugs. Are there the right bugs in There. And then thyroid binding, thyroid hormone binding is that your bugs are really important for making sure that you are binding thyroid hormone. Lactobacillus can improve function of thyroid. It increases levels of T4. Your lactose and your bifidos are often reduced in hypothyroidism. So your hypothyroid patients may benefit from specific strains of lactoembifidose. And we've seen that probiotics can actually improve and stabilize thyroid function, which is really exciting. Instead of just treating the thyroid, we're treating the root cause, right? Adrenals. And your microbes is your microbes will drive corticosterone production. So you do a Dutch test, right? You see that cortisol is very abnormal. And we often associate cortisol with anxiety and panic. We want to look at that cortisol rhythm. It should spike in the morning around 8am and then go down throughout the day and into the evening. And imbalances in your gut microbiome can result in imbalances in your cortisol. There is this 2021 study that was published in the International Journal of Molecular Sciences, and they revealed that corticosterone production is driven by the gut microbes and that they actually work on the gene level. Now we see that microbes are affecting epigenetics, the way that your genes are expressing themselves. And so I know that I've been saying this a lot, but instead of just going and working on cortisol, let's go deeper, right? Let's go deeper and figure out what might be getting in the way of cortisol functioning normally. And why have the bacteria in the gut adapted so that they're attenuating cortisol in the way that they are? Right. What are they adapting to? Because if we look at it again as the body is wise and it's trying to heal, there's something that it's adapting to. And so you want to remove those causes. So let's get into some cases. This is the fun part. And so this is Susie. She's 51. She had gut anxiety. And she came to me and had a very long history of chronic illness. She had Graves disease in 2001, breast cancer in 2010, 2013. She had a stroke. She had an oophorectomy. Then in 2014, and then a he a year later got appendicitis. She has done many disease specific interventions. She's been on long term Synthroid, of course, she had Graves disease. They took her thyroid out. She's on long term Albuterol, and she's worked on her diet, she's done detox, she's taken probiotics, she's used botanicals, supplements, all sorts of different things. When she came into my office, she was dealing with a lot of digestive upsets, such. So she had a lot of that kind of lower gut anxiety, the gas, the bloating, the indigestion. She's gaining weight despite working really hard on regular exercise. She had a personal trainer. She counted her macros, she did a lot of calorie counting. So she's really committed to a healthy diet and exercise program. She had a lot of mood swings. She had that kind of irritability, anxiety, kind of a low mood, just sort of dysthymic. Right. She had headaches every single day, a ton of muscle tension, especially the neck and shoulders. And her priority was to focus on anxiety. And then, wow, it would be awesome if my gut could feel better. Right. So we started her with some objective testing I like to use for anxiety, the Hamilton Anxiety Rating Scale. You can get that online for free. And we did stool testing, so. So here's a screenshot of her Hamilton Anxiety Rating Scale before starting treatment. It was a 55% score, so it's pretty decently high. And when we look at the scoring of the Hamilton Anxiety scale is that 0 is, no, the symptom isn't present, and 4 is pretty severe. And the range is 0 to 56. And so if somebody has less than 70, 17 is mild, 18 to 24 indicates mild to moderate severity of symptoms of anxiety. And then 25 to 30 is pretty moderate to severe. And she was 31, so she was off the charts. All right, stool analysis. So this is a screenshot of her result and some of the high yield. This was years ago, before some of the more recent tests that I did. This is a little bit older of a test. And so I ran a more updated one, which you'll see next. But there's some good information on here. She had klebsiella. What? Okay. And then she had some elevations in calprotectin, and she had really high secretory iga. And she definitely had dysbiosis, a lack of microbial diversity. And there's this, you heard in my bio that I contribute to Psychology Today. This is one of the great articles that the team has written, Team Biotic, and it's about meta inflammation and mental health. And we know that inflammation in the brain is associated with mood changes. And so when we look at Susie's presentation, we see High calprotectin, so high inflammation in the gut, right? High secretory IGA levels. So we have a compromised gut, gut layer. And then we have unchecked inflammation that can cause systemic inflammation that can go to the brain. And you've probably heard the term leaky gut, leaky brain. And when we have a lot of chronic inflammation and she had inflammation evidence from many, many years ago and then arguably just got worse and worse and worse with each subsequent treatment, is that when we have a ton of inflammation that that can actually signal up to the brain. And the amygdala in the brain will receive those inflammatory signals. And remember, your amygdala is the danger. Danger Will Robinson part of the brain, right. It's the danger detector. And when it gets that signal, it will send to the hypothalamus, it will send these danger signals then down to that organ and then that will send information to your adrenal glands. And then that will create that whole fight flight freeze response. And so now you have cortisol getting released. So you have a person who's really inflamed and then there's cortisol release which is attempting to combat inflammation and bring that inflammation down. But then when inflammation is brought down, these circulating pathogens are, they're like a Trojan horse. And then they're able to sneak, they're able to colonize in the gut and then they eventually break down that gut wall and then they're able to, to sneak through and into the bloodstream. And so then you have toxins and critters that are sneaking through into the bloodstream that shouldn't be there, which then of course provokes an immune response. But then also all of that is going through your circulation and it's damaging other parts of your body, including the brain. And after enough time, we end up with compromised blood brain barrier. And now things are leaking into the brain that don't belong to there. So she had done a lot and so I added in a probiotic and that was all that we did. And so this is her 30 day follow up. And she seemed just. Her shen was better. She was more calm and cheerful and clear. And look at her hama score. So it was so much better. Look at this. It went down to 4. Remember what it was a minute ago or right, it was 31. This is just a probiotic, y'. All. Like this is amazing. And so she was significantly better. It reduced all the way down to 7%. Her subjective report, my gas and bloating were gone in two days. She Said, this is, this is like one of my favorite cases. And I talk about it a lot with my friend Pam and it's just like amazing. She was like, this is a magical elixir. And I'm like, it's so science. It's like a product that actually works and you needed it. So her gas and bloating were gone in two days. She said, I didn't realize how anxious I was. So I took that questionnaire and wow, it's so much better. Her mood is lifted, her concentration is better, her sleep is better. She's been sleeping through the night. She let me do follow up stool testing, which is such great science. I love that. So I got out, this is a newer test that I was much more excited about. And so we got some objective changes. We see that her secretory IGA levels were significantly reduced. Her calprotectin elevation was resolved, the infectious agents were gone. We didn't even do a killing agent. We just gave her body what it needed and the bacteria did the job. They can audit themselves, which is incredible. And dysbiosis resolved. And this isn't, this is amazing. This is just one psychobiotic. So we decided to continue that and discussed doing a more targeted cleanse. Let's move on to Matthew. Matthew, he had a horrible trauma when he was in third grade and he had an incident where he involuntarily passed stool and gas in a very sad way and got shamed and made fun of for that. And he developed really pretty severe phobia ago agoraphobia and just tons of gut anxiety. And so this made his world smaller and smaller. And by the time he came into my office, he would cover himself in cologne so that just in case gas leaked out that hopefully it would be blocked by the cologne. He was afraid to travel many places because he needed to be near a bathroom in case his bowels rebelled and it was really severely interfering with his life. He tried the things that we talked about, antidepressants, benzodiazepines. He'd taken anti diarrheals, anti nausea medications, some anxiolytic botanicals, and he had done extensive amounts of cognitive behavioral therapy. But as we know from the trauma research is that trauma doesn't just affect your logical prefrontal cortex, but trauma can affect your whole brain. It can affect the non verbal parts of, of the brain. And so we can't get to them with logic, we can't get to them with cognitive behavioral therapy. We have to go from a bottom up approach. And so this is from the research of Bessel van der Kolk. And top down he talks about is more like that logical brain to body. And then bottom up is more starting with the body, starting with the nervous system, starting with the vagus nerve, starting with the gut, starting with all of those things that are underneath our conscious awareness, awareness and then working that up to the brain. So he didn't get that, so we decided to do that. So we added a psychobiotic. I gave him a carbonate of gut blend and he did emdr, which is eye movement desensitization and reprocessing therapy, which is the number one researched form of therapy for trauma, anxiety, depression. And we had him enroll in a martial arts program which was really super fun. And then here is his PHQ9 and GAD7. These are other objective tests for mood. So his PHQ9 baseline, it was 6 and then within 3 months it was 0. His GAD7 was 173 months, it went down to 2. His gut anxiety, when he started, he had 10 out of 10. At 3 months his anxiety in his gut was down to 3 out of 10. Excuse me, his episodes of diarrhea, his baseline frequency was that every time he went out he would have it. And then after three months it hadn't occurred at all. Number of jiu jitsu classes he was going one time week one, two times week two. And then he started going more and more. He loved it. And he started going three times a week. And there's a lot of really, really cool bottom up research on the efficacy of martial arts and jiu jitsu on actually re equilibriating the nervous system and re patterning the brain, rewiring that neuroplastic brain for healing from anxiety. And that's just so awesome. EMDR session, he was doing that weekly. He was on two weeks of his carminatum and psychobiotic and his need for an anti diarrhea medication. He had been taking it twice a week. And then at three months he, he hadn't needed it as of day three of the psychobiotic, which was really, really encouraging. Got his life back. And now he's actually working as an airline, airline steward. And so he's like out and about all the time and like living, living his best life. It's really, really cool. Let's do our last case. This is Sarah. She had ptsd, post traumatic stress disorder, depression, recurrent urinary upper respiratory infections and, and gut anxiety. She's a really complex history of trauma. She's 39 and she had a lot of religious trauma. Church trauma, family trauma was really in interwoven into herself of her sense of identity and who she was. She had a ton of headaches, insomnia, allergies, blood sugar spikes, and she had a lot of suicidal ideation. When we were working together originally, she had attempted multiple times, thankfully not successful. And that had been provoked by antidepressant use. And so that wasn't an option for her. And at the time when we started, she was taking Excedrin every single day in Claritin. She tried supplements, diet, homeopathy. She'd seen a lot of naturopaths, functional medicine, doctors. She tried everything. Psychiatric meds, spiritual counseling, EMDR counseling, dietary management, genetic counseling. And so over the years working together, she did get significantly better. But there was one sticky factor. The sticky factor is like that piece that isn't shifting. And she was getting every cold and flu that anybody around her in her proximity had, and she was tired of getting sick. And so we started her on a psychobiotic that started focused on targeting the immune system and really replenishing that microbial diversity. And so these are the bacteria that were in the psychobiotic. And what you're going to notice when you're looking at psychobiotics is that you have the name of the bacteria and then you have these funny numbers and letters after it. And so these are the different strains. And that's really important information because an analogy is that that you have dogs. And if you say, well, I need a dog, and you're thinking in your mind like a cute little Yorkie and then your partner comes home with a Great Dane, that's a really big difference, right? And so it's the same thing like a Lactobacillus Yorkie and a Lactobacillus Great Dane, but they're not the same. They're both dogs, but they're not the same. Right? So different bacteria are differentiated by their different strains and they all have different actions. And so that's where it gets a little bit more complicated, is that not all psychobiotics are the same. So at the four month follow up, Sarah was doing significantly better. She said it seemed to really help. It's worked better than any other probiotics I've tried. She felt more physically healthy, her digestion was more routine. She got off of the sugar kick. She was, which goes back to the first thing we talked about, right? That delicious brownie, those bacteria, right. So she shifted her bacteria, got off of her sugar kick, she was able to reduce her Excedrin dosing and she hadn't gotten sick, which was like a huge victory. So you may be wondering, how can I get these kinds of results? This is amazing. So there's four steps. That's it, four steps. You address acute concerns. You start with the main thing, keep it as simple as possible possible. Number two, remove the obstacles to cure. And this could be identifying what the mind, the body and the nervous system is adapting to that is rendering these symptoms to be produced by the body. And how do we get to the root cause of that? Using natural medicines that stay with the laws of nature. And then number three, we give the body what it needs to heal. Sometimes you don't need a killing agent if there's a dysbiotic critter in the there. You just let the body do what it does when you give it what it needs. And then number four is using a whole person approach. And one of the biggest surprises that I wrote in this slide is that it was amazing how people improved as a whole person because remember, it's so multifaceted. It's that Venn diagram. And so instead of trying to play a game of Whack a Mole where I'm trying to treat this symptom and that symptom, and that symptom is if we often go to the the bottom of that Jenga tower and just pull out that bottom piece, the whole thing will fall. Right. So you don't have to start at the top of the Jenga tower and treat symptom by symptom by symptom. It'll take you forever. If you can get to the root of that Jenga tower and pull out that linchpin, the whole thing will fall. Ethical considerations for psychobiotic use is you want to make sure that you are actually giving a good quality product. You want to make sure that it is sourced from an appropriate location. Are the organisms viable by the time they get cultured, manufactured, put in a bottle, put on a shelf, purchased, put in the cart, brought home, put in the cupboard, opened, taken into the mouth, down the digestive onslaught, through the stomach, all the acids, all the digestive juices, through the duodenum and into the parts of the bowels that they need to be Right. Is it viable by the time they get there? A lot of studies show that it's less than 10% viable for many of these products. What are their manufacturing practices? Have they actually researched how well these bacteria work together? Some are synergistic, some are antagonistic. What are the side effects? Some people react to certain strains and so there's A possibility of an allergic reaction, an infection, a herx reaction. And there's a lack of FDA regulation. And so just in the last couple of minutes that we have together, I just want to talk a little bit about the manufacturing. And so the activity of bacteria may change based on dosage. So more isn't necessarily better. So I remember when I was in medical school, I was just looking for the probiotic that had the most bugs in it, but it doesn't always work that way. You want to get the dosage that's been researched to be the most clinically effective. Right. The level of efficacy to confirm benefit. You also want to make sure that the individual strains are going to behave the way that you want them to and introduced into a new ecosystem. And so this is, you'll learn this by looking at the clinical trials and what actually happened in human beings. And so if the product hasn't been tested as a product in human beings, then you don't know, it's guessing. And some bugs work synergistically together and other bugs are antagonistic together. And it's just like if you put a bunch of dogs in one room, some may play and others maybe may fight. It's the same with your gut bacteria. We talked about human clinical trials and we talked about viability. Here's one study that is in the strain that I talked about earlier. And so this was a double blind, randomized, pre and post intervention assessment design study. And they were looking at a four week effect of probiotic administration. And they actually did brain studies, which I think is the coolest thing, especially for mental health. And what the results revealed is that on functional MRI they saw that in four weeks that these probiotics, that this combination of bacteria, these nine bacteria together influenced brain activation. It helped emotional decision making patterns, it helped recognition, memory and healthy volunteers. And then they also identified that there is a close relationship between the effects of probiotics and behavioral and neuroimaging readouts. And so we're seeing that some of these companies are actually doing high integrity research. And that's what you want for your patients, is to make sure that you're getting something that has been prepared clinically. And so I'm Dr. Nicole Caine. If you have questions, I'm definitely happy to stay after and answer them for you. You can also reach me at Instagram and leave a comment or send it to you and I'll definitely answer that for you. Thanks for having me. The recording you just listened to consists of the personal opinions of Dr. Nicole Caine, a naturopathic doctor with a master's in Clinical psychology and Happy Healthy Hadley, an Ayurveda expert with a master's in health, behavior and health education. While these opinions are based upon literature, counseling education, medical training and clinical experience, this content should not be viewed as the definitive opinion on these subjects. Listening to this podcast is not a substitute for any sort of medical, psychological or other form of treatment. If you are in a craft Crisis, please call 911-OR call the National Suicide Prevention Line at 1-800-273-8255. If you are in need of counseling, don't hesitate to make an appointment with a counselor in your area. Dr. Nicole and Hadley are passionate about you becoming the expert of your own emotional and physical well being. If this resonates with you and you think this policy podcast would help someone you love, please share it with them. We look forward to seeing you on the next episode of the Holistic Inner Balance Podcast. Sam Sa.