Download Diagnostic Standard of Care for Sadness

Examining Medical Causes of
Psychological Symptoms: An
Orthomolecular and Functional
Medicine Approach
David Reinhardt Ph.D. ABMP
National Alliance of Professional Psychology Providers
2010 NAPPP Practice Conference October 9-10 Las Vegas NV
[email protected]
www.CenterforHealthScience.com
Useful Links
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www.CenterforHealthScience.com
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Symptom Checker
Discount lab service / Alternative treatment products
Affiliate Program and Referral Service
Power Point Presentation
“Drugs That Cause Psych Effects” Excel file
www.Epocrates.com
Free and Fee Software for Desktop and Mobile
Drug and natural medicine information
Practice guidelines
Many free tools
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www.orthomed.org
www.ohmsociety.com
functionalmedicine.org
www.labtestsonline.org
www.apexseminars.com
Orthomolecular Medicine Online
Orthomolecular Health Medicine Society
The Institute for Functional Medicine
Complete information on lab tests
Lab Test courses
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
intended to be construed or to serve
as a standard of medical
care…Communication with other
clinicians who are providing treatment
for general medical conditions is
recommended."
APA Differential Diagnosis of
Depression:
Rule Outs:
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Stroke
Parkinson's
Dementia
Multiple Sclerosis
Thyroid Disorders
Hypercalcemia
Malignancy
Infectious Diseases
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Medications
including:Anti-rejection
Agents
Chemotherapy Agents
Interferon
Steroids
Some Antibiotics
Tests:
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No Recommendations
The Merck Manual for
Healthcare Professionals
does better
Merck Depression Chart
Unfortunately, the Merck
Manual is seldom followed
and offers little guidance on
other psychological symptoms
Epocrates Inc. Software
Clinical information and decision
support tools
Used by “over 40% of US
Physicians”
www.epocrates.com
Offers reliable free and
subscription applications for
handhelds and desktop
Epocrates Home Page
Diagnostic Standard of Care for
Depression
(Epocrates.com)
Differential
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Situational adjustment
reaction with depressed
mood
Bipolar disorder
Premenstrual dysphoric
disorder (PMDD)
Grief reaction
Dementia
Anxiety disorders
Alcohol abuse
Anorexia nervosa
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Hypothyroidism
Medication adverse effects
Cushing disease
Vitamin B12 deficiency
Tests
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Symptom questionnaires
CBC
Thyroid function tests
24-hour free cortisol
Vitamin B12
Folic acid
Epocrates Page
Diagnostic Standard of Care for
Anxiety
(Epocrates.com)
Differential
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Panic disorder
Social phobia
Post-traumatic stress disorder
Obsessive-compulsive disorder
Depression
Substance-induced anxiety disorder
Anorexia nervosa
Situational anxiety (nonpathologic)
Cardiac disease
Pulmonary conditions (i.e., COPD,
asthma)
Hyperthyroidism
Infections
Crohn disease
Irritable bowel disease
Ulcerative colitis
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Asthma medications
Corticosteroids
Antidepressants
Beta-blockers
Peptic ulcer disease
Tests
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Thyroid function tests
Urine drug screen
24-hour urine for vanillylmandelic and
metanephrines
Pulmonary function tests
Echocardiogram
Electrocardiogram (EKG)
Electroencephalogram (EEG)
Epocrates Page
Diagnostic Standard of Care for
Insomnia
(Epocrates.com)
Differential
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Restless leg syndrome
Periodic limb movement
disorder
Obstructive sleep apnea
Circadian rhythm
disorders
Tests
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Symptom questionnaires
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Polysomnography
Sleep Diary
TSH
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Epocrates Page
Diagnostic Standard of Care for
Schizophrenia
(Epocrates.com)
Differential
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Substance-induced psychotic
disorder
Dementia with psychosis
Malingering and factitious
disorders
Delusional disorder
Brief psychotic disorder
Pervasive developmental
disorder
Organic psychosis
Carbon monoxide poisoning
Heavy metal poisoning
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Medication-induced psychosis
Liver disease
Hyperthyroidism
Hyperparathyroidism
Tests
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CT/MRI head
Serum HIV
Serum rapid plasma regain
CBC
Urine drug screen
Plasma drug level monitoring
Epocrates Page
Diagnostic Standard of Care for
Bipolar Disorder
(Epocrates.com)
Differential
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Mood disorder due to
general medical condition
Substance induced mood
disorder
Major depressive disorder
Dysthymic disorder
Cyclothymic disorder
Psychotic disorders
Personality disorders
Obsessive-compulsive
disorder
ADHD
Tests
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Symptom questionnaires
CBC
Thyroid function tests
Serum Vitamin D
Toxicology screen
Fasting lipids
Fasting glucose
MRI brain
Epocrates Page
Diagnostic standard of care for
OCD
(Epocrates.com)
Differential
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Obsessive-compulsive
personality disorder
Body dysmorphic disorder
Hypochondriasis
Delusional disorders
Severe social phobia
Panic disorder
Autism
Asperger syndrome
Tests
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Symptom questionnaires
No lab tests recommended
Epocrates Page
Diagnostic Standard of Care for
Dementia
(Epocrates.com)
Differential
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Mild cognitive impairment
Delirium
Depression
Vascular dementia
Dementia of Lewy body
Frontotemporal dementia
Parkinson disease
Creutzfeld-Jacob disease
Tests
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Cognitive testing
CBC
Erythrocyte sedimentation
rate
Metabolic panel
Serum TSH
Serum B12
Serum 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
science, learning from the
discoveries of genetic
research 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:
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Vitamins
Minerals
Amino acids
Essential fatty acids
Fiber enzymes
Antibodies
Antigens
Cell therapy
Acupuncture
Massage
Exercise
Biofeedback
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Chelation therapy
Dialysis
Plasmapharesis
Hydrotherapy
Thermal therapy
Phototherapy
Electrotherapy
Air ion therapy
Light Therapy
Solar therapy
Hypnotherapy
Psychotherapies
7 Cardinal Rules of
Orthomolecular Medicine
1. Nutrition comes first in medical
diagnosis and treatment
2. Drug treatment is used only for
specific indications and always with
an eye to the potential dangers and
adverse effects
7 Cardinal Rules of
Orthomolecular Medicine
3. Environmental pollution and food
adulteration are an inescapable fact
of modern life and are a medical
priority
4. Biochemical individuality is the
norm in medical practice; therefore
stereotyped RDA values are
unreliable nutrient guides
7 Cardinal Rules of
Orthomolecular Medicine
5. Blood tests do not necessarily reflect tissue
levels of nutrients
6. Nutrient diagnosis is always defensible
because nutrient related disorders are
usually treatment responsive or curable
7. Hope is an indispensable ally of the
physician and an absolute right of the
patient
(Richard 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)
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:
 Antecedents
 Triggers
 Mediators
ANTECEDENTS
Are things that happen before
disorders 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
TRIGGERS
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
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 “workaround” to impaired metabolic pathways
at the Trigger level.
Example
5,10-methylenetetrahydrofolate reductase
(MTHFR) polymorphisms impair
conversion of folic acid to methionine,
resulting in increased risk of:
Coronary Artery Disease
 Inflammatory bowel disease
 Depression
 Down’s Syndrome
 Alzheimer’s disease (possibly)
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MTHFR variant C667T
Occurs in:
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26.6% of Whites
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12.4% of Blacks
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41.5% of Hispanics
Identification of MTHFR related
risk can be made by:
Genetic testing
 Nutrient testing
 Interpretation of subtle symptoms
 Best guess
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Typical Orthomolecular
Intervention: Supplemental Folic
Acid!
Taking high dose supplemental folic acid
“pushes” the metabolic pathway to create
sufficient methionine. This is safe, and has
no adverse effects.
MEDIATORS
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 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 Dosage
 Adverse Effects
 Interactions Checker
 Consult when beyond your level of
expertise
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Abilify
Drugs Excel
3. Consider Possible Alternate
Explanations
Consult!
 www.wrongdiagnosis.com
 www.CenterforHealthScience.com
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CHS depression
4. Recommend or Obtain
Medical Labs
to rule out physical causes
For Information on Lab Testing:
 labtestsonline.org
 CenterforHealthScience.com
 Apexseminars.com
Depression Labs
Apex
5. Refer for Treatment!
Allopathic Physician
 Naturopathic Physician
 Doctor of Oriental Medicine
 Ayurvedic Physician
 Medical Psychologist
 Nutritionist
 Other Professionals
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Qualified Referral Sources
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Institute of Functional Medicine members:
www.functionalmedicine.org
Orthomolecular Health Medicine members:
www.ohmsociety.com
ISOM Members:
www.orthomed.org
Center for Health Science:
www.centerforhealthscience.com