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  1. The EnvironmentalMedicine Approach toNeurobehavioral Disorders ALBERT F. ROBBINS, D.O.,MSPH Fellow, American Academy of Environmental Medicine Board Certified in Occupational/Environmental Medicine & Preventive Medicine

  2. ? Environmental Medicine • What is it? • Who practices it? • Why is it a growing field?

  3. The EnvironmentalInvestigation Environmental factors…what we are exposed to…as causes of conditions and as triggers of symptoms—are investigated as part of a comprehensive medical workup.

  4. Shift Happens! • Instead of just seeing a neurologist or a psychiatrist, consider an environmental physician • Some neurologic conditions such as OCD, tics and depression, improve when environmental factors are addressed • Many chronic illnesses may improve with an environmental medical PARADIGM SHIFT !

  5. Causes of OCD, TS and Depression • Dysfunction of the neurotransmitter systems • Multiple other neurochemical systems are implicated • Genetic factors most likely increase susceptibility • Environmental factors play a larger role than is currently recognized

  6. Neurotransmitters Specialized chemical messengers that allow brain cells to “communicate” or talk with one another.

  7. Effect of Neurotransmitters • Neurotransmitters are tied to mood; serotonin, dopamine, acetylcholine, endorphins and histamine are affected; • With every thought the brain releases neuro-chemicals; • Emotions are felt in the body.

  8. Some Key Neurotransmitters • Dopamine: feel good--marijuana, cocaine, speed • GABA: needed in depression; a natural relaxant • Endorphins: Sense of well being; improved with running and aerobic exercise • Serotonin: optimism; Prozac and SSRI’s • Acetylcholine: memory and alertness; pesticide exposure • Histamine: Found in many bodily systems

  9. Neurologic Disorders as Environmental Illnesses A neurologic disorder is considered an environmental illness if it is “triggered by environmental factors.” Principles & Practice of Environmental Medicine, Tarcher

  10. An EnvironmentalApproach • Find what is missing in the internal environment; • Eliminatewhat is toxic or infectious in the internal environment; • Determinewhat to avoid in the external environment; • Unmaskand treathidden allergy.

  11. Is It Genetic or Environmental? If genes load the gun, then the environment pulls the trigger. Sidney Baker, MD We can change our environmental exposures, our diet and habits. . . and change our health!

  12. Basic Principles of EMfrom Theron Randolph, MD • Allergic Load • “Masking” • Competitive inhibition-between nutrients and chemicals • Bioaccumulation • Maladaptation

  13. The Goals of Environmental Medicine • Find the environmental causes and aggravating factors of disease • Develop a treatment protocol to eliminate symptoms and stop the progression of the disease • Create a positive healing environment

  14. Disease Resistance vs. Susceptibility Factors you can control • Develop a good mental attitude • Create a healthy environment • Learn to handle stress well • Establish health habits • Do things that turn on good genes • Use safe medications

  15. Playing Sherlock Holmes • What was the patient exposed to? • A search for environmental clues or triggers • Observe where, when , and what causes symptoms

  16. Think Outside the Box! Man with a new idea is a crank until the idea succeeds. Mark Twain Nothing is more powerful than an idea whose time has come. Victor Hugo

  17. Case Report #1 Tourette syndrome: Thinking outside the box in a search for triggers and successful treatment…Role of allergens

  18. Focus on Tourette Syndrome, Tics and PANDAS

  19. Non-Genetic Contributions The individual variations in character, course and degree of severity by which TS is manifested cannot be explained by genetic hypotheses alone Tourette Syndrome Association

  20. Total Allergic Load The total of the factors contributing to the production of allergic disease and symptoms such as tics, depending on patient susceptibility. The allergic load staircase to reactions: ___ Emotions ___Foods __Inhalants __Chemicals

  21. Allergic Threshold • Each factor adds to the total allergic load until a final stress causes allergic symptoms…the threshold effect • Infections, emotions, exposures, and metabolic disease add to the allergic load intolerance • The cumulative effect pushes the patient closer to reactions or symptoms James C. Breneman, MD

  22. Asthma and Tics • Asthma & tics may occur together • Underlying allergies and chemical sensitivities are common triggers • An environmental approach with Neutralization Immunotherapy works well for both asthma and tic disorders, decreasing the need for medications

  23. Tic Triggers • Stress factors and emotions • Food allergies and eating behavior • Chemicals and drugs • Allergens to pollens, dust, molds, animals • Odors, fragrances, smells, fumes • Seasons • Polluted Indoor air environments • Sensory stimulation (light, touch, sound)

  24. Cat Allergy • Exposure can cause tics and other neurologic symptoms; headaches common • May need to remove the cat from house • It may take up to 6 months to remove all cat dander from the home • Furniture and clothing are contaminated • Dander floats through the air.

  25. Chronic Stress Stress depletes brain nutrients and affects hormone balance Chronic exposure to stress hormones can disrupt the production of neuro-transmitters in the brain including serotonin, dopamine, and acetylcholine. David Perlmutter, MD

  26. OCD & PANDAS • Special diets • Cow’s Milk • Food additives, colorings, flavorings • Hidden infection-strep and • Nutrient benefits • Chemical exposures

  27. Case Report #2 Help for mood swings, OCD, and tics with environmental medicine. Chemical exposures Inhalant and food allergy treatment

  28. Focus on Depression

  29. Causes of Depression Hidden allergy: food, mold and more Chronic stress; Lack of sleep Hidden infection: fungal, viral, bacterial Toxic exposures Drugs-medication effects Poor diet

  30. What to Avoid • Pollutants • Allergens • Chemicals & toxins • Drugs • Excititoxins • Trans fats • infections

  31. Foods & Depression • Food allergy causes and contributes to depression,irritability,ADHD, tics, OCD • Determine what you are allergic to • Foods & food additives • Yeast allergy and infection • Address nutritional deficiencies

  32. Inflammation and the Brain

  33. Inflammation & Allergy All chronic illness involves inflammation at some level that cuts across many medical specialties. Signs and symptoms of illness in one part of the body can be a clue to a more widespread multisystem generalized disease throughout the body (ex: allergic fatigue). William Meggs, MD

  34. The Missing Link Inflammation is the common thread linking many of the chronic (allergic) diseases and autoimmune diseases Uncontrolled inflammation is bad;it causes the immune system to overwork It is like a car without brakes. . . It can’t be stopped William Meggs, M.D.

  35. Inflammation is influenced by many environmental factors: what we eat, breathe, drink, use, do, think and feel. Its effect “ripples” and can be felt throughout the body.

  36. Brain Inflammation Dr. Meggs reports that brain inflammation is thought to be related to: Depression Anxiety Allergy Chemical hypersensitivity Irritability Tremors Seizures Fatigue Headaches Brain fog & spaciness Memory disturbances Strokes Autoimmune diseases

  37. C-Reactive Protein (CRP) This test measures generalized inflammation in the body Inflammation is a sign your brain neurons are under attack from excessive free radicals

  38. Chemical Sensitivity: The Silent Epidemic

  39. There’s a silent epidemic out there guys, it’s a masked illness wearing a disguise. The Musician/Physician

  40. A Masked Illness • Repetitious exposures to allergic foods, inhalants and chemicals can lead to a masking effect • Once masked, symptoms become chronic • The link between the exposure and the symptoms cannot be determined until there is a break in the exposure pattern

  41. How to Unmask the Illness • Identify and avoid allergic & environmental triggers • Create environmental controls • Learn stress reduction techniques • Allergy evaluation and treatment

  42. Competitive Inhibition Nutrients and chemicals compete for receptors at the cellular level Nutrients are important for chemical detoxification, immune system support and optimal cellular and neurologic function

  43. Bioaccumulation • When toxic, infectious or allergic substances accumulate in the body, they can set off biological regulatory system abnormalities which can trigger symptoms anywhere • The body’s enzyme and detoxification systems may be adversely affected • Lead and mercury are neurotoxic

  44. Maladaption • The body’s attempt to adjust to an offending, allergic or irritating environmental agent one is exposed to. • Symptoms are the result of the body’s attempt to adapt …or more precisely a “maladaptation.” • With maladaptation, symptoms becomes chronic and masked.

  45. Effects of Toxic Chemicals • Decrease the nutrient pool • Damage and overload biological regulatory pathways and systems • Interfere with detoxification pathways • May adversely affect neurotransmitter function Example: some drugs, formaldehyde products, pesticides, food additives, cosmetics, VOC’s

  46. Many Chemicals & Drugs Are: • Stored in lipid cell membranes • Damage detoxification pathways • Activate the immune system • Aggravate allergies • Adversely affect the brain and nervous system Chemicals can have a pharmacologic” effect

  47. American ChemicalDream We are the first generation on earth to be exposed to toxic chemicals from the womb to the grave. Rachel Carson Silent Spring, 1952 We’ve become the prozac nation seeking chemical gratification. The “Musician/Physician”

  48. Toxic Metal Overload Can Increase Chemical Sensitivity • Mercury is a neurotoxin The Mad Hatter who made felt hats in Alice in Wonderland; use caution with fish and dental amalgams, some paints • Lead is a neurotoxin Paints and lead pipes in old homes, some ceramic dishes • Blood, hair and/or urine tests are available for testing these and other toxic metals (i.e. cadmium)

  49. Pesticide Exposure • Delayed, persistent or latent neuropsychogical effects on the central nervous system. (Organophosphates) • Common symptoms include impaired memory and concentration, confusion, agitation, irritability, insomnia and nervousness • Pyrethroids also can cause allergic and toxic reactions.

  50. Avoid Pesticides! • Say no to pesticides…they target the nervous system…and they can build up in the body • Pesticides are neurotoxins • Pesticides are linked to Parkinson’s and ALS • Pesticides are designed to kill living organisms • They promote free radical production and inflammation