Integrated Traditional & Western Medicine
Stress and Mood Disorders - Taking a Deeper Look
By Angela Carroll Adv. Dip. H.Sc. (Nat.), Adv. Dip. H.Sc. (Acu.), Adv. Dip. H.M.
Drivers of Stress and Mood Disorders
It is well known that dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis, the core physiological stress-coping mechanism, affects the delicate balance of cytokines, neurotransmitters and hormones within the body. This, in turn, can detrimentally affect mood, causing low mood, irritability, anxiety and sleep disturbances. Restoring health to your stressed, sad, anxious and/or insomniac patients requires that balance be restored. In addition to addressing the delicate balance of cytokines, neurotransmitters and hormones with herbal formulas, such as those mentioned in the article “Low Mood – A Chinese Medicine Perspective” on page 2, we also need to assess and resolve driving factors that may be reducing that patient's stress tolerance and influencing their overall health. Underlying driving factors that can accelerate the development of stress and mood disorders include:
- Insulin resistance
- Sex hormones and gonadal dysfunction
- Impaired thyroid function
The Role of Inflammation in Stress and Mood Disorders
Inflammation and mood disorders are often seen together. Inflammation is the direct result of immune activation. Any process that activates the immune system (such as those listed in Table 1) triggers an adrenal response, eliciting an increase in cortisol production to help control the inflammation and enable a return to homeostasis.
TABLE 1: MAJOR CAUSES OF INFLAMMATION
|Allergens – environmental allergens, food allergens, pollens, dust, mould, animals, etc. |
|Dysglycaemia and insulin resistance |
|External (exogenous) toxins – pollutants, drugs, toxic metals |
|Infection – acute or chronic |
|Internal toxins – gut-derived |
|Lack of blood flow |
|Nutritional deficiencies |
|Oxidative stress |
|Physical injury or trauma |
Long-term production of pro-inflammatory cytokines, such as, tumour necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1) and interleukin-6 (IL-6), cause HPA dysregulation. Raised levels of IL-1, IL-6 and TNF-alpha are implicated in the generation of certain mood disorders – particularly conditions characterised by lowered serotonin levels.1 In fact, there is some evidence that mood disorders, insomnia and anxiety are often accompanied by activation of the inflammatory response.2 Interestingly, inadequate rest or sleep may actually generate inflammation, contributing to a vicious cycle of inflammation, stress and further sleep disturbance. Sleep loss increases levels of TNF-alpha and IL-6 and thus contributes to the inflammatory response and HPA activation.3 Inflammation can be a significant driver of stress and mood disorders, and research indicates that reducing inflammatory mediators in the body can improve HPA activity and reduce stress and mood disorders. Managing inflammation in TCM involves the use of herbal formulas that primarily clear damp and certain heat patterns. For herbal recommendations see Integrated Traditional and Western Medicine. Sun Ten Newsletter; Jan/Feb, 2005: 8-11 and Integrated Traditional and Western Medicine. Sun Ten Newsletter; Winter, 2007: 6-7.
The Role of Insulin Resistance in Stress and Mood Disorders
Inflammation and insulin resistance are intimately linked. Insulin resistance increases inflammation and, to compound this, insulin resistance is driven by inflammation. In order to improve stress tolerance, it is necessary to reduce both inflammation and insulin resistance because both these metabolic conditions exacerbate stress and mood disorders. Insulin resistance is frequently associated with greater body fat stores. Essentially, adipocytes produce pro-inflammatory cytokines (e.g. IL-1, IL-6 and TNF-alpha) and raised levels of IL-1, IL-6 and TNF-alpha are implicated in the generation of anxiety and mood disorders. Therefore, maintaining weight within a healthy range is vital for assisting patients to improve their stress-tolerance and to reduce symptoms of stress.
Fat loss and improved insulin sensitivity are, therefore, essential for stressed patients. In the management of insulin resistance and obesity, your patient's fat to muscle ratio must be improved by both diet and exercise. Consistently, research is finding the most effective dietary program for increasing insulin sensitivity, reducing fat mass and improving mood, is a carbohydrate-restricted, adequate protein diet.
Supporting insulin signalling pathways is important for insulin resistant, stressed patients. Powerful insulin sensitising herbs such as Cinnamon (Rou Gui), and Panax ginseng (Ren Shen) may support healthy blood sugar metabolism.4,5 Additionally, the use of anti-inflammatory herbs, through reducing the levels of circulating pro-inflammatory cytokines, not only improves insulin signalling, may also improve mood and sleep disorders. For herbal recommendations to support insulin signalling and fat loss see Sun Ten Newsletter; Spring, 2007.
The Role of Sex Hormones and Impaired Gonadal Function in Stress and Mood Disorders
As well as inflammation, obesity and insulin resistance, the state of a patient's sex hormone balance and gonadal function can also affect their stress response and mood. For example, testosterone reduces HPA responses, suggesting that males are better adapted to dealing with stress. Clinical studies show that hypogonadal males are more susceptible to stress and mood disorders and that androgen replacement can reduce depressive symptomology.6 For hypogonadal men, the herb Tribulus terrestris (Bai Ji Li) may increase serum testosterone levels. Tribulus is traditionally used to support reproductive health and sexual vitality, due to its effects on testosterone levels.7 This herb, although traditionally used in TCM for different purposes, is gaining a strong fellowship among TCM herbalists for male reproductive health.
Oestrogen, on the other hand, upregulates HPA responses.8 Women are, therefore, inherently more reactive to stress and more prone to mood disorders. Women's increased vulnerability to mood disorders occurs post-pubertally, with the beginning of cyclical changes in oestradiol (E2) secretion from the ovaries. It is postulated that the changes in E2 levels may increase women's susceptibility to anxiety and mood disorders.
For herbal recommendations on improving oestrogen balance see Integrated Traditional and Western Medicine and TCM Principles. Sun Ten Newsletter; May/June, 2005: 7-8.
The Role of Impaired Thyroid Function in Stress and Mood Disorders
Stress has a significant impact on thyroid activity, and thyroid function can exacerbate anxiety and low mood. There is a positive feedback loop that runs from the sympathetic nervous system (SNS) to the thyroid via the adrenals. The activation of the SNS during acute stress upregulates noradrenaline and adrenaline production; this, in turn, excites the thyroid, releasing more thyroid hormone, leading to stress-induced hyperthyroidism.
“...to improve stress tolerance, it is necessary to reduce both inflammation and insulin resistance...”
However, chronic stress has an inhibitory effect on thyroid activity. Chronically raised levels of corticotropin releasing hormone (CRH) and cortisol reduce the levels of the active thyroid hormone triiodo-thyronine (T3). Hence, ongoing stress has a detrimental affect on thyroid function, which subsequently affects energy, vitality and mood. In fact, hypothyroidism is common in patients with HPA dysfunction, and is associated with reduced serotonin activity and reduced serotonin receptor sensitivity.
If hypothyroidism is contributing to a patient's mood disorder, you must support thyroid function by providing adequate nutrition for thyroid hormone production and function – i.e. use a high iodine and tyrosine supplement with the addition of adequate zinc and selenium, as a base for thyroid hormone structure. These nutrients will also assist to improve the conversion of thyroxine (T4) to T3. Selenium and zinc additionally support adrenal function in cases where cortisol production is altered. Performing the simple Zinc Taste Test on all patients is a wise practice to help identify if suboptimal zinc levels are a potential problem.
Hyperthyroidism can cause significant anxiety, and conversely, acute stress may cause hyperthyroidism. In these circumstances, a calming nourishing approach achieves the best clinical outcomes. Rehmannia glutinosa (Sheng Di Huang) is a herb that has been traditionally used in TCM for the management of those with hyperthyroid, anxiety and fatigue patterns. Recent research has found Rehmannia favourably alters thyroid hormone levels in hyperthyroid patients,9 with the additional benefit of reducing anxiety.
The Role of Toxicity in Stress and Mood Disorders
The final driver of stress and mood disorders that must be addressed is toxicity. Toxins can initiate a stress response from the HPA and/or may exacerbate existing mood disorders. This can include exotoxins (i.e. toxins from external sources), such as alcohol, heavy metals and organic chemicals, as well as endotoxins (i.e. toxins from within us), such as bacterial lipopolysaccharide (LPS). One particular study found that acute administration of alcohol induces dose-related increases in plasma adrenocorticotropic hormone (ACTH) and cortisol levels in an animal model. In contrast, chronic alcohol intake results in blunted HPA activity. This study revealed both hypothalamic and pituitary mediated HPA dysfunction in chronic alcohol exposure.10 Other examples of the effects of exotoxicity on stress responses include findings that occupational toxin exposure may cause stress-related symptoms. In workers performing confined space welding without adequate protection, significant inverse toxin dose-effect relationships were found for IQ, executive function, sustaining concentration and sequencing, verbal learning, working and immediate memory. Other symptoms reported by the welders while working were as follows:
- Tremors (41.9%),
- Numbness (60.5%),
- Excessive fatigue (65.1%),
- Sleep disturbance (79.1%),
- Sexual dysfunction (58.1%),
- Toxic hallucinations (18.6%),
- Depression (53.5%), and
- Anxiety (39.5%).11
Endotoxins can also affect HPA function. LPS is the major endotoxin to be aware of. This constituent of the cell walls of gramnegative bacteria is a well-known inducer of the inflammatory response and strongly activates IL-6. Dysbiosis (an overgrowth of the wrong type of bacteria in the gut that produces excessive amounts of LPS) is one of the most common sources of chronic HPA dysfunction.12
“Stress has a significant impact on thyroid activity, and thyroid function can exacerbate anxiety and low mood. "
The elements that need to be considered with detoxification are all addressed in the recently updated Metagenics' Key Clinical Concepts Practitioner Guide to Detox. This program provides an effective elimination and repair program for patients with gut and/or liver toxicity issues.
Drivers of Stress and Mood Disorders – Improved Clinical Awareness
These HPA activators enhance the effects of stress on the HPA axis and predispose patients to the development of stressrelated mood disorders. It is important to understand the role these factors play in stress and mood disorders, to increase your awareness in your practice of considerations that may need to be addressed when assisting patients with stress and mood disorders.
References available on request.
*Reproduced with kind permission from Health World Limited – Australia and New Zealand
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