David Reinhardt Ph.D. ABMP National Alliance of Professional Psychology Providers

1. 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 Askdrdave@gmail.com www.CenterforHealthScience.com

2. Useful Links • www.CenterforHealthScience.com • 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 • www.orthomed.org Orthomolecular Medicine Online • www.ohmsociety.com Orthomolecular Health Medicine Society • functionalmedicine.org The Institute for Functional Medicine • www.labtestsonline.org Complete information on lab tests • www.apexseminars.com Lab Test courses

3. 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.”

4. “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)

5. “Modern” Mental Health Treatment IS NOTModern Mental Health Science

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

7. 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."

8. Rule Outs: Stroke Parkinson's Dementia Multiple Sclerosis Thyroid Disorders Hypercalcemia Malignancy Infectious Diseases Medications including:Anti-rejection Agents Chemotherapy Agents Interferon Steroids Some Antibiotics Tests: No Recommendations APA Differential Diagnosis of Depression:

9. The Merck Manual for Healthcare Professionals does better Merck Depression Chart

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

11. Epocrates Inc. Software Clinical information and decision support tools Used by “over 40% of US Physicians” www.epocrates.com

12. Offers reliable free and subscription applications for handhelds and desktop Epocrates Home Page

13. Differential Situational adjustment reaction with depressed mood Bipolar disorder Premenstrual dysphoric disorder (PMDD) Grief reaction Dementia Anxiety disorders Alcohol abuse Anorexia nervosa Hypothyroidism Medication adverse effects Cushing disease Vitamin B12 deficiency Tests Symptom questionnaires CBC Thyroid function tests 24-hour free cortisol Vitamin B12 Folic acid Diagnostic Standard of Care for Depression (Epocrates.com) Epocrates Page

14. Differential 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 Asthma medications Corticosteroids Antidepressants Beta-blockers Peptic ulcer disease Tests Thyroid function tests Urine drug screen 24-hour urine for vanillylmandelic and metanephrines Pulmonary function tests Echocardiogram Electrocardiogram (EKG) Electroencephalogram (EEG) Diagnostic Standard of Care for Anxiety(Epocrates.com) Epocrates Page

15. Differential Restless leg syndrome Periodic limb movement disorder Obstructive sleep apnea Circadian rhythm disorders Tests Symptom questionnaires Polysomnography Sleep Diary TSH Diagnostic Standard of Care for Insomnia(Epocrates.com) Epocrates Page

16. Differential 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 Medication-induced psychosis Liver disease Hyperthyroidism Hyperparathyroidism Tests CT/MRI head Serum HIV Serum rapid plasma regain CBC Urine drug screen Plasma drug level monitoring Diagnostic Standard of Care for Schizophrenia (Epocrates.com) Epocrates Page

17. Differential 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 Symptom questionnaires CBC Thyroid function tests Serum Vitamin D Toxicology screen Fasting lipids Fasting glucose MRI brain Diagnostic Standard of Care for Bipolar Disorder(Epocrates.com) Epocrates Page

18. Differential Obsessive-compulsive personality disorder Body dysmorphic disorder Hypochondriasis Delusional disorders Severe social phobia Panic disorder Autism Asperger syndrome Tests Symptom questionnaires No lab tests recommended Diagnostic standard of care for OCD (Epocrates.com) Epocrates Page

19. Differential Mild cognitive impairment Delirium Depression Vascular dementia Dementia of Lewy body Frontotemporal dementia Parkinson disease Creutzfeld-Jacob disease Tests Cognitive testing CBC Erythrocyte sedimentation rate Metabolic panel Serum TSH Serum B12 Serum VDRL Diagnostic Standard of Care for Dementia (Epocrates.com) Epocrates Page

20. All of these approaches, if followed, allow the patient to be put into a diagnostic boxTreatment consists of prescribing psychotropics and, hopefully, psychotherapy

21. Current practice guidelines have 2 things in common...Treatments mostly suppress symptoms Causes are seldom explored

22. “Modern” Medical Treatment IS NOT Modern Health Science

23. A branch of healthcare has looked to treat CAUSES since the days of Ancient Civilizations

24. It has been MARGINALIZED by “Modern Medicine”It offers limited profit potential for drug companies

25. Psychology!

26. Another branch of healthcare has been similarly marginalized by Modern MedicineIt too has limited profit potential for drug companies

27. Orthomolecular Medicine

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

29. 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

30. “Orthomolecular medicine aims to restore the optimum environment of the body by correcting imbalances or deficiencies based on individual biochemistry”(Linus Pauling)

31. “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)

32. Orthomolecular medicine uses substances natural to the body such as vitamins, minerals, amino acids, trace elements and fatty acids

33. Orthomolecular Medicine has a Big Tent

34. Vitamins Minerals Amino acids Essential fatty acids Fiber enzymes Antibodies Antigens Cell therapy Acupuncture Massage Exercise Biofeedback Chelation therapy Dialysis Plasmapharesis Hydrotherapy Thermal therapy Phototherapy Electrotherapy Air ion therapy Light Therapy Solar therapy Hypnotherapy Psychotherapies Orthomolecular Medicine uses:

35. 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

36. 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

37. 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)

38. 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)

39. Functional Medicine puts a fresh name to the core concepts of Orthomolecular MedicineThe Institute of Functional Medicine was founded by Jeffrey Bland in 1991

40. Orthomolecular/Functional Medicine identifies and treats using a 3 prong approach: • Antecedents • Triggers • Mediators

41. ANTECEDENTS • Genetic Variations • Genetic Regulation • In-utero Exposure • Early Life Exposure Are things that happen before disorders starts

42. 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

43. Genetic variations can impair absorption of sufficient nutrients, leading to mood, behavior and physical symptoms

44. 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

45. 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.

46. 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)

47. MTHFR variant C667T Occurs in: 26.6% of Whites 12.4% of Blacks 41.5% of Hispanics

48. Identification of MTHFR related risk can be made by: • Genetic testing • Nutrient testing • Interpretation of subtle symptoms • Best guess

49. 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.

50. MEDIATORS Are those things your body does to try to rectify the consequences of the antecedents and triggersFeedback loops are Mediators that attempt to compensate for imbalances in an attempt to reach homeostasis