Examining Medical Causes of Psychological Symptoms: An Orthomolecular and Functional

Medicine ApproachDavid Reinhardt Ph.D. ABMPDavid Reinhardt Ph.D. ABMP

National Alliance of Professional Psychology ProvidersNational Alliance of Professional Psychology Providers2010 NAPPP Practice Conference October 9-10 Las Vegas NV2010 NAPPP Practice Conference October 9-10 Las Vegas NV

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The Doctor of the Future“The doctor of the future will be an integrative healer whose practice differs in many ways from that of today's typical physician. The doctor of the future will provide care that is patient-centered and comprehensive (body, mind, and spirit), and care that is both high-tech (using genomic prediction tools, systems biology, and functional medicine, for example) and high-touch.”

“Care will focus more extensively on preventing disease and injury. The practice of the future will be provided by smoothly working teams that will include primary care physicians, complementary and alternative health practitioners, health coaches, and wellness mentors, as well as medical specialists, allied health and nursing practitioners.” (Foundation for Alternative and Integrative Medicine)

“Modern” Mental Health Treatment

IS NOT

Modern Mental Health Science

“Diagnostic Standards of Care” are poorly written and generally lacking for symptoms of mood, cognition and behavior

APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder May 2010  

152 Page Document states "...not 152 Page Document states "...not intended to be construed or to intended to be construed or to serve as a standard of medical serve as a standard of medical care…care…Communication with Communication with other other clinicians who are providing clinicians who are providing

treatment for general medical treatment for general medical conditions is recommended."conditions is recommended."

APA Differential Diagnosis of Depression:

Rule Outs:Rule Outs: StrokeStroke Parkinson'sParkinson's DementiaDementia Multiple SclerosisMultiple Sclerosis Thyroid DisordersThyroid Disorders HypercalcemiaHypercalcemia MalignancyMalignancy Infectious DiseasesInfectious Diseases

Medications Medications including:Anti-rejection including:Anti-rejection AgentsAgents

Chemotherapy Agents Chemotherapy Agents InterferonInterferon SteroidsSteroids Some AntibioticsSome Antibiotics

Tests:Tests: No RecommendationsNo Recommendations

The Merck Manual for Healthcare Professionals

does better

Merck Depression Chart

Unfortunately, the Merck Manual is seldom followedand offers little guidance on other psychological symptoms

Epocrates Inc. SoftwareClinical information and decision Clinical information and decision

support toolssupport tools

Used by “over 40% of US Used by “over 40% of US Physicians”Physicians”

www.epocrates.comwww.epocrates.com

Offers reliable free and subscription applications for

handhelds and desktop

Epocrates Home Page

Diagnostic Standard of Care for Depression (Epocrates.com)

DifferentialDifferential Situational adjustment Situational adjustment

reaction with depressed moodreaction with depressed mood Bipolar disorderBipolar disorder Premenstrual dysphoric Premenstrual dysphoric

disorder (PMDD)disorder (PMDD) Grief reactionGrief reaction DementiaDementia Anxiety disordersAnxiety disorders Alcohol abuseAlcohol abuse Anorexia nervosaAnorexia nervosa

HypothyroidismHypothyroidism Medication adverse effectsMedication adverse effects Cushing diseaseCushing disease Vitamin B12 deficiencyVitamin B12 deficiency

TestsTests Symptom questionnairesSymptom questionnaires CBCCBC Thyroid function testsThyroid function tests 24-hour free cortisol24-hour free cortisol Vitamin B12Vitamin B12 Folic acidFolic acid

Epocrates Page

Diagnostic Standard of Care for Anxiety (Epocrates.com)

DifferentialDifferential Panic disorderPanic disorder Social phobiaSocial phobia Post-traumatic stress disorderPost-traumatic stress disorder Obsessive-compulsive disorderObsessive-compulsive disorder DepressionDepression Substance-induced anxiety disorderSubstance-induced anxiety disorder Anorexia nervosaAnorexia nervosa Situational anxiety (nonpathologic)Situational anxiety (nonpathologic) Cardiac diseaseCardiac disease Pulmonary conditions (i.e., COPD, Pulmonary conditions (i.e., COPD,

asthma)asthma) HyperthyroidismHyperthyroidism InfectionsInfections Crohn diseaseCrohn disease Irritable bowel diseaseIrritable bowel disease Ulcerative colitisUlcerative colitis

Asthma medicationsAsthma medications CorticosteroidsCorticosteroids AntidepressantsAntidepressants Beta-blockersBeta-blockers Peptic ulcer diseasePeptic ulcer disease

TestsTests Thyroid function testsThyroid function tests Urine drug screenUrine drug screen 24-hour urine for vanillylmandelic and 24-hour urine for vanillylmandelic and

metanephrinesmetanephrines Pulmonary function testsPulmonary function tests EchocardiogramEchocardiogram Electrocardiogram (EKG)Electrocardiogram (EKG) Electroencephalogram (EEG)Electroencephalogram (EEG)

Epocrates Page

Diagnostic Standard of Care for Insomnia (Epocrates.com)

DifferentialDifferential Restless leg syndromeRestless leg syndrome Periodic limb movement Periodic limb movement

disorderdisorder Obstructive sleep apneaObstructive sleep apnea Circadian rhythm Circadian rhythm

disordersdisorders

TestsTests Symptom questionnairesSymptom questionnaires

PolysomnographyPolysomnography Sleep DiarySleep Diary TSHTSH

Epocrates Page

Diagnostic Standard of Care for Schizophrenia (Epocrates.com)

DifferentialDifferential Substance-induced psychotic Substance-induced psychotic

disorderdisorder Dementia with psychosisDementia with psychosis Malingering and factitious Malingering and factitious

disordersdisorders Delusional disorderDelusional disorder Brief psychotic disorderBrief psychotic disorder Pervasive developmental Pervasive developmental

disorderdisorder Organic psychosisOrganic psychosis Carbon monoxide poisoningCarbon monoxide poisoning Heavy metal poisoningHeavy metal poisoning

Medication-induced psychosisMedication-induced psychosis Liver diseaseLiver disease HyperthyroidismHyperthyroidism HyperparathyroidismHyperparathyroidism

TestsTests CT/MRI headCT/MRI head Serum HIVSerum HIV Serum rapid plasma regainSerum rapid plasma regain CBCCBC Urine drug screenUrine drug screen Plasma drug level monitoringPlasma drug level monitoring

Epocrates Page

Diagnostic Standard of Care for Bipolar Disorder (Epocrates.com)

DifferentialDifferential Mood disorder due to general Mood disorder due to general

medical conditionmedical condition Substance induced mood Substance induced mood

disorderdisorder Major depressive disorderMajor depressive disorder Dysthymic disorderDysthymic disorder Cyclothymic disorderCyclothymic disorder Psychotic disordersPsychotic disorders Personality disordersPersonality disorders Obsessive-compulsive Obsessive-compulsive

disorderdisorder ADHDADHD

TestsTests Symptom questionnairesSymptom questionnaires CBCCBC Thyroid function testsThyroid function tests Serum Vitamin DSerum Vitamin D Toxicology screenToxicology screen Fasting lipidsFasting lipids Fasting glucoseFasting glucose MRI brainMRI brain

Epocrates Page

Diagnostic standard of care for OCD (Epocrates.com)

DifferentialDifferential Obsessive-compulsive Obsessive-compulsive

personality disorderpersonality disorder Body dysmorphic disorderBody dysmorphic disorder HypochondriasisHypochondriasis Delusional disordersDelusional disorders Severe social phobiaSevere social phobia Panic disorderPanic disorder AutismAutism Asperger syndromeAsperger syndrome

TestsTests Symptom questionnairesSymptom questionnaires No lab tests recommendedNo lab tests recommended

Epocrates Page

Diagnostic Standard of Care for Dementia (Epocrates.com)

DifferentialDifferential Mild cognitive impairmentMild cognitive impairment DeliriumDelirium DepressionDepression Vascular dementiaVascular dementia Dementia of Lewy bodyDementia of Lewy body Frontotemporal dementiaFrontotemporal dementia Parkinson diseaseParkinson disease Creutzfeld-Jacob diseaseCreutzfeld-Jacob disease

TestsTests Cognitive testingCognitive testing CBCCBC Erythrocyte sedimentation Erythrocyte sedimentation

raterate Metabolic panelMetabolic panel Serum TSHSerum TSH Serum B12Serum B12 Serum VDRLSerum VDRL

Epocrates Page

All of these approaches, if followed, allow the patient to be

put into a diagnostic box

Treatment consists of prescribing psychotropics and, hopefully,

psychotherapy

Current practice guidelines have 2 things in common...

Treatments mostly suppress symptoms

Causes are seldom explored

“Modern” Medical Treatment

IS NOT

Modern Health Science

A branch of healthcare has looked to treat CAUSES since

the days of Ancient Civilizations

It has been MARGINALIZED by “Modern Medicine”

It offers limited profit potential for drug companies

Psychology!

Another branch of healthcare has been similarly marginalized by

Modern Medicine

It too has limited profit potential for drug companies

Orthomolecular Medicine

“Critics have described some aspects of orthomolecular medicine as food faddism or quackery.” (Wikipedia)

Orthomolecular Medicine draws on health knowledge with roots

in pre-history

It reflects the most recent It reflects the most recent science, learning from the science, learning from the

discoveries of genetic discoveries of genetic research and bioscienceresearch and bioscience

“Orthomolecular medicine aims to restore the optimum environment of the body by correcting imbalances or deficiencies based on individual

biochemistry” (Linus Pauling)

“Orthomolecular practice rests on a foundation of basic science advances in biochemistry, biophysics, genetics, physiology, psychophysiology and ecology. We do not eschew drug therapy or pharmacology; but we do recognize their limitations and their potential for toxicity.” (Richard Kunin)

Orthomolecular medicine uses substances natural to the body

such as vitamins, minerals, amino acids, trace elements and

fatty acids

Orthomolecular Medicine has a Big Tent

Orthomolecular Medicine uses: VitaminsVitamins MineralsMinerals Amino acidsAmino acids Essential fatty acidsEssential fatty acids Fiber enzymesFiber enzymes AntibodiesAntibodies AntigensAntigens Cell therapyCell therapy AcupunctureAcupuncture MassageMassage ExerciseExercise BiofeedbackBiofeedback

Chelation therapyChelation therapy DialysisDialysis PlasmapharesisPlasmapharesis HydrotherapyHydrotherapy Thermal therapyThermal therapy PhototherapyPhototherapy ElectrotherapyElectrotherapy Air ion therapyAir ion therapy Light TherapyLight Therapy Solar therapySolar therapy HypnotherapyHypnotherapy PsychotherapiesPsychotherapies

7 Cardinal Rules of Orthomolecular Medicine

1. Nutrition comes first in medical 1. Nutrition comes first in medical diagnosis and treatment diagnosis and treatment

2. Drug treatment is used only for 2. Drug treatment is used only for specific indications and always with specific indications and always with an eye to the potential dangers and an eye to the potential dangers and adverse effectsadverse effects

7 Cardinal Rules of Orthomolecular Medicine

3. 3. Environmental pollution and food Environmental pollution and food adulteration are an inescapable fact adulteration are an inescapable fact of modern life and are a medical of modern life and are a medical prioritypriority

4. 4. Biochemical individuality is the Biochemical individuality is the norm in medical practice; therefore norm in medical practice; therefore stereotyped RDA values are stereotyped RDA values are unreliable nutrient guidesunreliable nutrient guides

7 Cardinal Rules of Orthomolecular Medicine

5. Blood tests do not necessarily reflect tissue 5. Blood tests do not necessarily reflect tissue levels of nutrientslevels of nutrients

6. Nutrient diagnosis is always defensible 6. Nutrient diagnosis is always defensible because nutrient related disorders are because nutrient related disorders are usually treatment responsive or curableusually treatment responsive or curable

7. Hope is an indispensable ally of the 7. Hope is an indispensable ally of the physician and an absolute right of the physician and an absolute right of the patientpatient (Richard (Richard Kunin)Kunin)

Orthomolecular medicine does not purport to treat all diseases, nor is it "a replacement for standard treatment. A proportion of patients will require orthodox treatment, a proportion will do much better on orthomolecular treatment, and the rest will need a skillful blend of both”

(Abram Hoffer)(Abram Hoffer)

Functional Medicine puts a fresh name to the core concepts of Orthomolecular Medicine

The Institute of Functional Medicine was founded by Jeffrey Bland in 1991

Orthomolecular/Functional Medicine identifies and treats using a 3 prong approach:

AntecedentsAntecedents TriggersTriggers MediatorsMediators

ANTECEDENTS

Are things that happen before Are things that happen before disorders startsdisorders starts

• Genetic Variations

• Genetic Regulation

• In-utero Exposure

• Early Life Exposure

Genes control the formation and structure of nutrient and

neurotransmitter receptors

Genetic variations influence metabolic pathways and lead to the

“Neurotransmitter Imbalances” claimed by the drug makers

Genetic variations can impair absorption of sufficient nutrients,

leading to mood, behavior and physical symptoms

Things that unmask your antecedents

They are involved in REGULATION and EXPRESSION of particular genes

Early life events may alter gene expression through:•Viral Exposure•Radiation Exposure•Drugs•Environmental Pollutants

TRIGGERS

Orthomolecular Scientists counsel to avoid disorders caused by antecedents through appropriate lifestyle, nutritional supplementation, diet, and shunning of additives and industrial pollutants.

Nutrients may be used as a “work-around” to impaired metabolic pathways at the Trigger level.

Example

5,10-methylenetetrahydrofolate reductase 5,10-methylenetetrahydrofolate reductase (MTHFR) polymorphisms impair (MTHFR) polymorphisms impair conversion of folic acid to methionine, conversion of folic acid to methionine, resulting in increased risk of:resulting in increased risk of: Coronary Artery DiseaseCoronary Artery Disease Inflammatory bowel diseaseInflammatory bowel disease DepressionDepression Down’s SyndromeDown’s Syndrome Alzheimer’s disease (possibly) Alzheimer’s disease (possibly)

MTHFR variant C667T

Occurs in:Occurs in: 26.6% of Whites26.6% of Whites 12.4% of Blacks12.4% of Blacks 41.5% of Hispanics41.5% of Hispanics

Identification of MTHFR related risk can be made by:

Genetic testingGenetic testing Nutrient testingNutrient testing Interpretation of subtle symptomsInterpretation of subtle symptoms Best guessBest guess

Typical Orthomolecular Intervention: Supplemental Folic

Acid!

Taking high dose supplemental folic acid Taking high dose supplemental folic acid “pushes” the metabolic pathway to create “pushes” the metabolic pathway to create

sufficient methionine. This is safe, and has sufficient methionine. This is safe, and has no adverse effects.no adverse effects.

Are those things your body does to try to rectify the consequences of the antecedents and triggers

Feedback loops are Mediators that attempt to compensate for imbalances in an attempt to reach homeostasis

MEDIATORS

Mediators are very effective at rectifying imbalances due to

drugs

These feedback loops are the Achilles’ heel of Modern

Medicine

Orthomolecular/Functional medicine tries to understand antecendents and intervene at the

trigger level.

Modern Medicine understands mediators and intervenes at the symptom level.

That is one of the fundamental differences

between the two disciplines

A Proposed Diagnostic Protocol for Assessment of Mental Health

Symptoms

1. Diagnostic Interview

Symptom Questionnaire

Symptom Checker

2. Medication Review

Appropriateness of DosageAppropriateness of Dosage Adverse EffectsAdverse Effects Interactions CheckerInteractions Checker Consult when beyond your level of Consult when beyond your level of

expertiseexpertise

Abilify

Drugs Excel

3. Consider Possible Alternate Explanations

Consult!Consult! www.wrongdiagnosis.comwww.wrongdiagnosis.com www.CenterforHealthScience.comwww.CenterforHealthScience.com

CHS depression

For Information on Lab Testing:For Information on Lab Testing: labtestsonline.orglabtestsonline.org CenterforHealthScience.comCenterforHealthScience.com Apexseminars.comApexseminars.com

4. Recommend or Obtain Medical Labs

to rule out physical causes

Depression Labs

Apex

5. Refer for Treatment! Allopathic PhysicianAllopathic Physician Naturopathic PhysicianNaturopathic Physician Doctor of Oriental MedicineDoctor of Oriental Medicine Ayurvedic PhysicianAyurvedic Physician Medical PsychologistMedical Psychologist NutritionistNutritionist Other ProfessionalsOther Professionals

Qualified Referral Sources Institute of Functional Medicine members: Institute of Functional Medicine members:

www.functionalmedicine.orgwww.functionalmedicine.org Orthomolecular Health Medicine members: Orthomolecular Health Medicine members:

www.ohmsociety.comwww.ohmsociety.com ISOM Members:ISOM Members:

www.orthomed.orgwww.orthomed.org Center for Health Science:Center for Health Science:

www.centerforhealthscience.comwww.centerforhealthscience.com