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Little evidence for SSRI use in anxiety and compulsions in ASD: my interview on Nourishing Hope for Autism Summit

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One of the reasons I’m so passionate about participating on summits like The Nourishing Hope for Autism Summit and sharing the powerful nutritional interventions is due to the fact that medications such as antidepressants and benzodiazepines are frequently prescribed in ASD – and the research and clinical evidence shows that children and adolescents with ASD (autism spectrum disorder) are more vulnerable to the side effects.

This paper, Psychopharmacological interventions in autism spectrum disorder, makes the following conclusion:

Psychopharmacological treatment of core and associated symptoms in ASD is challenging, in large part because ASD presents in many different ways. Furthermore, children and adolescents with ASD are more vulnerable to the side effects of psychopharmacological intervention than their age-matched, typically developing counterparts.

This paper, Pharmacotherapy of emotional and behavioral symptoms associated with autism spectrum disorder in children and adolescents, supports this, stating there is little evidence to support the use of SSRIs in ASD:

Selective serotonin reuptake inhibitors are often used in clinical practice to target anxiety and compulsions; however, there is little evidence to support its use in this population. There is a great need for further research on the safety and efficacy of existing psychotropic medications in youth with ASD.

And this paper published a few months ago, An update on pharmacotherapy of autism spectrum disorder in children and adolescents, concludes that

Overall, the evidence is limited for pharmacotherapy in children with ASD, and side-effects with long-term use can be burdensome.

Much of this also applies to adults with ASD and in my interview I talk about the psychiatric medicine concerns within the ASD community and the high incidence of anxiety, aggression, irritability and OCD in this population.

We also discuss the following nutritional solutions in my interview (appropriately titled: How to calm anxiety, and eliminate aggression and OCD) –

  • the role low serotonin plays in anxiety, aggression and OCD/obsessions and the use of tryptophan and when to avoid 5-HTP
  • the low GABA type of physical anxiety and how to effectively use GABA for results
  • how to use inositol for OCD and some wonderful success stories
  • lead toxicity and increased anxiety and the protective role of tryptophan and ascorbic acid
  • phenols and oxalates other special diets (and my story with oxalate issues)

Our interviews are always fun, science based and practical – and in this one we even shared some of our personal results (both good and bad) with some of these nutrients.

Here are just a few of the speakers and topics I’m really looking forward to hearing:

  • James Adams, PhD: The Scientific Evidence Linking Nutrition and Autism Improvement
  • Dietrich Klinghardt: Understanding Lyme, Infections, Mold, and Heavy Metals and the Effects on Autism
  • Chef Pete Evans: Food is Medicine, Inspiration from a chef
  • Kaalya Daniel, PhD: How You Can Use the Healing Properties of Camel’s Milk for Autism
  • Dominic D’Agostino, PhD: Is the Ketogenic Diet Right for an Autistic Child?
  • Susan Owens, MS: The Inflammasome, Oxalates, Autoimmunity and Autism
  • And of course, Julie Matthews, CNC: When GFCF Diets Don’t Work – BioIndividual Nutrition for Autism

This summit provides you with information and tools that address the root causes so medications such as the above do not even have to come into the picture!

The Nourishing Hope for Autism Summit runs July 30 to August 3 and is hosted by my dear friend and colleague Julie Matthews, whose work you’re probably very familiar with. In case Julie’s work is new to you, in my eyes, she is THE autism nutrition expert. I’ve had the pleasure of interviewing her a number of times on the Anxiety Summit, I endorse her Bioindividual Nutrition training (special diets) for practitioners, I highly respect the work she does and I adore her!

The focus of this summit is clearly autism and Julie is THE expert so you’ll learn a ton from the experts she has gathered.

But do keep in mind that those with autism or Asperger’s are often considered the canaries in the coalmine and even if you don’t have a loved one with ASD many of the interviews have wider applications for anxiety, ADHD and other developmental and learning disorders.

Register here for The Nourishing Hope for Autism Summit to learn more! It airs online from July 30 to August 3, 2018

Trichotillomania: NAC, GABA, tryptophan, inositol and zinc?

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This recent paper reports on a case study with NAC – Trichotillomania: a good response to treatment with N-acetylcysteine

Trichotillomania is considered a behavioral disorder and is characterized by the recurring habit of pulling one’s hair, resulting in secondary alopecia. It affects 1% of the adult population, and 2 to 4.4% of psychiatric patients meet the diagnostic criteria. It can occur at any age and is more prevalent in adolescents and females. Its occurrence in childhood is not uncommon and tends to have a more favorable clinical course.

The scalp, eyebrows and eyelashes are the most commonly affected sites. Glutamate modulating agents, such as N-acetylcysteine, have been shown to be a promising treatment. N-acetylcysteine acts by reducing oxidative stress and normalizing glutaminergic transmission. In this paper, we report a case of trichotillomania with an excellent response to N-acetylcysteine.

In this case report an 11 year-old male student had been pulling his hair out for 6 months. He had a relationship problem with this father and also suffered from asthma and dermatitis. He was started on NAC:

Treatment with N-acetylcysteine was initiated ​​(1200 mg/day for three months). The patient’s outlook improved dramatically, but complete remission was not achieved. We chose to increase the dosage to 1800 mg/day, which resulted in almost complete regrowth.

[From: Trichotillomania: a good response to treatment with N-acetylcysteine]

In this paper from 2009, N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study, it is reported that

  • Fifty individuals with trichotillomania (45 women and 5 men) received 1200-2400 mg/day of N-acetylcysteine or placebo over a 12-week period.
  • 56% percent of patients experienced “much or very much improved” hair-pulling symptoms with N-acetylcysteine use compared with 16% using the placebo, and the improvements were first noted after 9 weeks of supplementation.
  • Those in the N-acetylcysteine group did not experience any adverse events.

As you can see, the results with NAC are excellent but it can take 9 weeks and more before results are seen. For this reason, I would always also assess for low serotonin and low GABA and do trials of tryptophan or 5-HTP for low serotonin and GABA for low GABA. With any compulsive and obsessive behaviors I always consider inositol too and we may add this once the ideal dose of tryptophan has been found.

What is my rationale for recommending GABA, tryptophan, 5-HTP and/or inositol?

  • Since NAC works on reducing oxidative stress and normalizing glutaminergic transmission, GABA may help too and will certainly help to ease any physical anxiety that is being experienced
  • “Recommended first-line therapy for this psychiatric condition is administration of SSRIs” even though their efficacy is not yet proven in children – for this reason I’d recommend tryptophan or 5-HTP
  • Also “according to the psychiatric definition, these patients pull their hair because the act is gratifying and reduces tension, anger, depression and anxiety” (these are all signs of low serotonin and another reason to consider tryptophan or 5-HTP)
  • Because they offer relief right away, within 1-5 minutes

A complete nutritional and functional medicine work-up would be part of the plan too – to address the asthma and dermatitis (in the first paper above) and any other symptoms the person is experiencing and may be a contributing factor.

I’d expect the 56% of improved patients (in the second study above) to go to a much higher percent with all of the above approaches.

When I shared these papers on Facebook I was asked this question from someone who pulls out her eyelashes:

I pull my mascara off what is left of my eyelashes every night. I try my hardest not to do it but I find it impossible once I’ve touched my lashes. I’m about to start taking GABA and I was thinking about taking NAC. Would it be a bad idea to take both these amino acids?

This is my feedback: I always like to do one thing at a time and (as mentioned above) I would do the amino acid questionnaire and a trial of tryptophan and GABA first if the scores are high, and then look at adding NAC. If there are still some obsessive tendencies I would consider adding inositol. I am not aware of any issues with using all of these nutrients at once.

Someone else asked this:

Wouldn’t you deal with the psychological cause of it too – at the same time?

My response: Yes absolutely – if there is a psychological cause. But be aware that sometimes it’s purely nutritional or biochemical.

Another person shared that she only exhibits these behaviors when she’s stressed. Of course, the nutrients mentioned above, plus dietary changes, adrenal support, improving gut health and everything that I educate about, are important for reducing stress.

I also received some success stories. Here is one of them:

I’ve struggled with trichotillomania and dermatillomania (skin picking) for years and years. I underwent hypnosis that was extremely effective. When I added in zinc (after reading your book) the urge is almost completely gone. Thank you!

Keep in mind that zinc is a co-factor for making serotonin and GABA, is important for overall adrenal support and stress reduction, is needed for glutathione production and works as an antioxidant. I’d actually love to see these studies repeated with zinc alone.

And then I received this message from someone else:

I’m messaging you my answer about NAC because it’s slightly embarrassing I’ve always had terrible acne and always have picked at it obsessively and could not stop until I was given some supplements for PCOS which happened to contain NAC. To my surprise I lost the compulsion to pick at my skin, something I had never thought possible!

How wonderful for both of them! I always appreciate feedback like this and have to say nothing is too embarrassing to share (especially if it helps someone else).

Have you used NAC with success – with trichotillomania or dermatillomania (skin-picking) or even nail-biting? Or some other compulsive behavior?

What about GABA or inositol or tryptophan or zinc (or something else) for the same purpose and/or for additional emotional and stress-reducing support?

Anxiety, compulsive thinking, counting behaviors: gluten, tryptophan and inositol

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Today I’m going to share my feedback on a question I received on how to approach working with a child with anxiety, compulsive thinking and counting behaviors in the hope it can help you or someone you know (or are working with if you’re a practitioner). Here is the question:

Regarding anxiety and compulsive thinking/OCD counting behaviors in a 12 year old, have you experienced (or heard through client sharing) a correlation with certain foods or inflammatory compounds? In a younger person, I am trying figure out the triggers if there is low production of certain neurotransmitters driving the symptoms. This child in particular has had a long history of allergies and terrible asthma (requiring nebulizer treatments) so I’ve long suspected food sensitivities as a driver for systemic inflammation but am trying to connect the dots for her parent. The counting seems to be a distraction of sorts for her – I assume following a triggering thought. This parent is very new to integrative therapies so treating with an amino acid is going to *feel* like she’s not doing enough as parent. Standard talk therapy has not helped.

This is how I responded and it’s how I would start to work with a parent with a child with these types of issues.

After looking at the basics to make sure the child is eating real whole food with no additives, is not consuming any caffeine and is getting quality animal protein at breakfast (to keep blood sugar stable and reduce anxiety), I always consider gluten and even dairy and other food intolerances. I write about the success of a gluten-free diet with a 7 year old boy in this blog: Integrative Medicine Approach to Pediatric Obsessive-Compulsive Disorder and Anxiety. He saw a “marked reduction of OCD symptoms and anxiety along with marked improvement of social behavior and school work.”

OCD and counting behaviors are classic low serotonin symptoms and her anxiety could be the low-serotonin worrying type or the low GABA type which is more physical anxiety. I’d have them do the amino acid questionnaire

I’d start with a trial of tryptophan – using 100mg of Lidtke Chewable Tryptophan – to help with the OCD, counting and worry-type anxiety. If it helps, I’d have her use it twice a day mid-afternoon and evening, increasing it over the course of a few weeks to find the ideal amount for symptom relief (and keeping a food mood log to record doses and symptoms).

Some people do really well with tryptophan, others do better with 5-HTP for low serotonin symptoms, so doing a trial with 25mg of 5-HTP would be an option if the tryptophan doesn’t help as expected.  

I would carefully review the precautions with the mom as tryptophan and 5-HTP can sometimes be an issue with asthma and may need to be lowered or discontinued.

Inositol can be added if additional nutritional support is needed for the OCD and counting behaviors and may even be needed to replace the tryptophan or 5-HTP if either one triggers asthma. The maximum dose in the research is 18g of inositol per day and I start at 2g once a day and increase slowly over a few weeks to find the ideal dose. Here is feedback from one mom on how inositol alone helped her son with migraines, stress, anxiety and OCD

Once we’ve figured out nutritional support for the low serotonin symptoms then we’d address low GABA if needed, using sublingual GABA. [Update Nov 17, 2017: I mentioned GABA as a possibility but with her symptoms and the new GABA research on intrusive thoughts, a GABA trial would definitely be something to pursue]

I found this comment to be rather unusual: “treating with an amino acid is going to *feel* like she’s not doing enough as parent.” The parents I work with are thrilled to discover how powerful the amino acids are and how quickly they provide amazing results.

These other factors would also be addressed: possible high cortisol, gut health and any of the other possible contributing root causes. I also always keep Lyme disease, heavy metals and PANDAS on the list as possible areas to refer out for if symptoms are not resolving with the above approaches.

Here are links to the amino acid questionnaire, the precautions and the supplements:

  • I have my clients complete the Amino Acids Mood Questionnaire from The Antianxiety Food Solution and check off their symptoms in each of the sections. The rating uses scale of 1-10 with 10 being worst.
  • I also have my clients review the Amino Acids Precautions and we figure out which amino acids they can and can’t use
  • These are some of the supplements I use with my clients

Have you used any of the above approaches with your child or for your symptoms or for a client/patient?

Anxiety in autism, ADHD and sensory processing disorders

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I had the pleasure of being interviewed by Tara Hunkin on the upcoming Autism, ADHD and Sensory Processing Disorder Summit and share my expertise on anxiety since we so often see anxiety in this population. My topic is: Anxiety’s Role in ASD, ADHD and SPD and how nutrient therapy can help.

I start out sharing some of the research on the incidence and connections.

This 2009 paper Sensory Overresponsivity and Anxiety in Children With ADHD in the American Journal of Occupational Therapy, reports that:

Approximately 25% of children with attention deficit hyperactivity disorder (ADHD) have a comorbid anxiety disorder.

The purpose of this particular study was to determine whether sensory overresponsivity (SOR) or sensory processing disorders are related to increased anxiety in children with ADHD. There were twenty-four children between the age of 6 to 10 with ADHD and 24 children without ADHD.

The study concluded that:

Children in the ADHD + SOR [sensory over responsivity] group were significantly more anxious than both the ADHD-only and non-ADHD (control) groups.

Occupational therapists treating children with ADHD and SOR should be aware that these children may also have anxiety and discuss options with families for prevention or treatment.

I would add that anyone working with these children should be aware of the connections: doctors, nutritionists, psychologists and anyone else on the health team.

We also discuss this 2012 paper, also from the American Journal of Occupational Therapy – Sensory Overresponsivity and Anxiety in Typically Developing Children and Children With Autism and Attention Deficit Hyperactivity Disorder: Cause or Coexistence?

Reviews of the coexistence of ASD [autism spectrum disorder] and anxiety disorders have concluded that among children and youth with ASD, anxiety disorders are highly prevalent, clinically significant, and varied as to specific type of anxiety disorder

Approximately 25% of children with attention deficit hyperactivity disorder (ADHD) also have anxiety disorder, a rate that is elevated when ADHD is seen in conjunction with conduct or oppositional defiant disorders

The paper mentions these 3 factors as models worthy of further study in order to understand the relationship between anxiety, sensory overresponsivity, autism and ADHD:

(1) anxiety caused by, or a symptom of, SOR (primary anxiety model);
(2) SOR caused by, or a symptom of, anxiety (primary SOR model); and
(3) the presence of both anxiety and SOR, linked by way of another factor

Based on what I know about anxiety I feel it could be a combination of all of the above.

My interview also covers the following around how to address the anxiety in these children and their moms (who also often have anxiety):

  • Low serotonin anxiety, symptoms, using tryptophan and 5-HTP and precautions with using them with an SSRI
  • A young girl with RAD (reactive attachment disorder) with rage/anger, anxiety, insomnia, and sugar cravings and the successful use of chewable tryptophan, addressing low iron and a gluten-free diet
  • A young boy with OCD and the successful use of both tryptophan and inositol
  • Low GABA anxiety, the use of GABA and not phenibut, and cautions about using too much
  • A young girl with ADHD and irritability and the successful use of GABA
  • Pyroluria incidence and symptoms and how it ties back to neurotransmitter imbalances

Sensory processing disorders, ADHD and autism are not my expertise and I don’t work much with children so I’m really pleased to be bringing you this information via the other amazing speakers AND listening and learning myself!

Here are some speakers and topics I’m particularly interested in

  • Brandon Brock, RN, DC: Understanding PANS and PANDAS role in ASD, ADHD and SPD.
  • Elizabeth Mumper, MD: Mitochondrial Dysfunction: What it is and how to address the underlying causes.
  • Richard Frye, MD, Ph.D.: Cerebral Folate Deficiency: and how it impairs neurological health.
  • Nancy O’Hara, MD: What you need to know about cell danger response in ASD & other neurodevelopmental disorders.
  • John Tjenos, NTP: The importance of the vagus nerve and how to build vagal tone with essential oils.

We have so much to learn from practitioners and researchers working in this area. And children affected by these conditions do recover!

The Autism, ADHD and Sensory Processing Disorder Summit, hosted by Tara Hunkin, NTP, runs from June 19-28, 2017.

It will be 10 days of eye opening information into the root causes of your child’s neurological dysfunction. Imagine learning about what may have caused their symptoms and how to address them with nutrition and biomedical approaches and leverage the power of positive neuroplasticity to improve function, health and their lives.

Do also keep in mind that these topics may have relevance for you even if you don’t have a child with a sensory processing disorder, ADHD and/or autism. These children are the canaries in the coal mine and many of my clients with anxiety can benefit from the biomedical support that many of these speakers are addressing. Simply replace sensory processing disorder, ADHD and/or autism with anxiety and listen and learn.

You can register for The Autism, ADHD and Sensory Processing Disorder Summit here

Feel free to ask questions or provide feedback and your experiences in the comment section below.

Anxiety and OCD: Inositol instead of tryptophan or 5-HTP?

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inositol for anxiety and OCD
DFH Inositol powder – it’s pleasant-tasting and 1 teaspoon is about 3g

Have you used inositol for anxiety and OCD (obsessive compulsive disorder) or even obsessive thinking or behaviors? Have you used it alone or with tryptophan or 5-HTP? I’d like to share an interesting discussion on a recent blog I wrote: Amino acids for anxiety – which ones and for how long? to illustrate how we are all unique and how some nutrients work well and some not so well.

I received this question on the blog regarding the use of amino acids tryptophan or 5-HTP and OCD/anxiety:

I was wondering if this will help with OCD? I did not see any mention of OCD in your articles. Do you feel it can be treated the same way you would treat other anxieties? I was told that since I take serotonin medication that I should not take 5-HTP because it may cause too much serotonin. What are your thoughts?

My answer was as follows (I’ve added a few links because I like to share the research):

OCD can often be related to low serotonin so yes tryptophan and/or 5-HTP can help and is often very effective. If you take an SSRI then tryptophan and/or 5-HTP should only be taken under a doctor’s supervision and at least 6 hours from the SSRI. I would suggest working with a practitioner who knows the amino acids too. And talk to your doctor about doing a taper if that’s what you’d like to do

The other nutrient that helps with OCD is inositol and this is fine to take with an SSRI. I start my clients on 2g/day and go up to 18g/day. Here is one of the older papers on inositol, showing benefits for depression, panic attacks and OCD and a more recent paper discussing OCD and inositol and other nutrients such as NAC and glycine.

With OCD I’d always also look into past strep infections and PANDAs as this could be a factor too.

One of my blog readers, Tracy, responded to the question with some encouragement (how lovely!) and gave us a great example of how we are all different and there is no one size fits all:  

Chiming in with a bit of encouragement here – a bit late perhaps, but wanted to let you know that my teenage son suffers from OCD and anxiety. A number of years ago I found Trudy’s website while trying to find some natural ways to help him. We tried 5-HTP with good success (it also helped lessen the frequency and intensity of his migraines) but it caused stomach upset with him, even when taken with food, so be aware that it may have this effect on you if you try it. After about 9 months of 5-HTP we kind of “forgot” to give it to him and he continued to feel good.

Once my son started high school he started having more stress in his life and his OCD, anxiety and migraines returned. I started him on inositol about 8 months ago. It has had an even greater effect on the OCD than the 5-HTP (remember everyone is different tho!).

I’d highly recommend you try the inositol since 5HTP/tryptophan is not an option for you at this time. My son has had no side effects from inositol at all. Good luck!!

I was pleased to hear that the 5-HTP helped when Tracy’s son was younger. Some people do have digestive issues with 5-HTP. It’s usually in the first week and then typically resolves. This was obviously not the case with this young man.

I was also thrilled to hear that the inositol is helping so much now and wanted to know how much helps so I asked her. Tracy shared how much her son needs (not much at all) and the symptoms it helps with:

My son takes 500mg (NOW brand) daily in the mornings, usually with breakfast. That amount works well for him most days.

When stress is higher and he starts experiencing “breakthrough anxiety” or obsessions, I have him take another 500mg in the evenings as well, just for a couple days or until the stress has diminished.

I should mention that his OCD tends to be primarily obsessive in nature with very little compulsion. His father was actually diagnosed with mild OCD before I met him and he learned to deal with his through counseling and behavior modification. I read about tryptophan (Julia Ross) and asked him to try it. It works well for him when his anxiety acts up (which interestingly tends to have a seasonal component!) It has been an education living with these two!

You can take up to 18g a day of inositol but I suggest starting with 2g a day and building up as needed.  But as you can see above, even 500mg to 1000mg (which is 1 g – I grew up in South Africa and love the metric system!) may be enough.

I happen to use the DFH Inositol powder (pictured above). It has a pleasant slightly sweet taste and is easy to increase the amount based on how much you find helpful. You can find this on the supplements blog here.

As I mentioned above, tryptophan or 5-HTP can help with anxiety, OCD, obsessive thoughts and behaviors (and panic disorders and depression). Adding inositol is an option when the tryptophan/5-HTP isn’t quite enough, or simply use inositol alone.

I also think inositol makes a great addition for mixing into the nasty tasting tryptophan if you find you get better benefits with the tryptophan capsules opened. I suggest starting with 2g inositol per 500mg tryptophan.

I appreciate Tracy giving me permission to share her son’s success with these nutrients. We can all learn so much from stories like this. If you’ve been using any of the amino acids and/or inositol, I hope this has been helpful for you.

Please share how you’re doing in the comments and feel free to ask additional questions.

If this sounds intriguing and you’d like guidance with using the amino acids and other nutrients like inositol, stay tuned for the launch of The Amazing Aminos for Anxiety homestudy group program. This homestudy group program will provide guidance with using each of the targeted individual amino acids, including nutrients like inositol. You can also add your name in the comments if you’d like to be notified when it launches. You’re also welcome to sign up here to be notified when we have more details about the start date.