Stress, Anxiety, and Depression

HPI

A 30 yo female who presents with a history of depression and chronic feelings of hopelessness, fatigue/low energy, and poor memory, and current extreme stress, anger & irritability. She has felt these feelings more acutely in the past 3 weeks and describes her symptoms as worsening when under stress, which is triggered by certain places & environments, disturbing world issues, “flaky/flighty” people, a strained relationship with boyfriend and family issues around her mother & sister’s dependency on her.

She feels consistently “let down” by people, and that she has “been depressed my whole life”. Though she is unsure what her needs are, she feels that they aren’t being met. She has tried various antidepressants in the past and found that they made her symptoms worse. Her most marked concern is her high stress levels and fluctuating mood which she describes as “consistently inconsistent”.

She associates her depression with various physical manifestations of acute stress and anxiety such as palpitations & dyspnea (will wake from sleep with chest feeling “compressed”), as well as sugar cravings & acne breakouts. She also reports a worsening of her symptoms prior to her menstrual cycle, feeling bloated and intensely sensitive, angry and frustrated. She notices her stools are looser during menses, and has intermittent clots with menstrual flow and some spotting between cycles. She also reports that every oral contraceptive she has tried causes her to dry heave for first 2 weeks in the AM for first 2 cycles menstrual cycles.

Past medical history of depression (Rx unknown antidepressant medication, which “made things worse”). MVA in 2010 – was rear ended and suffered whiplash. History of abnormal pap smear (6 months ago)

Family history of mood disorders (depression, anxiety, Parkinson’s, dementia), Alcoholism, Diabetes, Eating disorder, Heart disease/stroke & Thyroid disorders.

Social history: She is an RMT who takes care of others all day, but feels she is not being taken care of herself. Her previous profession was as a transmissions rebuilder (for 2 years) and has doubtless encountered a high degree of toxic exposure. Currently living with boyfriend for past 8 months. Situation is rocky due to poor communication issues, and needs being unmet and is considering moving out. Uses marijuana daily, Alcohol 4x/week, and frequent binge drinking, Quit smoking cigarettes in 2017.

Sleep: 7-8 hours/night, no problems falling asleep, vivid dreams – reoccurring & frequent, floating/paranoid themes. Nocturia disrupts 1-2x/night.

Toxic Exposure: Transmissions rebuilder (2000-2002) – used solvents/carcinogens, asbestos, often with no gloves/protective wear.

Diet & Digestion: 1-3 BM/day, generally solid, large, sometimes loose and slender, occasional diarrhea worse with fatty foods. Sometimes pain & mucus occasionally, no signs of undigested food. Salt & sugar cravings, hypoglycemia, avoids milk, soy (possible allergen) and red meat. Drinks 1-2L water/day. Coffee 2-3x/day. Herbal teas & juice occasionally.

Medications:

• Tricyclin Lo for past 2 months, was previously on Yasmin for past 8 years.

Self-Prescribed Supplements:

• Vitamin D – 2000IU/day
• Greens Powder every morning
• Pre-work out weight loss powder – containing caffeine 50 mg, L-carnitine 1000-1500 mg
• Multivitamin intermittently

Physical exam

• 6 Mercury amalgams (2 upper & 4 lower molar), 1 Gold (lower molar)
• Slight cervical lymph node enlargement, non tender and moveable
• Vitals, BP 105/70 T 36.8 oral HR 72 bpm

Labs and Imaging

• None ordered on initial visit but in the future consider:
  • Heavy metal testing
  • Adrenal Stress Index – 4 point cortisol
  • Food allergy panel
  • Neurotransmitter testing or questionnaire
  • Blood work: CBC w ferritin, B12, TSH, LIV enzymes

Working diagnosis and interpretation

1. Depression

• Ddx: Hypothyroid

2. Generalized Anxiety Disorder

• Ddx: Adrenal Dysregulation, Substance or drug induced anxiety disorder, Fe deficiency anemia, vitamin B12 deficiency

3. PMS-A (Anxiety) with irritability & mood swings (high estrogen relative to low progesterone)

The etiology of the patient’s symptoms are multifactorial. A combination of genetic, biochemical, environmental and psychosocial factors are likely behind the majority of her symptoms. From a TCM perspective Liver Qi stagnation appears as a standout diagnosis, as her depression stems from repressed anger causing moodiness, irritability and frustration, and thus being prone to outbursts of anger. The patient is at a point in her life where she feels she is lacking ideas, projects, aims and direction, which may be causing, or coming from suboptimal liver function and/or HPA-Ovarian axis dysregulation. An ability to detoxify and regulate blood sugar caused by chronic detox exposures must primarily be addressed. As well a deficiency or decreased activity of cortisol, serotonin, norepinephrine, dopamine and/or other neurotransmitters.

In PMS-A there is an excess of estrogen relative to progesterone. Estrogen stimulates the brain by altering the ratio and levels of certain neurotransmitters. Specifically, raising levels of epinephrine (→ anxiety), norepinephrine (→ hostility and irritability) and serotonin (→ nervous tension & palpitations) and decreasing levels of dopamine (→  reduced feelings of mental relaxation and impaired mental clarity). Estrogen also affects mood by blocking the action of vitamin B6 and decreasing the body’s ability to maintain normal blood sugar levels. There is also a possibility that high estrogen and low progesterone may impair the functioning of the endorphins which promote mental relaxation (epinephrine and norepinephrine are competitive inhibitors of progesterone receptors which further compounds the problem). The situation is aggravated by poor nutrition in general (especially an excess of sugar) and by stress.

Overall our goals for this patient will be to:

• Support the liver – promote phase 1 & 2 detoxification, remove toxic exposures & excess endogenous estrogen, aid the regeneration of hepatocytes
• Stabilize blood sugar & cravings
• Identify and eliminate potential allergens
• Correct nutritional deficiencies ensuring adequate amount of key nutrients involved in metabolic pathways of concern
• Limit alcohol, marijuana, caffeine use
• Support GIT – heal the immune barrier and gut flora with probiotics
• Address mental/emotional component with counseling around life goals/ambitions
• Promote the smooth flow of liver Qi & the calming of Shen using regular acupuncture

Treatment Plan 

1. Lifestyle: Marijuana cessation protocol & counseling around stress coping mechanisms. Referral for mercury amalgam removal.
2. Dietary: Add “brain foods” – cold water fish, avocados, nuts/seeds. Increase fiber & whole grains & limit refined carbohydrates. Reduce caffeine intake.
3. Supplemental: Nutritional chelator powder daily, EFAs 1-3 g, Multivitamin daily, Inositol – 12g QD for mood, anxiety, depression.
4. Herbal:

• Liver Tonics – Milk Thistle (7 g), Schisandra (3 g), Rosemary (1.5 g) daily
• Anti-inflammatories – Turmeric (6-12 g) daily
• Nervine Tonics & Adaptogens – Ashwagandha (5 g), Skullcap (1-2 g), Rhodiola (6-12 g), St. John’s Wort (1-3 g), Saffron (0.5-1 g) daily

Progress:

1 month follow up

After the first appointment the patient decided personally to go off of her birth control to see if it would help with her mood and so far is “feeling about the same” and expressed interest BBT/fertility awareness & information on non-hormonal forms of contraceptives. After 1 week on the nutritional chelator, Turmeric & Liver Tonic Herbs she noticed her stools have been looser and expressed that it had an odor of marijuana (Has limited her marijuana from intake from 5-2 times a week. Has inquired about mercury amalgam removal but is not able to commit to it financially at this time. Has increased cold water fish (2x/week), avocados, nuts/seeds and is consistent with her Vitamin D, EFA & Multivitamin. Performed acupuncture at this visit to promote the smooth flow of LIV Qi & calm the mind, recommended increasing fiber and water intake and commencing Nervine Tonic/Adaptogens herbs & Inositol.

2 month follow up

Patient present frustrated, and stress & anxiety is currently high due to relationship issues. Has not been consistent with taking Nervine Tonics & Adaptogens or Inositol. (Took for 1 week after last follow up then “forgot”. Has managed to maintain taking her multivitamin, Vitamin D and EFA. Though the basics of a healthy lifestyle are in place in terms of a balanced diet and exercise, however her addiction to toxic stimulants (caffeine, marijuana, alcohol, unfulfilling relationships) persists. New coping mechanisms and promoting a safe, relaxing space in which to heal will be sure to assist her healing process. Giving her the tools (both psychological and biochemical) and being a constant support will sure to seem some steady progression in her clinical picture. It is important that she feels emotionally stable enough to make changes in her life that will benefit her health. Patient is counseled on re-framing, remembering how to trust her body, and believing that she has the capacity to heal. Neurotransmitter testing and/or Questionnaires may be valuable in this case, as she may benefit from seeing the evidence of her health imbalances and progress going forward.

3 month follow up

Because her complaints have been life long and she is unmotivated to change her lifestyle in a meaningful way, progress has been slow and compliance has not been ideal, however she did express feeling some relief after the last visit and and been able to maintain taking the Nervine Tonic/Adaptogenic herbs at least once a day. She expresses a desire to do another round of liver support as she thinks that “seems to have helped with her mood”. She does report some improvements in her anxiety levels, and that when familiar stressors present themselves she feels like she cares less about the outcome. She requires a lot of encouragement in this appointment and is prescribed another round of liver supportive herbs with nutritional chelation for 30 days  while maintaining nervous system herbs at the same dose daily. EFAs are reduced 1 gram daily and 1-2 Tbsp flaxseeds with 1-2 L water a day is reinforced to ensure full and regular bowel movements. She is also prescribed gratitude journaling daily, and 30 minutes in Nature at least 3 times a week.