Case Study -Insomnia
Memory Loss, Stroke, Sjogren’s Syndrome, Heart Failure, and Insomnia
Sondra is a retired psychologist who suffered a stroke in May of 2008, at the age of 69. She met me at a lecture entitled Build a Better Brain, that I presented in May of 2009. She was intrigued by the topic, and consulted me just a couple weeks after.
In the lecture we discussed how you can exercise your brain and literally build a better brain. A “better brain” provides improved coordination, energy, memory, focus, attention, and enjoyment of life.
How does a better brain provide greater enjoyment of life, you may ask?
Much of the top of the brain is sensory…meaning it senses what you feel, taste, hear, smell, and see. Of course, your senses depends on the sense organs, such as the eyes, ears, skin, tongue, and nose, and of course, your enjoyment of life can be affected by damage to the nose or eyes…the sense organs…but as we age the probability of neuro-degeneration, or, as in Sondra’s case, neuro-injury due to a bleed or clot, increases as a potential source of decreased sensory perception and enjoyment of life.
The health of your brain determines how wonderful a touch feels, a food tastes, or how well you see, smell, or hear. Hearing problems late in life are often brain problems, only the brain doesn’t get addressed…the ears do, via hearing aids. If we treated the brain more effectively, I wonder how many people would be able to save their hearing and sight!
Back to Sondra…when she consulted with me, her main concerns were a loss of memory, difficulty completing projects or staying focused, both of which affected her confidence and anxiety levels. She also suffered with insomnia and “very low energy.” She wondered if I could help her sleep again, and assist with returning the sharpness of her memory and focus.
She related that she was a greeter at church, and as she greeted, she recognized the faces, but the names wouldn’t come. She said it was “like an eerie horror movie,” and the effort and anxiety was exhausting.
She also related that her speech was slowed and her voice had changed, which again affected her self confidence.
Practicing generalized medicine, versus specialized medicine, I wanted to know everything…how was she digesting, how was her blood sugar regulation, how was her circulation…I had her fill out our comprehensive metabolic questionnaire, which is a memory jogger of sorts, that lists a variety of little symptoms that people tend to ignore.
One thing that stood out right away was the “little” disturbances she had around meal times. Specifically, if she was late for a meal, she felt jittery, irritable, and lightheaded, which was immediately relieved by eating. Those are symptoms of hypoglycemia or low blood sugar. You cannot correct your adrenal rhythms, which affect your sleep cycles, if you are hypoglycemic. No chance!
Many people “live with” this abnormal process. It doesn’t bother them that much, since they can eat and feel ok. But the bigger picture is how that is influencing your hormones systemically. Most doctors don’t connect the dots to link this back to insomnia…in fact, insomnia is treated most often with a brain drug that has nothing to do with adrenal function or blood sugar regulation, it simply knocks you out.
I tell my clients that we have a built in regulation system that triggers eating…and it is not feeling jittery, irritable or lightheaded…it is called hunger. Feeling hungry and then feeling full are your neurological signals. Anything other than that is a health problem.
Digging deeper with the symptom questionnaire, we also noted that her insomnia was difficulty falling asleep, which is much different than difficulty staying asleep. Difficulty falling asleep often occurs because your daytime cortisol burden, the total output of the adrenal glands, is high. Difficulty staying asleep is just the opposite, the total cortisol output is often low. We will test Sondra and see if this is correct later on.
We noted some digestive upsets, although rated as relatively minor…perhaps one of our opportunistic bacteria, yeast or parasites that try not to “upset the apple cart.”
Her thyroid symptoms were also very high…fatigue, dry skin, red, flaky skin, hair loss, depression…
Past Medical History
The circumstances were that she had suffered a stroke, which had affected her memory, focus, sleep patterns, and energy. What did the road to these circumstances look like?
The highlights included a bout with hepatitis in 1963, dysentery in 1965, arthritis in 1982, “dry eye” in 1990, environmental allergies in 1997, Parvovirus and Sjogren’s Syndrome in 2001, skin cancer in 2003, and then the stroke in 2008.
With a generalist perspective, I can easily see a pattern of immune insult, immune dysregulation, and eventually multiple immune diseases, culminating in an inflammatory event, the stroke.
Hepatitis is a viral or autoimmune inflammation of the liver…dysentery is an infection of the intestines, arthritis is inflammation and erosion of the joints, dry eye syndrome may be autoimmune, parvovirus is of course a viral infection, Sjogren’s Syndrome is an autoimmune disease of the secretory (moisture) glands, and cancer is a complex of immune and hormonal imbalances resulting in cell mutation.
And…that’s not all. In 1971 she was diagnosed with a left Bundle Branch Block, which is a heart disorder where the left ventricle fails to contract on time with the right ventricle, resulting in a decreased blood flow, which they measure as injection fraction. At the time that Sondra consulted me, her ejection fraction was at 15%. Her heart is failing…why?…they call it cardiomyopathy, which is an inflammation of the heart, suspected cause…viral.
She had lived an immune challenged life, and the technology was not there to test or correct the immune consequences.
Today, using functional medicine, we may have been able to prevent most of this experience.
“THE FULL COURT PRESS”
As a result of the heart failure and stroke, her cardiologists are providing their version of a “full court press” including medical (pharmaceutical) management using a Beta Blocker, an ACE inhibitor, a diuretic, Coumadin (blood thinner), Zocor for cholesterol, Nexium for reflux, an anti-malarial drug, an acetylcholine blocker for her autoimmune conditions, and an anti-depressant for pain and depression (that blocks reuptake of dopamine, noradrenalin, and serotonin).
I realize that is a lot of technical medical jargon, so just understand that they were using everything including the kitchen sink, for heart and brain. The only brain chemical not manipulated at this point is GABA. Ten pharmaceuticals!
Interestingly, about 3 years ago, a study was published showing that once you reach four medications of any type, it is an absolute certainty, 100% probability, that at least one symptom you are experiencing is a result of the medications you are taking.
These medications are not studied in combination. There are no statistics showing this combination of drugs is good, bad, or what the possible consequences or benefits might be. None. If you ever had the impression that medicine was “very” scientific, based on the scientific method, including double blind studies…think again.
Think about it…could you imagine putting 1000 people on these 10 drugs, and another 1000 on 10 sugar pills per day to see what would happen? I would love to see this study, because I would put a small wager that the sugar pills would lead to a better outcome. You simply can’t manipulate human physiology that much without a consequence.
My version of the full court press included a vast amount of testing, and based upon the test results, I would provide the stimulation, support, and nourishment that she needs. Seems self evident, but only if you ask the question, “How can we move towards health?”
Specifically we would be testing her immune function with the most advanced testing available today (which is largely not utilized and not considered a medical necessity), we would test all her hormones, including TSH, LH, FSH from the pituitary gland, T3 and T4 from the Thyroid glands, Insulin from the pancreas, cortisol and DHEA from the adrenal glands, and estrogen, testosterone, and progesterone from the ovaries (which is actually levels produced by the adrenal glands after menopause); we would also test her intestinal ecology (who is living in there) as well as the intestinal barrier test (the condition of the lining of the intestines). Both can be an ongoing source of immune activation, so in any autoimmune or inflammatory condition should be assessed.
We also filled in the gaps of the previous medical labs her cardiologists had performed by adding four other indicators of inflammation, including high sensitivity C-Reactive Protein, SED Rate, Fibrinogen, and Homocysteine.
Again, I realize that this is a lot of technical medical jargon, so just understand that I tested nearly everything that could cause or contribute to inflammation, immune dysregulation, and/or the slow demise of her heart.
That is what I call the full court press…leave nothing to chance…test it all and treat what you find in the person…not what the person has found (the disease or circumstances).
The Test Results
As expected, her adrenal results showed an elevated cortisol output through the day, corresponding to the difficulty getting to sleep. Her hormones were not allowing her to rest. What we discovered on this test that we did not expect, was a drastically low hormone called DHEA.
DHEA helps the body to regulate inflammation, the immune system, and other hormones, as well as slowing the aging process in the brain. It tends to decrease with conditions that consistently increase cortisol production.
We began treating her stress physiology, using bioidentical DHEA and a substance called phosphatidyl serine. This substance works in the brain to regulate cortisol output from the adrenal glands.
The bigger picture question, however, is what is stressing her body so consistently. Life can be stressful at times, but I was convinced that something inside her was a bigger source of stress, such as an immune irritant, or problems producing energy and carrying oxygen to her cells.
Hypoglycemia can produce chronic stress states, as one function of cortisol is to increase blood sugar in response to the fight or flee nervous system mechanism. If you literally find yourself in a dangerous situation, your body needs glucose for the muscles to respond quickly…fight or flee. Cortisol rapidly releases stored glucose along with increasing heart rate, blood pressure, and other “sympathetic” nervous system functions. This also includes “ignoring” the digestive functions and health of the intestines, since you don’t have time to go to the bathroom if threatened.
When we received her Intestinal Permeability test, it showed severe compromise of the intestinal absorption of nutrients, and a moderate loss of its “barrier” function. When the barrier system is compromised, fractions of food and waste pass into the blood that normally wouldn’t and shouldn’t, resulting in an immune attack on these “foreign” substances. For Sondra, the simple act of eating to nourish her body had become an immune disaster.
Her Intestinal Ecology test revealed more immune compromises. She had a significant reduction in healthy “flora,” the bacteria that we require for digestion and immune competence. This test also checks for unfriendly bacteria, yeast, and parasites. Some of these microorganisms are termed pathogenic, meaning they really mess things up. Others are termed opportunistic, meaning they do not cause intense intestinal distress, but they do activate the immune defenses, resulting in inflammation and chronic immune stress. Sondra’s lab testing revealed an opportunistic and unfriendly parasite.
Her Immune and Inflammation Panels revealed that she was systemically inflamed and her immune system was suppressed, particularly the B cells, which are the “smart” cells that tag viral pathogens for destruction.
Her blood work also showed several other concerns, including kidney failure, mineral imbalances, and low Vitamin D. These were tests ordered by her physicians prior to me. These labs would lead you to believe that her kidneys were the main concern, but with the additional labs we performed, we knew the whole story. The kidneys were most likely failing because of blood sugar regulation problems (diabetic complications include kidney failure), stress physiology, immune suppression, intestinal barrier compromise, and an intestinal parasite that never gave the immune system a break to recover.
If the cardiac myopathy (heart failure) is truly viral, the best thing we could do for her is to regulate her immune system, improving B cell counts and function, and letting nature take its course, as her then healthy immune system resolves the viral component.
If the kidney failure is from cortisol elevations and blood sugar dysregulation, the best thing we could do for her kidneys is to correct those problems. This is upstream medicine in action.
Let’s not forget that the reason Sondra consulted with me was to improve her brain function, notably her memory and focus. We have to get her sleeping to allow the healing to occur, which requires correcting the adrenal hormones, and we have to balance her immune system to fully treat the adrenal hormones, and we have to remove active infections, such as the parasite before we can balance the immune system…and then we have the environment to heal and build a better brain.
That’s Brain Based Functional Medicine in action.
When we evaluated Sondra’s brain, there were a few tests that really stood out. One was the pupil response to light. The pupil should constrict to light, partly to protect the sensory nerves from damage, but also so you don’t get a headache every time you go outside in the sun. Neither pupil constricted for Sondra.
Another interesting sign was a loss of visual fields on the left. I would start with my hand behind her ear, and slowly move forward while wiggling my fingers. Most people can detect the wiggling fingers right at about the time your fingers are just beside the eyes. On the left, I brought my hand approximately 2 inches in front of her eyes before she could recognize the fingers. The right side was normal. We know from her MRI that the occipital cortex was spared, so this was “collateral damage” not as a result of tissue destruction from a stroke, but from a loss of activation.
She also had a complete loss of patellar reflexes on both sides. That is the test with the hammer, tapping your tendon under the kneecap, and the lower leg kicks out. She had no “kick.” What an appropriate test to watch…she wanted more “kick” in her life…energy, vitality, confidence. This test indicates that her thigh muscles lacked appropriate tone, which can result from nerve pressure at the spinal cord, or represent a decreased cortical activation (activity) from above.
When I tested her muscles, she exhibited a left sided loss of extensor tone in the arms, and flexor tone in the legs. This is a brain pattern of muscle weakness, or inhibition as we call it in neurology. We wanted to increase activation all over her brain, starting with the left side.
I describe this concept to patients using the analogy of a Christmas tree. Most people have seen the tree that Charlie Brown of the Peanuts comics puts up each year, and the giant Christmas tree on the lawn of the White House in Washington DC. The lights represent the activity of the brain, which, if you have ever seen a brain scan, accurately depicts the function of the brain. In a scan, a healthy brain looks “lit up,” bright and full, and an unhealthy or damaged brain looks dim, with many “dead bulbs.” Our goal is to light up that Christmas tree by slowly increasing the activity into the brain, by way of senses, such as smells, sounds, or visual stimulation, or through motor (movement) activities, such as wiggling fingers, moving the eyes, or challenging balance.
In Sondra’s case, I used the weakened muscles and reflexes to evaluate what activities would activate her brain just enough, but not too much, to light up just a few bulbs each visit. Initially, I chose exercises that challenged her memory. Following the (very short) exercise set, her reflexes were worse. We call that “exceeding the metabolic capacity,” which simply means that we exercised too hard. She felt and functioned “worse” following those initial attempts. If I had continued to prescribe this protocol, she would have most likely discontinued her care after a couple weeks of feeling worse. Of course we didn’t, and I switched her to visualizations, vibration to her right foot and leg, and gentle adjustments of the right side of her body. We did all her therapy along with concentrated oxygen.
Visualization of movement is well known to athletes and even NASA pilots. Some call it Visual Motor Rehearsal. You think of the movement without actually performing the movement. It “fine tunes” the neurological connections and gently exercises the brain. Of course, Tiger Woods does not visually rehearse his slice, rather a perfect drive. Then when he hits the course, his actual drive has a greater probability of being perfect, as the neural pathways for “straight drive” are already there.
Following Sondra’s new protocol, her muscle strength and reflexes were improved. We continued this protocol, gradually increasing time and oxygen, lighting up just a few bulbs each time. Over time, we changed the activities making them more challenging as she could handle it.
Sondra’s Metabolic Tune Up
As you could appreciate from her testing, there weren’t many systems that were working for Sondra. This required a careful application of hierarchical medicine…knowing what to do first, next, and last.
The first priority was the immune activation. We had to remove any active irritants, such as the parasite, and any potential food allergens, which we predicted was gluten. We started with a botanical (herbal) formula that is known to eliminate intestinal pathogens. We removed gluten from her diet.
Immune activation results in the release of hormones, which are in a sense messengers to the brain, that send the message, “I’m sick” to the brain. The brain then sends messages to the endocrine system, particularly the adrenal glands that “I’m in danger.” When your body and brain are sending these messages, it changes the entire function of the body toward a fight or flee physiology, increasing blood pressure, mobilizing blood sugar, and shifting away from a healing and repair physiology. Survival becomes the priority of the brain.
With this physiology, which I often refer to the chemical “soup” that you are made up of, restoring hormonal balance, cardiovascular health, or digestive health is impossible.
At any given time, your body and specifically your blood contains a certain balance of hormones, fats, proteins, and nutrients that feed your cells and provide messages as to what is going on and what needs to be done about it. It turns on and off genetic codes that either creates health or disease. Your diet and lifestyle, your environment internally and externally, and even your thoughts determine the recipe for this soup.
Once we eliminated the immune irritants, we attended to balancing her immune system and stress system. We used a combination of immune balancers, since she was overall immune suppressed as evidenced by her lab testing, including Echinacea, astragalus, and resveratrol, the antioxidant in red wine. All of these substances provide antioxidant protection and “clean up” of immune battlefields, and are immune cell nourishing. We also used vitamin D, an important immune regulator, and slowly introduced fish oils which are regulatory of immune cells and inflammation.
For her adrenal glands and stress physiology, we used a group of herbal adaptogens, and phosphatidyl serine, which allowed her to fall asleep more easily.
We also included a nutritional supplement for healing the intestinal mucosal lining, and a digestive and elimination support, focusing on liver and gall bladder function.
Sondra has had many functional improvements so far, including improved energy, sleep, and memory. She no longer feels like she is in a horror movie, and actually is connecting names and faces. We will continue to treat her towards increasing health and function, with the expectation that anything is possible.